2015-Jan/Feb - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2015

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Medicine 3

PRESIDENT’S MESSAGE Impacting Change Through SSVMS

Placing Risk of Ebola into Context

Glennah Trochet, MD

Medicare in Controversy

Gerald Rogan, MD

Jason Bynum, MD

EDITOR’S MESSAGE Justice is Served

Nathan Hitzeman, MD

Corporeal Punishment of Children

EXECUTIVE DIRECTOR’S MESSAGE Prop. 46 Defeated!

John Loofbourow, MD

Aileen Wetzel, Executive Director

BOOK REVIEW Escape From Camp 14

Removing the Scarlet Letter

Lee Welter, MD

Marion Leff, MD

BOOK REVIEW The Gut Solution

Sacramento County’s Fraying Medical Safety Net – Part Two

George Meyer, MD

Celeste Reinking, MD

IN MEMORIAM Douglas M. Enoch, MD

What’s the Mutter?

James Hamill, MD

Meet the Applicants

All Aboard! SSVMS’ Fall Social Event Photos

Board Briefs

Cover Image Details

A Personal Perspective on Heart Disease

Inam Ali, RA II

Rajiv Misquitta, MD

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 beautiful image of the Orion Nebula is by Inam Ali, Research Assistant II, who is an astrophotography hobbyist and coworker of an SSVMS Alliance member. It was taken on October 21, 2014 at Blue Canyon with a Stellarvue SV80 Triplet 80mm telescope, and a QSI 683 monochrome CCD camera with filterwheel containing colored filters. The basic idea is to repetitively image a single object through each of the four filters (LRGB: Luminance, Red, Green, and Blue) on manual exposures up to 10 minutes in length, until you have a set of multiple LRGB files. The electronic mount holds the telescope and camera while keeping the scope pointed at the object as the object moves across the sky during the night. A more detailed description of how this image was made is on page 36.

January/February 2015

Volume 66/Number 1 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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MEDICINE 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. 2015 Officers & Board of Directors Jason Bynum, MD, President Thomas Ormiston, MD, President-Elect José A. Arévalo, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Laurie Gregg, MD Vijay Khatri, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD

District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Kieu-Loan Luc, DO

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 Maynard Johnston, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Adam Dougherty, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Thomas Ormiston, MD Richard Pan, MD, Senator Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD

District 1 Kevin Elliott, MD District 2 Don Wreden, MD District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Sean Deane, MD Kevin Jones, DO Thomas Kaniff, MD Olivia Kasirye, MD Vijay Khatri, MD Sandra Mendez, MD Caroline Peck, MD Patricia Samuelson, MD Armine Sarchisian, MD John Tiedeken, MD Vacant Vacant Vacant Vacant

CMA Trustees District XI Barbara Arnold, MD

Douglas Brosnan, MD

Richard Thorp, MD

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

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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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.

CMA Imm. Past President Richard Thorp, MD AMA Delegation Barbara Arnold, MD

Membership Has Its Benefits!

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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. ©2015 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.

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President’s Message

Impacting Change Through SSVMS By Jason Bynum, MD I AM HONORED TO BE your 2015 Sierra Sacramento Valley Medical Society President. There is so much history in our medical society, and it is exciting for me to be part of it. As a child and adolescent psychiatrist, we often quip, “the past is present,” meaning that our past experiences and history guide who we are and the choices we make today. As such, maybe a brief introduction of myself is in order. Born and raised in the Midwest, I travelled to the East Coast for medical school where I fell in love with my chosen field of psychiatry. While there, I was involved in an Acute Treatment Team (ACT) county program where we would visit boarding houses, government-assisted living facilities, and even homeless patients. This was one of the most unique approaches I have seen to “deinstitutionalize” the mentally ill. I was also able to visit St. Elizabeth’s Hospital, and I saw the past of “institutionalization” with its hundreds of acres and many buildings, all in decay, where the mentally ill were historically housed. I completed my residency in adult psychiatry in Los Angeles, when there were significantly more resources available than today, and I saw the benefit of meeting basic needs such as housing, sober living facilities, and appropriate use of disability monies. While on faculty in an academic institution in Michigan post fellowship, the laws governing patient’s rights were the best I’ve seen in multiple states. After a brief stint in Colorado, I returned to California to work as the inpatient child psychiatrist at a local hospital. Observing mental health services in other parts of the country has given me some insight

into the benefits, and shortcomings, we have in the Sacramento region. Let me be very clear when I say, we are in a crisis of how to triage, manage and treat the growing volume of mentally ill patients in this area. I am sure you have felt this impact in your practices: The patient who comes to your office and is depressed, but cannot find a therapist or psychiatrist with any openings; the mother who has a defiant and aggressive child and doesn’t know where to turn for help; the growing foreboding of yet another mass killing, where in each case, there seems to be a history of missed opportunity for mental health treatment. All of these are examples of a system which is neglected and in need of repair. While I understand tough choices had to be made in the face of the greatest financial crisis we may ever see in our lifetimes, I have yet to see the resources return with the improvement in the economy. I believe we are left now without the benefit of long-term treatment programs (such as St. Elizabeth’s), without novel treatments (such as the ACT team), and without many of the intermediate care facilities I saw in Los Angeles. I see the issues stemming from two areas. The first is how to manage an explosion of need for mental health services with the implementation of the Affordable Care Act. Depressive disorders, anxiety disorders, and substance abuse disorders are consistently within the top three medical diagnoses in ERs, physician offices, and hospitalizations, yet when have any of us seen one comment on how the ACA will address mental health? With so many people newly eligible for Medi-Cal, how will the

January/February 2015

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.

mental health needs of this population be met? The second issue pertains to the treatment of mental health in minors. In brief summary of a very complicated issue, California, prior to 2012, had one of the most progressive and helpful approaches for minors with mental illness I had ever seen. When I first moved to Sacramento I was absolutely awestruck at its ingenuity in how to address serious emotional disturbances in collaboration with school districts and county mental health departments. As with all good social services, however, in budgetary crises they are quickly cut and this progressive program was dissolved in 2012. Newly-introduced legislation, however, did not give guidance on how to implement the new system of mental health delivery within the school districts or in collaboration with county services. What the state has been left with is a haphazard approach, county by county, and even school district by district. SSVMS has Requirements:

Want to lead a Walk with a Doc event? We are planning for one Walk with a Doc event per quarter in 2015. Saturday, March 14, 2015

LOCATION: Howe Park, 2201 Cottage Way, Sacramento

June (date to be determined) LOCATION: Elk Grove Regional Park, 9950 Elk Grove-Florin Road, Elk Grove Saturday, August 15, 2015

An interest in talking to a group of walkers about health and wellness for 10 minutes before the walk. Ability to walk for 30 minutes and chat with walkers.

To volunteer, or for more info., contact Kris Wallach at 916 453-0254 or kwallach@ssvms.org

Sponsored by:

LOCATION: Valley Hi Community Park, 8185 Center Parkway, Sacramento

Saturday, October 10, 2015 LOCATION: Sheldon Park, 600 Orange Ave, Sacramento

Supported by:

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begun to look at this issue, and the big question is what to do with this new system. Fortunately, through the Society, we have access to legislators as physicians that we would not normally have, and I think this is where I will be advocating further in the year to come on this issue. Those of us who work with minors agree that this current system is not meeting the needs of the community in either educational, safety, or treatment avenues. What options are available and how to solve this dilemma will include major health providers in the area, the county mental health department, and legislators. It is SSVMS that has the ability to convene these stakeholders. Where to go or what to do, however, is the difficult part. What I can assure you, however, is that if this system does not change, the question is not if, but when, a major tragedy will occur in Sacramento. This is one of my most pressing concerns in the year to come, and if we can impact change through SSVMS, we should take every opportunity available, which I plan to do. In March 2014, SSVMS’ Board of Directors established a task force to address mental health issues in our region, of which I have the privilege of chairing. The charge of the Mental Health Task Force is to identify and recommend to the Board of Directors specific mental health issues within our region that SSVMS can raise awareness, educate and take action to resolve. This committee, along with the medical society’s Emergency Care Committee, is working on solutions to disimpact our region’s ERs of patients needing mental health services. I look forward to updating our members on these efforts throughout the year. As you can see from my writing, I see my presidency through the eyes of a psychiatrist. As president, I will rely on the vast knowledge and expertise of the members of SSVMS in many other areas. I think we can accomplish a great deal this year. Feel free to come by and recline on the office couch and share your stories and ideas. And no, I won’t light a cigar! jason.p.bynum@kp.org

Editor’s Message

Justice is Served By Nathan Hitzeman, MD PROP 46 HAS BEEN appropriately put to rest. But the issue of medical lawsuits, patient safety, and the culture of physician practice continues to be on the forefront of our minds. The articles in this issue speak to my post-Prop 46 psyche. Dr. John Loofbourow’s Corporeal Punishment of Children reminded me of why I don’t like spanking. Multimillion-dollar lawsuits for noneconomic damages and mandated post-bad outcome drug tests are spankings. They teach doctors to live in fear and to practice defensive, costly medicine rather than evidence-based, patient-centered medicine. Dr. Marion Leff, a well-respected family physician and Golden Stethoscope Award recipient, gives us a candid portrayal of her experience with a malpractice case that went to trial (thankfully ruling in her favor). Reading her account reveals how agonizingly slow, subjectively biased, and professionally destructive the legal process is in this country. It will serve instructive for you young ones just starting your medical journey and for the more seasoned among us who already have had brushes with the malpractice system. It could happen to anyone! Dr. Celeste Reinking speaks to a fragmented health care system that fuels our angst, and is probably most responsible for bad outcomes. Americans are notorious for ignorance about how things are done outside their state or country. As we are bombarded with black and white political ads, rarely do we see any thoughtful discussion of systems that work abroad. In a previous editorial, I suggested T.R. Reid’s book, “The Healing of America,” as a brilliant portrayal of diverse health care systems abroad that successfully insure and treat all people for a fraction of what the U.S. spends.

A June 30, 2009 article in the Wall Street Journal by Richard Epstein entitled, “How Other Countries Judge Malpractice,” highlights the four weaknesses of the U.S. malpractice system: jury trials subject to medical ignorance and personal biases, a contingency-fee system that incentivizes lawyers, a rule that makes defendant and prosecution bear their own costs (rather than loser pay all), and extensive pretrial discovery outside the direct supervision of judges. The author refers to a 2006 JAMA study that showed juries get it wrong about a quarter of the time. The author also points to a 1992 study that estimated 10 percent of medical care in the U.S. to be unnecessary “defensive medicine.” In Canada, there are less than a third of the malpractice claims than in the U.S., and their population is just as healthy, if not healthier, than we are. Noneconomic damages are capped at $300,000. In Britain, the National Health Service oversees an efficient claims process that provides smaller payouts, apologies, and demonstration that action has been taken to prevent similar problems in the future. In Germany, which has universal coverage through hundreds of regulated private insurers (yes, it can be done!), malpractice claim discovery is done by mediation boards and experts, and judges decide the awards based on standardized reimbursement tables. California is often considered a country of its own. I see this as a compliment, in many ways. Let’s keep setting a good example for others and stay open to innovations that work for our collective wellbeing and not just for the greedy few! hitzemn@sutterhealth.org

January/February 2015

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.

Executive Director’s Message

Prop. 46 Defeated! By Aileen Wetzel, Executive Director

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 NOVEMBER 4, THE VOTERS of California spoke loudly and definitively, sending the trial lawyers’ Proposition 46 to defeat by a vote of 67 to 33. The message is clear – Californians simply don’t want to increase health care costs and reduce health access so trial attorneys can file more lawsuits. An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again: 10 times in court, five times in the Legislature and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap. But this time, we energized the membership of SSVMS/CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about, and the care that we have committed to provide them. Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well – physician drug testing and mandatory checking of a prescription database – voters said NO on Election Night. As people throughout the state heard from physicians and NO on 46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition. One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse campaigns in California history. The breadth of the coalition — which includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters and more – underscores just how important affordable,

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accessible health care is to every Californian. In addition to the groups on the ground talking to voters about the deception and trickery behind Prop. 46, every major editorial board in California opposed the initiative. • The Los Angeles Times said, “As worthwhile as [Proposition 46’s] goals may be, the methods the measure would use to achieve them are too flawed to be enacted into law.” • The San Francisco Chronicle decried Prop. 46, saying that the measure “overreached in a decidedly cynical way.” • The Orange County Register, UT San Diego, San Jose Mercury News, Monterey County Herald, Sacramento Bee and dozens of other newspapers echoed these sentiments. The efforts of CMA, SSVMS, and the county medical societies across the state are a tremendous showing of what we can do for the future of health care, the quality of medicine and the dedication to patients everywhere. Working together to spread the truth about Prop. 46, building coalitions across communities and standing strong as one united voice is what helped carry us to victory. This was one of the most contentious and high-stakes ballot fights in California history, and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value SSVMS and CMA bring to the profession of medicine and stay united for whatever comes our way next. awetzel@ssvms.org

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Removing the Scarlet Letter Reflections of a Family Doctor on Being Sued for Malpractice

By Marion Leff, MD THE LITERATURE REGARDING being named in a malpractice lawsuit is sobering. A 2011 NEJM article indicates that by age 45, 36 percent of doctors in low-risk specialties and 88 percent in high-risk specialties will be sued. By age 65, the percentages increase to 75 percent and 99 percent, respectively. Hence, we are nearly guaranteed to be sued at least once, if not more than once. Along with increasing lawsuits comes the damage to physician wellbeing. I recently learned of the newly-coined condition MMSS: Medical Malpractice Stress Syndrome, somewhat akin to PTSD. I share this story for my own healing, as well as for that of my physician colleagues and friends. Looking back, I cannot help but think of Nathaniel Hawthorne’s indelible work, The Scarlet Letter, at two very specific points in my medical career when I felt branded.

1980

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.

Eitan, an angelic toddler, lay dying in his mother’s arms while she spoke to our office by telephone. The antibiotics I prescribed for an ear infection were failing. A child dying of H. Flu meningitis is local news, and the University pediatric infectious disease specialist in interviews described the devastating disease that had been missed by the local doctor, perhaps to educate rather than condemn. I could not treat another sick child for a year without curbsiding a colleague. The shame I felt was overwhelming. I thought everyone could see the scarlet letter on my white coat. I found support from an older, wiser, seasoned physician. I was not sued, but I can never forget.

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2010 A 63-year-old man walked into my office with minor respiratory complaints. I examined him and reassured him. The next day, doing what he loved best – duck hunting – he suffered a fatal MI and died in the duckblind. Three hundred sixty four days later I am served with “papers.” The dormant scarlet letter reappears. It would be a three-year journey from start to finish, including a jury trial ending in my favor, leaving me neither jubilant nor vindicated, merely spent. After my patient died, his wife called me immediately to ask how this could have happened. She, too, was my patient and these were lovely folks. I liked them both. I combed over the visit to see what I missed. I sent a condolence card as is my custom and then I opened a confidential file. One year later, I became acquainted with my new best friends: my attorney and malpractice carrier agent. In fact, they were very important support people, constantly checking in with me when there was a lot of activity and always available to talk. They helped normalize the process each step of the way and answered my most naïve questions, including those I was afraid to ask. My deposition was given. I felt very awkward, especially as one of the attorneys was a physician, as well. The plaintiffs had a team from Southern California, somewhat intimidating, but again my team reassured me, saying that no local attorneys would accept the case. When my malpractice carrier sent me a video to watch about being sued, I put it away for months, not able to believe my case would progress. Yet things crept forward after

a failed arbitration. The two sides were miles apart, and my legal team felt strongly that my case was defensible. Hence, the wheels were set in motion and now began the gathering of depositions from expert witnesses. If the plaintiffs obtained a cardiologist, then defense must find one as well… and so it went with ER specialists, family doctors, and even economists to determine damages. No wonder the expense of these cases can spiral upward so quickly! Consider the cost of flying a cardiologist in to testify in Sacramento for a day. It was time to watch the video. To my surprise, I recognized a few colleagues I knew to be excellent doctors telling their story. I was able to reach out and call one. He assured me that it would not be easy, but that I would make it through. After that, I was finally able to share with trusted friends what I was going through. Remarkably, each time I mentioned I was going through a tough time, out came a story from those I could not imagine having ever made a mistake. I asked how they had managed. One became an expert witness for defense cases, another pursued fitness aggressively, and most acknowledged that they addressed patient care differently after being sued. Supportive family was essential and I had that from the start. The problem with a malpractice case hanging over you is that it sucks the life out of special events. Each time that I anticipated an end in sight – such as during my anniversary, a birthday, a family reunion – a scheduling change occurred, pushing my trial date out further and further. On one occasion, it was the serious illness of my attorney’s father. Later, my own father’s health would impact my attendance at trial. Disruption to my practice was also terrible. Each time a court date was scheduled, I blocked out not one but two weeks from my practice, advised that the case might take five to seven days. Each time, I leaned on my partners who stood by to cover for me. I marveled that I could be both witness in my own case and later in the day compose myself to take care of patients. Ultimately, the trial started. Having been a juror myself before, I was acquainted with the

“voir dire” process to select or dismiss jurors. Each day I showed up and sat behind my attorneys and across the aisle from the plaintiffs. There is an awkward civility in this process. I took the stand several times to tell my story, as well as listen to “experts” describe presumptions of what they would have done and what should have been done had they been there. I learned the art of prepping for the jury in my demeanor and dress. I was pleased that my attorneys thought I would make a strong and sympathetic defendant. It became very clear that this process is more about gamesmanship than about justice, and, indeed, the truth is viewed differently depending on how well the story is told. My attorneys would debrief with me daily at lunch or after court adjourned. I was glad for their competitive nature, but mostly felt I was along for the ride, swept up by the process that could have significant ramifications for me and my practice. Jury deliberation was the worst time. I was told that if the jury came back quickly, it was typically in favor of the defendant. This jury did not come back quickly. I spent a day holed up at the public library, keeping to myself awaiting a call that did not come. Each day I was advised to show up when the jury arrived so they would see that my involvement in the case did not waver. As day two dragged on, I received permission from my attorney to catch the plane to see my father, who was hospitalized and failing, and on the other coast. Driving across Tampa Bay in a rental car, I received the call. It was over. I was acquitted.

It became very clear that this process is more about gamesmanship than about justice…

Fast forward many months I don’t think I am any more resilient than my colleagues, but what helped me through the dark period was, in fact, my colleagues, my spouse, himself a physician, mentors and legal experts who could paint a picture for me of a land quite foreign − the courtroom. What surprised me most, however, is the support from patients who left me with more gratitude than I could imagine. Sacramento still

January/February 2015

seems such the small town – like when the court recorder recognized me as her family doctor. (How bright was my scarlet letter then!) She was gracious and professional as I blabbered my embarrassment about meeting her under these circumstances. She had brief comforting words, “Oh, we see this all the time…it’s just business,” or something to that effect. When almost a year later I happened to see her in our clinic as I supervised the resident visit, I felt compelled to share with her the outcome of the trial, to again dampen the glow of the scarlet letter. Part of me had thought she would move herself and her family to a less tainted doctor. Little did she know her part in my healing. Then came another incident almost seven months post trial, again in our residency clinic. As I introduced myself to the intern’s patient, the woman looked familiar and she agreed I did as well, but I could not place her as a former patient. “I was on your jury, doctor,” she said calmly. Awkward seconds passed as I recognized her as the juror whose personal story included death of a spouse to a medical condition. Then she added, “ I hated seeing you sit alone each day in the courtroom. None of us thought you could have done anything to save that man.” I was probably crying silently at that moment.

I managed to stammer some words to explain this bombshell news to the intern whose eyes had doubled in size. Yes, I have a wound. It is permanent, but it is moments like these that remind me not to forget compassion. I am now able to give what I hope is a gift to younger colleagues faced with self-doubt when confronted with what feels like a frontal attack on self-esteem. My particular means of coping has been to dedicate time to becoming a mentor to colleagues who find themselves in this situation. I am convinced that it is a better strategy than shutting out any conversation of such ordeals, or inappropriate use of drugs and alcohol, tempting as that may seem at times. I was frequently reminded that lawsuits are a business to obtain money and much less about weeding out incompetent or negligent physicians. It is worth remembering that during those dark times. Despite our efforts and good intentions, bad outcomes happen. Life goes on. We do a lot of good for a lot of people, and most of our patients and their families appreciate our care and kindness. leffm@sutterhealth.org

MRAC SSVMS’ Medical Review and Advisory Committee (MRAC) is comprised of members of the medical society who serve as peers to review confidentially the medical issues of a professional liability case. The review is a detailed, comprehensive and objective presentation of the pertinent medical facts. The reviewing physician (case manager) and the physician committee members provide the defendant physician’s legal representatives and NORCAL Mutual Insurance Company with medical information and analyses helpful to evaluating liability, specifically from a standard-of-care perspective. The MRAC functions as both a peer review and medical review committee within the meaning of Sections 43.7 and 43.8 of the California Civil Code, and Section 1157 of the California Evidence Code. The Medical Review and Advisory Committee meets monthly and is chaired by Howard Slyter, MD. While any member of SSVMS can have a case reviewed by the committee at the request of their defense attorney, the committee primarily serves those insured by NORCAL Mutual Insurance Company.

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you work to protect your patients. We work to protect you.

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Sacramento County’s Fraying Medical Safety Net Part Two – Community Clinics

By Celeste Reinking, 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.

IN MY LAST ARTICLE (SSV Medicine Nov.-Dec. 2014), I discussed the history of Sacramento County’s hospital and clinics, including the largest blow to the county clinic system: the financial crisis in 2008. As a result of that crisis, five of six county clinics closed their doors, and some 26,000 patients stopped receiving basic primary care. The landscape is poised to change significantly this year, however, with the vast majority of county patients now being enrolled in Medi-Cal as a result of its expansion under the ACA. This is, undoubtedly, a big step forward. The Medi-Cal expansion won’t just cover the former county patients, who represented the poorest of the poor — those with incomes below 67 percent of the federal poverty level. It will cover patients up to 138 percent of the federal poverty level. The biggest question is: Where are all those patients going to be receiving services? Of course, expansions in coverage under the ACA have raised this question all over the country, as new patients covered by both private and public insurance will have to scramble to find primary care services from a pool of providers that was too small to begin with. But it’s an especially acute crisis for patients covered by Medi-Cal. Medi-Cal pays far less to most providers than the commercial insurance companies. California ranks 49 out of 50 states in terms of reimbursement to physicians. As a result, many providers are unable to accept Medi-Cal patients. Even at public hospitals receiving public funding, many specialty clinics do not accept Medi-Cal. And in Sacramento

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County, where Medi-Cal patients have already been struggling to get access to providers, the problem is expected to get worse now that we’ve added another 70,000 patients or so to the 270,000 Medi-Cal patients so far under the Medi-Cal expansion program.1 The natural answer to this crisis would seem to be the network of community health clinics (CHCs), specifically Federally Qualified Health Clinics (FQHCs), FQHC “look-alikes,” which function similarly in many respects, and rural health clinics. These CHCs negotiate payments for Medi-Cal patients that, for the most part, far exceed the payments that private providers can obtain. FQHCs, in addition, receive a range of other benefits, including federal grants, to cover unreimbursed care for uninsured patients who are seen on a sliding scale basis. As a result, in California, FQHCs and other CHCs are the key providers of basic primary care and some ancillary services to Medi-Cal patients, making them our best hope in our effort to provide health care to all the new enrollees under the Medi-Cal expansion. However, historically Sacramento County has a very low capacity for serving patients within its network of CHCs, at least relative to the level of need. In addition to Planned Parenthood and Women’s Health Specialists, which primarily focus on reproductive health services, we have six other CHCs providing primary care services to low-income people. To get a sense of how our safety net compares to the rest of California, I looked at a state database that compiles data from all the

CHCs in the state,2 county by county. However, since each county differs in the size of its population, as well as in the level of need for health care services for low-income patients, I calculated the number of patients seen by CHCs as a proportion of the number of people living under the poverty line, according to census data — a reflection of how well CHCs were able to meet the needs of the low-income patients in their communities. For example, Sacramento County has 236,000 people living in poverty, and its CHCs saw 100,000 patients in 2012, so the CHCs saw a number equivalent to 43 percent of the number of poor residents in the county. When you compare Sacramento County to other Central Valley counties with large populations, Sacramento’s CHCs see far fewer patients relative to the number of patients living under the poverty line. Most other counties don’t have county health care systems to supplement the CHCs in caring for patients, but remember that Sacramento’s county clinics saw only a small number — you can tack on another 6 percent to the 43 percent you see in the chart below — and it still doesn’t amount to much.

In an effort to be fair, I tried several other comparisons: I looked at the counties that are immediately adjacent to Sacramento County, counties with populations over 1 million, Bay Area counties, and California as a whole.

No matter what the comparison, Sacramento comes out behind in numbers. These numbers support the general consensus that Sacramento County’s health safety net is weak, among the weakest in the state. As the California HealthCare Foundation reported in 2009, the safety net in Sacramento County is comprised of “a fragmented group of small and financiallyfragile health centers that together offer limited outpatient capacity.”3

If low-income patients are not being seen at CHCs, where are they being seen? Many patients are being seen by private providers, some of whom do an admirable job of trying to meet the needs of their patients. However, the quality and accessibility of services for patients, who rely on private providers accepting Medi-Cal, is very hard to determine, as MediCal keeps very poor track of its network of providers and the type and volume of services recipients receive. Those of us working at free and studentrun clinics know that many patients insured under Medi-Cal encounter lots of obstacles in using their insurance to obtain services, and

January/February 2015

If lowincome patients are not being seen at CHCs, where are they being seen?

many are not receiving any services at all, which provides yet another compelling reason for us to have a strong CHC network in Sacramento County. What is the reason for the low capacity of CHCs in Sacramento? I’ve asked a number of clinic leaders, county officials and academics this question, and I encountered many opinions. One widely-cited reason is a lack of cooperation among the CHCs, and between CHCs and the major hospital groups in Sacramento. Better cooperation between the major players in health care in the region and the CHCs might enable more CHCs to achieve full FQHC status (which comes with federal grant money), and to expand their services. There have been hints of growth and cooperation. In 2013, WellSpace formed an alliance with Dignity Health and made plans to open several new clinic sites; and two other clinics — Elica Health and CARES — have managed to secure FQHC status in the last few years. As a result, Sacramento’s CHCs have been able to increase their patient numbers from about 65,000 in 2006 to 98,000 in 2012 — an accomplishment we should celebrate. But as the graphs here show, we have a long way to go. Another reason sometimes cited for the weakness of our CHC network is the lack of support at the county level. One example is our method of organizing Medi-Cal which, in Sacramento, is geographic managed care (“GMC”) — a system shared only by one other county in California, and which was chosen for us by state officials because years ago the county declined to make a choice about how to organize Medi-Cal. Within the GMC system, we have four private insurance providers who administer services for Medi-Cal, and unlike the vast majority of other counties in California, we do not have the equivalent of a “public option,” usually a non-profit insurance plan selected by the county. The details of the GMC system are beyond the scope of this article, but in my conversations with CHC leaders in counties outside of Sacramento, the complexity of reimbursement under the GMC system poses a significant barrier to CHCs that otherwise might Sierra Sacramento Valley Medicine

be able to either establish new clinics or expand their services in our county. Sacramento County Supervisors, as elected representatives, should be encouraged to focus resources and attention on health care services for low-income residents. CHCs, particularly FQHCs, are best positioned to provide services for Medi-Cal patients, since these institutions can get some relief from the low reimbursement rates that California insists on paying for Medi-Cal beneficiaries. If we don’t succeed in expanding Sacramento County’s CHCs’ capacity, our most vulnerable citizens, including many working poor, will continue being denied access to the health care that they need and deserve. ccreinking@gmail.com References 1 www.dhhs.saccounty.net/PRI/Pages/Sacramento-Medi-CalManaged-Care-Stakeholder-Advisory-Committee/BC-MCMC.aspx 2 Office of Statewide Health Planning and Development, primary care clinics annual utilization data, 2012. www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/PC_SC_ Utilization.html 3 California’s Safety-Net Clinics: A Primer, by California Health Care Foundation, 2009. www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/S/ PDF%20SafetyNetClinicPrimer.pdf

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January/February 2015

What’s the Mutter? By James Hamill, 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.

IN 1997, I VISITED the Mutter Museum in Philadelphia and very much enjoyed viewing its large collection of anatomical specimens, historical items and oddities related to medicine. The museum is housed at The College of Physicians of Philadelphia on 22nd Street and is open to the public. But while browsing there, I neglected to be curious about the museum’s namesake. Some weeks ago, I noted a book review in the Wall Street Journal that caught my eye. The book reviewed was entitled, Dr. Mutter’s Marvels, a title suggesting a carnival sideshow. But this 2014 book, by Cristin O’Keefe Aptowicz, was about Mutter of the Mutter Museum. Thinking that would make up for my lapse, I ordered the book. The author had toured the Mutter Museum as a fourth grader, and it obviously left its mark on her. Her 300+ page book chronicles the life of Dr. Thomas Dent Mutter (1811-1859) and how the museum, which bears his name, came to be. I immediately thought of the multiple fourth graders we Historical Committee docents yearly usher through our own SSVMS Museum of Medical History. Lots of interest expressed by them, but to date no published authors. What really struck me in reading her book was that Dr. Mutter was considered in his day to be one of America’s first plastic surgeons. Now, being as that was my calling, I must confess I had never seen his name mentioned in reviews of our specialty. So, my interest in Dr. Mutter increased as I read the book. Thomas Mutter of Virginia was orphaned by the time he was seven years old, with both parents probably dying of tuberculosis. And young Thomas was also infected, as he had a life-long lung illness with hemoptysis. He was fortunate to have a well-to-do guardian who supported him through home schooling, boarding school, college, a semester at Yale

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and eventual acceptance at the University of Pennsylvania School of Medicine. Influenced by the compassionate care he received for illness throughout his childhood, he had chosen medicine as his career. His two years in medical school at Penn (1829-1831) were sufficient, in those days, for him to earn his MD by age 20. It was fashionable upon graduation to go to Paris to study under the great teachers there. Thomas was able to afford that by booking passage on a freighter as a doctor for the crew. Paris was wonderful. He could live and eat cheaply. Anyone with an MD was welcome to witness surgery and, for a small price, could assist in dissecting cadavers (illegal at the time in Philadelphia). In Paris, he made two major observations. Surgery was fast and, as in Philadelphia, there was no concern for the pain suffered by the unanesthetized patient.

But his major discovery was that, unlike in Philadelphia, there was surgery available for patients with disfiguring congenital and traumatic deformities. The French called it “les operations plastique.” Mutter found this reconstructive surgery for these unfortunates both challenging and wonderful. He became an intern under Paris’ most celebrated surgeon, Guillaume Dupuytren, and learned the repair of the cleft palate, the release of burn scar contractures, pedicle flaps and skin grafting. At the end of a year, he returned to Philadelphia and opened his practice. Developing a referral surgical practice was painfully slow, so he sought out the disfigured, “monsters,” as they were termed in Philadelphia, and began their reconstruction. Filled with compassion for these patients, he would spend days prior to surgery explaining his reconstructive plan to them, showing them the instruments he would use, massaging the areas to be operated, and reassuring them that, even though surgery involved pain, they would be able to endure what he was planning to do. He became known for releasing burn scar contractures of the head and neck and closing the defects created with flaps and grafts. His successes with these abandoned patients caught the attention of the newly-formed Jefferson Medical College, and in 1841 at age 30, he was named to their Chair of Surgery. His teaching and operating career was filled with success. In 1848, he became a champion for the newlydiscovered ether anesthesia, while most surgical colleagues remained disinterested. His compassion for his patients went beyond the surgical procedure itself, for he established the first post-operative recovery room in Philadelphia. Throughout his years in practice, he collected anatomic specimens, models and casts of interesting medical conditions, as he had seen Dupuytren doing in Paris. In 1856, when his illness finally

forced him to retire from surgical practice and teaching, he ensured his collection of medical treasures would have a home. He provided an endowment for the establishment of a medical museum at The College of Physicians of Philadelphia. In 1859, at age 47, he died. Dr. Mutter had provided Philadelphia with more than a medical museum. He truly was its first plastic surgeon and the first to care for the disfigured. Through his years teaching at Jefferson, he had imparted to a generation of new physicians the gift of gentle care and compassion for those they would be privileged to treat. And more than a century and a half later, the Musee Dupuytren in Paris and his Mutter Museum in Philadelphia continue to attract visitors from throughout the world. And now I know the rest of the story.

On the facing page is a painting of Dr. Thomas Mutter from the Mutter Museum. Above is the bookcover of Dr. Mutter’s Marvels, and below is the museum’s main gallery.

Jphx2biz@aol.com

January/February 2015

All Aboard! The Sierra Sacramento Valley Medical Societyâ&#x20AC;&#x2122;s Fall Social Event was held at the California State Railroad Museum in Old Sacramento on Saturday, October 25. This family-friendly event was open to SSVMS members who were treated to a private gathering and tour. Hors dâ&#x20AC;&#x2122;oeuvres and beverages were served. Photos by Bob LaPerriere, MD.

6 7

Dr. Harvey Cain and Family

Drs. Erin and Sean Deane and family

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13 3

Board Member, Dr. Russell Jacoby with spouse, Carolyn Cole, and Dr. Peter Wu

Board Members, Drs. Dave Herbert and Ruenell Adams Jacobs

14 5

Drs. Lester Pan and Robert Suskind, with SSVMS Executive Director, Aileen Wetzel

10 Dr. John Finkler, Dr. John Fisher, and spouse Marianne Fisher

6 Carson

11 Dr. Donald Hopkins and Pat Baker

Drs. Andrea and John Belko and family with Drs. Cathi and Rajiv Misquitta and family

12 Dr. Henry Go

Jim McElroy, Dr. Ann Gerhardt, SSVMS Director and Kim Majetich, Alliance President

Dr. Al and Mildred Kahane

13 California State Railroad Museum 14 Keng Lan, MS I, Drs. Jack Ostrich, Don Lyman and Mark Jiang, MS I

January/February 2015

A Personal Perspective on Heart Disease By Rajiv Misquitta, 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.

SIX YEARS AGO, on my way to work on a cold November morning, I experienced crushing chest pain and shortness of breath. I managed to stumble into the Emergency Room at Kaiser South Sac, and say to my physician colleague, “I think I’m having a heart attack.” Next, I had two stents placed in my arteries. I was 40 years old at the time, and my two boys were toddlers. I switched to the Mediterranean diet, absent of all meat except fish, and changed my lifestyle to include regular exercise. Four months later, I experienced chest pain at rest and was rushed to the hospital where I subsequently underwent five-way bypass surgery. I had switched roles from a physician to a patient, and I felt powerless in the wake of this terrifying disease. After the surgery, I reviewed the medical literature, with the hope of making sure that this never happened again. The best drugs (statins) and surgical procedures seem to, at best, delay the advancement of heart disease. To me, this was not acceptable. That was when I stumbled upon the peer-reviewed research, published by Drs. Dean Ornish and Caldwell Esselstyn, which showed intensive lifestyle changes that halted and even reversed heart disease.1,2 I made a drastic change to my diet, following their recommendations, and gave up animal products, nuts, and added fat, and switched to a whole-foods, plant-based diet. I also turned my attention towards finding ways of dealing with the increasing demands of modern life. I found that reverting to the ancient teachings of yoga and tai-chi was useful, and I became a yoga instructor and personal trainer in an effort to learn more about stress relief and exercise. I lost 25 pounds following this lifestyle change, and

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have made it my mission to help others make positive changes in their lifestyle. Heart disease is the leading cause of death in the United States, killing roughly 600,000 each year. When one looks at epidemiological studies, there is a correlation between heart disease mortality and consumption of animal protein. In fact, in The China Study, T. Colin Campbell found that populations consuming more animal protein had a higher prevalence of chronic diseases like heart disease and cancer.3 The Standard American Diet (SAD)

is composed of far too much animal protein and refined, nutrient-poor food. Furthermore, the inflated marketing budget of fast food pushes our population towards an unhealthy diet. We consume an average of 185 pounds of added sugar or sweeteners a year. That is about as much as a whole person. It is no surprise that 70 percent of Americans are overweight or obese. Rates of type 2 diabetes have also increased steadily, to the point where we now have 100 million Americans who are diabetic or pre-diabetic. We live in a world where calories are unavoidable and exercise is hard to come by, and this is contrary to our genetic programming. When one looks at the rising tide of chronic illness, it is clear to me that drugs and procedures alone will not be enough to stem it. We will need to stop this rise at the source, by influencing the lifestyle that is causing it. The foundational pillars of our medical health don’t lie in high-tech procedures or fancy drugs, but in what we eat, and whether we exercise, reduce stress, get enough sleep, and eliminate bad habits like smoking. Unfortunately, the current healthcare system does not focus on intensive lifestyle programs. We cannot afford to continue building more hospitals, performing more surgeries and dispensing more medication. To help people make the transition to a healthier lifestyle, my wife and I published Healthy Heart, Healthy Planet. In this book, readers learn about the research supporting low-fat, plant-based diets and lifestyle changes to reverse heart disease. While other books have been published on how to reduce heart disease, many of the cookbooks available contain timeconsuming or flavorless recipes. As a result, my wife, Cathi, modified multiple recipes and created new ones in order to prepare low-fat, plant-based meals. There are also several tips on how to plan meals, shop for groceries, and prepare the recipes. Sprinkled throughout our book are eco-friendly kitchen tips and data to lessen our impact on the environment and contribute to a more sustainable future. Additional resources to support people who want to make a change can

At left are Dr. Cathi Misquitta and Dr. Rajiv Misquitta, authors of Healthy Heart, Healthy Planet

be found at www.healthyhearthealthyplanet.com. A portion of the proceeds from our book will be donated to the Plantrician Project and the Sierra Club. The mission of the Plantrician project is to educate, equip, and empower physicians and healthcare practitioners with knowledge about the benefits of plant-based nutrition. The Sierra Club is the nation’s largest and most influential grassroots environmental organization. Our food choices not only impact our health, but also our environment. Plant-based diets are easier on the eco-system. David Pimentel, in his article in the American Journal of Clinical Nutrition, also writes that animal-based foods take more energy, land and water resources than vegetarian diets.4 In a report published in 1978 by soil and water specialists at the University of California Agricultural Extension, it states that it takes 5,214 gallons of water to produce one pound of beef.5 According to data from the USDA, one in seven households in the United States had difficulty in providing enough food through the year. What if the resources saved by consuming more plant-based foods could be devoted to feeding the hungry? Eating a whole-foods, plant-based diet is not just good for you, but it is also good for our planet. Even eating one vegetarian meal a week can make an impact on our environment and is a great way to initiate change. I invite you to join me in taking care of yourself and our planet.

…the inflated marketing budget of fast food pushes our population towards an unhealthy diet.

Rajiv.Misquitta@kp.org 1 Ornish D., Scherwitz L.W., Billings J. et al., “Intensive Lifestyle Changes for Reversal of Coronary Heart Disease.” Journal of the American Medical Association vol. 280, no. 23 (1998): 2001– 2008.

continued on next page January/February 2015

2 Esselstyn C.B., Ellis S.G., Medendorp S.V. et al., “A Strategy to Arrest and Reverse Coronary Artery Disease: A 5-Year Longitudinal Study of a Single Physician’s Practice.” The Journal of Family Practice vol. 41, no. 6 (1995): 560–568. 3 Campbell T.C., Campbell T.M., Lyman H. et al., The China Study (Texas: Benella Books, 2006). 4 David Pimentel and Marcia Pimentel “Sustainability of meat-based and plant-based diets and the environment.” The American Journal of Clinical Nutrition vol. 78 (September 2003): 660S–663S. 5 Tom Aldridge and Herb Schlubach, “Water Requirements for Food Production,” Soil and Water 38 (Fall 1978).

Indian Style Hummus This recipe is a family favorite, and I’ve taken it directly out of our book. It is great for lunch on sandwiches with lettuce and tomato, or served with carrots and celery as an afternoon snack. 3 cups garbanzo beans (chickpeas) ½ tsp. garlic powder ½ tsp. salt ½ tsp. curry powder ¼ tsp. cumin 3 tbsp. rice vinegar ¼ tsp. coriander ¼ cup lemon juice ¼ tsp. paprika ¼ cup chopped cilantro (fresh) 2 tbsp. water or liquid reserved from canned beans 3 oz. sun-dried tomatoes, chopped into relish sized pieces Combine all ingredients except the sun-dried tomatoes in food processor with S-blade and blend for 1-2 minutes, until hummus is creamy. Transfer to a large mixing bowl, and fold in sun-dried tomatoes. Serves 8. Each serving contains: 130 calories, 1 gram of fat, 5 grams of fiber

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Placing Risk of Ebola into Context By Glennah Trochet, MD, former Sacramento County Public Health Officer THE WORLD HEALTH Organization counted 15,351 cases of Ebola as of November 21, 2014. These cases were reported from eight countries around the world and 5,459 individuals had died from the disease. Most of the cases have occurred in the West African countries of Guinea, Liberia and Sierra Leone, but Nigeria, Senegal and Mali have also reported cases related to this outbreak, as have Spain and the United States. There is a very big difference between countries like Guinea, Liberia and Sierra Leone, where Ebola transmission is intense and widespread, and those that have had initial cases imported with localized and limited transmission. Of the number of confirmed cases of Ebola, 588 cases have been health care workers. Of the four confirmed cases in the United States, three were health care workers, and two of these were incidental to the care of one fatality from Ebola in the United States, that took place in Dallas, Texas. Another physician transferred to the United States for treatment has died, but his case is not counted for the U.S. Despite the very small number of cases of the disease in the United States, there has been an enormous amount of concern voiced by elected officials and others regarding the danger that the disease poses to this country. Ebola is a viral hemorrhagic disease that is endemic in several African countries. It was first discovered in what is now the Democratic Republic of the Congo in 1976, and is named after the Ebola River in that region. Five strains of the virus have been identified: Bundibugyo, Ivory Coast, Sudan, Zaire and Reston. Four of these strains cause disease in humans. Reston virus can infect humans, but there have been

no reports of illness and death from it. Over the past decades, there have been several Ebola outbreaks in countries such as Uganda, Gabon, South Sudan and South Africa. However, the current outbreak involving several countries in West Africa is the largest that has been recorded. Ebola can be caught through close contact with blood, secretions or other bodily fluids of a person who is sick with Ebola. It is not air-borne, and a person becomes infectious when symptoms develop. The early symptoms of Ebola resemble those of any viral syndrome: fever, headache, muscle pain, weakness and fatigue; as the disease progresses vomiting and diarrhea are common. Hemorrhage occurs in less than 50 percent of the cases. Because early symptoms are so non-specific, the early diagnosis of Ebola is based on epidemiologic history, such as travel to an area with widespread Ebola infection or contact with a person who is known to have Ebola. Diagnostic laboratory tests include PCR, virus isolation and IgM ELISA early in the disease, with IgM and IgG testing done later in the disease or during convalescence. Symptoms usually appear between 2 and 21 days after exposure, with the average being 8 to 10 days. Survival depends on the individual’s immune system, as well as on good supportive care. According to the CDC, once someone has recovered from Ebola infection, they develop antibodies that last at least 10 years. The biological reservoir of Ebola virus is unknown, although African fruit bats, forest antelope, porcupines and primates are known to carry it, and there has been transmission documented from all of these African animals

January/February 2015

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.

Of the number of confirmed cases of Ebola, 588 cases have been health care workers.

to humans. Dogs are also known to become infected with the virus, but do not appear to be sickened by it. There is no evidence that dogs play any role in the spread of Ebola in Africa. Ebola does not occur naturally outside of the African Continent, therefore, Americans are not at risk for acquiring this disease. Ebola has not been found in bats or primates of any part of the Americas. Only those who have traveled to countries where the disease is widespread, or those who have been in close contact with someone known to have Ebola, are at risk for developing the disease. A person with the Ebola disease becomes infectious when they develop symptoms. In the last hours before death, the virus also becomes extremely virulent. Since there is no infectious period prior to developing symptoms, with proper epidemiologic followup and education, it should be easy to contain its spread. Part of the reason why Ebola has been rampant in West Africa is because there are few trained health care workers, there is difficulty in obtaining personal protective equipment, and there is little infrastructure, such as running water in hospitals. In addition, there are cultural practices that put people at risk, such as family members washing and preparing the body of a loved one immediately after death in preparation for burial. None of these conditions exists in the United States.

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In order to contain the current outbreak, the World Health Organization has called for an international effort that will help affected countries carry out effective treatment of cases with full infection prevention and control, contact investigation, appropriate monitoring of contacts, supervised burials by dedicated expert burial teams, and full engagement of the community with education and risk mitigation. In addition, some extraordinary measures may be needed, including the limitation of non-essential movement in and out of the area, closure of venues where crowds gather, and ensuring that food and adequate supplies, including trained health care workers, can travel to the area. For unaffected countries, there are recommendations for the monitoring of travelers and preparedness for caring for an Ebola patient. The California Department of Public Health has developed protocols for monitoring people at risk for developing Ebola disease that are consistent with CDC guidelines. Public Health departments in each county are responsible for implementing these protocols in collaboration with the medical community. Ebola, like all hemorrhagic viral diseases, is a reportable disease. Physicians should immediately contact the local health department of the county in which a patient lives if Ebola is suspected. Do not wait for laboratory confirmation to report. Public Health workers have been trained to help health care providers decide whether or not a patient is at risk for having Ebola. A knowledge of geography is helpful, as travel to New Guinea (an island in the South Pacific) or Guyana (a country in South America) does not constitute risk for acquiring Ebola infection. In Sacramento, all hospitals have engaged in training for the possibility of a case of Ebola, including teaching personnel how to put on and take off Personal Protective Equipment. Many health care organizations have signs posted in their waiting rooms telling patients to let personnel know if they have traveled to West Africa in the past 21 days, or if they have been

in contact with someone known to have Ebola. Health care workers are being trained to care for patients with Ebola, and some health care systems have developed teams who will be in charge of these patients, should a case occur in this region. All of these precautions should be sufficient to protect the population living in the United States from this threat. It is important to place the risk of Ebola in the United States into context. Although we should be knowledgeable and alert to a possible case, we also should not ignore the fact that in this country, we are more likely to die from a motor vehicle accident or a gunshot wound than from Ebola. Public health experts agree that the most important action to prevent the spread of Ebola is to help the countries where it is widespread to contain the disease within their borders. Health care workers interested in helping to do this should be aware of the risks, trained in personal protection, and aware of the restrictions of movement that may be imposed upon them when they return to the United States. Prospective medical volunteers can contact Doctors Without Borders (Medicins Sans Frontieres), International Red Cross or other organizations that are currently working in the region.

Tracy Zweig Associates INC.

REGISTRY

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trochetg@gmail.com References WHO: http://apps.who.int/iris/ bitstream/10665/131596/1/EbolaResponseRoadmap. pdf?ua=1

Locum Tenens ~ Permanent Placement

CDC: www.cdc.gov/vhf/ebola/index.html Sacramento County Public Health: www.dhhs. saccounty.net/PUB/Documents/Disease-ControlEpidemiology/FL-FAQEbolaSAC.pdf Doctors Without Borders: www.msf.org/article/ faq-ebola-about-disease

V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

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January/February 2015

Medicare in Controversy By Gerald Rogan, MD, Former Medicare Contractor, Medicare Director

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.

“WORDS ARE TO CONFUSE, so that at election time people will solemnly vote against their own interests.” −Gore Vidal, 1992. In the November election cycle for the House of Representatives for the 7th Congressional District, California, the two leading candidates, Dr. Ami Bera and Mr. Doug Ose, proposed to “save Medicare,” but their agendas appeared different. This article focuses on the $716 billion in Medicare cuts projected over the next 10 years, and the changes from the Patient Protection and Affordable Care Act (ACA). What are the planned cuts? Whose income will be cut? Will benefits change? What about beneficiary access to care? In the 2014 election, Republican Candidate Ose said: 1 I am committed to protecting … Medicare. We must start …with a plan that … restores the $716 billion in Medicare cuts …, ensuring Medicare remain[s] solvent. Democratic incumbent Dr. Bera said: 2 … We can reduce runaway health care costs without making dramatic cuts to Medicare that will hurt our seniors. By lowering drug costs, ending wasteful tests, and encouraging preventive care, we can safeguard Medicare for future generations. FactCheck says:3 The $716 billion … cuts, enacted as part of the affordable care act, are cuts to the future growth of spending, which include a $415 billion reduction in anticipated growth payments to hospitals over 10 years. Leonard Schaffer says:4 The cost of Medicare will still increase each year. The ACA enacts 14 tax increases. The ACA increases taxes and penalties to pay for additional subsidies to individuals. The Medicare tax is increased on high earners on their unearned income including a tax on tax-exempt municipal bond income. The ACA

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imposes a medical supply and device tax and an eight percent additional tax on brand drugs that is paid by the manufacturers to the federal government. AARP estimates reductions in future increases to hospitals (2012-2022) will be $260 billion,5 $156 billion less to Medicare Advantage Plans (30 percent of beneficiaries), $66 billion less to home health services, $17 billion less to hospices, and $39 billion less to skilled nursing services. The Medicare Part A trust fund has been declining year after year. The cuts to future increases will prolong the life of the Medicare trust fund. Most of the trust fund is invested in U.S. treasury bonds. Without the reduction in future spending increases enacted by the ACA, the Part A trust fund was expected to be exhausted in 2016. With the reductions, that date is pushed back to 2024. However, some experts, including Medicare’s chief actuary, doubt that some of cuts to expected future increases will be implemented. The Centers for Medicare and Medicaid Services (CMS) claims the ACA will extend the solvency of the Medicare A Trust fund at least to 2029 due to reductions in waste, fraud, and Medicare costs. Presumably, “Medicare costs” means payments made to providers and suppliers.6 MedPAC7 estimates Medicare waste is as much as 30 percent of payments. The Office of Inspector General (OIG) estimates Medicare fraud is seven percent of payments. The ACA attempts to reduce waste by improving coordination of care through two programs: Accountable Care Organizations8 (two percent of beneficiaries affected) and the Comprehensive Primary Care Initiative. The Congressional Budget Office (CBO)

estimated the financial effect of the ACA in 2009.9 In 2011, Richard Foster, the Medicare Chief Actuary, projected the financial effect of the ACA.10 In 2012, the CBO estimated the financial effect of repealing the ACA.11 The ACA does not decrease the Medicare benefits.12 However, some Medicare Advantage plans may reduce their supplemental benefits (e.g. gym memberships, vision and dental coverage), increase premiums, or reduce the size of their physician networks.13 MedPAC tracks physicians who refuse service to Medicare patients. So far, reduced access is insignificant. The ACA expands benefits to include an annual wellness visit. It reduces the cost of part D covered brand drugs by 52.5 percent and 28 percent on generics when the beneficiary pays in the “doughnut hole,” which has saved $8.3 billion across 7.1 million Medicare patients through October 2013. The ACA eliminates the doughnut hole by 2020.14 Medicare Advantage Plans must offer all benefits offered by traditional Medicare in their contractor jurisdictions. There are now 10 Medicare contractor jurisdictions across eight contractors. Under the ACA, Medicare offers more preventive care benefits. The ACA mandates expansions to the minimum benefits packages of commercial insurance. The ACA attempts to improve quality of care by minimally penalizing (up to 0.025 percent of payments) hospitals with the highest rates of hospital-acquired conditions, such as decubitus ulcers; and by penalizing hospitals for excess readmissions within 30 days for myocardial infarction, heart failure, or pneumonia. Improved hospital efficiency will benefit Medicare beneficiaries and payers of the Medicare tax. Unfortunately, over the past 20 years, hospital consolidation has resulted in higher prices without improvement in quality or efficiency.15 Hospitals can charge a facility fee for patients who visit a hospital outpatient facility, resulting in a higher payment by Medicare and patients compared to a visit to the same physician in a physician’s office. Prices are not transparent.

Overall, with more taxes, more benefits, more subsidies, and expanded Medicaid, the ACA is projected to result in a net reduction in the federal deficits by $2 billion between 2012 and 2021. Patients who switch to individual plans may have to change physician networks and physicians. Non-compliant plans may lose subscribers. The effect on business varies. Businesses with fewer than 25 employees may benefit, whilst those with 50 or more may be impaired. Note that one in five Americans is now covered by Medicaid.16 Other considerations under review include multi-year insurance enrollment periods,17 a change in the Medicare fee-for-service insurance design so that beneficiaries who choose fee-forservice (traditional) Medicare must make an uninsured co-payment for selected services. The League of Women Voters18 recommends the following reliable sources of information: the Congressional Budget Office, the Joint Committee on Taxation, Factcheck.org, and the Pew Research Center for the People and the Press. Most health care is local. Local providers are more interested in their own piece of the pie, rather than the entire pie (tragedy of the commons). We will have 10 years of change to the ACA. Already, the ACA has changed 41 times. Medicare law changes about every two years, and regulations change several times a year. The ACA will be no different. You, the reader, can determine whether the reductions of predicted increases (a.k.a. Medicare cuts) are good or bad for Medicare and for the rest of our population. It seems clear that the “devil is in the details.” Understandably, messages of political campaigns may not clarify the details necessary to allow for an informed vote. Accordingly, two candidates with different agendas both promise to save Medicare.

Already, the ACA has changed 41 times.

jerryroganmd@sbcglobal.net Note: For additional information, refer to the Sept-Oct 2014 issue of SSV Medicine for continued on page 35

January/February 2015

Corporeal Punishment of Children The First Lesson in Violence

By John Loofbourow, 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.

PERHAPS NO ONE SINCE Mark Twain has been so effective in the intimate one-manshow style as Bill Cosby. He sits alone on a bare stage and talks, gesticulating with an unlit cigar, occasionally walking about to exchange comments or humorous insults with his audience, while hitching up his baggy, sagging sweat pants. Much of his material consists of first-person observations about his childhood and family, which he represents as very different from the Huxtable family of TV fame that introduced average Americans to sophisticated middle-class family blackness. During his stand-up, many of us in the audience can identify with his stories of “Whuppins” and his mother’s colorful threats of punishment in response to misbehavior; she promised some form of extermination. Cosby’s performance is brilliant, classic comedy in which a sensitive topic is dealt with obliquely through humor. We are relieved to escape into comedy when the subject matter is too serious to speak of − like corporeal punishment of children. We suspect we should treat a child with at least as much consideration as a pet dog! So we laugh in order not to cry over spanking and whupping and corporeal punishment of children. Like most men my age, I was raised when spanking of children was considered a parental duty or a virtue: “Spare the rod and spoil the child!” It was often administered with a dose of rather cynical regret: “This is going to hurt me more than it hurts you!”

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And cloaked in exaggeration and humor: “Speak roughly to your little boy and spank him when he sneezes; He only does it to annoy, because he knows it teases. Be quiet, Pig!” − The Duchess, Alice in Wonderland

Alice and the Duchess, John Tenniel, 1865 Yet “spanking” is a euphemism for striking a child, even though an adult striking — or sometimes even touching – is considered an assault. Corporeal punishment is, somehow,

acceptable in a child, but not an adult, even though the child is relatively powerless. Spanking is nominally intended to discipline, to punish, to correct, to improve future unwanted behavior, or even to protect children from the danger. We are well aware that a dog can be made aggressive by physically harsh treatment. Yet we, as a society, seem more offended by striking of a pet dog than a child. In fact, corporeal punishment is a child’s first lesson in the primordial value of physical violence. It teaches a lesson, the first of many, making clear that might is right. Doctors are sometimes asked about corporeal punishment, and I suspect our responses vary based on our backgrounds and experiences. Yet the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry do not support corporeal punishment, including spanking – the latter suggesting that it can escalate to abuse, make a child learn that aggression is acceptable, and cause the child to behave out of fear rather than from knowing what is right or wrong. Moving to adolescence, aggression becomes righteously Darwinian, directed at those who are different from the norm: weak, ugly, dull, foreign. It can take the form of hazing as a rite of passage for the newcomer or the outsider who hopes to prove worthy of acceptance: high school freshmen boys religiously “head flushed” at the nearby gas station; or justifiable humiliation of college freshmen, fraternity and military recruits. We tend to take such things as the norm, and, fortunately, serious consequences are rare. Yet hazing’s uglier form is mob violence, rioting, lynching, hate crime, and gang violence, including rape. We may delight in violent movies, electronic games, TV shows, and degrading literature. We defend the right to act, dress, or speak in aggressive and violent ways. Isn’t it our attitude that needs changing, rather than some ineffective laws, the Constitution or Bill of Rights? It is not automatic for children schooled in violence to become civil, thoughtful, considerate adults. I, like many people my age, was schooled

in aggression, learning to accept it, especially in males, as normal. I didn’t suspect aggressive actions or words might be interpreted − by those whose personal history was very different from my own − as very frightening or loaded with significance. I learned about the full spectrum of violence from patients, and from those greatest of all educators, Time and Error. Yet there should be a better way than a midlife correction or epiphany; perhaps that can begin in childhood. I suggest that physicians, as members of a profession that so often deals with the consequences of violence, should relentlessly condemn corporeal punishment of children. We must insist a child be treated as well as a pet dog. At the very least, that can do no harm. I am convinced it can do much good. And with that, I will light my cigar. john@loofbourow.com

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January/February 2015

Book Review

Escape From Camp 14 One Man’s Remarkable Odyssey from North Korea to Freedom in the West. Author Blaine Harden, Publisher Penguin Books, Reprint Edition March 2013, ISBN-13: 978-0143122913

Reviewed By Lee Welter, MD THIS IS THE STORY OF Shin Dong-hyuk, the only known person born and raised in a North Korean prison camp to escape to the West. Camp 14 was a North Korean political prison/ labor camp located approximately 60 miles from Pyongyang, the capital city, a camp from which there is no release for its inmates, a camp with a strict and harsh regime, where there is little food and where the work often results in early death. No one had escaped from Camp 14 or any other such camp, until Shin succeeded in

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early 2005, eventually making his way via China and South Korea to the U.S. Imagine a community of obedient residents who know the rules and accept their strict enforcement. The rules are very simple, and are enforced swiftly: 1) Do not try to depart; 2) No more than two residents can meet together; 3) Do not steal; 4) Government agents must be obeyed unconditionally; 5) Anyone who sees a fugitive or suspicious figure must promptly report him; 6) Watch one another and report any suspicious behavior; 7) Residents must complete their daily work assignment; 8) No personal intermingling between the sexes; 9) Residents must genuinely repent of their errors; 10) Those who violate the rules will be shot immediately. For a select few, this is the only life they know. Those few residents are very privileged. Born in this community, they are the product of a “marriage” arranged by the government agents and are given free education in the very disciplined public schools. Any other pregnancy is against the rules; all involved are subject to Rule #10. Blaine Harden’s book is the compelling tale of the “life” (survival) of Shin Dong-Yuk, one of those privileged few citizens. After his amazing escape from the control of Korea’s “Dear Leader,” Shin learned about the outside world, ultimately recognizing that “I am evolving from being an animal.” This book helped me appreciate the world of difference between the slavery of a totalitarian regime and the liberty and justice of a much freer humanity. I strongly recommend this book to anyone who might also appreciate this difference.

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Book Review

The Gut Solution For Parents With Children Who Have Recurrent Abdominal Pain and Irritable Bowel Syndrome. Authors Michael Lawson, MD, and Jessica Del Pozo, PhD. ISBN-13: 978-0615879758

Reviewed By George Meyer FACP, MACG, MD TO BEGIN THIS REVIEW, I must disclose that Dr. Lawson and I worked together for 12 years and we remain in contact. I also must disclose that I have been present for much of the discussions that have lead to the development of this, so far, highly successful program for children with irritable bowel syndrome (IBS). The results of this work were presented as oral presentations at Digestive Disease Week in 2013 and 2014. The book, aimed at parents of IBS sufferers, is divided into two main sections, the first concerned with “Understanding the Problem,” and the second, an introduction of the revolutionary program called SEEDS: Stress and calming the central nervous system, Education and Communication, Exercise with all fours, Diet – How and what to eat, and Sleep. SEEDS has led to a major improvement in the symptoms of children with IBS, resulting in fewer contacts with the medical system by participants. Families are empowered to manage this increasingly common disorder. In the first section, the authors present an overview of the problem and then discuss the brain-gut axis with emphasis on the gate theory of pain. Chapter three discusses the diagnosis of IBS, while the fourth chapter reviews potential tests and treatments. Section two is devoted to the explanation of the SEEDS program with each chapter devoted to the letters in SEEDS. The authors also touch upon the low FODMAP diet (Fermentable Oligo-Di-Monosaccharides and Polyols). Although there are no footnotes to the statements made in the text, the index contains recommendations for further reading.

This book is easy to read and is written with the lay parent in mind. I recommend it to any parent who has a child with IBS, or even for adolescents. Adult sufferers of IBS might also benefit. I also think that pediatricians, family physicians, and gastroenterologists would benefit from reading this book so that they could recommend the SEEDS approach to their patients. geowmeyer1@earthlink.net

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January/February 2015

In Memoriam

Douglas M. Enoch, MD 1933–2014

AN ICON HAS PASSED on to the neurosurgery operating room in the sky. At the relatively young age of 81, Doug Enoch quietly expired on November 14th in the UCD CTICU, where he had fought a month-long battle trying to recover from injuries sustained in a fall. Doug attended Northwestern University where he was AOA and Phi Beta Kappa. He then attended Northwestern University Medical School, and interned at Philadelphia General Hospital. He did his Neurosurgery Residency at the Mayo Clinic, which ended with a year-long fellowship in medical research. In 1967, he joined the Sacramento practice of Drs. Holland and Bard, Douglas M. Enoch, MD which was soon interrupted by a mandatory invitation to join the U.S. Navy (great assignment – San Diego). After his military obligation was completed, he returned to Sacramento and subsequently had many years of busy, successful neurosurgery practice with Dr. Craig Pfeiffer. They also had a short association with Dr. Thomas Boulter. Although he started working at all of the Sacramento hospitals, plus Roseville, the majority of his work was at Mercy San Juan Hospital. His professional memberships included the American Association of Neurological Surgeons, (of which he was board certified), the California Association of Neurological Surgeons, (where he served a term as president), the Congress of Neurological Surgeons, a founding member of the Sacramento Neurological Society, the American College of Surgeons, the American Medical Association, California Medical Association and the Sierra Sacramento Valley Medical Society where he served on numerous

committees and continued on the Medical Review and Advisory Committee until the time of his death. He also was a Clinical Assistant Professor of Neurosurgery at UC Davis School of Medicine. He passed much knowledge to many neurosurgery residents from his vast neurosurgical experience. He also went on two educational exchange trips: one to England, Germany, France, the Czech Republic and Sweden, and the second one to Estonia and Russia. Doug’s community interests included board membership in the Sacramento Symphony and Opera, membership in the James Mitchell Chorale, the Sacramento Capitolaires Barbershop Chorus and the Rotary Club of Sacramento. Doug had a wide love of sports activities and friends in each of these recreational endeavors. These included flying (he was a member of the Sacramento County Sheriff’s Squadron), hunting (big and small game), fishing (big and small fish), skeet, trap, rifle and pistol shooting, snow and water skiing, sailing (he went on sailing charters to the Greek Isles, the Caribbean, the San Juan Islands, and Tonga), power boating and scuba diving. He had a passionate love for his wife of 38 years, Sylvia, his family, his profession, friends, patients, professional organizations and societies, music, and sports. He accomplished more in his 81 years than most could in four lifetimes. He is survived by his wife, Sylvia, his stepson, Mark, brother-in-law, Will, one nephew and four nieces. Doug, we love you and we miss you. Please put in a good word for us. − Frank C. Palumbo, MD

Sierra Sacramento Valley Medicine

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.

Ahdoot, Roben D., Radiology/Interventional Radiology, The Chicago Medical School 1995, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Ahmadi, Mazyar E., Radiology, Drexel University 2004, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Borges, Paula M., Otolaryngology, Stanford University 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322 Brothers, John A., Family Medicine, The Ohio State University 2000, Sutter Medical Group, 1201 Alhambra Blvd., #300, Sacramento 95816 (916) 451-4400 Buss, Kimberly A., Family Medicine, UC Davis 1995, Sutter Medical Group, 3100 Douglas Blvd., Suite 204, Roseville 95661 (916) 774-8885 Cohen, Stuart H., Infectious Diseases, Chicago Medical School 1978, UCDMC, 4860 Y St #0101, Sacramento 95817 (916) 734-2737 Cupp, Davis G., Ophthalmology, Pennsylvania State University 2008, Retinal Consultants Medical Group, 3939 J St #106, Sacramento 95819 (916) 454-6486 Dawson, Lindsey M., OB-GYN, Pennsylvania State University 2004, Camellia Women’s Health, 5821 Jameson Ct, Carmichael 95608 (916) 486-0411 DeNardi, Sofie A., Neonatal-Perinatal Medicine, UC Davis 2004, Mercy Medical Group/Mercy San Juan Hospital-NICU, 6501 Coyle Ave, Carmichael 95608 (916) 537-5135 Evans, Brian T., Radiology, George Washington University 2003, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Fan, Guinea S., Gastroenterology, Dayanand Medical College and Hospital, India – 2002, The Permanente Medical Group, 6600 Bruceville Road, Sacramento, 95823, (916) 688-2000 Getman, Carolyn E., Neonatal-Perinatal Medicine, UC Davis 1984, Mercy Medical Group/Mercy San Juan Hospital-NICU, 6501 Coyle Ave, Carmichael 95608 (916) 537-5135 Goetz, C. Stephen, Dermatology, University of Nebraska 1972, 6401 Coyle Avenue, #315, Carmichael 95608 (916) 966-6444 Gorin, Frederick A., Neurology, Washington University 1979, UCDMC, 4860 Y St #0100, Sacramento 95817 (916) 734-3588 Harrison, Zhanetta M., OB-GYN, UC Davis 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95816 (916) 973-5000

Howell, Lydia P., Pathology/Cytopathology, Northwestern University 1981, UCDMC, 4400 V St, Sacramento 95817 (916) 734-3330 Khaira, Ravinder S., Pediatrics, St. George’s University School of Medicine 1995, 1355 Florin Road, #10, Sacramento 95822 (916) 422-7273 Kugel, Gregory B., Radiology, University of Miami 1998, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Lares, Melissa B., OB-GYN, University of Washington School of Medicine – 2010, The Permanente Medical Group, 1650 Response Road, Sacramento, 95815, (916) 973-5000 Leiserowitz, Gary S., Gynecologic Oncology/ OB-GYN, University of Iowa 1981, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-5959 Lenaerts, Marc E., Neurology/Headache Medicine, State University at Liege, Belgium 1980, UCDMC, 4860 Y St #0100, Sacramento 95817 (916) 734-6284 Lin, Wen, Radiology/Neuroradiology, Mt. Sinai School of Medicine 2008, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040

Sandhu, Sujan K., Pediatrics, University of Southern California 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Shiraga, Sharon, General Surgery/Minimal Invasive Surgery, UC Los Angeles 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Siegel, Bary J., Internal/Geriatric Medicine, UC Irvine 1983, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Steinhorn, Robin H., Pediatric Neonatology, Washington University 1980, UCDMC, 2516 Stockton Blvd., Sacramento 95817 (916) 734-3456 Truong, Vu D., DO, Radiology, WUHS/College of Osteopathic 2004, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Vinh, Phillip P., DO, Radiology, WUHS/College of Osteopathic 2004, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 Yamamoto, Alvin J., Radiology, University of Pennsylvania 2001, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040

Mallari, Alexander O., Internal Medicine/Hospitalist, University of the Philippines 2005, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Maney, Rachel K., Neonatal-Perinatal Medicine, Eastern Virginia 2001, Mercy Medical Group/Mercy San Juan Hospital-NICU, 6501 Coyle Ave, Carmichael 95608 (916) 537-5135

Visit our magazine archives to catch up on previous issues. Just use your smart phone to scan this code:

Marder, Richard A., Orthopedic Surgery/Sports Medicine, UC Los Angeles 1980, UCDMC, 2805 J St #300, Sacramento 95816 (916) 734-6805 Marentis, Theodore C., Radiology/Nuclear Medicine, Harvard University 2008, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 McGarry, Thomas J., Radiology/Neuroradiology, New York Medical College 2005, Mercy Radiology Medical Group, 3400 Data Dr, Rancho Cordova 95670 (916) 363-4040 McLellan, Anne M., DO, Radiology/Pediatric Radiology, Arizona College of Osteopathic 2006, Mercy Radiology Medical Group, 3400 Data Dr, Ranch Cordova 95670 (916) 363-4040 Mirmanesh, Michael E., Plastic Surgery, Drexel University 2014, UCDMC, 2221 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Nishimura, Karen Y., Dermatology, UC Davis 1995, Sutter Medical Group, Three Medical Plaza, #230, Roseville 95661 (916) 797-4766

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January/February 2015

Board Briefs October 13, 2014 The Board: Kris Wallach, Program Director for the Community Service, Education and Research Fund (CSERF), provided the annual report. CSERF is a 501(c)(3) non-profit organization and exists as a vehicle to involve physicians and the larger healthcare community in service, education and research. The primary functions of CSERF are the Sierra Sacramento Valley Museum of Medical History, the William E. Dochterman Medical Student Scholarship Fund, Walk with a Doc, the Sacramento Physicians’ Initiative to Reach out Innovate and Teach (SPIRIT) project and other small projects such as Covered California Provider Education. Approved supporting in concept the reconsideration by the CMA Board of Trustees of maintaining the Ethnic Medical Organization Section Trustee seat on the CMA Board of Trustees as originally recommended in the April 2014 Governance Technical Advisory Committee Report. Approved to make a one-time contribution to CMA to assist in the repayment of CMA incurred expenses in relation to the NO on 46 MICRA Campaign. Approved the Nominating Committee Report containing nominations for the 2015 slate of officers. Approved the following changes in the SSVMS Delegation for the 2014 CMA House of Delegates: 1) Appoint Pat Samuelson, MD to Fill At-Large AlternateDelegate Office #14 (Term 2014-2015); 2) Appoint Olivia Kasirye, MD to Fill At-Large Alternate-Delegate Office #16 (Term 2014-2015); 3) Move Elisabeth Mathew, MD from District 5, Office 5 Delegate to At-Large Delegate Office 11; 4) Move Maynard Johnston, MD, from At-Large Delegate Office 11 to District 5, Office 5 Delegate; 5) Move Kevin Elliott, MD from Alternate-Delegate At-Large #14 to Alternate-Delegate District 1 Office 1. Approved the Membership Report: For Active Membership — Gauray Aggarwal, MD; Roben D. Ahdoot, MD; Mazyar E. Ahmadi, MD; Paula M. Borges, MD; William E. Bragg, MD; David G. Cupp, MD; Lindsey M. Dawson, MD; Sofie A. DeNardi, MD; Brian T. Evans, MD; Howard J. Fan, MD; Carolyn E. Getman, MD; Zhanetta M. Harrison, MD; Gregory B. Kugel, MD; Wen

Sierra Sacramento Valley Medicine

Lin, MD; Rachel K. Maney, MD; Theodore C. Marentis, MD; Thomas J. McGarry, MD; Anne M. McLellan, DO; Sujan K. Sandhu, MD; Vu D. Truong, DO; Phillip P. Vinh, DO; Alvin J. Yamamoto, MD. For Reinstatement of Active Membership — Kimberly A. Buss, MD; C. Stephen Goetz, MD; Karen Y. Nishimura, MD. For a Change in Membership from Multiple to Active Membership — Vanessa J. Mandal, MD. For Reinstatement to Retired Membership — Ronald A. Rogers, MD. For Retired Membership — Richard N. Astorino, MD; Franklin L. Banker, MD; Alan P. Cubre, MD; Arthur T. Glover, MD; Richard D. Hauch, MD; Thomas P. Kidwell, MD; Paul R. Phinney, MD; Gail Pirie, MD; Myo Shin, MD; Richard R. Stack, MD; Nancy P. Torres, MD; David C. Yang, MD. For Resignation — Erin A. Boyd, MD (moved to Portland, OR); Gehan P. Devendra, MD (moved to Hawaii); Xin Gao, MD (transferred to Stanislaus); Sonya S. Heitman, MD (moved to Ventura); Naduvathusery J. Jacob, MD (transferred to Solano); Diana D. Lee, MD (moved to Henderson, NV); Dave C. Lu, MD (transferred to Solano); Matthew J. Lutch, MD (transferred to San Diego); Vivek Mittal, MD (transferred to Fresno); Tuan A. Nguyen, MD (Resident Member transferred to Placer-Nevada); Bernard Ormsby, DO (transferred to DO Society); Maureen R. Park, MD (transferred to San Mateo); Robert F. Stephens, MD (Resident Member Transferred to San Diego); Marie K. Yamamotoya, MD (moved to Hawaii).

November 10, 2014 The Board: Approved the Third Quarter 2014 Financial Statements, Investment Reports and Recommendations for SSVMS. Approved the 2015 SSVMS Budgets for the General Fund and the Building Fund. Serving as the Board of Directors to the Community Service, Education and Research Fund (CSERF), approved the Third Quarter 2014 Financial Statements, Investment Report and 2015 Budget. Approved the following Scholarship and Awards Committee recommendations for the 2014 annual awards:

Delphine W. Ong, MD, Golden Stethoscope Award; Paul R. Phinney, MD, Medical Honor Award; Elizabeth Cassin, CEO, Elica Health Centers, Medical Community Service Award. The recipients will be honored at the January 8, 2015 SSVMS and Alliance Awards and Installation Dinner at the Hyatt Regency Hotel. Approved the selection of the accounting firm of James Marta & Company LLP to perform the annual audit, audit review and prepare the tax returns and schedules for SSVMS and CSERF. Ratified the 2014 election results. Approved the Membership Report: For Active Membership — John A. Brothers, MD; Stuart H. Cohen, MD; Guinea S. Fan, MD; Frederick A. Gorin, MD; Melissa B. Lares, MD; Gary S. Leiserowitz, MD; Marc E. Lenaerts, MD; Alexander O. Mallari, MD; Sharon Shiraga, MD; Robin H. Steinhorn, MD. For Reinstatement to Active Membership — Lydia P. Howell, MD; Ravinder S. Khaira, MD; Richard A. Marder, MD; Bary J. Siegel, MD. For a Change in Membership Status from Resident to Active — Naomi E. Ross, MD For Resident Membership — Michael D. Mirmanesh, MD For a Change in Membership from Active to Active 65/20 — Lawrence Bass, MD; Steven Polansky, MD For Retired Membership — Sandra I. Barbour, MD; Joanne Berkowitz, MD; Aaron C. Cook, MD; Michael Lawson, MD; Gerson Stauber, MD; Terry M. Williams, MD

For Resignation — Florence B. Chong, MD (transferred to Orange); Guy L. DiSibio, MD (transferred to San Mateo); Benjamin L. Franc, MD (transferred to San Francisco); Estella M. Geraghty, MD (transferred to San Bernardino); Karna S. Gocke, MD (transferred to Santa Barbara); Donald M. Hilty, MD (transferred to Los Angeles); Jason H. Kim, MD (transferred to Orange); Richard J. Maddock, MD; Anjlee Mahajan, MD (transferred to San Francisco); Laila Niazi, MD (transferred to Ventura); Erica C. Niedbalec, MD (transferred to San Diego); Brian F. Poirier, MD (moved to Arizona); Usha Rao, MD (moved to Dallas, TX); Lorenzo Rossaro, MD (transferred to San Mateo); Kelly C. Wilkenson, MD (moved to Idaho).

DocbookMD is a FREE communication tool for physicians who are members of SSVMS. DocbookMD allows physicians to send X-rays, EKGs, and other patient information directly to their colleagues for quick consultations. Find out more at

Medicare in Controversy continued from page 27 Dr. Rogan’s article, “Who Runs Medicare?” In it, Dr. Rogan discussed how Medicare works and what does its future hold? References: 1 www.dougose.com/issues accessed 11/17/2014 2 http://bera.house.gov/issues/health-care#medicare accessed 11/17/2014 3 www.factcheck.org/2012/08/medicares-piggy-bank/ accessed 11/17/2014 4 www.rand.org/multimedia/audio/2014/06/12/affordable-care-actchange-only-constant.html 5 www.aarp.org/health/medicare-insurance/info-12-2013/medicareand-affordable-care-act.html 6 www.medicare.gov/about-us/affordable-care-act/affordable-careact.html 7 www.medpac.gov/ 8 www.medicare.gov/manage-your-health/coordinating-your-care/ accountable-care-organizations.html

9 www.cbo.gov/publication/25017 10 http://budget.house.gov/uploadedfiles/fostertestimony1262011. pdf 11 www.cbo.gov/sites/default/files/cbofiles/attachments/43471hr6079.pdf 12 www.medicare.gov/about-us/affordable-care-act/affordable-careact.html 13 www.aarp.org/health/medicare-insurance/info-12-2013/medicareand-affordable-care-act.2.html 14 www.medicare.gov/forms-help-and-resources/mail-about-medicare/comprehensive-primary-care-initiative-notice.html 15 Paul Ginsberg referenced by Leonard D. Schaeffer: www.rand. org/multimedia/audio/2014/06/12/affordable-care-act-change-onlyconstant.html 16 www.rand.org/multimedia/audio/2014/06/12/affordable-care-actchange-only-constant.html 17 www.rand.org/topics/patient-protection-and-affordable-care-act. html?gclid=CLvkzLPWicICFdKEfgodOIkARA 18 http://lwvpt.org/files/aca_mythsfactsLWV.pdf

January/February 2015

Cover Image Details By Inam Ali, RA II THE COVER PHOTO FOR THIS issue was taken of the Orion Nebula on October 21, 2014 at Blue Canyon with a Stellarvue SV80 Triplet 80mm telescope, and a QSI 683 monochrome CCD camera with filterwheel containing colored filters. I would finish an imaging session with five Luminance frames, five Red frames, five Green frames, and five Blue frames, with each frame being 10 minutes in exposure length (a total of 200 minutes). The concept behind taking multiple frames and stacking them together with software is to enhance the detail of the object and reduce image noise or defects. The mount alone is not accurate enough to follow the object with precision, which is where my Lodestar guiding camera comes into play. The Lodestar assists with precision tracking by taking a picture of a star near the object every five seconds and correcting the mount’s tracking ability. The Orion Nebula is located in the distant constellation Orion and is categorized as an emission nebula. An emission nebula emits radiation from ionizing gas, usually ionized hydrogen which appears in a pink or red color. While the nebula may not appear to change shape due to its distance and size, its structure is constantly in movement from clouds of gas and dust traveling at speeds of up to 10 km/sec or more. This nebula is known for its star formations. Stars form when clumps of hydrogen and other elements and gases contract under their own gravity.

The nearby Running Man Nebula (the blue/purple object to the left of the Orion Nebula) is a reflection nebula. A reflection nebula is made up of interstellar gas and dust with no nearby stars close enough to ionize the contents of the nebula to make

it an emission nebula. However, the nearby stars are close enough to cause their light to reflect off the contents of a reflection nebula, which makes the nebula visible. Inam_Ali@CalPERS.CA.GOV

Meet Mrs. Chase By Bob LaPerriere, MD, Curator, SSVMS Museum of Medical History A RECENT CALL FROM the School of Nursing at California State University, Sacramento, offering an item for our Medical Museum collection, led me to pick up an unexpected donation. There, sitting in a wheelchair waiting for her transportation, was ”Mrs. Chase.” Also, affectionately called Josephine, Arabella and Miss Demon Strator, Mrs. Chase was the second generation of a “simulation mannikin” used from 1910 to the 1970s for training nurses, a major improvement over the prior straw-filled mannikins. She was created by a former doll maker who was convinced by her husband, a physician, to develop an adult-sized version of her dolls. Mrs. Chase, for decades, has endured daily baths, enemas, splints, injections, dressings

Sierra Sacramento Valley Medicine

(bandages) and shampoos. She now resides at peace in our Museum of Medical History.

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