Sierra Sacramento Valley
MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
November/December 2014
The Sierra Sacramento Valley Medical Society is dedicated to bringing together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.
Unified Voice of All Physicians o Promote inclusiveness to members and prospective members o Collaborate across health systems and medical groups o Advance legislative advocacy for physician and physician-patient issues o Realign committees and councils with mission statement and strategic goals Membership Retention and Growth o Effectively communicate value of membership to members and prospective members o Strive to meet the individual needs of all members o Promote members-only benefits and services Promote and Protect Access to Care o Defeat trail-attorney threat to the Medical Injury Compensation and Reform Act (MICRA) o Develop and promote resources to enhance physician practice viability o Advance legislative advocacy for physicians and physician-patient issues Enhance physical and mental health of our community o Expand physician volunteer opportunities through the Community Service, Education and Research Fund (CSERF) o Expand services provided to the region’s uninsured and medically indigent through the Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) program o Work collaboratively to address mental health needs of our community (See the SSVMS President’s Message by José A. Arévalo, MD, on Page 3)
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Medicine 3
PRESIDENT’S MESSAGE A Simple Thank You
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Scholarship Awards
Kris Wallach, CSERF Program Director
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Heed the Warning
Jack Ostrich, MD
José A. Arévalo, MD
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EDITOR’S MESSAGE Simplicity, NOS
Nathan Hitzeman, MD
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Pertussis has Become Epidemic in California
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EXECUTIVE DIRECTOR’S MESSAGE Top Five Reasons for Joining SSVMS and CMA
Glennah Trochet, MD
Aileen Wetzel, Executive Director
BloodSource’s Role in Plasma-Derived Medicines
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Hobby: USATF Official
Ann Gerhardt, MD
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A Really Nice Lady and Her Gift
Ann Gerhardt, MD
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Member Stories: Oddest Requests From Patients
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IN MEMORIAM Frank J. Glassy, MD
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Chris Gresens, MD
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SPIRIT Volunteer Donates 100th Surgery
Kris Wallach, CSERF Program Director
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An ICD-10 Christmas Tale
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Hello From Uganda; How are you?
George Meyer, MD
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Sacramento County’s Fraying Medical Safety Net – Part One
Celeste Reinking, MD
26 “Aleph-null”
John Loofbourow, MD
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Meet the Applicants
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Board Briefs
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 This photo was taken by Holly Fischer of El Dorado Hills. “What I love most about this photo is that it was taken not far from my home in El Dorado Hills. For a few days we had incredible cloud formations in the late afternoons. On this particular day, I watched the clouds dramatically form as evening approached. I dashed out of the house with my camera equipment and got several beautiful shots from that evening. I used my 16-35mm wide-angle lens at f22, ISO 800 to take in the vast skies and foregound. Take a good look at the photo and see if you can spot a fun, interesting image within the image!” For more photos of our region’s natural beauty, visit www.hollyfischerphotography.com.
November/December 2014
Volume 65/Number 6 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
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Sierra Sacramento Valley
MEDICINE
SAVE THE DATE!
The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.
Thursday, January 8, 2015 SSVMS & Alliance Annual Installation and Awards Dinner
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 Vacant 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 Thomas Kaniff, MD Vijay Khatri, MD Don Wreden, MD Vacant Vacant
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
Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly
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Hyatt Regency Hotel 1209 L Street, Sacramento 6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program
Installations Jason P. Bynum, MD, President 2015 2015 SSVMS Officers and Board of Directors
Award Presentations Golden Stethoscope Award Medical Honor Award Medical Community Service Award Dorothy Dozier Helping Hands Award
Entertainment To Be Announced
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. 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.
Sierra Sacramento Valley Medicine
President’s Message
A Simple Thank You By José A. Arévalo, MD WHEN I WAS ASKED BY THE leadership of our SSVMS to take on the role as the 140th President, I knew that 2014 would be a landmark year for me, for our Medical Society and for our Health Care Ecosystem. On one hand, as the year rolled out, I was humbled by the magnitude of the changes that have occurred, and on the other hand, I have been invigorated by the challenges and opportunities. It has been a tremendous learning experience, and I owe it to a dedicated and hardworking Board of Directors, an amazing and talented staff, and a strong and growing membership. As my term comes to a close, I would like to thank you and highlight some of the key events in my tenure. We began the year by educating our leadership and our members about the trial lawyers’ attack on California’s landmark tort reform law, the Medical Injury Compensation Reform Act (MICRA). During the NO on 46 campaign, I had the privilege of traveling throughout El Dorado, Sacramento and Yolo Counties speaking to physicians of all specialties and modes of practice. My travels and the people I met left me more convinced than ever that the strength and partnership of organized medicine unites us as physicians. The year also began with a bang as the next phase of health care reform swept through our region with its promise of health care coverage for all citizens. Thousands of new individuals and families were enrolled in health care coverage through Covered California or through expanded Medi-Cal. SSVMS, through a modest grant, took the lead on educating providers about the Exchange and how to talk to patients about their options. In March, our Board of Directors, with the help of our talented and skilled CEO, Aileen Wetzel, hammered out a new mission statement and crafted a comprehensive and
dynamic Strategic Plan for the medical society with four key strategic goals: • Unified Voice of All Physicians • Membership Growth and Retention • Advocacy for Physicians and Patients • Community Engagement In 2014, we successfully influenced legislation by engaging with our local, state and federal representatives. CMA defeated a series of dangerous scope-of-practice bills and advocated for increased funding to the Medi-Cal program. We worked with our Congressional representatives to successfully eliminate the flawed Medicare Geographic Practice Cost Index (GPCI) which, for many years, resulted in physicians practicing in El Dorado, Sacramento and Yolo Counties being underpaid by Medicare. On a regional basis, this is equal to an annual underpayment of $3,388,669. The new law will become effective in 2016. Finally, we continue to advocate for the full repeal of Medicare’s flawed Sustainable Growth Rate (SGR) formula which results in underpayment to physicians. The SSVMS Board of Directors recognized the importance of all modes of practice by establishing an ad-hoc committee, headed by Dr. Christian Serdahl, to identify the key challenges to practice viability for physicians in solo and small group practices, with an aim to report back actionable recommendations to the Board of Directors. We also created a new Past President’s Forum, inviting many of our recent Past Presidents. I have found their collective wisdom to be an invaluable resource. Dr. Jason Bynum, our incoming President, was instrumental in creating and chairing our new Mental Health Task Force. The physicians on this task force are charged with identifying and recommending to the Board of Directors specific issues impacting mental health within continued on page 11 November/December 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
Simplicity, NOS 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.
ON THIS BIG BLUE BALL hurtling through space lives a race of beings determined to make life harder for themselves. In this issue, we present the intricacies of ICD-10 coding, and Dr. Jack Ostrich speaks to the ubiquity (stupidity?) of warnings and cautions that have come to permeate our everyday lives. At my health organization, we are wading into the waters of ICD-10. Our EMR flashes a pop-up when I type in Low Back Pain and a bunch of check boxes ask me if it’s the “initial encounter, subsequent, sequela, without or without sciatica, worse on Tuesdays,…” etc. Imagine doing this nonstop next year with the full roll out. So long to the days of Depression, NOS (not otherwise specified). When EMR came out, docs were wowed by the ease of electronic prescribing and quick access to lab results. The joy was short-lived after we found out that we would have to be typists too, battle an array of piddly hypothetical drug reactions and health maintenance items, and respond to inquiries, both large and trivial, by patients. An amazing amount of trivials come through. Try sending an EPIC message to your lawyer for a little free advice? Good luck! Unless more physicians get involved in EMR development and testing, we will continue to have a creep of unrealistic and unwieldy expectations piled onto us. I must invoke the first law of thermodynamics here and argue that more time spent with the computer means less time with the patient. An April 2013 issue of JAMA Internal Medicine found that, in the wake of stricter duty hours and more EMR, interns today spend 12 percent of their time in direct patient care, and 40 percent of the time in front of the computer. I don’t see that glorified on medical TV dramas. (Click, click, click on the computer, making out in the supply room, click, click, click on
the computer…) And with the ease of mobile technology, guess what? We can do more office work outside of the office too! Regarding Dr. Ostrich’s article on warning labels in our life, how can we not be fed up with the waste of time and energy put into meaningless warnings in our society? Junk mail, confidentiality assurances, agreement terms on app websites, coffee cups warning that contents are hot. I grew up a Gen-X’er with baby walkers, lawn darts, and lots of flammable toys. Somehow I survived. I walked into a hospital the other day, and the sign out front said that under California law, this facility may have toxic substances. Ok, what should I do with that information? Meaningful public health warnings are often at odds with corporate greed. Showing people with tracheostomies on cigarette boxes would have saved lives, but that got sacked through corporate machinations. A society where many peoples’ job is to micromanage others and create more rules/laws is one that will continue to make our lives more cumbersome. In yet another strike of HIPAA misguidedness, OB docs have been told to take down photos of babies they have delivered that traditionally have graced their waiting rooms. Breach of confidentiality. Are you kidding me? And then there is Prop 46 to make sure you are drug tested every time your patient has a bad outcome (blame the doc – don’t blame the cigarettes!) or that requires we magically create more than a 24-hour day to battle a defunct state database for practically each patient encounter. Not so simple, is it? I became a doctor to help people, not get jerked around. My patients need more than 12 percent of my increasingly distracted time. Let’s try to do something about this! hitzemn@sutterhealth.org
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Sierra Sacramento Valley Medicine
Executive Director’s Message
Top Five Reasons for Joining SSVMS and CMA By Aileen Wetzel, Executive Director WORKING TOGETHER, THE Sierra Sacramento Valley Medical Society (SSVMS) and the California Medical Association (CMA) are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining SSVMS and CMA, five stand out: Legislative Advocacy. Dual membership provides for unparalleled legislative advocacy at the local, state and federal level on behalf of our members. In 2014, CMA defeated several legislative attempts to expand the scope of practice of nonphysicians. We successfully lobbied Congress to eliminate the flawed Medicare Geographic Practice Cost Index (GPCI) which, for many years, resulted in Medicare underpayments to physicians practicing in El Dorado, Sacramento and Yolo counties. Significantly, SSVMS/CMA led the fight against Prop. 46, an effort by the trial attorneys to eviscerate California’s landmark tort reform law, the Medical Injury Compensation Reform Act (MICRA). FREE Reimbursement Assistance. Tired of fighting to get paid? The experts in CMA’s Center for Economic Services recovered over $7 million on behalf of members in the past three years alone. Services include reimbursement assistance, health plan advocacy, contracting resources and more! This service is free to CMA members (not available to nonmembers). For assistance, call CMA’s Reimbursement Helpline
at (888) 401-5911 or email economicservices@ cmanet.org. FREE Legal Assistance. Save time and money by getting your questions answered by a CMA legal expert before hiring a lawyer. CMA’s Center for Legal Affairs helps members comply with laws and regulations that impact the practice of medicine. This service is free to CMA members (not available to nonmembers). For assistance, call CMA’s member help center, (800) 786-4262 or email legalinfo@cmanet.org. State-of-the-Art Communication. Information is power. SSVMS and CMA produce several publications full of valuable information and updates, including SSV Medicine, SSV Medical Society News, and CMA Practice Resources. Visit www.ssvms.org. Access to Physician Advocates. If you come across a challenge and you are not sure what to do, simply call SSVMS, (916) 452-2671 or email info@ssvms.org. We are here to support your practice and professional needs. Your membership in SSVMS and CMA pays for itself. SSVMS members tell us their annual return on investment is almost seven times their annual dues. Join or renew you membership for 2015 by visiting www.ssvms.org/Membership/ RenewandPayDues.aspx. Membership dues for 2015 are due by January 1, 2015. awetzel@ssvms.org
November/December 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.
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BloodSource’s Role in Plasma-Derived Medicines A Chance Encounter Highlights the Importance of Plasma Donations
By Chris Gresens, MD, Senior Medical Director and VP of Global Medicine, BloodSource
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.
EARLIER THIS YEAR, WHILE I was waiting in Chicago’s O’Hare International Airport to board a delayed flight, a chance encounter occurred that affected me deeply. The airport eatery was crowded, my feet were tired, and all I wanted to do at that moment was to sit down and drink my coffee. So I asked a woman of about my age if I might share her otherwise-unoccupied table. She indicated yes, and I plopped down, gratefully. My brain felt somewhat numb and my eyes were bleary from several hours of in-flight journal review, coupled with an early-morning wakeup, so I decided to take a few moments to relax and people-watch as I sipped my coffee. Human connections sometimes can be difficult to make in our fast-paced culture, and on this afternoon almost everyone seemed too busy to lock eyes with mine – except for the woman seated on the other side of the table who, by this time, had smiled twice, kindly, when my gaze passed her direction. Guessing that she might be in a mood similar to mine, I took a chance by asking where she was traveling and for what purpose. The poignancy of her reply surprised … and ultimately inspired … me. “Carol” told me that she was headed to upstate New York to coordinate her older brother’s funeral arrangements following his recent death from complications associated with hemophilia A. Her brother had led a difficult life, so both of them had been prepared for this day and were grateful for the almost 60 years he had lived. As she acknowledged both the comfort she took in her faith and
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her appreciation for the work done by her brother’s many dedicated doctors and nurses, she mentioned, too, how her brother’s best days – as well as some of his worst − were entwined with the many “special products” he had received during the last five decades of his life. I quickly became engrossed by her story and was struck by its relevance to my travels, since I was en route to a San Antonio-based meeting to share how BloodSource supports the manufacture of plasma-derived medicines (PDMs) such as the “special products,” i.e., the clotting factors, her brother had received. As we spoke further, it occurred to me how the gift of her story was not only generous and heartfelt, but also serendipitous.
Another Type of Blood Donation Many of the health care colleagues in our community understand, intimately, the role BloodSource has played, since its founding by the Sierra Sacramento Valley Medical Society in 1948, in producing transfusable blood components – i.e., the red blood cells (RBCs), platelets, plasma, and cryoprecipitate that we distribute to patients throughout our local communities, as well as across the United States. Most people, however, are unaware of how, for decades, we’ve also supplied excess plasma (recovered as a byproduct primarily from whole blood donations) for the manufacture of PDMs, such as the factor VIII concentrates used by Carol’s brother. Nor do they realize that, at BloodSource,
we recently have expanded our efforts to support PDM production by developing a robust program for collecting source plasma, a blood product that is destined, from the very beginning of our engagement with each donor, to be converted into PDMs. Both source plasma (collected via apheresis) and recovered plasma are utilized to manufacture PDMs. This process – involving a series of physical and chemical steps that isolate and purify many of the essential proteins residing in our bodies and blood – is performed on a large scale using pools of hundreds to thousands of pre-pooled donor plasma units for each lot of the specific medicine that is manufactured.
A Step Forward Advancing technologies have led to substantial increases in the numbers of patients who can benefit from PDMs. The indications for this class of drugs include, but are not limited to: (1) hemophilias A and B (for which coagulation factors are used), (2) selected immunodeficiencies, autoimmune diseases, and neurological disorders (immune globulins), (3) certain thromboembolic complications, as well as a rare lung and liver disease (antithrombin III and alpha-1 antitrypsin, respectively), and (4) severe burns and disorders treated by therapeutic plasmapheresis (albumin).
BloodSource has been licensed to collect source plasma since 1989. Only recently, however, have worldwide challenges with the supply and demand of PDMs intersected with both our mission (“dedicated to providing
blood and services to those in need”) and our unique operational capabilities such that it now makes medical and business sense for us to begin collecting this product on a large-scale basis. The use of PDMs continues to grow at an 8–10 percent annualized rate. As a result of this expanding need, too many patients – especially in resource-challenged countries, but sometimes even in resource-rich countries such as our own – lack access to these medications. This is our main reason for refocusing a significant portion of our efforts in this direction. Fortunately, at BloodSource, we have sufficient resource capacity to add source plasma collections to our repertoire. A major reason for this is that our community’s, as well as our nation’s, need for whole blood and RBC collections has declined during recent years owing to the application of sound patient blood management strategies and tactics that BloodSource, for decades, has championed on behalf of our patients. Thus, we have reapportioned some of our resources, allowing us to go operational at our new Granite Bay Source Plasma Donor Center this past September. Soon thereafter, we also began collecting source plasma at our Midtown center; and we anticipate adding additional collection sites over the months and years ahead. If you or your family and/or friends are interested in learning more about blood donations, including source plasma donations, please visit www.bloodsource.org/sourceplasma or call (866) 985-0598. So much more can be said about the importance of PDMs and, therefore, I look forward to sharing additional background about these and other lifesaving opportunities that are being shepherded by BloodSource within future issues of Sierra Sacramento Valley Medicine. For now, though, I want to express my gratitude to Carol for what she conveyed to me at a time when she must have been at her lowest. It is through patients like her brother – as well as our many tens of thousands of blood (and now source plasma) donors who support patients like him – that our mission truly comes alive.
Advancing technologies have led to substantial increases in the numbers of patients who can benefit from PDMs.
Chris.Gresens@BloodSource.org November/December 2014
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Global Symposium BLOODSOURCE PROUDLY hosted the inaugural IPFA/BCA Global Symposium of the Future for Blood and Plasma Donations September 23-24, 2014 at the Sheraton Grand Sacramento. With nearly 200 attendees representing 22 countries, the symposium addressed the global patient need for essential lifesaving plasma-based therapies. Internationally-recognized experts presented topics of interest to colleagues from blood banking, patient groups, donor organizations and more. Founded by SSVMS in 1948, BloodSource has grown from a single blood bank beneath a water tower in Sacramento to one of the premier blood organizations in the world and was the driving force in bringing this inaugural conference to the Capital region.
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Sierra Sacramento Valley Medicine
The Sierra Sacramento Valley Museum of Medical History’s iron lung was the star attraction at the IPFA/BCA Inaugural Global Symposium. The iron lung was on the dais during the opening address. Steven Snyder of Rotary International provided a presentation on Rotary International’s efforts to eradicate polio across the globe.
SPIRIT Volunteer Donates 100th Surgery By Kris Wallach, CSERF Program Director SACRAMENTO PHYSICIANS’ Initiative to Reach out, Innovate and Teach (SPIRIT) Program volunteer physician, David Kissinger, MD, recently donated his 100th hernia repair surgery through SPIRIT to an uninsured Sacramento resident. Dr. Kissinger has been a SPIRIT volunteer since 1998, and donates hernia surgeries at Kaiser South Sacramento after hours, supported by an all-volunteer team. He is a General Surgeon who joined Kaiser Permanente in 1998 after completing a 21-year career in the U.S. Air Force Medical Corps. He graduated from George Washington University Medical School, did his residency at Wilford Hall Medical Center at Lackland Air Force Base, Lackland, Texas, and completed a fellowship at Washington Hospital Center in Washington, DC. He is certified by the American Board of Surgery. SPIRIT was established in 1995 to increase and enhance physician response to the medical needs of the targeted population through volunteerism. It is a program of the Community Service, Education and Research Fund (CSERF)
of the Sierra Sacramento Valley Medical Society. Created to offer physicians innovative ways to improve the health of Sacramento residents through education and access to services, SPIRIT is a collaboration between SSVMS, Dignity Health, Kaiser Permanente, Sutter Medical Center Sacramento and the UC Davis Health System, and receives additional in-kind support for surgeries from Kaiser South Sacramento, Mercy General Hospital, Sutter Ambulatory Surgery Centers, Central Anesthesia Service Exchange Medical Group, Diagnostic Pathology Medical Group, and Sacramento Anesthesia Medical Group. SPIRIT patients are completely uninsured and fall below 200 percent of the federal poverty level. The program is funded through private donations and grants. SPIRIT volunteers provide out-patient surgeries including, but not limited to, cataract and hernia repair. All surgeries are performed at local hospitals and surgery centers where all of the supporting services are also donated. SPIRIT staff provides case management and care coordination for surgical and specialty cases, allowing volunteers to donate services with the least disruption to their office and staff. To date, SPIRIT volunteer physicians have treated 40,519 patients, performed 614 hernia surgeries, 87 cataract surgeries, and 27 other out-patient surgeries. Some 32,938 hours have been donated for a total value in excess of $8.87 million. For more information about the SPIRIT Program, please call Kristine Wallach at (916) 453-0254. kwallach@ssvms.org
November/December 2014
Dr. David Kissinger, above, in 1984 as a surgery resident in Little Rissington, England. This was taken of the group of U.S. Air Force doctors training at a contingency hospital in the U.K. At lower left is Dr. Kissinger with the local team that volunteered for surgery at Kaiser.
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.
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Sierra Sacramento Valley Medicine
OR SCAN TO LEARN MORE!
President’s Message continued from page 3 our region so that SSVMS can raise awareness, educate and take action to resolve them. During the year, I actively represented our Medical Society at the Healthy Sacramento Coalition, the University of Best Practices/Right Care Initiative, and Drexel University Health Care Forum. Our membership continues to grow as more physicians understand the value of participation. We continue to work with Dr. Julie Freischlag, Vice Chancellor and Dean, to strengthen our partnership with the UC Davis Health System. We have connected with Dr. Robert Suskind, Dean of California Northstate Medical School, to encourage faculty and student participation in our medical society. Our partnerships with The Permanente
Medical Group, Mercy Medical Group and Sutter Medical Group have brought new members and new energy. Outreach to physicians in solo and small practice continues in our effort to ensure that all specialties and modes of practice are represented at the SSVMS table. I hope that, during my term, I have been able to make a positive impact on both the current and future direction of SSVMS. Thank you for providing me this wonderful opportunity to lead, and for your patience as I grew in my position. Special thanks to Aileen Wetzel and Chris Stincelli for your amazing support, and to each of our incredible Board of Directors. This is definitely the experience of a lifetime! arevalJ@sutterhealth.org
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November/December 2014
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An ICD-10 Christmas Tale `Twas the night before Christmas, when all through the house, Not a creature was stirring, not even a mouse. W53.01XA Bitten by mouse, initial encounter W53.01XD Bitten by mouse, subsequent encounter W53.09XA Other contact with mouse, initial encounter W53.09XD Other contact with mouse, subsequent encounter The stockings were hung by the chimney with care, In hopes that St. Nicholas soon would be there. X06.2XXA Exposure to ignition of other clothing and apparel, initial encounter X06.2XXD Exposure to ignition of other clothing and apparel, subsequent encounter X06.3XXA Exposure to melting of other clothing and apparel, initial encounter X06.3XXD Exposure to melting of other clothing and apparel, subsequent encounter The moon on the breast of the new-fallen snow Gave the lustre of mid-day to objects below. X37.2XXA Blizzard (snow)(ice), initial encounter X37.2XXD Blizzard (snow)(ice), subsequent encounter When, what to my wondering eyes should appear, But a miniature sleigh, and eight tiny reindeer. 201.01 Encounter for examination of eyes and vision with abnormal findings R44.1 Visual hallucinations With a little old driver, so lively and quick, I knew in a moment it must be St. Nick. R54 Age-related physical debility F22 Delusional disorders
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More rapid than eagles his coursers they came, And he whistled, and shouted, and called them by name: R49.8 Other voice and resonance disorders R49.9 Unspecified voice and resonance disorder “Now, Dasher! now, Dancer! now, Prancer and Vixen! On, Comet! on Cupid! on, Donner and Blitzen! W55.39XA Other contact with other hoof stock, initial encounter W55.39XD Other contact with other hoof stock, subsequent encounter To the top of the porch! to the top of the wall! Now dash away! dash away! dash away all!” V97.0 Occupant of aircraft injured in other specified air transport accidents
Sierra Sacramento Valley Medicine
W13.0XXA Fall from, out of or through balcony, initial encounter W13.0XXD Fall from, out of or through balcony, subsequent encounter W22.01XA Walked into wall, initial encounter W22.01XD Walked into wall, subsequent encounter As dry leaves that before the wild hurricane fly, When they meet with an obstacle, mount to the sky, X37.0XXA Hurricane, initial encounter X37.0XXD Hurricane, subsequent encounter So up to the house-top the coursers they flew, With the sleigh full of toys, and St. Nicholas too. Y93.29 Activity, other involving ice and snow V96.8XXA Other nonpowered-aircraft accidents injuring occupant, initial encounter V96.8XXD Other nonpowered-aircraft accidents injuring occupant, subsequent encounter And then, in a twinkling, I heard on the roof The prancing and pawing of each little hoof. W13.2XXA Fall from, out of or through roof, initial encounter W13.2XXD Fall from, out of or through roof, subsequent encounter W55.32XA Struck by other hoof stock, initial encounter W55.32XD Struck by other hoof stock, subsequent encounter As I drew in my head, and was turning around, Down the chimney St. Nicholas came with a bound. X02.0XXA Exposure to flames in controlled fire in building or structure, initial encounter X02.0XXD Exposure to flames in controlled fire in building or structure, subsequent encounter He was dressed all in fur, from his head to his foot, And his clothes were all tarnished with ashes and soot. Y93.E9 Activity, other interior property and clothing maintenance A bundle of toys he had hung on his back, And he looked like a peddler just opening his pack. Z59.0 Homelessness Z59.1 Inadequate housing His eyes — how they twinkled! His dimples how merry! His cheeks were like roses, his nose like a cherry! L71.8 Other rosacea L71.9 Rosacea, unspecified And the beard of his chin was as white as the snow; His droll little mouth was drawn up like a bow. L67.1 Variations in hair color L67.8 Other hair color and hair shaft abnormalities L67.9 Hair color and hair shaft abnormality, unspecified
November/December 2014
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The stump of a pipe he held tight in his teeth, And the smoke it encircled his head like a wreath. Z72.0 Tobacco use Z57.31 Occupational exposure to environmental tobacco smoke F17.290 Nicotine dependence, other tobacco product, uncomplicated F17.291 Nicotine dependence, other tobacco product, in remission F17.293 Nicotine dependence, other tobacco product, with withdrawal F17.298 Nicotine dependence, other tobacco product, with other nicotine-induced disorders He had a broad face and a little round belly, That shook, when he laughed like a bowlful of jelly. E66.3 Overweight Z72.3 Lack of physical exercise He was chubby and plump, a right jolly old elf, And I laughed when I saw him, in spite of myself. R29.890 Loss of height E66.09 Other obesity due to excess calories A wink of his eye and a twist of his head, Soon gave me to know I had nothing to dread. H02.043 Spastic entropion of right eye, unspecified eyelid H02.046 Spastic entropion of left eye, unspecified eyelid H02.049 Spastic entropion of unspecified eye, unspecified eyelid He spoke not a word, but went straight to his work, And filled all the stockings; then turned with a jerk, R49.1 Aphonia (Loss of Speech) Z56.5 Uncongenial work environment Z56.3 Stressful work schedule Z56.6 Other physical and mental strain related to work G47.26 Circadian rhythm sleep disorder, shift work type And laying his finger aside of his nose, And giving a nod, up the chimney he rose. He sprang to his sleigh, to his team gave a whistle, V00.221A Fall from sled, initial encounter V00.221D Fall from sled, subsequent encounter V00.228 Other sled accident
Adapted from essay by Gerry Wieder, RN, of Seattle, WA, selfdescribed as “an RN with an MBA and a funny bone.” http:// gerrywieder.com/an-icd10-christmas-tale/
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And away they all flew like the down of a thistle. But I heard him exclaim, ‘ere he drove out of sight, W94.23XA Exposure to sudden change in air pressure in aircraft during ascent, initial encounter W94.23XD Exposure to sudden change in air pressure in aircraft during ascent, subsequent encounter “Happy Christmas to all, and to all a good-night.”
Sierra Sacramento Valley Medicine
Hello from Uganda; How are you? A traveler’s impressions of diseases and medical conditions seldom seen here
By George Meyer, MD, FACP, MACG IF YOU HAVE EVER BEEN to Uganda, you may have learned that to greet a person, hello is not enough. You are expected to ask, “How are you?” Although landlocked, Uganda sits on the northern and western shores of Lake Victoria, Africa’s biggest lake and second in the world in size only to Lake Superior. Uganda is bordered on the south by Tanzania, on the west by Rwanda and the Democratic Republic of Congo, on the north by South Sudan and on the east by Kenya. The capital, Kampala, has an estimated population of three to four million people. The northern edge of Lake Victoria at Jinja is where the lake empties into what becomes the White Nile River, at the same place as a spring bubbles up to become the source of the White Nile. (Some argue that it really starts in Rwanda or Burundi.) Most credit John Speke with being the first Msungu (white person) to identify the source. The Nile courses northward and westward before emptying into Lake Albert from whence it continues north as the longest river in the world. It has been estimated that it would take a molecule of water three months to start at the source before reaching the Mediterranean Sea, if flow is uninterrupted. The Blue Nile is said to originate in Ethiopia. The two Niles merge in Khartoum, Sudan. The health care system in Uganda is overwhelmed. When the British left in 1962, they built and gave the Mulago Hospital in Kampala to the country. A 1,500-bed hospital, it
was built to care for approximately 7.5 million inhabitants. The current population estimate is about 45 million (a census was planned beginning in late August 2014) and, often now, the average daily patient load is twice the bed capacity. The extra patients are in the hallways and in alcoves not previously intended for patients. A census was planned beginning in late August 2014. There are three public medical schools, Makerere in Kampala with about 100 students each year for five years, Mbarara, and Gulu.
A medical poster in Uganda from Dr. George Meyer’s visit.
November/December 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.
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There may be five private medical schools with two more planned to begin classes in 2015. There is no licensing exam at the end of the five years. There is a one-year internship following medical school. When asked about how they weed out the strong doctors from the weak, I was told that it happens in the mandatory one-year internship. Most people go into some kind of practice for a few years before doing a residency, if at all. Internal medicine subspecialty training is acquired as apprenticeships or outside the country, as best I can tell. Their national hospital system reminds me of the way the system is set up in Bhutan with four regional hospitals, centered on Mulago Hospital which also serves as a level one center for the Kampala area and as a tertiary referral center for the rest of Uganda. There is a central psychiatric hospital in Kampala, designated to be the national psychiatry hospital. Mulago’s inpatient system is overwhelmed with anywhere from 150-300 percent occupancy. Patients must pay for many labs, most procedures, and many medications, even at the governmentrun hospitals. The other centers are in Mbarara
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(south), Gulu (north) and Jinja (east). Probably the most common admission to GI at Mulago is abdominal swelling, mostly with ascites. The differential diagnosis includes cirrhosis, TB peritonitis, and schistosomiasis. Snails carrying S. mansoni are present in their lakes and swamps; anyone with portal hypertension and normal liver tests is suspected of having schistosomiasis. The most common causes for cirrhosis include hepatitis B and alcohol; hepatitis C occurs, but is less common. There is a fair amount of hepatocellular carcinoma, sometimes in young persons with no known liver risk factors. Because there is a nut with which they make gravy for a large part of their meals, there is the suspicion that in the drying process, the cracked nuts pick up a fungus which then yields aflatoxin, a known hepatotoxin. GI bleeding is common, mostly in those with known portal hypertension. Upper endoscopy has not been available for the past two years due to equipment issues. An EGD in a private clinic is $300 cash! UCSF has a large footprint in infectious diseases in Kampala with work specifically ongoing with HIV, TB, and malaria. In Jinja, there is an interesting skin disease they call “jiggers,” which is medically called tungiasis. Jiggers is caused by the chigoe flea. It is thought that Columbus’ men, when stranded in Haiti, may have first been affected. Since then, it has spread throughout Latin America and Africa, probably via the shipping routes. Although seen in the tropical areas of Latin America and India, it seems to be worse in some places in Africa, especially in Jinja. The female flea does not jump well, so it mostly enters the feet of persons going barefoot or wearing open-toed shoes. They burrow into the skin, feed, and lay tens to hundreds of eggs. This causes inflammation, abscesses and severe pain, and victims are unable to walk well. Incision and drainage seems to be the treatment of choice, but HIV seems to have been spread when unsterilized equipment is used, transferring the virus from an infected to a non-infected person. Tetanus may occur in the unimmunized, and
gangrene and secondary infections also occur. Tungiasis also seems to occur with significant morbidity in certain areas of Brazil, Angola, Trinidad and Tobago. Infections seem to peak in the dry season. Women, even those who are not smokers, are prone to a COPD/ asthma syndrome. The suspicion is that, since they cook indoors with charcoal, they are exposed to the kind of fumes that can lead to COPD/ asthma. It is not common, but does occur with some frequency. One other interesting disease found in Ugandans, many of whom seem to have Rwandan roots, is endomyocardial fibrosis (EMF). This disorder, currently thought to be idiopathic, may primarily affect young children, but there is a group of young people (teens to mid-20s) in the equatorial countries of Africa who seem to have a restrictive cardiomyopathy due to this. Associated with eosinophilia, some think it may be due to a diet high in cassava and low in protein, while others have suggested it may be due to viral infections. The endocardium is thick and pearly and does not dilate. About 20 percent of Ugandans with congestive heart failure may have EMF, with a high number of people from Rwanda who have moved to Uganda. There is no known treatment. Transplantation is a possibility, when available. Bottom line: We found Uganda to be safe. There is a lot for tourists to enjoy, but roads are poor in many areas. We always felt personally safe, an important issue in a country that uses mostly cash as only higher level hotels and restaurants take credit cards.
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November/December 2014
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Sacramento County’s Fraying Medical Safety Net Part One – The history of the county hospital and county clinics
By Celeste Reinking, MD MANY OF US PROVIDING primary care in Sacramento hear it over and over: the safety net for low-income patients in Sacramento is weak. After closure of the county clinics during the recession of 2008-2009, we haven’t yet managed to get community clinics to fill in the gap. As a result, uninsured patients, the undocumented, and even those with MediCal insurance, experience significant barriers to obtaining care. When I arrived in Sacramento for residency three years ago, I was curious – why is Sacramento in such bad straits? Is there some way to measure how we stack up against other cities and counties in the region or the rest of California? Most importantly, how do we change the status quo? I’ll share what I found in this article and the next.
The “Poor Farm”
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.
First, some historical background is essential to understanding how we ended up where we are today. Sacramento County established its first hospital to provide care to indigent patients in the 1850s. In the 1860s, the county hospital moved to a site on Stockton Blvd., considered rural in those days, where the hospital was initially associated with a “poor farm” at which the able-bodied were expected to work for their keep. The poor farm faded away, but the county hospital remained in place for a century. Then in 1968, the county agreed to hand over management of the hospital to UC Davis so that the university could establish its medical
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school and run the hospital as a teaching institution. Two years later, the county sold the building to UC Davis for the cost of $1. UC Davis then provided care to indigent county patients until 2008 under a contract with the county. For many years, patients still thought of the hospital as “the county” hospital, but this reputation faded over the years, particularly as UC Davis started to restrict, and eventually largely eliminate, outpatient services for indigent patients in its clinics. Meanwhile, the county, over the years, also established outpatient clinics. These received a big boost when Medicare and Medi-Cal were established in 1965. During its first years, MediCal covered indigent single adults, which meant that, suddenly, the same patients that the county had been providing services to on its own dime were insured, and the counties started receiving reimbursement for those services. Partly due to this influx of funds, Sacramento County expanded its outpatient clinic system to a total of six primary care sites, in addition to many other public health services, as well as a county mental health hospital that was quite large, compared to other counties in California.1 Medi-Cal dropped single adults from its rolls in the 1980s during a budget crisis, causing county medical systems to lose a fair amount of income. The state then designated “realignment funds” for counties to make up some of the lost income. Counties endured further cuts to state funding in another budget crisis in 1993, and many county clinics and hospitals
all over California had to close their doors in the ensuing years. Many other county hospitals were sold to private companies. In Sacramento, the county initially managed to keep all its clinics open, though after the cutbacks in 1993, the county dramatically cut clinic hours and saw fewer patients. Nevertheless, for many years the county did provide outpatient services that were important to many thousands of people.
Closure of Clinics The 2008 financial crisis was the death knell for county services for many indigent patients in Sacramento. Loss of a big chunk of state funding to the county was followed, one by one, by the closure of five out of six primary care clinics, the end of screening and treatment for sexually-transmitted infections, the end of the county immunization program, and the exclusion of undocumented immigrants from county health services. Many people lost access to basic outpatient care as a result of the county clinic closures. There is little published information on this, as counties are not required to report how they use state money for health services, such as how many patients they see, or details about the services they provide. However, employees at the county clinic ran a query for me in their computer and were able to estimate that the county saw approximately 89,000 patient visits to their primary care clinics in fiscal year (FY) 20062007, and only 32,000 visits in FY 2012-2013.The drop in number of patients seen for primary care services dropped similarly, from about 39,000 to about a third of this number, less than 13,000. These numbers match recent estimates from the Health Access Foundation’s Report on county medical services throughout California.2 The closure of the county clinics during the 2008 financial crisis also coincided with another big change
in services for the indigent — the end of the contract between Sacramento County and UC Davis for hospital care. In 2008, the county decided to contract with a third-party payor, Benefits and Risk Management Services, which would be in charge of paying UC Davis for hospital services for county patients. Why the decades-long arrangement between the county and UC Davis was ended is a subject shrouded in mystery, and appears to be a rather sensitive one to inquire about. In any case, in 2009, UC Davis sued the county, claiming $100 million in unpaid bills for indigent patients, and in 2010, the judge in the case agreed that the county owed UC Davis money, but declined to say how much. Four years later, the issue is still being litigated. How much has the end of the contract with UC Davis impacted patients? Federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA), has shielded many patients from feeling the effects of the end of the county’s contract with UC Davis for inpatient services. Emergency departments and physicians are required to treat all patients, without consideration of the patient’s ability to pay. EMTALA applies to all acute-care hospitals,
November/December 2014
This photo from the Thompson and West History of Sacramento County, published in 1880, is a penand-ink drawing of the County Hospital from the old days.
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In 2003, the UC Davis Medical Center and the Sacramento County Cemetery Advisory Committee worked together to install a bronze plaque near the water tower at 45th and V Streets dedicated to the people buried in the former indigent cemetery.
so responsibility for caring for indigent patients has now been spread among several health systems. Indigent patients are more likely to have felt the effects of the loss of outpatient services from Sacramento County. Some 26,000 patients who received services at the county in 2006 were no longer getting these services five years after the crisis. Have community clinics been able to step in and take up the slack? The short answer is no, but I’ll discuss this topic in more detail in my next article, which looks at some data comparing Sacramento County’s safety net to that of other counties in California.
What Comes Next? What comes next for the county’s clinic in the era of the ACA? After all, the county’s Primary Care Center building on Stockton Blvd. and Broadway still stands. However, pretty much all the patients who were previously eligible for county care under the County Medically Indigent Services Program (CMISP) have largely all been enrolled in Medi-Cal, and CMISP has essentially been eliminated. The county has decided it will continue to operate the clinic on Stockton Blvd. and Broadway, now serving
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as a provider of Medi-Cal services for some patients under a contract with Molina, and possibly other insurers in the future. Whether operating a county clinic as a provider of Medi-Cal services for a private insurance company is a good role for the county to fill depends on your opinion of what the county ought to be focusing on. We truly need Medi-Cal providers in Sacramento County. However, I would argue that we also truly need increased access to screening and treatment for sexuallytransmitted infections. Sacramento County lands among the top four counties in California for incidence of gonorrhea, chlamydia and syphilis, the only county besides San Francisco to do so. An immunization program that actually made it easy and free for people to get immunized might have helped Sacramento avert our very high rate of influenza hospitalizations and deaths this past year. These were all county services that were lost during the economic crisis in 2008, and I think that the county is uniquely positioned to provide these and other kinds of public health services and that they should be restored. Whatever you believe the county should be doing, it’s likely some decisions will need to be made soon, as the economy improves and county finances begin to look up. Physicians are encouraged to let members of the Sacramento County Board of Supervisors know what you think they should be focusing on. ccreinking@gmail.com References 1 Caring for Medically Indigent Adults in California: A History, by Deborah Reidy Kelch, for California Health Care Foundation, June 2005. http://beta.chcf.org/~/media/MEDIA%20LIBRARY%20 Files/PDF/C/PDF%20CaringForMedicallyIndigentAdults.pdf 2 California’s Uneven Safety Net: A Survey of County Health Care. Health Access Foundation Report, Nov 2013. www.healthaccess.org/files/expanding/California’s%20Uneven%20Safety%20 Net%20%20A%20Survey%20of%20County%20Health%20 Care.pdf
Scholarship Awards By Kris Wallach, CSERF Program Director ON WEDNESDAY, SEPTEMBER 3, 2014, the SSVMS Scholarship and Awards Committee met to decide this year’s recipients of the William E. Dochterman Medical Student Scholarship. The task was daunting because the committee received 14 highly competitive applications for scholarships. In previous years, the committee received only a handful of applications per year. Each applicant was very impressive, had a strong application and was truly deserving. The Scholarship Fund was established in 1966 with surplus funds from services donated by local physicians participating in the Sabin Oral Polio Vaccine Clinics, and is sponsored by the Sierra Sacramento Valley Medical Society. The fund is maintained as an endowment fund whereby the corpus or principal balance remains intact. The amount available for annual scholarship awards is determined by the interest and dividend income earned in the fund during the year. In September of each year, the Scholarship and Awards Committee reviews applications from medical students who have graduated from a high school in El Dorado, Sacramento or Yolo Counties and who are enrolled in an accredited American medical school on a full-time basis. The applications are evaluated primarily on the basis of financial need and academic achievement. Also considered are activities by the applicant outside of school, particularly community service work. The committee, led by Margaret Parsons, MD, Chair, selected the following seven applicants to receive 2014 scholarships: Tony Cun − 4th year at David Geffen School of Medicine/UCLA Medical Education Program. Victoria Hrabak − 1st year at University of California, San Francisco. Kim Le − 2nd year at University of California, Davis School of Medicine.
Kristiana Jasmine Lehn − 1st year at University of California, Davis School of Medicine. Olivia Nguyen − 3rd year at University of California, Davis School of Medicine. Akhilesh S. Pathipati − 2nd year at Stanford School of Medicine. Nazeela Sabir − 1st year at University of California, Davis School of Medicine. Please consider helping us grow the William E. Dochterman Medical Student Scholarship. Your tax deductible donation will help award worthy students and will help to build the future of medicine. For more information about how to give, please contact Kris Wallach at kwallach@ssvms.org or (916) 453-0254.
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November/December 2014
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Heed the Warning By Jack Ostrich,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.
A FEW MONTHS AGO, my wife and I had a bit of remodeling done at our home, and among the improvements was enlargement of the master bathroom and placement of a casement window in the shower stall. The window opens to a secluded side yard, and it has an interior screen. I had never looked closely at the screen until, a few weeks after the project was done, my wife became upset (grossed out, actually) by an accumulation of insect carcasses on the sill between the new window and the screen. It fell to me to get rid of the insectoid detritus. It was then, as I loosened the four plastic hooks that held the screen in place, that I noticed a black-on-white decal affixed to the left side of the screen frame. WARNING, it proclaimed and after WARNING, there was a bold black exclamation point in a white triangle. Then there were two lines of print so small that I needed a magnifying glass to read them, even with my glasses on. And next to the lines of print was a tiny cartoon of a teeny weeny child, tilted to its left, with its arms over its head as if in distress. The WARNING read: “Screen will not stop child from falling out window. Keep child away from open window.” So I showed the WARNING to my wife and we resolved never to allow any small child to sit on the shower stall window ledge. I have noticed our cat sitting there on occasion, and she is attracted to the window as it is a good place to observe the local squirrels scurrying along the top of a wooden fence a few feet away. But, we reckon that, if the cat falls out of the window, the likelihood of feline trauma is very low as it is only about four feet to the ground. I have been collecting similar admonishments for a couple of years. I am sure
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that, had I not noticed or heeded them, then either myself or a friend or a loved one would have suffered a grievous injury. Most, like the WARNING on my window screen, are printed on the potentially-harmful product, but some are on the packaging that contains the threat. Others, like “speed bumps” on our streets or “yellow bumpy sidewalks,” grab our attention by their mere presence. The hammer in my toolbox has a decal on its shaft that urges me to “Wear safety goggles, user and bystander.” So now, when I use my hammer, I usually make a cursory search for my safety goggles − I know they’re around here somewhere!! − and then warn bystanders to stand at least 10 meters away and avert their eyes before I start pounding. A small cloth tag on my car’s sun shade counsels me never to “operate the vehicle with this product in place.” Just to be sure that such a warning was always attached to automobile sunshades, not just on mine, I went to an auto supply store where they had four types of sunshades for sale. They all had a similar cautionary label appended. In the California Driver Handbook, there is good advice regarding blocking one’s view out the front windshield. It says, “Do not block your view by putting signs or other objects on the front windshield.” No advice, however, regarding the rear windshield. My wife and I have always taken the DMV advice to heart and have rarely driven very far with the sun shade in place, even on a hot sunny day. If you are the sort of person who regularly drives your car with sun shades in place, then you probably get very upset when you go to Rite Aid to buy surgical masks to protect you and your family from becoming ill during flu season, and you find a WARNING on
the package that says: “This product will not provide supplementary oxygen.” She: “Did you pick up the face masks, honey? Flu season starts tomorrow, you know.” He: “No, I didn’t. The ones at Rite Aid don’t give extra oxygen, so I’ll run over to CVS to see if they have the good ones, even if they are more expensive.” She: “Don’t forget to remove the sun shade in the car before you drive over there.” He: “Oh, thanks for reminding me, sweetie.” As he exits the CVS store, still frustrated by having found no oxygenating surgical masks, he trips on a patch of yellow bumpy sidewalk, falls on outstretched hands, and suffers a right side Colles’ fracture. Later, as he waits in the ED for the ortho tech to apply his cast, he wonders to himself where all those yellow bumpy sidewalk inserts came from all of a sudden? Well, they were invented in Japan in 1965, are officially called “Tactile Paving” or “Detectable Warning Surfaces,” and, as most of you have noticed, they have become ubiquitous in the past 50 years. The Americans with Disabilities Act (ADA) of 1990 has made them mandatory in many public settings. A subsection of the ADA, the ADA Accessibility Guidelines (ADAAG), specifies where they are to be installed, their dimensions, and the size and shape of the little bumps. Thus, “...domes should have a diameter of 0.9 inch at the bottom, 0.4 inch at the top, a height of 0.2 inch, and a center-to-center spacing of 2.0 to 2.35 inches.” Some countries, such as Australia, think truncated domes are better than rounded
ones, and both types are used in the USA. In this country, the Tactile Pavement area must be colored in sharp contrast to the surrounding pavement, and bright yellow is most often used. In December of 2000, Bryan Bashin, then the Executive Director of the Sacramento Society for the Blind, testified before the “City of Sacramento ADA Transition Team” regarding plans to place Tactile Pavement patches at virtually every intersection in the city. He said, “The reality is lack of tactile warning in curb cuts is a trifling issue for the blind...(and) it is not the way blind people are taught to navigate and may, in some cases, actually increase the risk of crossing intersections.” He said that there were about 76,000 eligible curb cuts in the city, and that putting yellow bumpy patches at all the curbs would cost about $20 million. He concluded, “That’s an enormous sum, and the expense (would be) on the order of $10,000 for every blind Sacramentan, (and) if you asked a group of blind Sacramentans how to (better spend) a $10,000 per-capita city expenditure, I doubt that even one in a hundred would vote for bumpy plastic curb-ramp tiles...” And, you know what? I bet that even fewer of them think that surgical masks are meant to deliver supplemental oxygen.
Wacky labels ... Don’t say we didn’t warn you.
jmost119@aol.com
November/December 2014
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Pertussis has Become Epidemic in California 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.
RECENTLY A STAFF MEMBER mentioned that a young relative, who was fully immunized, had still come down with whooping cough and the entire family was now getting preventive treatment with antibiotics. Pertussis, also known as whooping cough, has become an epidemic in California this year. As of September 15, 2014, the California Department of Public Health (CDPH) reported 8,278 cases in California. Since January 1st of this year. Sacramento had reported 346 cases, El Dorado County 23, and Yolo County had 124 cases by the same date. Quoting directly from the CDPH report: • “Pertussis activity is widespread throughout California. • 288 cases have been hospitalized; 68 (24 percent) of these required intensive care. • 181 (63 percent) of hospitalized patients were infants under 4 months of age. • One death has been reported with disease onset in 2014 in an infant who was 5 weeks old at time of disease onset. • Two additional deaths occurred in 2014, but with disease onset in 2013 having been reported, these cases will be attributed to 2013. Both infants were under 2 months of age at disease onset. • Of the 165 (46 percent) cases under 4 months of age whose mother’s vaccination history was available, 135 (82 percent) did not receive Tdap during the third trimester of pregnancy between 27-36 weeks gestation. • The majority of cases with known age have occurred in infants and children under 18 years of age (6,312; 89 percent) and the peak ages are 1 year and 15 years. • 516 (8 percent) of pediatric cases were infants
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under 6 months of age. • 4,130 (65 percent) of pediatric cases were children/adolescents 7-16 years of age. • Among 5,277 (84 percent) of pediatric cases with vaccination history information, 10 percent had never received any doses of pertussis-containing vaccine. • Elementary, middle and high school outbreaks have been reported from counties all over California. • Overall pertussis rates are highest for infants under 1 year of age and older children and adolescents and teens 10-17 years of age. Rates by race/ethnicity are highest for Hispanic infants under 1 year of age and white, non-Hispanic adolescents and teens aged 7-17 years of age.” This illness, caused by the bacterium Bordetella pertussis, is transmitted through droplets when an infected individual coughs or sneezes and those in close contact inhale the bacteria. Infants, who cannot be immunized, are at highest risk from the complications of pertussis, which include pneumonia, seizures and death. Symptoms of pertussis begin with a runny nose, low-grade fever, and cold-like symptoms that progress to coughing spells that are prolonged and can end in vomiting. In younger children, these coughing spells end in the classic “whoop” that gives the disease its common name. Infants, who are at the highest risk for death, may not exhibit the coughing spells, but instead, may turn blue and have apnea. The cough can last for weeks after the person is no longer infectious. Antibiotics are recommended as early as possible in the
course of the disease. Once the coughing spells are established, they can last for weeks, and antibiotics are unlikely to shorten the course. Post-exposure prophylactic antibiotic treatment is recommended in specific cases where the person involved is at risk of severe complications from the disease or likely to spread it to at-risk individuals, such as babies. Although it is a vaccine-preventable disease, in the past decade there have been increasing numbers of pertussis cases reported throughout the United States. In the 1990s, the United States began using an acellular pertussis vaccine for primary immunization against pertussis. Prior to that, the only preparation available was a whole-cell vaccine, which, although effective, had several adverse reactions, including redness and swelling at the injection site, fever and agitation. The severity of the adverse reactions increase with the number of injections given and age, therefore it was not recommended to be given beyond infancy. Acellular pertussis vaccines contain purified components of the bacterium and appear to have fewer adverse effects. They can also be used in adolescents and adults. By the late 1980s, we began to be aware that the pertussis vaccine does not convey lifelong immunity, that older children and adults can have pertussis without having the typical “whoop� that is seen in younger children, and that adults could give the disease to younger children and infants. With the availability of the acellular vaccine, and on the heels of a pertussis epidemic, in 2010 the law was amended, so that all children entering 7th grade are required to have a tetanus, diphtheria and pertussis booster. The acellular pertussis vaccine was licensed for use in 2005; therefore, it is not known how long immunity from it lasts. According to the CDC, it is 80-90 percent effective in providing immunity in the first year following the last dose in the 5-dose initial series, and 5 years following the last dose. Seventy percent of those who received it are still fully protected, while 30 percent are partially protected. The experts at the CDC speculate that the increasing numbers of pertussis cases can be
due to more awareness of the disease, better reporting and more bacteria circulating while the vaccine most commonly used does not provide immunity for as long as the previously used vaccine did. Current recommendations for vaccination past infancy include pregnant women in the third trimester of pregnancy, health care workers, children entering 7th grade in California, childcare providers and anyone who is likely to come into contact with a newborn, including grandparents and older siblings. Laboratory tests for pertussis include culture, which is the gold standard, and polymerase chain reaction assays (PCR). Physicians who suspect pertussis can obtain a nasopharyngeal swab or aspiration using polyester swabs. Cotton or calcium alginate swabs interfere with the polymerase chain reaction and should not be used. Only test symptomatic persons in the first 3 weeks of cough who have not been on antibiotics, as this is when bacterial DNA is still present. Cultures of Bordetella pertussis can be positive within 3-4 days, but can’t be called negative until 10 days have passed. False negative results occur because of poor specimen collection or handling, or because the person has been previously immunized or is on antibiotics; or the specimen was collected too late in the course of the disease. False positive tests can occur if testing asymptomatic individuals or if the area is contaminated with bacterial DNA from the vaccine. More detailed information on testing and specimen collection can be found at www. cdph.ca.gov/programs/immunize/Documents/ PertussisLaboratoryTesting.pdf.
Although it is a vaccinepreventable disease, in the past decade there have been increasing numbers of pertussis cases reported throughout the United States.
trochetg@gmail.com References www.cdph.ca.gov/HealthInfo/discond/Pages/Pertussis.aspx www.cdc.gov/pertussis/about/faqs.html#booster www.cdph.ca.gov/programs/immunize/Documents/Pertussis_ report_8-18-2014.pdf
November/December 2014
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*
*Aleph-null, the smallest infinite cardinal number By John Loofbourow, MD
Extruded from a loving womb, one is separate yet alive, sweating at the fount of mothermilk in an endless struggle To survive; One roams a hostile peopled world to find whatever proof one can of storied human kindliness and love for other than the Self; Where food, shelter, and justice, Like goods or private property Are bought and sold through lies and bartered Liberty.
Among shards of broken nations, One is damned by jealous gods, for greed and sanguine sinning in nature’s cruel race, or Winning. Whether in old age or youth One learns that every being, Every object, every truth, is an expression of the Self. Alive or dead, every thing, waits or wanders here on earth in fear–or hope–that time will bring eternal death; or life; or Birth. john@loofbourow.com
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Hobby: USATF Official By Ann Gerhardt, MD I’M A MASTER-LEVEL USA Track and Field (USATF) official. I came to this hobby by accident, and might have left when I stopped competing, but I really enjoy helping youth, college, elite and masters athletes to enjoy fair, organized competition. Officials enjoy camaraderie with each other and the athletes. We derive self-satisfaction from knowing that organized, fair competition wouldn’t happen without us. As an official, I’ve helped with three Olympic trials meets (two in Sacramento and one in Eugene, OR), mingled with elite athletes and eaten some really gooey treats in the officials’ tents. What other hobby gives you all that? Recently our ranks have dwindled, due to age, illness and relocation. This article is meant as much as a shout-out to would-be new officials as it is a story about my experience. You can become an official just by going to a one-day officials’ clinic in December or January, buying an official shirt and some rule books, and showing up for a track meet in the spring. We are very welcoming and don’t bite. People assume I officiate because I was some kind of track star in school and now want a way of reliving the glory days. No way. I was a second-string basketball player in school and didn’t start running until I was 29. In 1995, I shifted to race walking and, by 1996, was injured. In order to remain part of the sport, I became a race walk judge through USATF. Race walking requires officials, called judges, to ensure compliance with the two rules which distinguish it from running. Walkers must: 1) maintain contact of some part of either foot with the ground at all times, and 2) straighten the leading leg’s knee upon foot contact with the ground and keep the leg straight until it passes underneath the hip. We need these rules because fast walking can quickly become slow running.
Really fast walkers can walk sub-seven minute miles for 10, 20 or even 50 kilometers, faster than most runners can run. Something has to distinguish this type of walking from running. Our USATF association was short of judges back then, so I filled a need. I was injured about six months out of every year, even though it’s not a contact sport and most people don’t fare so poorly. I wanted to race fast, which I did, but that strained my crooked back and tight hamstrings, so something was always in spasm. I’d train and do really well in a race, then sit out the races and judge until I recovered. Maybe I should have taken up psychology as a hobby instead. After the requisite number of years judging, national-level races judged and tests passed, I became a Master level judge. Younger people who get that far can try for IAAF certification and judge the Olympics, but I’ve had too many birthdays. I’m content judging our local races and an occasional National Championship or big Masters meet. Race walk judges are also encouraged to officiate more traditional track and field events, like discus and 4X100 meter relay races. Back in the 1990s, I tried officiating track events prior to the universal use of computers and fully automated timing. That ended with the splitting headache resulting from being the head finish line official at a long meet – Just imagine being responsible for timing and determining order of finish for eight lanes of runners all finishing within two seconds of each other, race after race after race. After that, I experimented with field events. Discus, hammer, shot put and javelin are pretty cool, but turned out to be too inexact for my Internist OCD proclivities. I settled on the long and triple jumps, known together as the horizontal jumps, which are really fun events. November/December 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. 27
The concept is pretty simple: run down a runway, jump from behind a foul line and land on your butt in a sand pit. It’s so cute to see little kids’ legs churning down the runway and into the air. Teens can jump amazing distances without any fear. And aging Boomers, who never competed in their lives, take up sports like the long jump and gain fitness and pride. Officiating jumps entails a variety of tasks, ranging from assessing fair or foul at the takeoff board (you get to whip a white or red flag in the air with an optional audible snap) to getting some exercise raking the sand pit to perfect smoothness. Sounds simple, but given that humans are doing the jumping, the rules become nuanced as athletes do the unexpected. Leads to some interesting discussions, which is why one of the other officials’ jobs is to be referee. We deal with athletes ranging in age from six to 92 years. Youngsters need to understand the rules even if the parents who are also officiating don’t think rules apply to their own
Race walkers must keep one part of either foot on the ground at all times. In the photo at right, a USATF official judges a very good race walk technique.
Department of Family and Community Medicine presents the George F. Snively Visiting Professorship Denise Rodgers, M.D. Vice Chancellor of Interprofessional Programs Rutgers Biomedical and Health Sciences University Please join us for an informative evening with Denise Rodgers, M.D. In her role as Vice Chancellor of Interprofessional Programs for Rutgers Biomedical and Health Sciences University, Dr. Rodgers is developing an educational model to advance effective collaboration among health professionals. Dr. Rodgers has devoted much of her career to advancing primary care and addressing health disparities among minority and underserved populations and communities, and has been nationally recognized for her dedicated scholarship, leadership and service. Tuesday, November 4, 2014 5:00 Reception, 5:30 Presentation The event is free and open to the public UC Davis Comprehensive Cancer Center Auditorium 4501 X Street, Sacramento, CA 95817
children. At college meets, the challenge is to keep the coaches from pushing the rules’ limits and the athletes within bounds. For the oldsters, the goal is getting them to understand that the rules still really apply to them. We also keep events safe for all. At the Masters Outdoor championship a few years ago, a 92-year-old man took forever to finish the 10,000 meter “run,” then hobbled over to do his long jump. We had finished with his age group (over 80) by then and had moved on to the women. His special handler sat him in a chair under a sun umbrella until he recovered. We then ran a strip of tape across the runway, about one foot from the pit edge, to serve as his foul line (the usual distance is about two meters). He “ran” about three feet, jumped from the tape and landed standing up in the pit. Having successfully won the over-90 age group gold medal in the event, he passed on his next two jumps, rather than risk an injury, and walked away. Pretty cute. Needing some variety last spring, I officiated the high jump and pole vault, or at least started to learn. Those sports entail even more precision than the horizontal jumps and the race walk... and they may be my new homes. Explore USATF officiating at USATF.org or email me. Check out the upcoming clinic schedule at our Pacific Association website, PAUSATF.org.
Kindly RSVP to: snively@ucdmc.ucdavis.edu
algerhardt@sbcglobal.net 28
Sierra Sacramento Valley Medicine
A Really Nice Lady and Her Gift By Ann Gerhardt, MD HARRIET MARTIN, AN 80-year-old long-time patient of mine, made a dollhouse replica of my two-room office as a gift. This picture does only partial justice to her attention to detail. In order to give an idea of scale, the miniature office sits next to a standard stethoscope. She did much of the work, but had ample assistance from her daughter, Carol, who dutifully made an office contents inventory and took pictures of wall coverings. I believe that she had the book and sink cabinets made from scratch. The other furniture, including exam table with functioning parts, are standard dollhouse miniatures. I really do have a credenza, copy machine, Oriental rug and rock that says “Nurture.” On the walls are miniaturized pictures of what was actually on my walls, including medical certificates, awards and sports medals. A picture of the handmade quilt of the food-guide pyramid is just a blur on the left wall of the outer office. She found tiny bottles of medicine, a box of Band-Aids and a Stedman’s Medical Dictionary for the exam room cabinet. There is a microscope to the left of the sink and a sphygmomanometer and surgical instruments to the right. On the stool is a
stethoscope, on the exam table are a reflex hammer, otoscope and ophthalmoscope, and in the exam table drawer is a very cute hot water bottle (an extra, since it don’t really have one in the office). Her only major deviation from reality was to print “Think Thin” on the scale. Unfortunately, her efforts to be thin came to fruition only with the onset of diffuse lymphoma. She refused treatment and died at the age of 83. Enjoyment of her handiwork lives on. algerhardt@sbcglobal.net
November/December 2014
Minute attention to detail went into building this replica of Dr. Gerhardt’s office.
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Member Stories: Oddest Requests From Patients Background: SSMVS members love their patients, even when they come in with unusual requests. Managing these requests reminds us of the art of medicine, and keeps us on our toes! Replies from our members follow below. Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors.
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.
Just before one of my breast cancer patient’s general anesthetic was induced, she asked me to sing, “Jesus Loves Me.” As everyone in the OR knew that I’m Jewish, an awkward giggle erupted. Fortunately, I knew the beginning of the song, and was able to comply with my patient’s request long enough for her to reach a blissful and temporary coma. Thankfully, all went well. −Scarlet La Rue, MD The patient was a teacher who had an argument with her principal. She booked a flight for a six-week vacation to Hawaii and called me the night before, demanding I write her a doctor’s note for six weeks of time off of work, due to stress, so she would not be fired whilst on vacation in Hawaii. She did not have six weeks of vacation accumulated, but if I wrote the note excusing her, it would cover her and they could not fire her. −Aysha Mahmood, MD The patient asked me for FMLA (Family Medical and Leave Act) for being the carrier of a genetic mutation that was not affecting her in any way. −Jennifer Tillman, MD I recently had a patient’s husband ask me for a letter stating that the patient has upcoming (elective) surgery in 10 days, because she had been arrested and they were hoping it would help get her out of jail sooner. −Holly Haight, MD A patient asked me to check her for all
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sexually transmitted diseases. She was a porn star and the condom broke. −Gerald Rogan, MD When I was working in the ER as a medical student, a lady came in who had been stung by a bee. After examining her and determining her to be okay, she then took out of her purse the dead bee that she had put in a jar. She asked me if the bee was diseased or not. I took the bee out of the container and examined it and told her, “for a dead bee, it is one of the healthiest bees I have seen in a long time.” She was assured by that and went home relieved. −Robert Bellinoff, MD A request came for a “Pabst” test instead of a “Pap” test. −Julita Fong, MD There’s a name for it, but I don’t remember… I had a guy come in who was convinced he had strings under his skin. He wanted me to incise his skin and get them out. He would find pieces of lint, etc., and show them to me, and insist they came out of his body. Weird! −Richard Gray, Jr., MD I was asked by the family of a deceased patient to obtain a skin biopsy for genetic testing to determine issues related to the estate, some infighting I suspect. I complied, went to the funeral home, got the biopsy, and sent it to the place requested by the family. I had difficulty finding a code to bill for the service but did eventually. I never did hear the outcome. −Thomas Atkins, MD When I practiced in Los Angeles, I had as patients a married couple, she a mother and housewife, he a head waiter at one of L.A.’s finest restaurants. She, demure and diffident. He, self-confident and autocratic. If she came in with a complaint, he was always with her, and he did most of the talking. One day, he came
in, along with her, with his own complaint of severe fatigue. He looked sick, and very uncharacteristically deferred to his wife to speak for him. Tests revealed Addison’s Disease as the culprit. Treated appropriately, he had a rapid and dramatic improvement. After a follow-up appointment, his wife took me aside and gently asked, “Doctor, do you think you might lower the dose of those pills he’s taking? I liked him better when he was sick.” −John Ostrich, MD I had a patient state that I, as her physician, should pay for the portable nebulizer machine she needed since she could not afford it. She thought that it should be the financial responsibility of the doctor who was prescribing it. −Anissa Slifer, MD One Saturday morning in the early days of my ObGyn practice, a teenager dressed in loose-fitting apparel presented with a history of increasing lower abdominal and back pain. “I have not been to a doctor, but I think that I’m pregnant and in labor. Would you check?” After we confirmed that she was, indeed, in early labor, she explained that she lived at home with her parents, and worked part-time after school in the medical records department of our clinic. She had told her parents that she would be sleeping at a girlfriend’s home that weekend, and would return home after finishing classes on Monday. Her boyfriend wanted no part of fatherhood. She requested that I deliver the baby at our hospital, but without divulging her situation to anyone except staff members when necessary. She also asked me to find suitable parents for her baby, and arrange for him or her to be adopted immediately. A tall order, especially on a weekend! Early that evening, without benefit of prenatal care or support, other than that of our Ob staff, she delivered a healthy boy with apparent ease and no complications. An attorney member of our hospital board readily agreed to handle the adoption legalities. One of my infertility patients was delighted to have the opportunity of adopting the baby, and arrived starry-eyed with her husband at our nursery the following morning.
My patient was discharged that afternoon, resuming to classes and returning home the next day. She returned for a normal postpartum checkup in a month, as happy with her decision as the adopting parents and their thriving newborn. Only then did she notify her parents, who apparently accepted the news of this unusual course of events with love and without recriminations. −James McGibbon, MD Toward the end of residency, I was doing Urgent Care shifts for some supplemental income and because I like the acuity. One busy night, after seeing kids with ear infections and stitching up minor wounds, a pleasant elderly lady who lived alone came in complaining of neck pain. It quickly became clear that it was a chronic issue and that she was not in a crisis. “I was just hoping that someone could massage it for me and get the kink out.” So I massaged this lady’s neck for 10 minutes while having pleasant conversation and listening to the sounds of doors opening and closing as other rooms filled up with patients needing urgent attention. In hindsight, it was time well spent. I think she appreciated it. −Nate Hitzeman, MD
—William Nakashima, MD
November/December 2014
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In Memoriam
Frank J. Glassy, MD 1921-2014
DR. FRANK JOSEPH GLASSY, MD, passed away on March 4, 2014 in Palos Verde, CA, at the age of 93. He was born March 4, 1921 in Tacoma, WA, the first of eight brothers and sisters, to Marguerite and Frank Glassy. Frank had a twin brother, John, who predeceased him. Frank grew up in Tacoma and graduated from Bellarmine High School in 1938. After high school, he attended the University of Seattle and then Marquette University Medical School. After medical school, he served in the U.S. Army as a pathologist and was stationed in Vienna to help oversee the end of World War II. After leaving the service, Frank was at the Armed Forces Institute Frank J. Glassy, MD of Pathology before relocating to Wawatosa, WI. From there, he and his family moved to Marshfield, WI, where he was the pathologist at St. Joseph’s Hospital. In 1962, Frank and his family moved to Sacramento, CA, where he practiced at Sutter Hospitals, in particular, Sutter Memorial. During this time, he became an expert in hematopathology with both patients and publications about his work. After retirement, Frank was a consultant to Kaiser Hospitals and taught pathology to medical students at UC Davis School of Medicine. He was also a dedicated and long-time member of our Society’s Historical Committee. In addition to his lifelong medical profession, Frank also went on to get his master’s degree in theology from the Graduate Theological Union at UC Berkeley. His hobbies included photography and traveling. He married Lorraine Gay in 1944, and they were happily married until Lorraine’s death in 1981. Frank is survived by their three children,
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Pam (Gary), Eric (Chris), and Mark (Donna). Son, Eric Glassy, is a pathologist working for the National Institute of Pathology and is practicing at San Pedro in Southern California. Son, Mark Glassy, PhD, is a research scientist for Nascent Biologics and lectured at UCSD. Frank has seven grandchildren and six great grandchildren. After Lorraine passed away, Frank married Phyllis Iwanski in 1982 and remained happily married until Phyllis passed away in 2012. − Mark Glassy, PhD Former colleagues recall that Dr. Glassy was “a wonderful, kind, gracious, bright and thoughtful physician. He was an expert in lymphomas, lymphoid lesions, and hematopathology, and was a highly-respected consultant for Kaiser Hospital for many years, coming in to to look at difficult lymphoid cases. “He consulted from the 1970s to the 1990s. His opinions were always highly-valued and he was willing to consult on cases at a moment’s notice. He was well-regarded and very well-liked by the pathologists and staff.” In a 1983 article in The Sacramento Bee, it was noted that Dr. Glassy had earned quite a reputation for his spiffy taste in clothing. “I feel that one’s dress aids in governing how he acts toward other people,” he commented. “I don’t see patients on a regular-basis, but I do feel that they are more receptive to someone who is well-groomed and well-dressed.” Dr. Glassy had been known to have shoes dyed to match trousers and would wear ultra suede sport coats on occasion, even under his lab coat, and would avoid garments that were “too loud or offbeat in color or design.”
We are looking for Doc leaders for all 2015 Walk with a Doc events.
Requirements: An interest in talking to a group of walkers about health and wellness for 10 minutes before the walk.
To volunteer, or for more info., contact Kris Wallach at 916 453‐0254 or kwallach@ssvms.org
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The information within while not guaranteed has been secured from sources we deem reliable. However, no warranty or representation express or implied is made as to the accuracy of the information contained herein. All information should be verified by the recipient prior to purchase or execution of legal documents.
November/December 2014
33
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.
Aggarwal, Divya, Ophthalmology, Lala Lajpat Rai Memorial Medical College, India 2002, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6400 Aggarwal, Gaurav, Internal Medicine/Hospitalist, University College of Medical Sciences, Delhi, India 2000, Mercy Medical Group/Mercy Methodist Hospital, 7500 Hospital Dr, Sacramento 95823 (916) 423-3000 Bandolin, Norkamari S., Emergency Medicine, University of Washington 2013, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 (Resident Member) Bowers, Elyn V., Dermatology, Medical College of Wisconsin 2006, Mercy Medical Group, 1264 Hawk Flight Ct #100, El Dorado Hills 95762 (916) 939-8400 Bragg, William E., Orthopedic Surgery, Stanford University 2008, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Caldwell, Nolan J., Emergency Medicine, UC San Francisco 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Chan, Choon-Weng (Andrew), Infectious Diseases, Dalhousie Medical School, Canada 2001, Mercy Medical Group, 8220 Wymark Dr #200, Elk Grove 95757 (916) 667-0600 Chen, Minzi, Rheumatology, Shanghai University, China 1997, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 662-3961 Cipot, Stephen J., IV, DO, Emergency Medicine, New York College of Osteopathic 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Cowan, Kristopher L., DO, Family Medicine, Kirksville College of Osteopathic Medicine 2011, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040 Dorey, Alyrene A., Emergency Medicine, University of Colorado 2014, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 (Resident Member) Douglass, Lucy M., Family Medicine, University of Washington 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Fan, Howard J., Neurology, St. George’s University 2008, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Ghias, Ali, Pulmonary/Critical Care Medicine, Isfahan University, Iran 2001, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333
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Heinert, Maya R., Pediatric Emergency Medicine, Wayne State University 1990, 951 La Sierra Dr, Sacramento 95864 (916) 996-7014
Ngo, Quang H., Internal Medicine, Jefferson Medical College 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106
Hoffman, Paul J., Pulmonary/Critical Care Medicine, University of Pittsburgh 2008, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333
Nguyen, Jennifer T., Emergency Medicine, University of Arizona 2014, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 (Resident Member)
Jacques, Dana R., OB-GYN, University of Pennsylvania 1993, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-2500
Nguyen, Judy QT., Nuclear Medicine, UC San Diego 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000
Jagdeo, Rochelle M., Emergency Medicine, Meharry Medical College 2014, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 (Resident Member)
Nguyen, Julie T., DO, OB-GYN, Touro University 2008, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5300
Kamal, Sally M., Otolaryngology, University of Southern California 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322
Parikh, Shalin U., Family Medicine, NHL Municipal Medical College, India 2003, The Permanente Medical Group, 9201 Bighorn Blvd., Elk Grove 95758 (916) 478-5000
Kovalenko, Tetyana O., Pediatrics, Dneprotetrovsk State Medical Academy, Ukraine 1997, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333
Patel, Ushir V., Nephrology, NHL Municipal Medical College, India 2006, Mercy Medical Group, 8120 Timberlake Way #101, Sacramento 95823 (916) 681-6000
Ledgerwood, Levi G., Otolaryngology, Mt. Sinai School of Medicine 2008, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350
Pearson, Ryan D., Family Medicine, Loyola University 2007, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 784-4050
Lee, Rebecca H., Pediatrics, Loma Linda University 2011, Mercy Medical Group, 8220 Wymark Dr, Elk Grove 95757 (916) 667-0600 Lemieux, Melissa H., Radiation Oncology, Stanford University 2009, Mercy Medical Group, 3301 C St #550, Sacramento 95816 (916) 556-3200 Lin, Jennifer L., Otolaryngology, Case Western Reserve 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Long, Jennifer R., Ophthalmology, Boston University 2009, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 784-4185 Lulu, Sabeen T.A., Neurology, Dubai Medical College, Dubai 2004, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3670 Marar, Devan M., Cardiology, Medical College of Virginia 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Mathews, Ethan R., Family Medicine, UC San Diego 2014, Mercy-Methodist Family Practice Residency Program, 7500 Hospital Dr, Sacramento 95823 (916) 681-1900 (Resident Member) McDaniel, Andrew S., Pediatrics, Albany Medical College 2011, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040
Sierra Sacramento Valley Medicine
Rash, Dominique L., Radiation Oncology, George Washington University 2009, Mercy Medical Group, 3301 C St #550, Sacramento 95816 (916) 556-3200 Reinking, Celeste C., Family Medicine, UC San Francisco 2011, UCDMC, 4860 Y St #1600, Sacramento 95817 (916) 734-2820 Rome, Aaron M., DO, Emergency Medicine, Chicago College of Osteopathic 2014, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 (Resident Member) Seo, Lisa, Palliative/Internal Medicine, Ross University 2010, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Skaria, Shaji, Pulmonary/Critical Care Medicine, St. George’s University, West Indies 2007, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Unold, David, Blood Banking/Transfusion Medicine, Medical College of Wisconsin 2009, BloodSource, 10536 Peter A. McCuen Blvd., Mather 95655 (916) 456-1500 Walker, Vanessa J., DO, Pulmonary/Critical Care Medicine, Kansas City University 2007, Pulmonary Medicine Associates, 5 Medical Plaza Dr #190, Roseville 95661 (916) 786-7489
Board Briefs September 11, 2014 The Board: Received an update regarding the SSVMS Fall Member Social scheduled for Saturday, October 25, 2014, 6:00 pm – 8:30 pm at the California Railroad Museum. Received an overview of the SSVMS and CSERF investments from Patty Estopinal, Investment Advisor, R. W. Baird and Company. Received NO on Prop 46 Campaign Message Training from Molly Weedn, CMA Associate Vice President of Public Affairs. Approved the 2014 Second Quarter Financial Statements for the SSVMS General Fund, Building Fund, the Community Service, Education and Research Fund (CSERF) and the R. W. Baird Investment Reports and Recommendations. Approved the Membership Report: For Active Membership — Divya Aggarwal, MD; Elyn V. Bowers, MD; Nolan J. Caldwell, MD; Choon-Weng (Andrew) Chan, MD; Minzi Chen, MD; Stephen J. Cipot, IV, DO; Kristopher L. Cowan, DO; Lucy M. Douglass, MD; Ali Ghias, MD; Maya R. Heinert, MD; Paul J. Hoffman, MD; Dana R. Jacques, MD; Sally M. Kamal, MD; Levi G. Ledgerwood, MD; Rebecca H. Lee, MD; Melissa H. Lemieux, MD; Jennifer L. Lin, MD; Jennifer L. (Rizzo) Long, MD; Sabeen T. A. Lulu, MD; Andrew S. McDaniel,
Meet the Applicants continued from previous page Wheatley, Matthew D., Radiation Oncology, Medical College of Wisconsin 2009, Mercy Medical Group, 6511 Coyle Ave, Carmichael 95608 (916) 904-3440 Xia, Guohua, Psychiatry, Beijing Medical University, China 1986, Brainefit, 324 Madson Place #500, Davis 95618 (530) 231-5858 Yang, Kou, Family Medicine, University of Southern California 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Zhu, Guanglan, Family Medicine, Guangdong College of Medicine, China 1990, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631
MD; Julia T. McManus, MD; Quang H. Ngo, MD; Judy Q. T. Nguyen, MD; Julie T. Nguyen, DO; Shalin U. Parikh, MD; Ushir V. Patel, MD; Ryan D. Pearson, MD; Celeste C. Reinking, MD; Lisa Seo, MD; Shaji Skaria, MD; David Unold, MD; Vanessa J. Walker, DO; Matthew D. Wheatley, MD; Kou Yang, MD; Guohua Xia, MD; Guanglan “Gigi” Zhu, MD. For Reinstatement to Active Membership — Ron E. James, MD; Lester C. Pan, MD. For Resident Membership — Norkamari S. Bandolin, MD; Alyrene A. Dorey, MD; Rochelle M. Jagdeo, MD; Ethan R. Mathews, MD; Jennifer T. Nguyen, MD; Aaron M. Rome, DO. For a Change in Membership from Resident to Active Membership — Lenora W. Lee, MD; Dominique L. Rash, MD. For Retired Membership — Karen Y. Poirier-Brode, MD (transferred from San Joaquin). For Resignation — Silvia C. Arizaga-Peverini, MD; Artha Je Gillis, MD (Transferred to LACMA); Andrew L. Holz, MD; Jeffery J. Leinen, MD (transferred to Contra-Costa); Michael A. Patmas, MD (moved to Spokane, WA); Anna Petrovich, DO; Harris Tong, DO; Ryan Young, MD (moved out of area). Serving as the Board to the Community Service, Education and Research Fund (CSERF), approved providing grants from the William E. Dochterman Medical Student Scholarship Fund to the following individuals for 2014: Tony Cun, a 4th year student at David Geffen School of Medicine/UCLA Education Program; Victoria Hrabak, a 1st year student at the University of California, San Francisco; Kim Le, a 2nd year student at UC Davis School of Medicine; Kristiana Jasmine Lehn, a 1st year student at UC Davis School of Medicine; Olivia Nguyen, a 3rd year student at UC Davis School of Medicine; Akhilesh Pathipati, a 2nd year student at Stanford University School of Medicine; Nazeela Sabir, a 1st year student at UC Davis School of Medicine; Bathsheba Wario, a 1st year student at the University of Utah.
November/December 2014
35
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Doctor-Mentors Needed Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: managers@willowclinic.org.
Visit SSVMS online at www.ssvms.org
Membership Has Its Benefits!
SIERRA SACRAMENTO VALLEY
MEDICAL SOCIETY
Free and Discounted Programs for Medical Society/CMA Members
Auto/Homeowners Discounted Insurance
Mercury Insurance Group 888.637.2431 orwww.mercuryinsurance.com/cma
Car Rental / Avis or Hertz
Members-only coupon codes required. Go to: www.cmanet.org/memberhip-benefits or call 800.786.4262
Clinical Reference Guides
Epocrates discounted mobile/online products. www.cmanet.org/membership-benefits
Conference Room Rentals
Medical Society 916.452.2671
Healthcare Information Technology (HIT) Resource Center
www.cmanet.org/health information technology
HIPAA Compliance Toolkit
PrivaPlan Associates, Inc. 1.877.218.7707 / www.privaplan.com
Insurance Mercer Health & Benefits Insurance Life, Disability, Long Term Care Services LLC /1.800.842.3761 Medical/Dental, Workers’ Comp, more... CMACounty.Insurance.Service@mercer.com www.CountyCMAMemberInsurance.com Legal Services & CMA On-Call
800.786.4262 or email legalinfo@cmanet.org
Magazine Subscriptions Subscription Services, Inc. 1.800.289.6247 50% off subscriptions www.buymags.com/cma Medic Alert
1.800.253.7880 / www.medicalert.org/cma
Medical School Debt Management
Members-only coupon required: www.cmanet.org/membership-benefits
Practice Financing Reduced Loan Administration Fees
Members-only coupon required: 1.800.786.4262 / www.cmanet.org/benefits
Office Supplies/Equipment-Staples, Inc. To access the members only discount link visit: Save up to 80% www.cmanet.org/membership-benefits Reimbursement Helpline Contact CMA at 888.401.5911 or email Assistance with contracting or reimbursement economicservices@cmanet.org Security Prescriptions Products
RX Security, www.rxsecurity.com/cma.php or call 800.667.9723
Travel Accident Insurance/Free
All SSVMS Members $100,000 Automatic Policy http://www.ssvms.org/Membership/ BenefitsandServices.aspx
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.
PLANET DESIGN / MARKETING
Kelly K elly Rackham Rackha m [916] 616 6270 planetkelly@me.com www.planetkelly.com
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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.
Sierra Sacramento Valley Medicine
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