2014-Sep/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2014

Confidence The feeling you have when you are affiliated with Hill Physicians. Katherine Bisharat, M.D.

Hill Physicians provider since 1998. Uses Ascender preventive care reminders, RelayHealth online communication tools, Hill inSite to review eClaims and eligibility and Hill EHR for a comprehensive solution to patient care, practice management and ePrescribing.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.

Hill Physicians’ 3,800 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Administrators (San Joaquin), Health Net, Humana, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.

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Medicine 3

PRESIDENT’S MESSAGE Patient Privacy Threatened

We Can Still Cure the SGR Mess

Amerish Bera, MD, Congressman, District 7

The Yellow Oleander

Gopal Nemana, MD

José A. Arévalo, MD

EDITOR’S MESSAGE Choosing Wisely for Your Patient

Nathan Hitzeman, MD

2014 Education Series

EXECUTIVE DIRECTOR’S MESSAGE Join the Campaign to Defend MICRA Today

Call for Awards Nominations

Aileen Wetzel, Executive Director

Commitment Wins on Election Day

Who Runs Medicare?

Gerald Rogan, MD

“i”

John Loofbourow, MD

Most Memorable Off-Duty Medical Experience

IN MEMORIAM Max D. Shaffrath, MD IN MEMORIAM Ralph M. Isola, MD

Assemblymember Richard Pan, MD

Google Glass in Medicine

John Paul Aboubechara, MS II, and Rami Hosein, MS IV

OrCam — A Distant Glass Cousin

Bob LaPerriere, MD

Time to Address the Health of the Undocumented

Glennah Trochet, MD

Board Briefs

Marta’s Child

John Loofbourow, MD

Meet the Applicants

Classified Ads

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx The Yellow Oleander (Thevetia neriifolia or Thevetia peruviana) is a beautiful, but potentially lethal, flower commonly seen in Central America, Asia and India. The long funnel-shaped, sometimes-fragrant flowers, bloom from summer to fall. Often called “the suicide plant,” the yellow oleander seeds contain the toxin glycoside which is similar to digitalis, a common drug used by cardiologists to help heart patients. On page 18 of this issue, Dr. Gopal Nemana tells a touching story about the role this plant has played in his life.

September/October 2014

Volume 65/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2014 Officers & Board of Directors José A. Arévalo, MD President Jason Bynum, MD, President-Elect David Herbert, MD, Immediate Past President District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Tom Ormiston, MD

District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Vijay Khatri, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD 2014 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Richard Gray, MD Karen Hopp, MD Maynard Johnston, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD

District 1 Jeffrey Cragun, MD District 2 Richard Pan, MD, Assemblyman District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large John Belko, MD Natasha Bir, MD Helen Biren, MD Gregory Blair, MD Kevin Elliott, MD Alan Ertle, MD Benjamin Franc, MD Karna Gocke, MD Thomas Kaniff, MD Vijay Khatri, MD Don Wreden, MD

CMA Trustees District 11 Barbara Arnold, MD

Douglas Brosnan, MD

CMA President Richard Thorp, MD

CMA Imm. Past President Paul Phinney, MD

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS II John Belko, MD George Meyer, MD Sean Deane, MD John Ostrich, MD Ann Gerhardt, MD Gerald Rogan, MD Sandra Hand, MD Glennah Trochet, MD Albert Kahane, MD Lee Welter, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Adam Dougherty, MD Shahid Manzoor, MD Executive Director Managing Editor Webmaster Graphic Design

Patient Backlog? We’re Just What The Doctor Ordered. The physicians at The Doctors Center are available to assist with that nagging problem of patient backlog. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 12 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. The Doctors Center is open from 8:00 a.m. to 8:00 p.m. Lab tests, x-rays and ECGs are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for most HMOs and PPOs.

(Please arrive by 7 p.m.) JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine ANITA H. BORROWDALE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287

The Doctors Center Medical Group Inc.

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2014 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

The Doctors Center hours are 8:00 a.m. to 8:00 p.m.

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President’s Message

Patient Privacy Threatened By José A. Arévalo, MD IN LESS THAN TWO MONTHS, voters will be asked to weigh in on Proposition 46, the MICRA (Medical Injury Compensation Reform Act) health care lawsuit measure, which will hugely jeopardize the privacy of patients’ personal prescription medical information. The initiative will force doctors and pharmacists to use a massive statewide database known as the Controlled Substance Utilization Review Evaluation System (CURES), which is filled with patients’ personal prescription drug information. Though the database already exists, it is underfunded, understaffed and technologically incapable of handing the massively-increased demands that this ballot measure will place on it. While many of you and your colleagues may find the general concept of the CURES database helpful, this ballot measure will force the program to respond to tens of millions of inquiries each year — something it simply isn’t set up to do in its current form or functionality. A system unequipped to handle these requirements will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing some patients much needed medications. Most concerning, the massive ramp up of this database will significantly put patients’ private medical information at risk and the ballot measure doesn’t contain any provisions or funding to help upgrade the system or increase the database’s security standards. As many of you know, the CURES database contains highly-sensitive patient information including personal and potentially-stigmatizing details about their health. Prescription information, including medication used to treat obesity, narcolepsy, conditions related to cancer and AIDS, asthma and other sensitive information, is all contained within the CURES

database. The ballot measure’s massive ramp-up of the CURES database comes with no funding for technological improvements and will lead to unintended problems. The NO on 46 coalition continues to grow. Teachers, health care workers, local community groups and hundreds of others have pledged to vote NO in November because they, too, understand the implications this measure would have on patients, taxpayers and consumers across the state. We know that if this measure passes, it won’t just be putting patients’ personal medical information at risk, but malpractice lawsuits and payouts will also skyrocket, adding “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. State and local governments face higher costs in two ways: 1) They provide health care for current and retired employees; and 2) They provide health care for low income residents through Medi-Cal and other locally-run health care programs like community clinics and hospitals. Someone will have to pay for these increased costs, and that someone is providers, taxpayers and consumers. The NO on 46 campaign is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, familyplanning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals. A full and updated list of groups opposing the campaign can be found at www.NOon46.com. You’ve been hearing about the campaign to oppose the costly MICRA health care lawsuit continued on page 5 September/October 2014

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 3

EDITOR’s Message

Choosing Wisely for Your Patient By Nathan Hitzeman, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

MOST OF THIS ISSUE OF SSV Medicine is about choosing wisely in the upcoming election to maintain the sanctity of the physician-patient trust. Multiple forces seek to erode that trust. Outsiders are phenomenal at missing the mark on what makes for good health care: from hyperboles about death panels, to men in black robes deciding female contraceptive availability, to a president promising you seamless websites and no risk of losing your physician network with health insurance reform. What is refreshing is when physicians become part of the solution. Who knows better than we do on what our patients need? Within our hospitals, we come together to oversee an amazinglycomplex infrastructure — where not everything comes off perfectly, but it does go surprisingly well. Outside the brick and mortar, we are becoming more organized through the CMA and our various specialty organizations. That our population is aging is beyond our control. That our nation’s culture, work environment, and food industry largely promote poor physical exertion and high caloric intake is beyond our control. But appropriate and thoughtful health care delivery and policy is not beyond our control. An example of this concept is the growing list of recommendations from the Choosing Wisely campaign, www.choosingwisely.org/. The National Physicians Alliance, various medical societies, and Consumer Reports spearheaded this project in 2009 through grants from the American Board of Internal Medicine (ABIM) Foundation. The premise of the project is that health care resources are finite and that physicians must become good financial stewards and must promote a “prudent” and “just” distribution.

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This is not “death panel” stuff; rather, these are lists of tests and interventions that are thought to be low-yield and may lead to more harm and waste than to any practical good. The list started with the ABIM and has branched out to dozens of medical societies. The complete list (126 pages) can be seen at the following link: www.choosingwisely.org/ wp-content/uploads/2013/02/Choosing-WiselyMaster-List.pdf. Ladled from this stone soup are a few of my favorites below. Can you think of some more to add? Feel free to write to us. • Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation. (While about 10 percent of the population reports a history of penicillin allergy, studies show that 90 percent or more of these patients are not allergic to penicillins and are able to take these antibiotics safely.) • Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. • Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency. • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement. • Don’t schedule elective, non-medically-indicated inductions of labor or Cesarean deliveries before 39 weeks gestational age. • Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.

• Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care. • Computed tomography (CT) scans are not necessary in the routine evaluation of abdominal pain (pediatrics). • Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening.”) • Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI). • Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience. • Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. • For a patient with functional abdominal pain syndrome (as per ROME III criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms. • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. • Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery — specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/ are expected to be minimal. • Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac in-patients). • Don’t perform population-based screening for 25-OH-Vitamin D deficiency. • Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia. • Don’t implant an ICD for the primary prevention of sudden cardiac death in patients unlikely to survive at least one year due to non-cardiac comorbidity. • Don’t use parenteral nutrition in adequatelynourished, critically-ill patients within the first seven days of an ICU stay. • Don’t recommend cancer screening in adults with life expectancy of less than 10 years. • Avoid using a computed tomography angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.

This is not “death panel” stuff…

hitzemn@sutterhealth.org

Patient Privacy continued from page 3 initiative for many months now, so how can you get engaged? We’re always looking for informed and engaged physicians to help educate about the dangers of this initiative. Is your name and the name of your medical group on the growing list of individuals and groups opposed to the MICRA health care lawsuit initiative? If not, add it today by visiting www.NOon46.com.

United as one voice, advocating for patients across the state, we can defeat this ballot measure in November, but we need everyone to commit and become engaged along the way. Thank you in advance for all that you do and all that you’ll continue to do. arevalJ@sutterhealth.org September/October 2014

A costly threat to your personal privacy Californians can’t afford. A costly threat to your personal privacy Californians can’t afford. A costly threat to your personal privacy Californians can’t afford. Prop. 46 is Costly for Consumers Prop. 46 is Costly for Consumers  Trial out to profit from medical lawsuits carelessly threw Prop. 46 together without Prop. 46 lawyers is Costly for Consumers     

Trialconcern lawyersfor outyour to profit from medical threw Prop. 46 together any pocketbook or yourlawsuits privacy,carelessly your health or your health care. without Trial lawyers out to profit from medical lawsuits carelessly threw Prop. 46 together any concern for your pocketbook or your privacy, your health or your health care. without If they get their lawsuits andprivacy, jury awards skyrocket. Someone will have to any concern for way, your medical pocketbook or your your will health or your health care. If they get costs. their way, lawsuits and pay those And medical that someone…is you.jury awards will skyrocket. Someone will have to If they get costs. their way, lawsuits and pay those And medical that someone…is you.jury awards will skyrocket. Someone will have to pay those costs. And that someone…is you.

Prop. 46 Jeopardizes People’s Access to their Trusted Doctors Prop. 46 Jeopardizes People’s Access to their Trusted Doctors  If46 Prop. 46 passes and California’s liability cap goes up, you could also lose your Prop. Jeopardizes People’smedical Access to their Trusted Doctors  

  

If Prop. doctor. 46 passes California’s medical cap you could lose your trusted It’sand true. Many doctors willliability be forced togoes leaveup, California toalso practice in states If Prop.medical 46 passes California’s medical liability cap you could lose your trusted doctor. It’sand true. Many doctors willaffordable. be forced togoes leaveup, California toalso practice in states where liability insurance is more trusted doctor. liability It’s true.insurance Many doctors willaffordable. be forced to leave California to practice in states where medical is more Even community clinics,isincluding Planned Parenthood, warn that specialists like whererespected medical liability insurance more affordable. Even respected community Parenthood, warn that specialists like OB-GYNs will have no choiceclinics, but toincluding reduce orPlanned eliminate vital services, especially for women Even respected community clinics, including Planned Parenthood, warn that specialists like or eliminate vital services, especially for women OB-GYNs will have no choice but to reduce and families in underserved areas. OB-GYNs willinhave no choiceareas. but to reduce or eliminate vital services, especially for women and families underserved and families in underserved areas.

Prop. 46 Threatens People’s Personal Privacy Prop. 46 Threatens People’s Personal Privacy  Money isn’t the only thing Prop. 46Personal will cost you.Privacy It could cost you your personal privacy, and Prop. 46 Threatens People’s     

  

Money isn’t you the only Prop. 46on. will cost you. It could cost you your personal privacy, and the doctors trustthing and depend Money isn’t you the only Prop. 46on. will cost you. It could cost you your personal privacy, and the doctors trustthing and depend Prop. 46 forces doctors and pharmacists to use a massive statewide database filled with the doctors you trust and depend on. Prop. 46 forces doctors and pharmacists to use a massive Astatewide filled with Californians’ personal medical prescription information. mandatedatabase government will find Prop. 46 forces doctorsmedical and pharmacists use a massive filled with Californians’ information. Astatewide mandate government find impossible topersonal implement, and aprescription databaseto with no increased security database standards to will protect Californians’ personal medical prescription information. A mandate government will find impossible to implement, and a database with no increased security standards to protect your personal prescription information from hacking and theft – none. impossible to implement, a databasefrom withhacking no increased security standards to protect your personal prescriptionand information and theft – none. And who controls the database? The government – inand an age when government already has your personal prescription information from hacking theft – none. And who controls database? government – in an age when government already has too many tools forthe violating your The privacy. And who controls the database? The government – in an age when government already has too many tools for violating your privacy. too many tools for violating your privacy.

Increased costs. Losing your doctor. Threatening your privacy. Increased costs. your doctor. privacy. Exactly whatLosing happens when trialThreatening lawyers playyour doctor. Increased costs. Losing your doctor. Threatening your privacy. Exactly what happens when trial lawyers play doctor. No on Prop. 46 Exactly what happens trial Nowhen on Prop. 46lawyers play doctor. No on Prop. 46

That’s why a diverse and growing coalition of trusted doctors, community health clinics, hospitals, That’s why a diverse and growing coalitionlocal of trusted doctors, health clinics, hospitals, family-planning organizations, educators, leaders, public community safety officials, businesses and That’s why a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, educators, local leaders, public safety officials, businesses and working men and women urge Californians oppose Prop. 46. family-planning organizations, educators, local leaders, public safety officials, businesses and working men and women urge Californians oppose Prop. 46. working men and women urge Californians oppose Prop. 46.

Executive Director’s Message

Join the Campaign to Defend MICRA Today By Aileen Wetzel, Executive Director BY NOW, MANY OF YOU are familiar with the MICRA lawsuit initiative that will appear on the November 4, 2014, ballot. As we enter the final phases of the campaign, I want to personally say thank you for the work you’ve done and for the commitment you’ve made to defeat this costly measure. Proposition 46 is being opposed by a coalition of doctors, community health clinics, Planned Parenthood Affiliates of California, local governments, working men and women, business groups, taxpayer groups, hospitals and educators, all of whom know that the measure will lead to more lawsuits and higher health care costs. What’s more, it will threaten personal privacy and jeopardize people’s access to their trusted doctors or clinics. While rhetoric is certain to run high in the final days, it is imperative that we show voters exactly how dangerous and harmful Prop. 46 would be for Californians. If approved by voters, this measure could add “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. These new costs would place additional burdens on taxpayers, consumers and patients across the state. A second study looking at the impact across all health care sectors shows that this measure would raise health care costs for a family of four by up to $1,000 per year. For many families, that is the choice between groceries and health care

in some months. This measure would also threaten every Californian’s personal privacy by forcing doctors and pharmacists to use a massive statewide database filled with patients’ personal medical prescription information. This mandate would be impossible to successfully implement and would result in a massive database with no increased security standards to protect our patients’ personal information from hacking and theft. Finally, Prop. 46 would have devastating effects on access to care for patients everywhere, but especially in rural and already underserved areas. Community health care clinics across the state say this measure will cause specialists like OB/GYNs to reduce or eliminate services provided to their patients. This measure could also cause doctors to leave the state, meaning thousands of Californians could lose access to their current physicians. I cannot think of a worse time to reduce access and increase health care costs – and so I ask you to join SSVMS and CMA in the campaign. Together, we can make a difference and let the public know what this deceptive, costly measure is really about. Please pledge your NO vote on Prop. 46 by completing and faxing the MICRA Commitment Card on page 9. awetzel@ssvms.org

September/October 2014

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Commitment Wins on Election Day Voting is not only an obligation of citizenship, but also the opportunity to shape the future of our state.

By Assemblymember Richard Pan, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

PHYSICIANS AND THEIR PATIENTS have a lot on the line this November 4th, Election Day. Two initiatives will have a profound impact on patients and physicians. Proposition 46 repeals provisions of MICRA, thus increasing health care costs and greatly raising the price of medical liability coverage, and reduces access to scheduled medications for patients with pain and certain mental health disorders. Proposition 45 will give the Insurance Commissioner unprecedented power over health insurance that could create greater uncertainty for patient care payment. In the Sacramento region, two physicians are in competitive races. Dr. Ami Bera is running for re-election to Congress in what may be the most challenging congressional race in California. As the only physician in the state legislature, I am running for State Senate against the trial attorneys’ top priority candidate. Despite the importance of this election to physicians and our patients, political observers anticipate a low turnout for the November election. The primary election last June broke a record for low turnout at 25.2 percent of registered voters. Without a presidential election or a competitive gubernatorial election, many people will not feel the urgency to vote in November. Elections are won by the side with the most votes, so the side that is most committed to getting their voters to cast ballots by Election Day usually wins. With 17.7 million registered voters in

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California, too many people feel their vote doesn’t matter. Yet last June, only 481 votes, or 0.012 percent, separated the second and third place candidates for Controller on the initial count, out of 4 million votes cast. If the other 13.7 million registered voters who didn’t vote had an opinion, they missed their chance to decide this election. With so much at stake in November, all physicians need to make a commitment for Election Day. Medicine needs you and all physicians to commit to getting like-minded people to vote in November and make a difference. Talk to your family, friends, co-workers and staff about the upcoming election and how important it is to you and them. If anyone you talked to is not registered to vote, they must register by October 20th to vote in November. Please stay up to date on CMA and SSVMS communications on the initiatives and the election. In the last week of October, talk to all the people you know who are supportive and remind them to mail in their ballot by Friday, October 31st or go to the polls on Tuesday, November 4th. Follow up and make another round of calls on Election Day morning itself and ask your family, friends, co-workers, and staff if they have voted on Election Day. Voting is not only an obligation of citizenship, but also the opportunity to shape the future of our state. As residency director, I provided coverage for a resident to leave continued on page 22

CoMMItMEnt CARd increased costs . losing your doctor . threatening your privacy .

VOTE NO ON PROP. 46 â&#x20AC;˘ JOiN TOdAy!

The Medical Injury Compensation Reform Act (MICRA) has helped contain health costs and reduce frivolous lawsuits â&#x20AC;&#x201D; but trial lawyers want to change the law. We need your help. Join today to get involved in the campaign to oppose their proposed ballot measure.

o - I will vote no on the deceptive ballot measure that will raise health care costs for all Californians by increasing lawsuits against health care providers and decreasing access to care for patients across the state.

o - I will be a Hospital Coordinator and provide information to my colleagues.

Name:

Email:

Preferred Phone:

Home Address:

City:

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Medical Staff Affiliations:

CUT AND FAX TO 916.444.5689 TODAY!

Zip:

Google Glass in Medicine By John Paul Aboubechara, MS II, and Rami Hosein, MS IV

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

GOOGLE GLASS IS A technology which enables its user to experience a whole new way of interacting with the world, and perhaps the medical world. The device is worn much like a pair of eyeglasses, but instead of lenses, it makes use of a small head-up display fitted at the top right corner of the user’s field of vision. The device has internet access, uses a built-in camera, and is operated via voice commands. Add to that a rapidly expanding list of apps, and you have a massive new way to perform just about any task. I have been particularly interested in how this technology can be adapted for the practice of medicine. Imagine you are a surgeon — not very difficult for some of you — performing a coronary artery bypass graft. With your hands in the patient’s chest cavity, you see the patient’s vital signs streaming on your Glass display in real time. At the same time, the camera on your Glass records the surgery, while the microphone records your narration. The entire narrated surgery can be streamed to students around the world. This technology may prove essential to rural clinics. Imagine you are a primary care physician in a rural community. A patient comes into your clinic with severe anaphylaxis. Medications have failed, so you must now perform an emergency tracheostomy. You last did this procedure in medical school long ago. Using Google Glass, you stream the patient encounter live to an expert in another city, who guides you through the procedure. An EMT can “live stream” the status of a patient out in the field so that the emergency department can be better prepared for the patient’s arrival. A cardiologist can use the Glass display to visualize the fluoroscopy as he or she performs a femoral catheterization of an occluded coronary artery. A physician can

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verbally dictate his or her note, while taking pictures of a patient’s wound, which all sync with the electronic medical record. The implementation of Glass in medicine is being pioneered by groups in our region — UC Davis and Kaiser Permanente. Keisuke Nakagawa, a medical student at UC Davis, is working with Dr. Douglas Boyd and Dr. David Cooke to implement Glass in their cardiothoracic surgery service. Ajay Kohli and Dr. Matthew Lutch have begun using Glass in their head and neck surgery service at Kaiser Permanente in Sacramento. Kohli, a medical student at Drexel who is now training at Kaiser, was first introduced to Glass at a conference in Silicon Valley. “As soon as I put it on, I was blown away by the intuitive capabilities of the device. Quite simply, I had never really seen anything like it,” Kohli said. Shortly thereafter, he began using Glass in the operating room. Surgeons equipped with Glass are able to share their perspective of the operation with the entire team. Moreover, by displaying imaging of the lesion on the head-up display, Glass is useful in guiding the surgeon’s approach. Another one of their projects aims to enable nurses to consult physicians at any time by transmitting live video of the patient to the physician who may be at home. Google Glass is also making a debut in medical schools. The University of California at Irvine has begun using Glass in several aspects of their curriculum. Being able to empathize with their patients by stepping into their shoes is a skill that physicians must learn if they are to provide compassionate care. UCI will enhance patient interviews by equipping standardized patients with Glass, which would be recording the student from the patient’s perspective. Also, when students wear Glass, they can have pertinent information delivered into their field

of vision by faculty, who can see exactly what the students see, and thus better guide them through procedures. Nakagawa is certain that, “the current medical applications of Google Glass, such as streaming surgeries or accessing medical data on Glass, are just the tip of the iceberg.” However, there are serious hurdles that must be traversed before Glass can become widely used. “It’s not patient hesitation [that’s the barrier] for sure! Contrary to popular belief — and in my experience — patients have universally been excited about seeing Glass used to enhance their care,” explained Kohli. Instead, it seems that many physicians are justifiably concerned that patient information would not be handled according to HIPAA standards. This concern is being addressed by many groups that are currently experimenting with various interfaces. Moreover, the current Glass simply is not powerful enough to meet physician needs. Although it is brilliantly constructed to fit a full computer in a small and elegant form factor, it lacks sufficient processing power and battery life. The processor begins overheating after just a short period of video streaming, and the battery gets drained quickly, as well. One solution is

Current medical applications of Google Glass such as streaming surgeries are just the tip of the iceberg of its uses.

to simply make it larger. Nakagawa explained, “I don’t think clinicians would mind having bulkier hardware for the benefits of improved functionality.” Glass has currently been in Beta testing. Google has made the “Explorer Edition” of the device available to technology enthusiasts who would help the company work out the bugs. By going to the Explorer Program website, www. google.com/glass/start, you, too, can get your hands on one, but you will need to part with $1,500. A public release of a more affordable version has not been officially confirmed, but Google did hint that it might be towards the end of 2014. jjaboube@gmail.com

OrCam – a Distant Glass Cousin By Bob LaPerriere, MD IN THE FUTURE, IF YOU see someone wearing what looks like Google Glass, look closely before you express your opinion of them…they may be wearing an innovative development from Israel called OrCam. The OrCam device (www.orcam.com) is a small wearable camera that gives people with poor and marginal vision the ability to do tasks not possible before. The OrCam camera can be mounted on any pair of eyeglasses and is connected to a compact computer the size of a glass case. Whereas good vision is required to fully benefit from Google Glass, the OrCam device is specifically intended for the visually impaired, is designed to be discreet, and is not reliant on (or even connected to) the internet. It relays visual information by audio feedback through a bone-conduction earpiece.

Current features allow reading text and recognizing products (both pre-entered and ones that the user teaches it). By simply pointing to an object, the person will instantly be able to tell the denomination of a dollar bill, the contents of a package at the grocery store, the items on a restaurant menu, or just to read the newspaper. Exciting additional features are under development, including face recognition, place recognition, public transportation (such as identifying approaching bus numbers), colors, and more. OrCam is currently available in the U.S. as part of a pre-launch pilot, and is expected to be fully launched in the U.S. later this year. drbob@winfirst.com

September/October 2014

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Time to Address the Health of the Undocumented Communicable diseases do not affect individuals in a vacuum.

By Glennah Trochet, MD, former Sacramento County Public Health Officer

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

MANY PHYSICIANS WOULD AGREE that universal access to health care is a human right that should be available to everyone who lives in California. For that reason alone, undocumented residents of our communities should have access to the benefits of the Affordable Care Act. But the ACA explicitly excludes undocumented individuals from having access to the health insurance exchanges or to expanded Medi-Cal. Even those who do not support the proposition that access to health care is a human right should consider the benefits of extending health insurance coverage to all who live in our community. Regardless of our insurance status, we are all susceptible to communicable diseases. Therefore, we should all have access to vaccinations that prevent these diseases, especially when California is undergoing a resurgence of pertussis. For people who cannot be vaccinated because of medical reasons, it is crucial that those around them have immunity so that the vulnerable individual is not exposed to these viruses and bacteria. An individual who has active pulmonary tuberculosis may not know it for a very long time. S/he can infect a large number of individuals, as recently happened with a case that was identified at Grant High School in Sacramento. As of last report, nine new cases of active tuberculosis disease have resulted from this exposure. Regardless of their immigration status (and I have no information on this), we can agree that all those who were infected and the

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new cases of active tuberculosis must be treated, not only to improve the health of the patients, but also to protect the entire community. Most people understand this argument and feel that public health departments should be responsible for communicable disease control. Unfortunately, some undocumented individuals may not present for treatment out of fear that they will be reported for deportation. In this case, access to a private provider or clinic would allay those fears. In addition, communicable diseases do not affect individuals in a vacuum. A person with active tuberculosis who also has diabetes is likely to remain infectious for a longer time if their diabetes is not under control. It makes no sense to treat tuberculosis without also treating diabetes. And people who have untreated diabetes are more susceptible to communicable diseases than those whose diabetes is controlled. Physicians understand that we take care of people; we do not treat diseases without context. There are approximately 2.6 million undocumented immigrants living in California, which is seven percent of our population, eight percent of all adults and nine percent of our workforce. Undocumented residents from Mexico tend to be younger and healthier than the legally-resident population. We all have benefitted from their work in industries such as agriculture, construction, personal services and retail. Although their wages are significantly lower than those of workers born in the U.S. —

in aggregate, undocumented workers earn $31.5 billion — much of this money goes back into our economy. Undocumented workers are not evenly distributed throughout California. Historically, there have been concentrations in the Central Valley and in Southern California, although there are undocumented workers living in every county of the state. Although a few might have access to health insurance through their employers, roughly one half to three quarters of all undocumented residents in California are uninsured. There is a growing body of research which shows that having health insurance reduces psychological distress and decreases premature mortality. There is also a positive association between health insurance and long-term individual health. The financial aspects of including them in our exchanges may not be as daunting as one would think. Most

of the undocumented workers in California are younger and healthier than the average population, and when they do use medical services, their average costs tend to be less than the average costs of legal residents. In summary, several studies now show that including undocumented workers in an insurance plan is not only the right thing to do for humanitarian reasons; it is also the smart thing to do to keep our community vibrant, healthy and economically sound. It will also protect us all when communicable diseases become epidemic. trochetg@gmail.com Bibliography: Ensuring California’s Future by Insuring California’s Undocumented, by Enrico Marcelli, Manuel Pastor and Steve Wallace http://healthpolicy.ucla.edu/publications/Documents/PDF/2014/ ensuringundocbrief-may2014.pdf

Marta’s Child John Loofbourow, MD Yes, you are one of those Who always work and dwell Where no one ever knows Of what you do so well.

Your precious life is spent In thankless silent toil ‘Til you at last relent And fertilize our soil.

With dirty rooms and sheets Or growing fruits and seeds Or many kinds of meats Or clearing yards of weeds.

Wherever you are from john@loofbourow.com Or what your sex or race With documents or none None here will take your place.

Or raising someone’s child Or renting flesh to one Who likes to be defiled And laughs when it is done.

You will change our choice Of food and art and song And color with your voice Our universal tongue.

So none can ever say If you are tú or me; Or put another way, If yo y tú are We.

Photo by John Loofbourow, MD

September/October 2014

We Can Still Cure the SGR Mess By Amerish Bera, MD, Congressman, District 7

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

AS A DOCTOR, I HAVE always enjoyed curing disease. Unfortunately, policymaking is far from a quick curative process, and I continue to fight hard for fellow physicians and their patients. I continue to be immensely appreciative of the support you have placed in me to be a voice of reason in what seems like the least productive session of Congress on record. I went into politics for the same reason I went into medicine: to help people, to make a difference. It might seem crazy, then, that I’m optimistic. But I truly am hopeful that there is a growing desire to make some big changes and a real chance that we’ll see that happen in the next few months. I believe we are close to a permanent repeal of the Sustainable Growth Rate, something that has seen 17 short-term patches over the last decade — the most recent being this past March when a year of work was killed at the last minute with another temporary patch. As a doctor, I understand why we need a permanent fix for the Sustainable Growth Rate (SGR), a fatally-flawed formula for reimbursing Medicare health care providers. For more than a decade, the SGR has called for unmanageable rate cuts for physician services and forced increasingly-expensive legislative patches to preserve access to care for millions of Medicare patients. Doctors are drawn to medicine by their desire to focus on patients, not payments. Yet, the financial uncertainty caused by the SGR has left many of them no choice but to reduce the number of Medicare patients they see, and to delay investments in new equipment and innovative practice models that reduce costs and

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enhance delivery of high-quality care. And as a former hospital administrator and chief medical officer, I understand the potential SGR reform has to transform how we deliver health care. Physicians have been a driving force behind the development of these new models of health care delivery and payment. Models that allow physicians to coordinate care as a team to reduce costs, and to bundle payment by ailment rather than per procedure, are just two examples of innovative approaches that encourage improving care while lowering costs. We are closer now than we’ve ever been before with a bipartisan, bicameral policy solution ready. It’s rare when Congress can agree on something, but just about as rare when the entire house of medicine agrees — and more than one hundred physician groups support this bill. It’s clear there’s an initial roadmap for the future. Now is the time to implement reform. There might not have been the political will to get the bill passed in March, but I don’t think it ends there. I’m a leader of a group called the “No Labels Problems Solvers.” We are a group of 49 Democrats, 43 Republicans, and one independent who want to work together, regardless of party, for the good of the American people. Members from both parties recognize that the first step in addressing many of our health care challenges has to be a payment system that aligns quality metrics and incentivizes high-value care. That’s why we have been meeting regularly to discuss SGR and strategies for moving forward, and we can be the critical mass in getting enough votes for this legislation to pass. SGR repeal and reform is exactly the kind of challenge that No Labels

members can help advance. We can’t let this opportunity pass. With 49 million patients enrolled in Medicare and another 10,000 baby-boomers aging in each day, we have a responsibility to seize this historic occasion to pass bipartisan SGR repeal and to right the Medicare system once and for all. It’s becoming more and more clear that if you are in medicine, you are also in politics, whether you like it or not. In addition to the work No Labels members are doing, doctors must play an important role in convincing Congressional leadership that this is not only necessary, but possible. So please keep sharing your stories of what it’s really like in the exam room, what inadequate and uncertain Medicare payments mean to your work and how political games have real consequences. Our seniors and their physicians do not have to continue to bear the consequences of Congress’ failure to fix a problem they created, and you can help make sure that this Congress does what’s right for everybody.

Tracy Zweig Associates INC.

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September/October 2014

The Yellow Oleander By Gopal Nemana, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

THIRTY FIVE YEARS AGO, our goldcolored Plymouth Valiant carrying a family of four inside, and a roof-top carrier over it with our belongings, passed over the Sierra Nevada and entered the Sacramento Valley on a July 10th. The Valiant was my first car, bought for $3,500 in Rochester, NY, during my residency. After settling in the new job, we used to take trips outside the town in different directions — some of them long distance. The weather in California was in striking contrast to Rochester, NY, from where I uprooted myself in search of new opportunities. The California freeways stretched for hundreds of miles with the center dividers lined by colorful oleanders — a sight not seen on New York State “Thruways,” as they called them in those days. For a poor boy like me from the other side of the globe, a car was certainly a luxury. Driving on the beautiful California freeways, looking at the beautiful oleanders in full bloom on the median, and at the orchards and the landscape with hills on the side, I thought of my parents who were responsible for my being here in this world, and making something of myself. I wished my mom were with me at that moment to tell stories of my childhood and to sing old, vaguely-remembered songs to my children. I lost my father to a massive heart attack a few months after I entered my Cardiology Fellowship. I did not know how my mom died and had almost no recollection of her, of how she looked or how she played with me. Later in my childhood and adolescence, I was told stories, both by my foster mom and a few others, that she may have committed suicide. Others said she died of a mysterious fever. She was born into a large family of 11 children. Hers was a child marriage like many in those days. I was told the girls were married around age 7 or 8, stayed with parents until they

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were of reproductive age and then sent to their in-laws’ place. I was told that she used to hold me in her lap and sing songs called Tarangas in our Telugu language. She lost a pair of twin girls before me and a beautiful boy after me. During my first year, she was so afraid that I, too, might perish that she took me to the Venugopala temple in another town nearby called Dharmavaram. There I was named Venugopala Sanyasi Rao. The name “Sanyasi” literally means a monk. I guess she would rather settle for me living as a monk than succumb to the high infant mortality in those days. Later, my foster parents changed my name to Gopal. We bought our first house in Carmichael in a new development, a four-bedroom model home for $70,000. I asked my neighbor, John, for suggestions on what low-maintenance plants I could plant as a hedge between our properties. Guess what? Red and white oleanders! Looking back, I wouldn’t do it again. We sold that house five years later and moved to where we live now. Times have changed. Our two sons have grown; one is married, and grandchildren arrived all in sync with the march of times. During the past three-and-a-half decades, I visited India several times. Every time I visited, I asked relatives how my mother died. A close cousin of mine, who unfortunately lost his leg in a freak accident while he lived with my mom and dad, said he never believed that mom killed herself. A few months ago, my cousin in India met Mrs. Rama Lakshmi, a 92-year-old lady who was my mom’s neighbor and who knew her very well. She witnessed her death. My dad was in school on that fateful morning. She found my mom violently vomiting on the back verandah. She looked ashen and was cold to touch. She immediately sent word for my dad

and her husband, and tended to her. She found my mom dying with her eyes rolling up. Mrs. Lakshmi got suspicious and walked to the back yard only to find the broken empty shells and seeds from the yellow oleander plant on the grinding stone. My cousin, who is now 80 years old, said this was never brought to light until 2012. I had a foggy memory of four people carrying a body in a litter draped in white over the threshold of the compound wall. I “Googled” the toxicology of oleander, or Nerium, plants. I could not believe my eyes when I found out that the toxin is a glycoside similar to digitalis, a common drug I have used all my life as a cardiologist! While the two plants are structurally different, the toxic glycoside is one and the same. The Digitalis Purpurea plant, discovered by Dr. William Withering for its medicinal value 200 years ago, is a beautiful small plant with small blue flowers. One can still see it on display at the visitor center of Humboldt National Forest and, for that matter, all over the world on hill slopes and forests. I finally got in touch with Mrs. Lakshmi in Visakhpatnam last Spring. Even at a ripe age of 92, her voice was steady. Her memory was good. She said she and my mom were like sisters. She said my mom was five months pregnant when she committed suicide. On that day, Mrs. Lakshmi was “outside,” an old custom in those days when the ladies were secluded from household duties during their menstrual periods and were “untouchable” for those few days. Her co-sister-in-law was the one who witnessed my mom vomiting and dying and yelled at Mrs. Lakshmi, who rushed to the scene. When her husband and my dad arrived, they were joined by the family doctor, “Dr.” Krishnamurthy, who instructed them to cover the vomit with sand and cremate soon. “It was true your mom sang to you in her lap and you used to make a mess of her Sari

as a toddler and she used to wash her clothes often in the day,” she said. Her songs called, “Tatvams,” were full of deep philosophical meaning. “With no formal schooling, maybe at best fifth grade, how she came upon these songs and where she learned to sing is unknown. But she sang beautifully.” Soon after my mom’s death, my father remarried. “Your stepmother was good to you during that brief period before you were taken away by your foster parents,” said Mrs. Lakshmi. “Your mom was profoundly depressed after your beautiful younger brother died. She would lean against the pillar in the back verandah and cry for long periods. She was a proud woman. She never spoke about the cruel, but traditional, tyranny of her mother-in-law (my paternal grandmother).” She used to eat “chaddi annam” — leftover rice from the night before, marinated in water only — as her breakfast. That morning, because of the holiness of the day, she was not supposed to eat until she bathed and did puja (worship) first. Being pregnant, she was so hungry that she made some coffee and drank it. My paternal widowed grandmother, who lived with us, saw

September/October 2014

that and criticized her severely because she drank coffee when she was really supposed to be fasting. My grandmother just picked up her “Binde” (a brass pot) and left to fetch drinking water from the pond we call “Cheruvu.” That was the flash point that triggered my mother’s suicide. That was the moment my mom went into the backyard to pick the oleander seeds, ground them on the grinding stone and drank with water. Thirteen years later, my grandmother died in my father’s home. She was bedridden following a stroke that rendered her a total invalid, and she lost her speech and her mind. Unkempt, ignored and neglected, she finally died. I was in college at that time. I received a post card from my father notifying me of her death. I recall attending the tenth-day ceremony at the village pond to bid goodbye with the rest of the family.

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Now I understood why some of my relatives, who lived at that time, said she paid for what she had done to my mom. In 2006, I happened to volunteer in a teaching hospital in India. A public relations officer there showed me an old book on the Taranga songs. I asked him to copy that book, and I took it with me. I was also able to find a couple of pictures of my mom. She was born in a village called Arasaville on the east coast where an ancient temple for Sun God exists and was appropriately named Savitri by my grandfather. The Sanskritic name, “Savitr,” meant Sun. She delivered me in a tiny room barely 3 x 6 feet in that ancestral home, a stone’s throw from that temple. My older brother named his daughter after her. I took a picture of that room. As a child, I heard stories from the epics and mythologies of India. One of them was that of Savitri, who lost her husband to a snake bite. She relentlessly follows the god of death named Yama who was taking her husband’s body with him. He tells her he would grant a wish if she left him alone. She then asks that he grant her a son. The moment he said, “ Let it be so,” she confronts him with the question, “How is it possible without a husband?” Unable to answer, the god of death had to give back her husband. Mom, who bore the same name, endured a lot in the prime of her life and was a victim of archaic, decadent and demeaning customs based on blind faith and sheer ignorance. The tyranny and injustice in the family compelled her to make peace through untimely death. My mom, who probably had a fifth grade education, learned the toxicology of the yellow oleander to end her life. She probably never thought that her boy, who was named a monk, would become a cardiologist and would help patients on the other side of the globe to live longer and more productive lives with the help of a drug called digoxin. gopalnemana@yahoo.com

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more informa�on or to register, visit www.cmanet.org/events or call CMA’s Member Help Center at (800) 786‐4262. September 10: HIPAA Update: Are You Compliant with the Final Omnibus Rule? 12:15 – 1:15 p.m. With so many changes to HIPAA, this rule is referred to as an "Omnibus Rule." This webinar provides an overview of the HIPAA changes and key steps medical prac�ces can take to comply with HIPAA; penal�es can be severe for medical prac�ces who are not compliant! 1.00 CME CREDIT. September 17: Managing Difficult Employees and Reducing Con‐ ict in the Prac�ce 12:15 – 1:15 p.m. This informa�on‐packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set prac�ce values; and reduce con‐ ict in the prac�ce. 1.00 CME CREDIT. October 1: Family Medicine, Frontline of Care 12:15 – 1:15 p.m. This webinar will review strategies to help the provider take a pro‐ ac�ve approach to dealing with external pressures, as well as re‐ view basics in documenta�on, prescribing, referring, and prac�ce management. 1.00 CME CREDIT.

October 8: Protect and Preserve Your Pa�ent Rela�onships 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understand‐ ing and awareness of the impact of fraud, waste and abuse on pa�ent care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/pa�ent rela�onship. 1.00 CME CREDIT. October 29: Managing Up! For Managers 12:15 – 1:15 p.m. Managers, Administrators and CEOs in medical prac�ce need to successfully learn to supervise staﬀ or manage down but also achieve results by inuencing their physician bosses by managing up. Learn techniques from Debra Phairas, President Prac�ce and Liability Consultants who has worked with over 1700 prac�ces and recruited over 100 Medical Prac�ce Administrators. 1.00 CME CREDIT.

September/October 2014

Commitment continued from page 8 the hospital to go vote because I wanted my residents to know how important voting is to being a good physician. As the only practicing physician in the California Legislature, I know what a difference it makes when the governor, legislators, and other elected officials see that physicians themselves are committed to working toward positive election results. It is not enough to persuade people to support our candidates and positions; physicians need to make it a priority to get those people to cast their votes. We must each do our part to make a positive difference for our patients.

• • •

• •

Information to Remember • Register to vote online at registertovote.ca.gov.

Recommend registering to vote by mail. Election Day is Tuesday, November 4th. Polls close at 8 pm. Vote-by-mail ballots are mailed to voters a month before Election Day. Mail-in ballots must be put in the mail no later than Friday, October 31. Mail-in ballots must be received by Election Day or they will not be counted. Mail-in ballots can also be dropped off at the polling location on Election Day. Polling locations can be found on your county website or the Secretary of State website. richard.pan@asm.ca.gov

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23-24 september 2014

Sheraton Grand Sacramento, CA, USA Register today: www.ipfa.nl

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Call for Awards Nominations Nominations are being sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting in January 2015. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado-

Sacramento-Yolo region. The candidate must be an SSVMS member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship & Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 452-2018, cstincelli@ssvms.org. Deadline: November 1, 2014.

What is it? This could easily pass as an instrument of torture. It is spring-loaded and creates 39 multiple punctures in the skin. This object is the “new model” of a multiple puncture apparatus for tuberculosis vaccination, originally from the Division of Laboratories and Research, New York State Department of Health. It features four sets of interchangeable needle plates that can be sterilized. BCG - Bacillus Calmette–Guérin – tuberculosis vaccine was first used in humans in 1921. It contained a live attenuated (weakened) strain of Mycobacterium bovis that was originally isolated from a cow with tuberculosis, but has gone through various spontaneous genetic changes since its origin. This tool was donated to the SSVMS Museum of Medical History by Dr. Donald Lyman.

September/October 2014

Who Runs Medicare? By Gerald Rogan, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

HOW DOES MEDICARE WORK and what does its future hold? Here is your Medicare 101 guide to help you advocate for the changes that your patients (Medicare beneficiaries) and physicians need. Medicare was signed into law by President Lyndon B. Johnson in 1965 and now covers more than 50 million Americans. In 1972, President Richard Nixon authorized Medicare coverage for end-stage renal disease (ESRD) patients. Currently, ESRD patients (over 500,000) account for only 1.3 percent of all Medicare beneficiaries, but 7.9 percent of expenditures. Hospice care became a benefit in the 1980s under President Ronald Reagan. Medicare Part A benefits cover hospital services. Part B benefits mostly cover outpatient services. Under President Bill Clinton in the 1990s, Medicare formalized its associations with HMOs (Part C Advantage plans). Medicare Part D prescription drug coverage was passed by President George W. Bush in 2003 and implemented in 2006. To learn more about future changes in Medicare, the Centers for Medicare and Medicaid Services (CMS) offers several resources. Each year, the CMS publishes proposed rules for physicians, called the Medicare Physician Fee Schedule. For hospitals, it publishes the hospital outpatient and hospital inpatient proposed rules, respectively. The rules are first published for notice and comment. CMS staff read the comments and then issue each final rule which includes a summary of the comments and CMS’ responses. Anyone can comment. One can even comment about tangential matters. If we are lucky, CMS staff may even keep good ideas in mind when developing future proposed changes. Each final rule explains what will change beginning the first day of the following year.

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For changes that may occur over a longer term, the Medicare Payment Advisory Commission (MedPAC) provides analysis of Medicare payment policy and offers change recommendations. MedPAC advises Congress in four quarterly reports. Interested parties can receive the publications in the mail. The most recent quarterly report was issued in June, 2014. In it, MedPAC discusses Accountable Care Organizations (ACOs). ACOs are a reimbursement and organizational hybrid between Medicare fee-for-service (FFS) and Medicare managed care (Part C). There are 646,000 beneficiaries enrolled in 69 ACOs. ACO payment policy is adjusted by quality, illness burden, resource utilization, and percentage of out-of-network use. For a variety of reasons, the current policy MedPAC describes makes me wonder whether ACOs will remain viable organizations financially. So we might see some changes to CMS’ method of ACO reimbursement. Medicare measurements of illness burden affect payment to Medicare Advantage Plans, such as to the Kaiser Permanente system. MedPAC explains the current payment method which may underpay for sicker patients and overpay for healthier patients. MedPAC discusses alternative approaches. Medicare also adjusts payments based on quality measures. MedPAC finds there are too many measures which are too burdensome to report. They stifle innovation, exacerbate FFS incentives to provide unnecessary services, and often do not correlate with health outcomes. MedPAC also is concerned that care of sicker patients can falsely appear to receive below average quality of care. MedPAC discusses alternative quality measures, including population-based health outcome measures and specific measures to

report systematic resource overuse. Interesting to me, MedPAC does not mention the potential benefit of measuring overuse through the peer review process that could be applied to determine whether or not a particular service for a particular patient is medically indicated, such as cardiac stent placement. MedPAC continues to advocate that Congress replace Medi-Gap coverage — i.e. private supplemental insurance plans that offset Medicare copays — with a higher Medicare payment percentage together with new patient copayments which insurance does not reimburse. Managed care plans require uninsured patient copayments. But under Medicare B with Medi-Gap, the patient makes no payment at the time of service. MedPAC believes uninsured copayments may reduce resource use for FFS beneficiaries by 30 percent. Annual Medicare payments for patients with Medi-Gap coverage average $15,230 v. $8,240 for those who must pay their 20 percent coinsurance (i.e. no Medi-Gap policy). Under MedPAC’s proposal, without Medi-Gap but with a higher Medicare percentage of payment, the beneficiary would not pay more because the uninsured copayments would be offset by avoiding the need to buy the Medi-Gap policy, which typically costs $1,400 per year. MedPAC explains that primary care is relatively underpaid as a specialty. For example, data presented shows radiologists average 220 percent higher compensation than primary care. MedPAC suggests primary care practitioners receive a supplemental capitated payment per patient per month taken from the FFS budget. However, it seems to me that the amount suggested — $2.60 per beneficiary per month — is too low to matter, but it is a start in the right direction. Once the process is established, the amount can be increased. Typically, change occurs this way, one small step in reimbursement, one giant leap for policy. The variation in specialty compensation is driven by the disparity of payment for the most commonly-provided services by each specialty. The disparities are affected by the relative value unit (RVU) calculations developed by

the Relative Value Scale Update Committee (RUC) and accepted by CMS to determine the Medicare allowances. Typically, innovative services, such as colonoscopy and MRI, remain highly compensated even after each becomes efficiently provided. MedPAC discusses alternative methods to calculate RVUs. In summary, I hope more of you will understand how changes to Medicare occur each year. When advocating for change, I recommend you read the relevant new Medicare rules and the MedPAC publications. It’s not sexy and gripping stuff, but it will continue to play a major factor in your career. Perhaps alternate the online updates with a chapter of “Fifty Shades” now and then. jerryroganmd@sbcglobal.net References: www.aarp.org www.cms.gov www.medpac.gov www.ama-assn.org

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September/October 2014

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OR SCAN TO LEARN MORE!

The pracTice was jusT beginning To Take off…

“i” John Loofbourow, MD She labors as we wait She’s premature. It’s late. Time’s thick tongue licks Her dry lips; 0436. The cervix, not complete Holds a butt and little feet There’s no cord, heart rate fine I worry, bide my time. Four people, one a fetus, wait for day to greet us. Morose, I begin to dwell On what there is to tell Of us: Mestizo Amerinds Whose trouble never ends In this our tortured land Far South the Rio Grande, How a child might survive How keep its inner i alive Unfed, untaught, but still Fly North on wings of will. I spend my little doctor life With death and birth and strife And when the poor can’t pay Stroke the rich to make my way,

Then wonderwords arrive: ‘Why am i alive?’ Where was i then? ‘Will i or I be me again?’ Answers, not persuasive, Seem lies or are evasive; Except a newborn’s i, Each word’s a subtle lie, As fluid as a bat in flight Whose image defies sight, Or the quantal ‘where’? Wherever, it’s not there. Past, future, time, Are imposible to define Like the timeless jive That we are all alive. By God! She is complete! Unblock the little feet; Ask pushes of the nurse; And breathe a prayerful curse. And with a defiant cry, There’s born another i Into this newborn day To blow mere words away. john@loofbourow.com

Watch somber children grow: Like years, they come and go, Mouthing countless whys, And not so simple lies.

September/October 2014

Sierra Sacramento Valley Medical Societyâ&#x20AC;&#x2122;s Fall Member Social California State Railroad Museum Saturday, October 25, 2014 6:00 pm - 8:30 pm This is a Family-Friendly Event! You and your guest(s) are invited to join the SSVMS Board of Directors for a private gathering at the California State Railroad Museum. This is a great opportunity to bring your family and visit with colleagues while touring the museum. Hors d'oeuvres and beverages will be served.

SSVMS Members and Family/Guest(s): No Charge RSVP to Shannon at: (916) 452-2671 or sbuchan@ssvms.org RSVP Deadline: Tuesday, October 22, 2014 Special Appreciation to NORCAL Mutual Insurance Company for Cosponsoring This Event

Most Memorable Off-Duty Medical Experience Background: “Is there a doctor in the house?” Many of us have heard these ominous words at some point while apart from our offices and white coats. This can happen at 30,000 feet in an airplane, while relaxing at a resort, or in a restaurant where someone hasn’t properly chewed their steak. Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows: I was ski patrolling at Homewood Mountain Resort on a Monday. I found a young snowboarder upside down in a tree well next to our terrain park. He was not wearing a helmet and was oriented to name only. The exam was negative except for pink, frothy exudate from his nose. My diagnosis was a basal skull fracture. We secured him to a back board, and I requested a helicopter transport directly to Renown’s Neurosurgery OR. He had two sets of burr holes done 30 and 45 minutes after I first saw him on the hill. He had full recovery. If I had not been on scene and recognized this, he would have been transported to a local ER by ambulance and definitive treatment would have delayed for at least one hour with a probable disastrous outcome. The National Ski Patrol acknowledged my life saving efforts with a Purple Merit Star, the NSP’s highest award for first aid, only 1,000 given out in the 75 year history. —James Margolis, MD My wife and I were on a flight from San Francisco to London in the late 1990s when the dreaded, “Is there a doctor on board?” announcement came on the loud speaker. I was on the way to attend the European Conference on multiple sclerosis and we were somewhere

over the Atlantic Ocean, three hours from our destination. Three men responded to the call. One was a neurosurgeon, one a pediatrician, and me, a neurologist. The woman, in her late 30s, was lying on the floor next to the bathroom in the business section of the Boeing 747, holding onto her lower abdomen in pain. She was pale; her pulse was rapid but regular. We looked at each other and divided our duties quickly. The surgeon started an IV, I examined her abdomen, and the pediatrician monitored her vital signs while I took an Hx. We gave her pain medications once she stabilized, and there was no sign of an acute abdomen. We made contact with London and were able to communicate with an ER physician in a local hospital. After consulting with him, we were confident she would make it to London without diverting the plane to Ireland. The pilot and crew were relieved and grateful for our decision. The three of us took turns monitoring her the rest of way while remaining in contact with the ER physician. We made it to London where an ambulance was waiting for her. She was feeling better by then, but we never got word later as to the cause of her abdominal distress. I did receive a bottle of champagne from the flight staff, a voucher for a discount on my next flight with United, and kind words of gratitude. It certainly was an exciting beginning to our trip. —William Au, MD Several years ago, coming back from a missionary trip to Romania on Lufthansa, there was a call for a doctor. As a pediatrician, I worry about having to care for an older person’s emergency problem. I was directed to a gentleman, about 65 years old, who was pale and clammy. He looked anxious. The stewards

September/October 2014

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

I requested the flight crew to declare an emergency... We landed while I was sitting in the aisle.

could not communicate with him, trying several languages. He was able to walk with assistance, and we went to the back of the plane where there was not even enough space to lie down. He had a pulse, looked confused, and his BP was normal. There was too much noise to hear his heart sounds. We checked glucose, and that was normal. All we could do was to take him back to his seat and periodically observe him. We believe he had a reaction to a medication and, fortunately, he did well the remainder of the flight. Lufthansa was very organized with two emergency suitcases full of materials. It was helpful that a steward was a former ICU nurse. Likely, I ended up almost as anxious as he was. They offered to reseat me in first class for my efforts. —Charles Maas, MD, MPH I was flying SAS from Copenhagen to Chicago in economy class in the summer of 1982. Midflight, there was a call for a doctor. Not being a primary care doctor, I didn’t respond. Five minutes later the call was repeated. This time I identified myself and was brought to a forward galley to see a crying child about 2 years old covered with pox lesions. His mother was in full Muslim dress and did not speak a word of English. The stewardess told me they had connected from a flight originating in East Africa. I immediately thought of smallpox, remembering the last reported case in the 1970s was in some East African nation. Although smallpox was unlikely, and this was probably chickenpox, I was still uneasy. I asked the stewardess to shepherd the woman back to her seat and try to comfort the child with whatever was available. I informed the stewardess that the child’s condition was contagious and that the plane should be quarantined upon landing in Chicago until a pediatric public health service doctor could board the plane and examine the child. That is exactly how it transpired with the doctor diagnosing chickenpox and the pilot informing everyone that they had been exposed to chickenpox. —James Hamill, MD Returning home late one evening, I found my street blockaded by seemingly every city police department patrol car. Parking behind

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the nearest one, I was told by a police officer, “We’ll have to wait before you can enter this cul-de-sac.” “What are we waiting for?” His reply, “An ambulance,” and (cued by my questions), “Are you a doctor? You’ll want to see this kid who shot himself in the head.” I nodded “Yes,” with an unspoken thought: “I don’t think so, but I am a physician.” Noting my hesitation, he handed me exam gloves: “You’ll need these.” Viewing the large puddle of blood, I prepared to pronounce death and save the ambulance its Code 3 risk. Opening his airway, a gurgling inhalation resounded, along with a bloody hand on my forearm. Riding in the ambulance, we placed an endotracheal tube and large IV catheter, infusing a liter and a half of saline before arriving at the emergency department. Despite the retained slug in his posterior fossa, the young man reportedly walked out of the hospital days later. This experience helped motivate my current role, teaching skills and patient assessment to paramedic students. —Lee Welter, MD While driving with my wife between Auburn and Grass Valley on Highway 49, we were behind a motorcycle. A deer jumped from the side of the road, colliding with the driver who flew into the air, landing on his helmet. He was unconscious, breathing with good pulses. I stabilized his neck until paramedics arrived. He later died in a trauma center. —Norman Label, MD One of my more unusual GYN consultations occurred one winter Sunday morning in the mid-1980s. While serving on the Sugar Bowl Doctors’ Ski Patrol, I was approached by a staff member in her mid-20s. She requested diagnosis and treatment of a worrisome rash, limited to her chest and abdomen, which had developed that morning. She was currently taking Ampicillin, recently prescribed by her family physician for IUD-induced endomyometritis. While examination of the affected area was indicated to confirm my impression of an Ampicillin-induced rash, finding an appropriate site in which to conduct the exam proved challenging. We agreed that the First Aid cabin,

its multiple windows covered with neither shades nor curtains, furnished insufficient privacy. The Sugar Bowl Ski Lodge Annex, a bar and grill managed by her husband, was not scheduled to open for business until noon. The three of us promptly adjourned to the confines of the Annex. While her husband assumed guard duty at the door, the patient and I adjourned to the ladies’ washroom for a brief confirmatory examination. The IUD was subsequently removed, alternate contraception provided, and the Ampicillin discontinued, with prompt resolution of the rash. — James McGibbon, MD I can recall being asked to see an ill passenger three times (not the same passenger − three different folks on three different flights). First one was on my way to Vietnam from McGuire AFB in New Jersey, and it was a very drunk sergeant who was escorted off the plane by MPs at Elmendorf AFB in Anchorage where, I am sure, he sobered up for a while. The next two were a middle-aged man with a very bad headache on a flight from Honolulu to SFO, and then a few years later, an elderly lady on a flight from NYC to Barcelona who felt very woozy, so we laid her out on the floor of the galley with a pillow under her head. Both of them seemed sober. Both did well. I was also in the audience at the taping of a TV show in Los Angeles probably around 197677 when one of the actors came rushing out of the wings and excitedly called out the classic line, “Is there a doctor in the house??” The show was a comedy and when the actor called out for help, most of the audience laughed. Then he said something like, “No, I’m serious. We have a sick lady backstage!!” So I and a physician friend who was with me, ran backstage to find a young woman (a member of the backstage crew) who had apparently fainted and was, by the time we arrived, now sitting up and telling everyone how embarrassed she was and she now was “fine” and thanked everyone for his or her concern, etc. and the show went on, as it always must. And I’ll bet that you thought that I have led a dull life!! —Jack Ostrich, MD

It was August, though I am not certain what year. My wife and I were flying American Airlines through DFW. We had all heard the announcement, and since I was just two rows ahead of a middle-aged, somewhat heavyset man who had just lost consciousness, I responded. He was in and out of alertness. I was unable to hear a BP or heart sounds as the engines were too loud. I did manage to start an IV and fluids, and he became a little more with it. We were about 25 minutes out of DFW, so I requested the flight crew to declare an emergency and come straight in. The flight attendants had been able to clear his row, and we were able to get him to lie down. We landed while I was sitting in the aisle. We taxied to the gate; the pilot asked everyone to remain in their seats to allow the emergency personnel to enter. They were no where to be seen, so they slowly allowed several rows at a time to disembark while awaiting the EMS. They finally arrived after the airplane had been cleared and took over his care. Probably the most exciting part was that when we landed the man had recovered enough to pull out his cell phone, punch a single number and immediately hand me the phone when his wife answered. With no warning, I had to try to explain to his wife what had happened. I never received feedback on his condition. — George Meyer, MD

Remember When?

September/October 2014

In Memoriam

Max D. Shaffrath, MD 1917–2014

I FIRST MET MAX WHEN I WAS in medical school. Soon after I completed my residency, he recruited me to serve as locum tenens in his office while he traveled to Pakistan and Iran as a Fulbright Scholar teaching orthopedic surgery. Upon his return, I joined his orthopedic practice. Max was my mentor in Sacramento for 35 years and the best friend I ever had. I firmly believe he was the best friend anyone could have had. At the medical practice of Horn, Shaffrath, Gibbons, Smoley and Wright, he and I shared an office with Gene Smoley, MD. Max was continuously involved with more good deeds than he could reasonably handle, and his Max D. Shaffrath, MD desk was piled high with notes and papers. Gene Smoley’s desk, on the other hand, was compulsively neat. He once left a note on Max’s desk saying, “A cluttered desk is the sign of a cluttered mind,” which Max returned with the footnote, “If that is so, what does an empty desk mean?” But, they were friends and remained friends. The following account of Max’s life was prepared by staff from Medical Society records. Max Shaffrath, MD, passed away on May 3, 2014 in Greenbrae, California at the age of 96, five months after the death of his wife, Louise, with whom he shared a life for nearly 70 years. Max graduated from Stanford University School of Medicine in 1944, and received his orthopedic surgery training at the University of California Affiliated Hospitals in San Francisco. He served as an Army medical officer from 1944-1946. He arrived in Sacramento in 1950 and began his 45-year medical career in Orthopedic Surgery. During the 1950s, he donated his time as rotating medical staff in charge of polio cases at the then Sacramento 32

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County Hospital (now UC Davis Medical Center). In one year, he treated 125 paralytic polio cases. He was Project Director of the Society’s Delta Health Care Project for seasonal agricultural workers, and chair of the Society’s committee to organize the UC Davis School of Medicine. He was a member of the Medical Society for 64 years serving as President of the Sierra Sacramento Valley Medical Society in 1971, at the same time his wife was serving as President of the SSVMS Alliance. The Medical Society presented him in 1982 with its highest award, the Golden Stethoscope, for his devotion to patient care and the medical needs of the community. At the age of 55, Max became a mountain climber and successfully climbed Kilimanjaro, Fuji, Olympus, Machu Picchu, Mauna Kea and Mt. Everest. He also ran in the Bay to Breakers 10 consecutive times. Max was a longtime member of the Sacramento Museum and History Commission. It was through his efforts during the country’s bicentennial celebration, that the Sacramento Tower Bridge was painted gold to symbolize Sacramento as the ‘49ers gateway to the gold fields. He continued his passion of history with the Histree Project, a 12-foot cross section of a 2,468-year-old redwood tree that he marked with plastic overlays to correlate tree rings to match dates of key historical events. He would travel around the country with the exhibit and provide lectures. Max retired in 1995 and shortly thereafter, he and his wife moved to Marin County where they lived throughout their retirement years. He leaves behind his three children, three grandsons and two great-grandchildren. − D. Gilbert Wright, MD

In Memoriam

Ralph M. Isola, OD, MD 1926–2014

DR. RALPH ISOLA PASSED AWAY on June 12, 2014 at the age of 88. He practiced ophthalmology for four decades in east Sacramento and was a 50-year member of SSVMS and a 52-year member of the CMA. He was born at Sutter General Hospital and attended high school in Roseville. He grew up speaking Italian at home and served as an interpreter for Italian POWs during World War II. Dr. Isola’s father, Angelo, worked for the railroad, and his mother, Angelina, raised vegetables, chickens and rabbits to feed their two sons during the Depression. He joined the Army after high school and was injured at the Battle of the Bulge. After working in a POW camp, he was in a joint ArmyNavy group assigned to the United Nations in San Francisco. He graduated from Sacramento State College (now CSU Sacramento) on the GI bill and later attended Optometry school in Los Angeles. He obtained a medical degree from the University of California, Irvine. Ralph completed his internship and residency in Ophthalmology at Los Angeles County Hospital. Returning to Sacramento in 1963, he opened his first practice in the Medicus Building, where the Alex Spanos Heart Center now stands at Mercy General Hospital. Ralph later moved his practice to 57th and J Streets where he worked until his retirement in 1999. His patients always remembered Ralph as a warm and compassionate man who connected easily with them. Among his peers, he was considered an excellent surgeon with a kind bedside manner. As associate professor of Ophthalmology at UC Davis, he mentored

dozens of residents and could always be counted on to provide common sense advice for the challenging patients. Ralph celebrated his Italian heritage serving as president of the Dante Club. An invitation to one of the Dante Club’s sausage feeds from Ralph was never turned down due to the exceptional food and wine that was copiously consumed, along with the amiable companionship. Recognizing his distinguished accomplishments as a first generation Italian-American, Ralph was awarded a Gold Medal from the city of Lucca, Italy, a Province of Tuscany. Although his professional contributions were extraordinary, Ralph will most be remembered for his gentle, Ralph M. Isola, OD, MD compassionate and caring nature. His quick wit, enthusiasm for life and his love for humankind was exceptional. He loved to learn and he enjoyed new adventures and travelling the world. However, he was the happiest in his kitchen. He was a gourmet chef who enjoyed cooking for his wife, Concetta “Dolly”, to whom he was married for 58 years. After retiring from medicine, he worked to perfect his recipes for osso buco, ravioli, tortellini, biscotti’s and other favorite Italian dishes he learned from his mother. Ralph’s family also includes his children Ralph, Angela, Mariann and eight grandchildren. He was preceded in death by adult son Joseph. − Chris Serdahl, MD

September/October 2014

Board Briefs July 14, 2014 The Board: Received an update from CMA President Richard Thorp, MD, on the NO on 46 campaign, including an update on the prior weekend’s California Democratic Party Convention. Dozens of physicians and medical students attended to represent the profession. Due to their efforts, the California Democratic Party took an official neutral position on Prop 46. Dr. Thorp also provided an update on CMA’s efforts to implement the Affordable Care Act. Approved the 2013 Annual Audit Report presented by CPA, Lindsey Kate Lane. The audit was conducted in accordance with the Statements on Standards for Accounting and Review Services issued by the American Institute of Certified Public Accountants. Approved the 2014 Second Quarter Financial Statements. Approved changes to the SSVMS Delegation for the 2014 CMA House of Delegates as follows: James Sehr, MD, to At-Large Delegate Office #19; Assemblymember Richard Pan, MD, to At-Large Delegate Office #20; Benjamin Franc, MD, to At-Large Delegate Office #21; Alan Ertle, MD, to At-Large Delegate Office #22; Adam Dougherty, MD, to Resident Delegate At-Large; Sean Deane, MD, to At-Large Alternate-Delegate Office #9; and Don Wreden, MD, to Alternate Delegate Office #2. Approved the Membership Report: For Active Membership — Amy V. Barnhorst, MD; Christina K. Chao, MD; Robert A. Dias, MD; Lilliam DiGiacomo, MD; Trang (Tracey) Dinh, MD; Matthew C. Eldridge, MD; Julie A. Freischlag, MD; Catherina C. Fu, MD; Stephanie M. Girton, MD; Steven C. Glocke, MD; Kjersti A. Johanson, MD; Eve A. LaValley-Willsey, MD; Yang (Ashley) Li, MD; Zhicheng Mo, MD; Rashmi K. Narayana, MD; Karega Y. Paisley, MD;

Sierra Sacramento Valley Medicine

Andrew J. Parker, MD; Joshua B. Radke, MD; Lorin M. Scher, MD; Tiffany H. Shu, MD; Mac T. Wayment, DO; Andrea Willey, MD; Alonzo S. Woodfield, MD; Wendy E. Ziegler, DO. For Resident Membership — Jamie Anderson, MD; Tuan A. Nguyen, MD; Verena Schandera, MD; Yen N. Truong, MD. For Reinstatement to Active Membership — Christopher Hoffman, MD; Virginia Joyce, MD; Mark D. Levine, MD; David W. Lin, MD; James J. Steidler, MD. For a Change in Membership Status from Medical Student to Resident Membership — Alex R. Buss, MD; Olivia M. Campa, MD; Michael T. Chew, MD; Hayley (Smith-Maclean) Coker, MD; Luz D. Contreras, MD; Adam P. Dougherty, MD; Luis A. Godoy, MD; Amir Goodarzi, MD; Kelly M. Gray, MD; Trevor M. Heneveld, MD; Tsung-Yen Hsieh, MD; Behnood Khodayari, MD; Evelyn B. Ling, MD; Andrew J. Meyers, MD; Erin J. Osiecki, MD; Claire C. Pierce, MD; Garret H. Sheng, MD; Wahid N. Syed, MD; William Thieu, MD. For a Change in Membership from Resident to Active Membership — Hollis M. Hopkins, MD; Peter R. Knudsen, MD. For Retired Membership — John J. Madigan, MD. For Resignation — Lynn N. Fitzgibbons, MD; Brit Hatfield, MD (moved to Salem, MA); Mohammed A. Shaikh, MD; Allen K. L. Tong, MD (transferred Resident Membership to San Francisco). Serving as the Board to the Community Service, Education and Research Fund (CSERF), approved the proposed revision to CSERF Scholarship Policy 100-114 to include recommendations from the auditor following IRS Guidelines for appropriate record keeping of scholarship applications.

Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Thomas W. Ormiston, MD, Secretary.

Anderson, Jamie, General Surgery, UC San Diego 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Fu, Catherina C., Radiology, UC Los Angeles 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 817-5250

Barnhorst, Amy V., Psychiatry, UC Davis 2006, Sacramento County Mental Health Treatment Center, 2150 Stockton Blvd., Sacramento 95817 (916) 875-1000/UCDMC, 2230 Stockton Blvd., Sacramento 95817

Girton, Stephanie M., OB-GYN, University of Iowa 2009, Camellia Women’s Health, 5821 Jameson Court, Carmichael 95608 (916) 486-0411

Buss, Alex R., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Campa, Olivia M., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Chao, Christina K., Emergency Medicine, Stanford University 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Chew, Michael T., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Coker (Smith-Maclean), Hayley, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Contreras, Luz D., Family Medicine, UC Davis 2014, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 734-7866 (Resident Member) Dias, Robert A., Neurology/Clinical Neurophysiology/ Sleep Medicine, University of Maryland 2005, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 DiGiacomo, Lillian, Surgical Critical Care, University of Washington 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Dinh, Trang Tracey, Pediatrics, University of Wisconsin 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916)6882106 Dougherty, Adam P., Emergency Medicine, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Eldridge, Matthew L., Infectious Diseases, Jefferson Medical College 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Freischlag, Julie A., Vascular Surgery, Rush University 1980, UC Davis School of Medicine, 4610 X St #3101, Sacramento 95817 (916) 734-3578

Glocke, Steven C., Emergency Medicine, Northwestern University 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Meyers, Andrew J., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Mo, Zhicheng, Pathology, China Medical University 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2300

Godoy, Luis A., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Narayana, Rashmi K., Family Medicine, Chengalpattu Medical College, India 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Goodarzi, Amir, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Nguyen, Tuan A., Nephrology, UC Los Angeles 2009, UCDMC, 4150 V St #3500, Sacramento 95817 (916) 734-3774 (Resident Member)

Gray, Kelly M., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Osiecki, Erin J., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Heneveld, Trevor M., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Hopkins, Hollis M., Emergency Medicine, University of Colorado 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Hsieh, Tsung-Yen, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Paisley, Karega Y., Occupational Medicine, St. George University 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Parker, Andrew J., Occupational Medicine, University of British Columbia, Canada 1981, USHealthworks, 1675 Alhambra Blvd., Sacramento 95816 (916) 451-4580 Pierce, Claire C., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Johanson, Kjersti A., Emergency Medicine, University of Southern California 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Radke, Joshua B., Emergency Medicine/Medical Toxicology, University of Iowa 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Khodayari, Behnood, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Knudsen, Peter R., Psychiatry, UC Davis 2010, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100 LaValley-Willsey, Eve A., OB-GYN, University of Nevada 2009, Camellia Women’s Health, 5821 Jameson Court, Carmichael 95608 (916) 486-0411 Li, Yang (Ashley), Internal Medicine, University of Illinois 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Ling, Evelyn B., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

McManus, Julia T., Family Medicine, Universidad Nacional Autonoma de Mexico 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Schandera, Verena, Emergency Medicine, UC San Diego 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Scher, Lorin M., Psychiatry/Psychosomatic Medicine, George Washington University 2005, UCDMC, 4610 X St, MES#3126, Sacramento 95817 (916) 734-0640 Sheng, Garrett H., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Shu, Tiffany H., OB-GYN, University of Illinois 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Syed, Wahid N., UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) continued on next page

September/October 2014

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Meet the Applicants continued from previous page Thieu, William, UC Davis 2014, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Willey, Andrea, Dermatology, UC San Francisco 2000, 2277 Fair Oaks Blvd., #402, Sacramento 95825 (916) 922-7546

Truong, Yen N., OB/GYN/Maternal Fetal Medicine, Tufts University 2008, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-6900 (Resident Member)

Woodfield, Alonzo S., Emergency Medicine, Johns Hopkins 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Wayment, Mac T., DO, Pediatric Critical Care/ Pediatrics, Kansas City University 2002, Mercy Medical Group, 1700 Prairie City Rd, Folsom 95630 (916) 351-4800

Ziegler, Wendy E., DO, Surgical Critical Care, University of New England 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Membership Has Its Benefits!

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

Visit SSVMS online at www.ssvms.org

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