Sierra Sacramento Valley
MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
March/April 2015
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.
Sierra Sacramento Valley
Medicine 3
PRESIDENT’S MESSAGE Addressing Access of Care for Mental Health Patients
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Annual Meeting
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A VA Hospital Then
Jason Bynum, MD
Ann Gerhardt, MD
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EDITOR’S MESSAGE Segregation in Medicine?
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SSVMS 2015 Committee Appointments
Nathan Hitzeman, MD
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Tomorrow’s Medics Today
Bob LaPerriere, MD
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e.Letter to SSV Medicine
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Anne Rudin – From Mayor to Mentor
Personal Reflections on Ebola Disaster Relief Work
F. James Rybka, MD
Hernando Garzon, MD
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SSVMS Election Results
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Report on the 2014 CMA House of Delegates
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Science Olympiad
Richard N. Gray, Jr., MD
Bob LaPerriere, MD
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Haiti and Quarantines
A Posit on Addressing Work Email at Home
George Meyer, MD
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Classified Advertising
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BOOK REVIEW Stiff – The Curious Lives of Human Cadavers
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Welcome New Members
Jack Ostrich, MD
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Board Briefs
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 SSVMS Alliance member, Joanne Graham, Ph.D, R.D., photographed this butterfly in the Monteverde cloud forest of Costa Rica in November of 2014 while on vacation with her family. The scientific name of this butterfly is Heliconius hecale zuleika, also known as Tiger Butterfly. Butterfly gardens seem ubiquitous throughout this lush, tropical country. The butterflies are most active in the mornings and when it is sunny. They seemed to enjoy the rotting mangos set out by the staff. Joanne photographed this one with a Nikon D90 on manual focus, while her husband, Dr. Nate Hitzeman, sat drinking Costa Rican coffee on a nearby bench. Their wings are very fragile, much to the horror of one of their daughters who accidently bent one and then proceeded to cry inconsolably.
March/April 2015
Volume 66/Number 2 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org
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Sierra Sacramento Valley
MEDICINE 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.
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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.
Sierra Sacramento Valley Medicine
President’s Message
Addressing Access of Care for Mental Health Patients By Jason Bynum, MD AS 2015 BEGAN, THE medical society enjoyed a robust turnout at the Annual Installation and Awards dinner held January 8 at the Hyatt Regency Sacramento. At the event, we honored Drs. Delphine Ong and Paul Phinney, recipients of SSVMS’ Golden Stethoscope and Medical Honor awards, respectively. Elizabeth Cassin, CEO of Elica Health Centers, and Sita Lalchandani, were also recognized for their contributions to our community. Each award recipient was extremely deserving, and I am continually awed by the generosity and compassion of our local medical community. As a psychiatrist, I am deeply concerned about the lack of mental health access in our region. I am acutely aware of the difficulties in the emergency room waiting times leading to overt “boarding” of patients with mental illness for days at a time, as well as the difficulty in appropriately discharging hospitalized patients with a dwindling support structure as an outpatient. I am pleased to report that SSVMS, through the efforts of our Emergency Care Committee and Mental Health Task Force, has made significant progress in researching and developing proposed solutions to increase access to crisis stabilization services. SSVMS is part of a newly-convened group of stakeholders, which includes physicians, health systems, community clinics and key Sacramento County personnel in the Departments of Health and Human Services and Behavioral Health. This stakeholder group has devoted significant time and resources to working collaboratively on solutions to the mental health crisis in our region.
In addition to the efforts listed above, members of SSVMS’ Emergency Care Committee are working diligently on standardizing admission criteria for patients discharged from the emergency department to local inpatient psychiatric hospitals. Standardization, along with printed admission criteria to be placed in each ER, is the ultimate goal. This endeavor has included evidencebased, best practice recommendations, and will also soon include discussions with each of the area psychiatric hospitals in collaboration. It is our hope that this effort will reduce administrative time significantly, and will reduce wait times in the ER by hours or days. Although the immediate need is to dis-impact the region’s emergency departments of psychiatric patients who can be best cared for in other settings, it is equally important that we address the difficulty in accessing preventive care for individuals struggling with mental illness. By addressing continuity of care across the spectrum of inpatient and outpatient care, I believe we can really make a difference in the Sacramento region and beyond. In short, what we are leading here at the medical society is a complete overhaul of the mental health system in Sacramento. While this is a lofty endeavor, and most likely will not be complete by the end of my presidency, this “top down,” broad-level view of service arrangement is very exciting. I can assure you that the excitement level for change is strong, and very contagious. I welcome your input as we move forward. jbynum23@me.com
March/April 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.
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Editor’s Message
Segregation in Medicine? By Nathan Hitzeman, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
WITH THE RECENT RELEASE of the movie Selma, the anniversary of Dr. Martin Luther King, Jr.’s birthday, and a news flash that the world’s richest one percent is on track to own 50 percent of the world’s wealth next year, I got to thinking about modern day segregation. Although overt racial segregation is largely gone in this country, segregation has become more financial and class-based. In certain ways, we also practice segregation in medicine due to organizational, insurance-driven, and political constraints. I would argue that when we pull the rug out from Medi-Cal reimbursement so that docs cannot recover costs, when we limit access to health care for the poorest and most vulnerable, when we use emergency rooms as medical homes for our psychiatric patients, we are, in essence, practicing segregation. “You, Mr. Banks, may see our multidisciplinary pain management team, and you, Mr. Jones, need to take the bus to Vacaville to see a pain specialist outside your usual network.” In residency, I remember seeing a wellto-do patient from Rocklin in the downtown emergency department horrified to see nearby street people ranting, one of them with a spit net on. Perhaps the ED is the equalizer where all of humanity must mingle. You can learn a lot about your community through a stroll down the hall of your ED, and it may not be pretty! As we pay off our medical student loans and nestle securely into our practices, some of us move to more affluent, better school communities. We may get NPPAs to talk to our more “difficult” patients and free us up for those anesthetized patients awaiting procedures. We may use our phone staff to shelter us from the Vikings with their helmets and swords – and forms that need to be filled out. We may drive home from our preferential
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physicians’ parking to our gated community and lock the doors as we pass the homeless near the train tracks. Are we losing touch? Are we making our community healthier? Much of community health relies on social determinants, more so than anything modern medicine can do. The articles on Haiti and West Africa in this issue speak to this. And when the most vulnerable get sick, it affects us all. The Letter to Editor on why it is hard to find physician providers for FQHCs and MediCal patients speaks to the need to incentivize more doctors to provide continuity for poor patients. Jim Rybka’s interview with former mayor Anne Rudin speaks to the need to find leaders who can effect change and help everyone in the community rather than spout out sound bites and run everything past their handlers first. I’ve been to enough poor countries to know where financial segregation leads. Next, we drive to work with throngs of poor people selling Chiclets and water bottles at intersections. When we park at the store, we pay someone to watch our car so that it doesn’t get broken into. When we return home, we pass through guarded, barbed wire fences into our driveways. Short of creating an orbiting Elysiumstyle space station for the wealthy residents in Silicon Valley (and they might be working on it!), we are all connected here on Earth. The widening wealth split translates into poorer health for most, which affects us all. Many docs donate, volunteer, serve the most vulnerable on our free time, but we need leaders to address the root of the problem. As physicians, we need to make our voices heard that our communities’ health is suffering! hitzemn@sutterhealth.org
e.Letter to SSV Medicine Re: Sacramento County’s Fraying Medical Safety Net
Dr. [Celeste] Reinking describes the precarious state of the local FQHCs [Federally Qualified Health Centers], but the situation is no better in the traditional Medi-Cal provider network. This loose collection of PCPs, known to the state as “high-tech providers” because they self-attested for meaningful use funds, provides Medi-Cal services to more than twice the number in Sacramento who are cared for by FQHCs. Most Medi-Cal providers in the private sector are hold-overs from the early days when most enrollees were healthy children and their mothers. In the days of the old Medi-Cal, our most vulnerable and fragile, the sickest of the sick, received their care at UCD’s specialty clinics, the emotionally ill at the County Mental Health Clinic, and the uninsured at the county clinics or local emergency room of their choice. All that has changed, and these
patient groups make up the new Medi-Cal. What has been the response to this influx of sicker, older and more Medi-Cal enrollees? Young doctors are heading for the large health systems that don’t partake in Medi-Cal, and young NPs and PAs are no match for the complexity of the new Medi-Cal enrollee or the ever-increasing expectations of the health plans. With the ACA, Medicare parity funding ended, and without the subsidies afforded the FQHCs, this component of Sacramento’s safety net will soon be gone. Dr. Reinking correctly described the dire shortcomings within the FQHC sector, but missed the fact that things are much worse outside that sector. Isn’t it time that we all recognized that the emperor has no robes? −Gilbert Simon, MD, Medical Director, Sacramento Family Medical Clinics
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
Saturday, June 6, 2015
LOCATION: Morse Park, 5540 Bellaterra Drive, 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:
—William Nakashima, MD
March/April 2015
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Anne Rudin – From Mayor to Mentor By F. James Rybka, MD On August 18, 2014, former mayor Anne Rudin granted an interview to members of the SSVMS Historical Committee that was conducted by Dr. Jim Hamill with Drs. Bob LaPerriere and Jim Rybka in attendance. In August 1920, the Nineteenth Amendment was ratified, granting voting rights to American women. However, their influence and involvement in politics emerged rather slowly. Leaders were needed, and a person in our community who has devoted her life to this role is former Mayor Anne Rudin.
Nursing Student
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 1924, Anna Noto was born in Passaic, NJ, where her parents were Italian immigrants. Soon her father’s quest for work moved the family to Philadelphia where she grew up. After high school, she became interested in a nursing career. “At the time I went into nursing, I didn’t know what else to go into. The women I knew were all either teachers, or librarians, or nurses. … I had an aunt who was a nurse, but she didn’t want to encourage me. She used to come to our home for dinner some nights after working all day, and she was exhausted and did not want to recommend it for anybody. It was really hard work. You had to work 12-hour shifts, and you did not have nursing assistants helping to do things that nurses get help with today.” Anna decided to do it anyhow, and ended up taking a five-year course − two years of college and then three years of nursing, graduating from Temple University with a bachelor’s degree. For part of her training, she rotated
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to the Philadelphia Hospital for Contagious Diseases where she worked on the polio ward. She has touched on this experience in an article that appeared in the September-October 2007 issue of our journal. The nurses applied “Kenny Packs,” squares of woolen blankets that, using tongs, had been dipped in steaming hot water to be applied to the afflicted paralyzed limbs of patients that, along with passive exercises, helped to prevent contractures. Those with bulbar polio were confined to iron lung respirators powered by electricity to create a negative pressure, simulating a diaphragm. A nurse was assigned to each such patient 24 hours a day, divided into three shifts. The nurse never left the patient unless there was a replacement. Power failures were not uncommon during summer thunderstorms. This alerted the staff to mechanically move a lever and take over the pumping action until the power was restored. They fed the patients and, using side port holes, gave them bed pans, turned them and exercised their limbs. They tried to keep up the patient’s spirits and would write notes for them to their relatives.
Marriage After graduation, Anna worked at Temple University Hospital where she also taught classes to nursing students. It was at this time that she met a Temple medical student, Ed Rudin. In the course of their dating, she recalls one particular day when it was snowing that they visited an abattoir together, and he helped her carry several packages of freshly-slaughtered animal organs − hearts, brains and kidneys
− back to the classroom for her students to dissect. By the time Ed graduated, they had agreed to get married, but they postponed this until after he finished his internship at Cedars of Lebanon Hospital in Hollywood. Then they got married in Philadelphia and moved to California where Ed had a residency at the Palo Alto VA Hospital. There they were provided with a Quonset hut for housing that they found very comfortable. Within a few years, they had three baby girls − the first followed 16 months later by twins. After Ed’s residency, they moved to Riverside where he served in the military as a psychiatrist at March AFB, one of only two military psychiatrists on the West Coast. After discharge, he became director of the Riverside State Mental Hygiene Clinic. By then, they had a fourth child, a boy, and Anna, who had begun to use Anne as her name, decided not to go back to work. Rather she would stay at home to raise the children. “But I had to have something else to keep me busy, and the League of Women Voters was just starting in Riverside. I was one of the founding members and, before I knew it, I was president. I went through the chairs, and I enjoy doing things like voter service, encouraging people to vote, getting them registered, presenting information about issues and candidates.” Soon Ed was recommended for a position in Sacramento to manage mental health under then Governor Pat Brown. He accepted it, and, in 1958, they bought a home in Land Park where she still lives. They were not here long before they each found a number of public projects to take on as volunteers. In fact, looking back, Sacramento probably has never had a more community-active couple than Ed and Anne Rudin.1 In the Capital City, the League was not new, but it was desperate for leadership, and it was not long before they asked Anne to be the president. She accepted and served for a couple of years, and then went on the state board where she became President of the California League of Women Voters.
“After that was over, I came back to local positions. And this (the League)2 is my hobby because it keeps me involved with political issues without having to be political.”
Former Sacramento Mayor Anne Rudin
Sacramento City Council 1971–1983 Despite her attempt to eschew politics, Anne was already a recognized local figure, so, in time, people began to ask her to run for the city council to represent District Four. It was a tough decision for her, but she finally agreed to run, and she won. At this time, Sacramento
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of initiat-
County directed most of the area’s health issues that were centered at the County Hospital. However, the city did have a Health and Human Services Committee, and the mayor appointed Anne as the chair. When Planned Parenthood wanted to have a downtown office for their headquarters, it became an issue because nobody wanted them in their neighborhood. She wanted to back them and find a place for them. In 1980, she proposed the first gay rights ordinance that prohibited discrimination against people because they were gay. She is particularly proud of initiating the ban on indoor smoking. For this, she found good support from the department stores, theaters and other merchants because people would go in with their cigarettes, would handle the merchandise and drop ashes on fabrics, causing cigarette stains on table linens, seats and rugs. The health issue was crucial, indeed, but aside from that, Sacramento merchants were being squeezed, having to pay for burned or damaged merchandise.
ing the ban
Mayor of Sacramento 1983–1992
on indoor
Sacramento City then was divided into eight districts, each of which elected a council member. Under the city charter rules, the eight council members selected one from their group to be mayor. This changed before the 1983 election. Thereby, Anne became the first mayor directly elected by the city’s entire populace. In regards to public health issues, in 1986 she helped organize an AIDS awareness task force “because people thought you might get AIDS from just shaking someone’s hand.” Furthermore, she spearheaded the installation of Sacramento’s light rail that made the city healthier with fewer vehicles on the roads and less exhaust. “I always appointed task forces; I never tried to do it all myself. I had a task force on AIDS and I spoke and gave testimony to a presidential commission. I had to go to San Francisco for that. I had task forces on drugs, child care, domestic partners, the ”buckle up” project for safe driving, and mental health issues. I even
She is particularly proud
smoking.
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appointed a task force to do something for pet overpopulation. …That’s what I liked about it. When you saw something wrong, you could do something about it. You didn’t have to pass a law, necessarily. You formed a task force and let them investigate it so it wasn’t just your idea. There was so much that a mayor could do.” Asked what she is doing now, Mayor Rudin replied: “People forget how old I am.” (She recently turned 90.) “They keep asking me to do things. I am trying to gradually groom other people to take my place. I’m still active in the League of Women Voters. I can’t give that up. That’s part of me. ...Every week I say, I am not going to take on another responsibility, and then something comes along and I cannot turn it down. And I guess, because of my long, long experience, they want me there. And that’s OK. I enjoy community work. I enjoy being influential. And it’s because of my longevity that I am influential, and people remember things that I have done. … So I’m called on to send letters, to appear before committees, and I’m willing to do that. But I am trying to hand it over to somebody else.” What an impressive legacy this former nurse has created from a second vocation: serving as a community volunteer for many years. jimrybka@hotmail.com 1 Ed Rudin, MD 1922-2003. In Memoriam, SSV Medicine, Vol. 54/ No. 4Jul/Aug 2003. 2 www.lwvsacramento.org/lwvs_info/mission.htm
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March/April 2015
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2015 Board of Directors
2015 CMA Delegation
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Sierra Sacramento Valley Medicine
Science Olympiad A Winning Program for Winning Students
By Bob LaPerriere, MD THROUGH THE FAMILY OF THE student who won our Museum of Medical History’s 2014 award for a History Day project, I learned about the Science Olympiad (http://soinc. org). Starting as a grassroots assembly of science teachers 31 years ago, this national non-profit organization has led a revolution in science education, providing standards-based challenges to almost 7,000 teams in 50 states. It affects both students, who are exposed to practicing scientists and career choices, and teachers, who become energized. The program spans students from kindergarten through 12th grade, and is dedicated to improving the quality of science instruction, recognizing promising young scientists, and increasing student interest in STEM-related fields which are the disciplines of science, technology, engineering and mathematics. Our medical museum became a sponsor for the Life, Personal and Social Science category which includes Anatomy (Cardiovascular,
Integumentary, Immune), Bio-Process Lab, Disease Detectives (Population Growth), Entomology and Green Generation. Other categories include: Earth and Space Science; Physical Science and Chemistry; Technology and Engineering; and Inquiry and Nature of Science. On December 6th, about 400 students in grades 6-9 spent their Saturday at Winston Churchill Middle School for the 2014 Northern California Science Olympiad Invitational. As a sponsor, we were able to have a table with exhibits and information on the SSVMS Museum of Medical History. Drs. Donald Hopkins and Gail Pirie assisted me in staffing the exhibit, which was well received. Churchill Middle School and Arden Middle School have won the Northern California Science Olympiad for nine years, and Churchill placed second in the National Competition in 2014. A link to the website showing the depth of this program for the anatomy category is: http:// soinc.org/anatomy_physiology_b. drbob@winfirst.com
March/April 2015
Above, Drs. Gail Pirie and Donald Hopkins man the table for the SSVMS science display. At lower left, winning students say “Thank You” to SSVMS for its support.
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
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Haiti and Quarantines By George Meyer, MD, FACP, MACG
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
I RECENTLY RETURNED from a brief visit to Haiti. They are still recovering from the terrible earthquake in January 2010 which killed more than 100,000 people and destroyed many buildings, including the president’s palace. The Montana Hotel, one of their best with a beautiful view over the city, collapsed all seven floors. They are continuing to dig out. Apparently, there is a State Department warning about safety in Haiti. My host said that the current president of Haiti has taken major steps to significantly decrease the almost daily kidnappings that have been occurring since the earthquake. I felt safe because we were always in his car when in the community; no one tried to get into the car while we were in it. I was interested that my host kept a pistol in his vehicle when he was driving. He says he has never had occasion to use it. The government-supported medical school’s buildings were destroyed by the earthquake. Many offices now are in large shipping containers. They are teaching classes in classrooms borrowed from other departments in the university. The United States Agency for International Development (USAID) has recently given a $20 million grant to rebuild the school; construction has started and is expected to be finished in two years. In the past 15 years, there have been four private medical schools that have started, all in the capital city of Port-au-Prince. These schools are six-year schools with entry-level students beginning after high school. The public medical school received over 8,000 applications for 125 first-year places. Six years later, they graduated 70-80 students. The other schools apparently graduate 80-100 each year. Some students choose to go elsewhere for medical school; some attend school in the nearby Dominican
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Republic. Tuition at the national school is free, while the private schools cost about $3,000 per year for six years. After graduation, there is a requirement to perform a year of social service, usually in a hospital under supervision (sounds like a rotating internship). After that year, doctors can apply for a residency. They all take the same ranking test, and those with the highest marks get to pick their residency of choice. It was not clear to me if there is a national licensing examination or not. Haiti’s national hospital was once a 700-bed hospital; following the earthquake, they are now able to operate in only 400. There are four hospitals that support internal medicine residency programs, a three-year process. I think any subspecialty training is usually done outside of Haiti. There are about 200 internists in Haiti, with general internal medicine and subspecialists. I was invited to speak at the second annual meeting of the Haitian College of Internal Medicine. This year they focused on IM emergencies. Although I am not a Francophone, I thought the topics were well chosen and the speakers generally were quite good (many slides were a combination of French and English). Next year, they will address internal medicine problems in the pregnant patient. Although I did not make hospital rounds, I was able to visit one GI office (there are only five gastroenterologists in Haiti, all in Port-auPrince). They do upper endoscopy and colonoscopy. Apparently no one in Haiti performs ERCP or endoscopic ultrasound. Esophageal motility is not available, either. There is cardiac ultrasound available in certain hospitals, and CT scanning is also available. I do not know about MRI availability. I was well cared for. The restaurants we
visited were very good. I was told that they all had clean ice. I tried to avoid eating unpeeled fruits and vegetables, but did succumb on Saturday evening to some wonderful tomatoes. Around 2 AM Sunday morning, I developed gastroenteritis with vomiting and diarrhea, which I was able to stop with Pepto-Bismol that I take with me when traveling. The reason I even mention this is that upon returning to Miami to go through passport control, the first question was, “Have you had fever, diarrhea, or vomiting in the past three weeks?” As soon as they saw my “yes” response, I was given a mask and escorted to a very sterile area where they keep their deportees and medical quarantinees. The room I was asked to sit in had narrow steel benches, and the only toilet was not in a separate room and could not be flushed by the user (can anyone say MULE?). After five separate individuals of increasingly higher rank asked me the same questions, they told me I could not be released until CDC said so. They went
off and 15 minutes later I was freed to catch my next plane with the warning to let CDC know if I got sick again. It was a very interesting trip and interesting to see my reception in Miami. They are primed to look for Ebola, but their officers are not knowledgeable on how to protect themselves should a real case show up. geowmeyer1@earthlink.net HISTORICAL NOTE: Haiti was originally supposed to be part of Napoleon’s strategy to use the Caribbean islands as part of his keeping the French interest in mainland North America, mainly centered in New Orleans. However, a slave uprising in Haiti led to Napoleon sending many troops to Haiti. After he lost more than 55,000 men, mostly from diseases in Haiti, he elected to sell New Orleans and the Louisiana Purchase for $15 million to help fund his activities against Britain.
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March/April 2015
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Book Review
Stiff – The Curious Lives of Human Cadavers Reviewed by Jack Ostrich, MD
Author, Mary Roach; Publisher, W. W. Norton & Company (2003); ISBN13: 978-0393050936
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.
FIFTY YEARS AGO, I walked into the Gross Anatomy Laboratory in McGuire Hall at the Medical College of Virginia in Richmond. It was time to meet my cadaver. I should say “our” cadaver, as there were four students assigned to each of the dark brown body bags that lay on the spotless, stainless steel tables. My fellow dissectors were all from Virginia − Rick, Harold, and Kinloch, who pronounced his name Kin-law. He was the only one of the three local boys who had a distinct and mellifluous Virginia accent. Directed by our instructor, we unzipped the bags and the air rapidly became infused with the smell of formalin admixed with an odor that reminded me of the skunk cabbage (Symplocarpus foetidus, if you must know) that grew in a swampy area near my home in Connecticut. Quite an olfactory combination. But Kinloch seemed enthralled and not at all displeased by the smell. He smiled broadly and exclaimed, “That smells just like Smithfield ham!” Kinloch then enthusiastically unzipped the bag fully, and there she lay, our cadaver. She looked to have been probably in her 60s, and she was ectomorphic. Unlike many of her much more obese colleagues on other tables, she had no superficial deformities or scars. We stood staring for a moment, and Rick said, “Let’s name her ‘Laura.’” So we all asked, “Why Laura?” Rick answered that he had recently seen the movie “Laura” on TV and could not get
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the song out of his head. And so the name stuck. Laura she was, and she served us well. In 2003, Mary Roach wrote a book entitled, Stiff, and subtitled “The Curious Lives of Human Cadavers.” It sold well, although it did not make the Amazon Top 100 for 2003 or 2004. But when I went to the Arden Fair branch of Barnes and Noble, the clerk knew exactly where to find it. They had three paperback copies on the shelf. He said they still sell a few copies now and then, so they keep some fresh ones for customers (weirdos?) like me. Ms. Roach writes in a lively, casual and occasionally flippant style about what most of us would agree is a fairly grim topic. She begins: “The way I see it, being dead is not terribly far off from being on a cruise ship. Most of your time is spent lying on your back. The brain is shut down. The flesh begins to soften. Nothing...happens and nothing is expected of you.” And so... “Why lie around on your back when you can do something interesting and useful? For over 2,000 years, cadavers have been involved in (some of) science’s boldest strides and weirdest undertakings. Cadavers helped test France’s first guillotines, and they were in the lab of Lenin’s embalmers, helping test the latest techniques. They helped debunk spontaneous human combustion and have been crucified in a Parisian laboratory to test the authenticity of the Shroud of Turin.” Relatively little of Ms. Roach’s narrative is devoted to, for lack of a better term, the most traditional and most common fate of unburied and uncremated, “donated” human remains.
That is, the medical and dental school anatomy labs. Over 70 percent of those bodies end up in those venues, and the supply is adequate these days. But there was a time not too long ago when fresh corpses were scarce, and recently buried people were profitably disinterred to provide fodder for scholastic medical dissection. In Edinburgh in 1828, William Burke and William Hare provided Dr. Robert Knox, a famed professor of anatomy at Edinburgh University, with even fresher material as they expertly suffocated at least 16 people, then sold the victims to Dr. Knox for 7 pounds 10 shillings each. When Burke and Hare were caught, Dr. Knox was not charged with any crime, and Hare turned state’s (King’s) evidence, so only Burke was hanged. His body was then publicly dissected (apparently not by Dr. Knox) and displayed. A contemporary jingle went − “Burke’s the butcher, Hare’s the thief, Knox is the boy who buys the beef.” Those were the days. And speaking of Dr. Knox, that name reminds Ms. Roach of Knox brand gelatin. She quite, at length, reports on another use for cadavers, as targets to study the effects of various projectiles on human tissue. But, it turns out that human or other animal flesh is not the ideal material with which to calculate ballistic trauma, because it “snaps back.” So the true degree of damage is difficult to assess. Some clever person, perhaps working at the Knox Gelatine (sic) Company (now part of Kraft Foods), discovered that models of humans or human parts made of gelatin provide an excellent facsimile for such investigation. Gelatin does not “snap back,” and the mayhem caused by a bullet or chunk of shrapnel can be easily seen and measured. The author explains: “Unlike real tissue, human tissue simulant doesn’t snap back. The cavity remains, allowing ballistics types to judge and preserve a record of a bullet’s performance. Plus, you don’t have to autopsy a block of human tissue simulant because it’s clear, so you just walk up to it after you have shot it, and take a look at the damage. Following which, you can take it home, eat it, and enjoy stronger, healthier nails
in 30 days!” But wait! It isn’t only human tissue simulant that can be recycled − we all can be recycled, thanks to the research and efforts of Swedish “biologist and entrepreneur” Susanne WiighMasak. Presently, over 70 percent of Swedes choose to be cremated, and scattering Dad’s ashes at sunset over Stockholm harbor does not, in any meaningful way, reduce pollution or help “the environment.” Plus, there are some who are concerned about the atmospheric emission of vaporized mercury and other metals, as well as dioxin-like chemicals during the process of human and animal cremation. So Ms. Wiigh-Masak devised a process that she dubbed “promession,” and founded a company called “Promessa.” The company’s website proclaims its “primary principles are preservation after death in organic form and shallow burial in living soil that quickly converts us to mulch.” Promession involves flash freezing the cadaver in liquid nitrogen and then exposing the solidified remains to mechanical vibration and ultrasound. Her patented machine, called a “promator,” is apparently able to separate metallic debris from the kibbled organic detritus which is then shoveled into a biodegradable box. That container is then shallowly buried and over it is planted a tree or bush which then is supposed to incorporate the loved one’s remains as it grows and thus becomes a living memorial. If the plant does not do well, one can always purchase another at the local nursery. A rather diametrically-opposite option is to have yourself “plastinated,” like the starkly fascinating cadavers and animal models in Gunther von Hagens’ “Bodyworld” exhibits. Most of von Hagens’ plastinated specimens were created in Dalian, China, at a place he called “Plastination City” that employed over 200 workers. Many, however, are made now in the USA, since Dow Corning Company improved on von Hagens’ process so it can be done more efficiently at room temperature instead of in a sub-freezing environment. Plastinated specimens are becoming popular continued on page 29 March/April 2015
For over 2,000 years, cadavers have been involved in (some of) science’s boldest strides and weirdest undertakings.
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Annual Meeting
Annual Meeting THE 2015 SIERRA SACRAMENTO Valley Medical Society and Alliance Annual Awards and Installation Dinner was held January 8, 2015, at the Hyatt Regency Hotel in Sacramento. Jason P. Bynum, MD, Child Psychiatrist with The Permanente Medical Group, was installed as the 141st President of SSVMS. Also installed were the following SSVMS 2015 Officers and Board of Directors: Tom Ormiston, MD, President-Elect; Rajiv Misquitta, MD, Secretary; Ruenell Adams Jacobs, MD, Treasurer; José Arévalo, MD, Immediate Past President; and Directors, Laurie Gregg, MD; Russell Jacoby, MD; Steven Kelly-Reif, MD; Vijay Khatri, MD; Kieu-Loan Luc, DO; Chris Serdahl, MD; Seth Thomas, MD; Sadha Tivakaran, MD; John Wiesenfarth, MD; Eric Williams, MD. The Society’s highest honor, the Golden Stethoscope Award, was presented to Delphine Ong, MD, a member of the Mercy Medical Group specializing in Hematology/Oncology. Dr. Ong received the award for her devotion to patient care and the medical needs of the community.
The Medical Honor Award was presented to Paul R. Phinney, MD, in recognition as a leading advocate for patients and physicians on health care issues. Elica Health Centers CEO, Elizabeth Cassin, received the Society’s Medical Community Service Award in recognition of the organization’s dedication to provide health services to the Sacramento region’s underserved, multiethnic populations. The Alliance presented its highest honor, the Dorothy Dozier Helping Hands Award, to Sita Lalchandani for devoting her time, energy and talents to the Alliance. Guests at the event were entertained with traditional jazz music by Cyr’s Combo, a group of young musicians from the Sacramento area who play regularly throughout California.
Jason Bynum, MD, SSVMS 2015 President
March/April 2015
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Annual Meeting
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Medical Community Award Recipient, Elizabeth Cassin, CEO, Elica Health Centers and Dr. José Arévalo, Immediate Past President
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Cyr’s Combo
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SSVMS Board of Directors present at the event include L-R, Drs. Sadha Tivakaran, Director; Tom Ormiston, President-Elect; John Wiesenfarth, Director; Lee Snook, CMA Vice Speaker; Ruenell Adams Jacobs, Treasurer; Jason Bynum, President; Russell Jacoby, Director; Vijay Khatri, Director; José Arévalo, Immediate Past President
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L-R Dr. Maynard Johnston; Medical Honor Recipient, Dr. Paul Phinney, and Bill Sandberg
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Golden Stethoscope Recipient, Dr. Delphine Ong and SSVMS President Dr. Jason Bynum
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Alliance Past Presidents, Gabriella Neubuerger, Mariann Fisher and Alliance President, Kim Majetich
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UC Davis Medical Students
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Dr. Jason Bynum SSVMS 2015 President receives the gavel from Dr. José Arévalo, SSVMS Outgoing President
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Annual Meeting
Sierra Sacramento Valley Medical Society and Alliance Annual Dinner January 8, 2015 Hyatt Regency Hotel Photos by David Flatter (flickr.com/davidflatter)
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Annual Meeting
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SSVMS Treasurer, Dr. Ruenell Adams Jacobs and Family
10 L-R UC Davis Recipients of William E. Dochterman Medical Student Scholarships, Kristiana Lehn, MS I; Nazeela Sibir, MS I; Kim Le, MS II; Olivia Nguyen, MS III 11 L-R Susan Brownridge, Sita Lalchandani, Recipient of the Alliance’s Dorothy Dozier Helping Hands Award and Alliance President, Kim Majetich 12 Medical Honor Recipient and CMA Past President, Dr. Paul Phinney and SSVMS President, Dr. Jason Bynum
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Sierra Sacramento Valley Medical Society gratefully acknowledges and sincerely thanks the following sponsors of our 2015 Annual Awards and InstallaƟon Dinner. PLATINUM LEVEL
GOLD LEVEL
SILVER LEVEL
BRONZE LEVEL
A VA Hospital Then Learning the “Art” of Medicine
By Ann Gerhardt, 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.
THE VETERANS ADMINISTRATION (VA) medical system has problems: Veterans may wait a long time to access the system, and doctors have three separate electronic medical record systems (for different practice settings) that don’t communicate with each other. But I’m told it’s a whole lot better than what existed in 1980 when I rotated through the Pittsburgh, PA, VA Hospital as an intern. On my first day, I was given a list of patients and told to see them before rounds with the resident. Since it was April and I had nine months of internship behind me, I was feeling less incompetent and headed off to one of the patients in a private room. He was a “yellow submarine” (a terribly jaundiced cirrhotic with huge ascites) projectile-vomiting blood. My feeling of confidence evaporated. I ran down the long hall to the nurses’ station to get help. The nurses were in a back room drinking coffee and eating donuts. All were on break at the same time. They helpfully informed me that that was his wont, the ICU didn’t want him and they (the nurses) weren’t responsible to help him or me. The vitals taken that morning were somewhere, if I could find the chart. I grabbed the blood pressure machine, rolled it to the room and was horrified at the result. Running back to the nurses’ station, I ordered blood, wheedled a nurse who was too new to know better into telling me where the venipuncture and IV paraphernalia was, and called to find an available GI doctor. My resident wasn’t in the hospital yet. Obtaining blood (I actually wondered if I could catch it coming out of his mouth) and placing a femoral line took a long time, since by then he was extremely
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hypovolemic. The bed was covered with blood. I started IV fluids and discovered that it would take hours to get lab results and typed and crossed blood. He stopped bleeding, probably because he had no blood pressure. By the time the resident arrived, he was dead. Welcome to the VA. Somehow, we interns made it through the month with very little support, working seven days a week, as long as it took to get the work done, and every third night. My three year-old son basically lived with the babysitter. “Stat” labs meant running down to the basement lab to sweet talk the tech into doing them quickly. Often, there was bargaining, to winnow down the number of absolutely necessary tests. Once I took the tech a soda to get him to do my tests before someone else’s. I never did befriend the nurses, being too hardheaded to kiss up to their irresponsibility and seriously wondering why they were being paid. I learned that the head nurse for the hospital, a huge and imposing figure, had long seniority and inordinate power. She basically dictated the laws of VA land, putting nurses at the top and patients and doctors at the bottom of the deference-deserving pile. I’m trying to remember the attending physicians, but don’t recall much supervision. One amazing doctor was Chief of Internal Medicine. I believe he saw most of the out-patients, treating them (and us) with a really down-to-earth style. He had mastered the system and didn’t waste time on fighting it. He just did what it took to get the vets as much care as they could handle. The experience wasn’t all bad. Though the VA has lots of rules, back then there wasn’t
enough supervision to enforce them. A surgical resident friend of mine used to climb the hospital walls (literally) to get his exercise. There was no pressure to discharge patients, so they would stay in-house for long work-ups that, today, would be done as out-patients. I would sit and listen to their stories – of their lives, time in the service and how they worked the VA system to get meds, cigarettes and medical care. Our inexperience and shortcomings were tolerated − If our superiors couldn’t accommodate us, who would do the work? The resident didn’t get too mad when Mitch (a fellow intern) did an emergency lumbar puncture on a patient who had died by the time he finished the procedure. The resident, who told me my son couldn’t sit at the nurses’ station while I was rounding on a weekend, gave in when I took off my white coat and told him that he could do the rounding, because I was quitting. The patients were far more appreciative of our care than the rich folks on the golden-slipper wards in our primary training hospitals down the hill. They hardly ever argued with our decisions. I even received the most expensive bottle of perfume I’ve ever owned from a sweet-talking vet with a stomach problem. I am reminded of a William Osler quote: “If it were not for the great variability among individuals, medicine might as well be a science and not an art.” The characters I had the privilege to meet in the VA system taught me a lot about the art of medicine and gave me entertaining memories. algerhardt@sbcglobal.net
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Sierra Sacramento Valley Medical Society 2015 Committee Appointments EDITORIAL -- REAPPOINTMENTS: Drs. Nathan Hitzeman, Editor/Chair; Sean Deane, Adam Dougherty, Ann Gerhardt, Sandra Hand, Albert Kahane, Robert LaPerriere, John Loofbourow, George Meyer, John Ostrich, Gerald Rogan, Glennah Trochet , Lee Welter, Gilbert Wright, John Paul Aboubechara, MS II, and Nan Crussell, Managing Editor EMERGENCY CARE -- REAPPOINTMENTS: Drs. Peter Hull, Chair; Seth Thomas, Vice Chair; Yener Balan, Matthew Donnelly, Troy Falck, Roel Farrales, Hernando Garzon, Kendrick Johnson, Vinh Le, Alexis Lieser, Devin Merchant, Karen Murrell, Jeff Rogerson, Dwight Stalker, R. Steve Tharratt, Sam Turnipseed, Justin Wagner, Brian Wippermann, David Wisner, and Rodolpho Zaragoza; Harold Renollet (guest), and Lee Welter (guest) HISTORICAL -- REAPPOINTMENTS: Drs. Robert LaPerriere, Chair, Malcolm Ettin, Christine Fernando, Francine Gallawa, James Hamill, Julian Holt, Donald Hopkins, Jack Ostrich, Gail Pirie, and F. James Rybka; Kent Perryman (guest) NEW APPOINTMENT: Dr. Elisabeth Mathew JUDICIAL -- REAPPOINTMENTS: Drs. Alicia Abels and Anthony Russell NEW APPOINTMENTS: Drs. José Arévalo, Jose Cueto and David Herbert MEDICAL REVIEW AND ADVISORY -- REAPPOINTMENTS: Drs. Howard Slyter, Chair; Joanne Berkowitz, Vice Chair; Alicia Abels, Denny Anspach, José Arévalo, Richard Axelrod, Helen Biren, Gregory Blair, Peter Carruth, Mark Chang, George Chiu, Jose Cueto, Ronald Foltz, Richard Gray, Kern Guppy, Ruth Haskins, Reinhardt Hilzinger, Stephen Hiuga Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Scarlett La Rue, Shahid Manzoor, Elisabeth Mathew, George Meyer, Robert Midgley, Michael Novotny, Tom Ormiston, Conrad Pappas, Gail Pirie, Kristen Robinson, Linda Schaffer, James Sehr, Gerald Simon, and Pandur Yenumula NEW APPOINTMENTS: Drs. Richard Jones and William Vetter PROFESSIONAL CONDUCT AND ETHICS -- REAPPOINTMENTS: Drs. Joanne Berkowitz, Chair, George Chiu, Malcolm Ettin, Richard Gray, James Hamill, Edward Hearn, Richard Jones, John Kasch, and Harold Renollet PUBLIC AND ENVIRONMENTAL HEALTH -- REAPPOINTMENTS: Drs. Donald Lyman, Chair; Ruenell Adams Jacobs, Regan Asher, Clinton Collins, Anthony DeRiggi, Christine Fernando, Albert Kahane, Olivia Kasirye, Robert LaPerriere, Stephen McCurdy, Robert Meagher, Dennis Michel, Robert Midgley, Caroline Peck, Richard Sun, and Glennah Trochet NEW APPOINTMENTS: Drs. Maynard Johnston, David Unold, and Rabia Aslam, MS I SCHOLARSHIP AND AWARDS -- REAPPOINTMENTS: Drs. Margaret Parsons, Chair, Ruenell Adams Jacobs, Sean Deane, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kelly, Robert Midgley, Travis Miller, Jack Ostrich, Patricia Samuelson, and Pandur Yenumula NEW APPOINTMENTS: Dr. Susanna Park WELLNESS COMMITTEE -- REAPPOINTMENTS: Drs. Michael Parr, Chair, Lee Snook, and Captane Thomson
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Tomorrow’s Medics Today By Bob LaPerriere, MD TO MANY IN MY AGE BRACKET, many of today’s professional workforce look like “teenagers” …and because of a goal to enhance the academic performance and career readiness of students, they may actually be teens, thanks to new funding and innovative programs in education. Approaches to integrating career skills in high schools have been in existence for some time, such as the health academies in some Sacramento schools. This attempt to introduce students to the “real world of work” has advanced recently through California Career Pathways Trust grants that support several industry sectors including engineering, information and communication technology, and the biomedical field. These grants contributed $250 million within California last year, and will again this year. Through the Sacramento County Office of Education and the Placer County Office of Education, 22 school districts and county offices of education in seven counties1 have partnered with NextEd (http://next-ed.org), and are collaborating in the Capital Region Academies for the Next Economy (CRANE) Consortium. NextEd is a Capital area not-for-profit that develops partnerships among business, labor, education, community, and government, and is the education/workforce affiliate of the Sacramento Metro Chamber of Commerce. A similar project, Capitol Academies and Pathways, exists for the Sacramento City and Elk Grove Unified School Districts. I was fortunate to be invited to the recent Summit for the Health Care Services and Biological Sciences Industry, a project of CRANE. A fascinating keynote address was given by Yan Chow, MD, MBA, former Director of Innovation and Advanced Technology at Kaiser Permanente’s Garfield Innovation Center
in Oakland, and now the Chief Innovation Officer for Washington, DC-based LongView International Technology Solutions. He vividly portrayed the future and the challenges it will bring to medicine. Dr. Chow showed exciting examples of the increasing role of virtual care and mobile health, highlighting concepts that today’s students may be intimately involved with in the near future. Mobile health includes wellness and fitness, a popular area as evidenced by over 50,000 mobile apps. With health care in crisis (increased demand and costs, decreased reimbursements and workers, and outcomes less satisfactory than those in many other nations), tomorrow’s health care workers face significant challenges. Students have to learn to be adaptable, experimental, open-minded, and innovative, i.e., not be afraid to fail at times, a change from the mindset developed in school. The remainder of this summit consisted of collaboration and discussion groups with local high school teachers and administrators, as well as representatives from industry, sharing best practices on how to prepare students for internships and discussing gaps and needs. The Sacramento area is an ideal place to pursue this program. It is home to about 100 biotechnology and life sciences industries and startups, fostered by the MedStart Initiative that supports them. MedStart is one of the programs of the Sacramento Regional Technology Alliance (http://www.sarta.org). The 2014 estimated industry growth in our region was about five percent or 69,000 jobs, with the largest gains in health care services. So, clearly, the need for the work being performed by these organizations is essential for the future of quality health care in our region. ssvmsmus@winfirst.com March/April 2015
1 El Dorado, Nevada, Placer, Sacramento, Sutter, Yolo, and Yuba Counties
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Personal Reflections on Ebola Disaster Relief Work By Hernando Garzon, MD, Medical Director, Sacramento County Emergency Medical Services Agency
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 DOZEN OR MORE international disasters to which I’ve responded, working with International Medical Corps (IMC) in Sierra Leone and Liberia for five weeks from late September to early November was my first opportunity to work in an infectious disease outbreak. In October 2014, as the Ebola outbreak in West Africa was raging out of control, Kofi Annan, the former United Nations Secretary General, called Ebola “a poor man’s disease.” Until now, almost every situation where Filoviridae (the family of Viral Hemorrhagic Fevers of which Ebola is a part) infections have occurred in a developed country, cases have been rapidly identified and treated, and contact tracing and public health measures have served well to contain any spread to no more than just one or a few cases in each event (1967 – Marburg Germany; 1976 – England [Lab infection]; 1990 – Reston Virginia; 1996 and 2004 – Russia [Lab infections]; 2014 – Spain; 2014 – Texas, USA). In truth, the number of people any one person with Ebola will infect is actually small – an average of two. This is much lower in comparison to HIV (four), SARS (four), Mumps (10), or Measles (18). Ebola’s threat to cause widespread infection in developed countries has been inappropriately represented in the media. As one journalist wrote, “Indeed, politicians’ fear of Ebola is more contagious than the disease.” The World Health Organization (WHO) recommends 23 health care workers per 10,000 people to be able to provide basic and necessary health care services to a population. In 2010, the U.S. ratio was 122:10,000. For Guinea,
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the ration is 1:10,000, and for Sierra Leone and Liberia it’s even smaller. These three West African countries spend anywhere from $100$300 per person, per year on health care. In the U.S., this figure is greater than $8,600, and the world average is $1,000. These three countries, and the central African countries previously affected by Ebola outbreaks, are among the lowest medicallyresourced countries in the world. At baseline, they are unable to provide the basic medical needs (as defined by the WHO) of their citizens. Knowing these figures helps us understand not only Mr. Annan’s comment, but the incredible difference in risk that Ebola poses to developing vs. developed countries. While emerging infectious diseases and potential pandemics are of great concern for our global health, the Ebola outbreak in West Africa is, for me, much more of a reminder of how incredibly low-resourced many developing countries still are, and how vulnerable these populations are to any problems that test their extremely-limited resources. It’s also a reminder for me of the developed world’s responsibility to respond to these events, knowing that the developing world cannot manage them alone.
Quantifiable Risk Many issues arise and are common to all disasters – complexity of logistics, failure of communications, lack of adequate resources, risks to responding aid workers, and more. For me, assessing and managing this was like managing any other risk in any other relief mission. The risks of Ebola to health care workers is quantifiable and measures can be
taken to mitigate the risk of infection. While the 20 or so cases of infected international health care workers have received the lion’s share of media coverage, little has been reported about the well over 1,000 workers who have gone and returned safely without infection. Adequate Personal Protective Equipment (PPE), strict adherence to proven infection control measures, and working with an organization committed to safety all make working in an Ebola outbreak as safe as possible. Vulnerable individuals and populations are often the most affected by disasters. This is also the case during any Ebola outbreak, and this applies to both the medically-vulnerable and the socioeconomically-vulnerable. It is not only the young and elderly who are at risk because of their medical condition, but also the poor, who have no other option than to live in cramped conditions with five to a bed, and/or lack the literacy or education to respond appropriately to public health messaging and “education.” While the aggregate data and statistics are eye opening, what affected me most during the Ebola response was the personal suffering and loss I witnessed. It was inescapable. Few of us experience seeing more than 50 percent of our patients die, and certainly not when that number is as high as 10 or 20 per week, week after week. I still think about the father, who recovered from Ebola infection himself, but held his five-year-old son as he died from the disease. This man managed to work through that incomprehensible loss and stayed in the treatment unit after recovery to work with other sick patients as he was now immune. I still think of the graveyard at the IMC Liberia treatment center, beautiful and peaceful, but where so many people were buried without their family present because family members were scared to contract the illness themselves, despite advice that it was safe to attend the burial as long as they maintained distance from the body. The quiet fear present in the family members of sick patients was palpable, and oppressive. Beyond the death toll, the effects of this Ebola outbreak on the affected countries is
profound. Farmers have abandoned their crops, and the World Food Program has warned of inadequate food supplies by spring. In addition to agriculture, other industries which have ground to a halt include construction, tourism, and manufacturing. Schools have been closed for over six months. More than 3,700 children have lost one or both parents. The World Bank has estimated over $32.6 billion in economic losses. With over 300 national health care worker deaths from Ebola and many more who have left their health care posts, there are largely no functional health care systems in these countries, and it will take many months or years to recover. The WHO has estimated that for every Ebola death, there has been another death from a preventable medical illness that did not receive any medical care.
Staggering Societal Effects My response to the Ebola crisis in West Africa is perhaps one of my most difficult responses in 19 years of disaster relief work. The total death toll is, by far, not the largest I have seen, but the societal effects are staggering. The risk to health care workers has not been the highest (I have been in conflict zones with higher risk), but I have rarely been a witness to more suffering or fear in the lives of the patients and families affected. Fear causes us to build walls. Collectively, we have done this in the U.S. around Ebola. Many in the U.S. have called for quarantine of returning health care workers, and other countries have prevented their willing health care workers from going to help in the first place. But as one of my IMC colleagues pointed out, “we are all in the same burning house.” The answer is not to close the door on the room that’s burning, but to send in the appropriate firefighters and adequate amounts of water. With Ebola, the answer is for the developed world to send adequately-trained health care workers and give them the resources to do their work. This is the only way we will save the whole house. hxgarzon@gmail.com
March/April 2015
NOTE: Dr. Garzon serves as Director of Emergency Management for Kaiser Permanente’s 21 Northern California hospitals. He has been deployed on 14 domestic and 10 international disasters from bombings and hurricanes to earthquakes and famines.
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Report on the 2014 CMA House of Delegates Richard N. Gray, Jr., MD, Chair, 11th District Delegation
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.
2014 WAS A UNIQUE YEAR for the House of Delegates (HOD). First of all, it was delayed by two months due to the necessity of focusing on Proposition 46, which was defeated by a coalition built by CMA leadership. Important to SSVMS physicians is that the 11th District, of which SSVMS is a part, had three members on the podium: Paul Phinney, MD, CMA Immediate Past President; Richard Thorp, MD, CMA President; and Lee Snook MD, CMA Vice Speaker. This type of leadership, coming from somewhere other than Los Angeles, San Diego, or San Francisco, causes people to take notice. Additionally, at this year’s HOD, Ruth Haskins, MD, (OB/GYN, Folsom) formally announced her candidacy for CMA President-Elect. The leadership just keeps coming. As always, the HOD considered numerous resolutions (more than 80 this year) and, through an incredibly democratic process, was able to come to a consensus on them. A number of these resolutions dealt with the way the HOD functions, e.g. referring a number of resolutions to the CMA Board of Trustees to determine how to address various issues; or dabbling with numerous small issues while overlooking the major ones that are at the center of what is troubling for doctors and patients. These resolutions regarding CMA governance and function are intended to streamline the process for the smaller issues, and to focus the brain trust, that is the HOD, on major issues that can truly impact the future of medicine. It is an exciting time for medicine in California. Still, the HOD did work on a number of issues that affect you and me. I do not have the space to mention all of them, but will highlight
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just a few. These are now policies of the CMA, not laws, but when legislation comes before our elected representatives, CMA will advocate for these positions. • That CMA support legislation to effect the disallowance of personal beliefs exemptions to public schools immunization requirements. • That CMA support mitigation or elimination of penalties for quality reporting and EHR incentive programs. • That CMA support Medicare and Medi-Cal reimbursement for multiple visits on the same day when medically indicated, allowing each provider to bill for the services provided. • That CMA urge that all public and private health care insurers be required to cover, at a reasonable reimbursement rate, counseling for end-of-life care planning as an accepted and integral part of good medical care. • That CMA continue to work with interested partners statewide to support the goal of developing a POLST registry in California with the following recommended characteristics: 1) secure; 2) easy submission of completed forms; 3) real time updates; 4) 24/7 HIPAA compliant access; 5) review of forms for proper completion; and 6) accessible directly from electronic health record systems; and that CMA support the development of an electronically fillable on-line POLST form. These are just a few of the issues the HOD worked with, ranging from reimbursements to electronic medical record interoperability, to ethical issues, and beyond. The full actions of
the HOD are available to members at www.cmanet.org/hod under the “documents” tab. As always, it was a great learning experience, designed to protect patients and to assist physicians. In 2015, the HOD will be held October 16-18 in Anaheim and is scheduled to return to Sacramento in 2016. We’ll keep you informed and, if you are not already involved as a delegate, you may wish to come see it in action. rgraymd@comcast.net L-R, 11th District Officers, James Schlund, MD, (Radiologist, Chico) Vice Chair; William Reeder, MD, (Rheumatologist, Redding) Immediate Past Chair; and Richard Gray, MD, (Family Practice, Sacramento) Chair
Stiff continued from page 15 teaching aids in human and veterinary anatomy labs worldwide. Contact Dow Corning if you are thinking of having yourself or Mom or Fido plastinated. A spokesman for Dow Corning estimates that, if well cared for, the specimen should last at least 10,000 years. Ms. Roach concludes, as she ponders donating her own body to a medical school − “...I will include a biographical note in my file for the students who dissect me...so they can look down on my dilapidated hull and say, ‘Hey, check this out. We got the woman who wrote the book about cadavers!’ And, if there’s any way I can arrange it, I’ll make the thing wink.” jmost119@aol.com
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OR SCAN TO LEARN MORE!
A Posit on Addressing Work Email at Home “Work-related email should be done during work hours and banned at home.”
Background: The German government is considering passing “anti-stress” regulation that would ban German employees from doing work-related email at home after hours or on weekends. The company Volkswagen has already voluntarily blocked employees from doing work-related email at home. The company simply turns off their email server after hours. Germany’s labor minister said that it is “indisputable that there is a connection between permanent availability and psychological diseases.” http://nbcnews.com/news/ world/germany-examines-ban-employees-checkingwork-emails-home-n262441 Note: Posits are aggressive statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 45/Agree – 28/Disagree. Commentary follows: I disagree. It would be nice – but you’ve got to be kidding. Most of us don’t have a 9-5 job. −Clifford Marr, MD I disagree. It depends on who bans the email at home. If it is the government, absolutely not. If it is your spouse, well, maybe. If there is any difference. −Gerald Rogan, MD I agree. Kaiser/TPMG physicians virtually all have to work from home to complete their work every day now. Just ask any of them…psychological diseases…hmmm. − David Moitoza, MD I disagree. It should be up to each individual to set appropriate limitations on their time according to their own particular circumstances. Besides that, the posit is non-sensical for
physicians who, for whatever reason, work from home. −Paul Phinney, MD I disagree. Relaxing at home and cleaning up emails, especially if you are gone for a few days from the office, can make for a less stressful day at work when you return, and also give you a chance to think a little longer before hitting the dangerous “send” button. −Jose Cueto, MD I disagree. As a surgeon, I never work 9 to 5. Doing the administrative portion of my job allows for flexibility to spend time with family. If I stayed at work every day until all my work was done, I’d never make it home for dinner. −Natasha Bir, MD I disagree. It would be great if we didn’t have to do work-related emails at home, but I do need access to the info in the emails and my schedule when I am at home. −Katherine Gillogley, MD I disagree. If so, I would never get my work done, OR would never get home. −Dennis Michel, MD Unless you’re a doctor in private practice. −Robert Miller, MD I disagree. There are times when doing work emails at home is better than spending more time at the office. −David Greenhalgh, MD I agree, however, as physicians, our work is more like being a religious leader, and we cannot simply turn our patients “off.” We have to have someone available at all times. −William Junglas, MD I agree. But if one is on-call, this cannot be avoided. −Matthew Watson, MD, MPH I agree. I am a retired Kaiser Permanente physician. My still-working colleagues tend to spend hours every night catching up on their March/April 2015
If I stayed at work every day until all my work was done, I’d never make it home for dinner.
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There is more to life than working ALL the time…
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email, so as to have a clear inbox in the morning. I recommend that they be given at least an hour of paid work time free of other responsibilities, so as to be able to work on this. −Scarlet La Rue, MD I agree, unless we can bill for it or get RVUs. −Sherry Nealon, MD I disagree. More freedom and liberties taken from the people by those “who wish to feel good.” −Robert Forster, MD In this increasingly connected world, time off from work is much needed to unwind. The work-related emails physicians see are part of permanent medical records in most cases. Hence, I agree with this posit. −Jignesh Patel, MD I agree. There is more to life than working ALL the time, it’s embedded in the culture of Europe that the enjoyment of life is primary; unfortunately, our culture is the opposite. − Michael Mirmanesh, MD I agree. Perhaps there should be an “I agree, but…” button. Striking a balance between work and family life has always been a challenge for physicians, and one of the things we took on when we decided to do this work was the responsibility to be responsible, somehow, for our patients whenever they were ill, something that doesn’t always happen on schedule. This is what drove many of us to practice in groups and cover for each other, but as groups we have not done as good a job as we should have looking out for our partners as well as our patients. − Francisco Prieto, MD I disagree. I feel that this should be offered per patient preference, but not forced upon the doctor. During much of my career, I wanted to leave the office early, spend time with my children before their bedtime, and then finish up with any work I had not completed. This option would preclude me from taking care of my patients’ needs at the time most convenient for me. −Tia Will, MD I disagree. People can make their own choices and put an “out of office” block on emails so the sender knows they are not available. It is that person’s fault for not doing the block, if it is needed. We don’t need the government to
Sierra Sacramento Valley Medicine
make this choice for us. I can only imagine how that would gum up the works. It is also possible to turn off phones and computers! (Perish the thought!) I think it is more damaging for those Volkswagen employees to have to stay at work longer to catch up on their email and not have the choice to catch up on a few emails while they are at home with their family. Maybe we should ban homework, too. My kids would be all for that! −Dana Jacques, MD I disagree. ”Ban” is a harsh word and too final. My answer goes both ways. Work-related email is very important and useful and way better today than it was ever done in the past, and the capacity to address issues before they fester and complicate is astounding, but does all of it have to be done by the physician? I feel that capable surrogates should be used for most of them and the ones that need immediate attention should be sent to the physician. There should be a message depository instead of the direct “email your physician” button where there is a sorting of the dire ones against the mundane ones; the dire ones being sent to the providers as they should be. The old paper messages were evaluated and dealt with by the nurses in the department and the dire ones sent to us. It worked well, though a tad slowly to say the least. −Elisabeth Mathew, MD I disagree. There is such a large volume of email it is very nice to be able to manage some of that online from elsewhere. −Reginald Rice, MD I agree with such a proposition, or at least a limitation in the time for doing home emails. However, I also agree that we not make it forbidden, but that there be no legal value for someone not reading emails after hours. −Marc Lenaerts, MD, I disagree. The proposed German regulation may be suitable for socialist politicians soliciting union support, but it’s not fitting for true professionals, at least not in a free country. Neither should voluntary arrangements between patients and their physicians (including agreements about compensation) be subject to government meddling. Communication channels such as email and
telephone promote better patient care. −Lee Welter, MD I agree. Doctors have to draw the line between work and home. Unfortunately, we bring our “work” home too often, be it workrelated emails, finishing notes, or following results. Banning work-related emails at home is a good start. −Guinea Fan, MD I agree. It isn’t often that I applaud the German government, but here I am in full agreement. −John Ostrich, MD I agree. We are already working extra hours for all the paper work in office. All work-related emails/work should be covered by freeing time up for us to do it in office or be paid at home. −Kenneth Corbin, MD I agree. However, as our health care system is currently structured, it actually helps my psychological health to address work email (particularly secure messages from patients) at home, as it is impossible to get this work done during work hours, yet we are held accountable to getting it done within a certain time frame. The current system does not support the work that physicians actually do. Providing quality care and timely responses to patients depends upon the unpaid work that physicians do seven days a week and after hours at home. In part, this occurs because the practice of medicine, a calling, rather than just a job. Despite viewing medicine as a calling, the practice of working seven days a week takes its toll on the human beings and their families (i.e. physicians) who provide that availability. −Dana Miller-Blair, MD I disagree. It is a matter of never having enough time to meet the demands required to complete the care of the number of patients required to be seen. Email is a part of this. You either do it at home or at work during off hours. The real questions is which location is less stressful. −Gregory Joy, MD The issue is more complex than a simple yes or no. Perhaps for line employees it is appropriate for them not to do emails at home. But as an administrator, I find it absolutely necessary to do them at home. I get over 150 emails per day, that is whether I am on vacation
or not. If I didn’t spend 30 minutes looking through them per day, I would come back so buried, it would make things worse. For physicians, it isn’t just emails, but tasks in the EMR along with documentation of visits. The question is WAY too-oversimplified and really isn’t helpful. −Alan Ertle, MD I agree. Work responsibility is taking on the personally-invasive aspects of social media, except failure to respond is actionable by the boss. It may take a law to make employers realize they only own part of their employee’s life. −Sandra Hand, MD I disagree. Come on...not that I like doing work emails at home but...buck up! −Jason Flamm, MD Large healthcare systems benefit tremendously from requiring their physician employees to respond to patient emails within 48 hours. I spent many years answering patient emails in the wee hours after working a 12-hour day, and patients often commented about the fact that my reply was written at 2:30 am. Some older patients even expressed concern about my welfare. Leadership tends to respond to queries about this unpaid and largely unacknowledged labor with an appeal to our professionalism and our sense of duty. I had to give this up eventually when chronic sleep deprivation began to have health consequences for me in my early 40s. I saw physician emails that were one- or two-word replies to patient questions and I recognized that it was self-preservation, and that I would have to adopt a similarly brief style. My own primary care doctor even has this ending after each email message: “Your gratitude is assumed; please do not send me a message just to say ‘Thank you.’” −Amy Black, MD
Come on... not that I like doing work emails at home but...buck up!
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March/April 2015
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Welcome New Members 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. — Rajiv Misquitta, MD, Secretary. Shideh Chinichian, MD, Family Medicine Resident, Medical College of Virginia Commonwealth 2014, Mercy/Methodist Hospital, 7500 Hospital Dr., Sacramento 95823 Carrieann Drenten, MD, Emergency Medicine, University of Arizona 2011, Sutter Medical Group, 5151 F Street, Sacramento 95819 Ngoc-Truc Thuy Duong, MD, Family Medicine Resident, Oregon Health and Science University 2012, Mercy/Methodist Hospital, 7500 Hospital Dr., Sacramento 95823 Katherine R. Fellman, MD, MPH, Emergency Medicine, Tulane University 2010, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825 Devon Elizabeth Ganter, MD, Pediatric Resident, Drexel University 2014, UCD Medical Center, 2221 Stockton Blvd., Sacramento 95817 Emma M. Garforth, MD, Family Medicine, UC Davis 1999, Sutter Medical Group, 2030 Sutter Place #2000, Davis 95616
Jeffrey Gaston, MD, Pediatric Resident, University of Miami 2014, UCD Medical Center 2221 Stockton Blvd., Sacramento 95817 Mamatha Gupta, MD, Nephrology, Bangalore Medical College, India 1998, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825 Dennis A. Idowu, MD, Obstetrics/Gynecology, Ohio State University 2010, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825 Ryan B. Hunt, MD, Emergency Medicine, Boston University 2010, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825 Luis A. Juarez, MD, Family Medicine, UC Davis 2011, Mercy Medical Group, 6501 Coyle Ave., Carmichael, CA 95608 Alan W. Michel, MD, MPH, Internal Medicine, University of Montemorelos, Mexico 2001, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825
Anthony S. Saetern, MD, Family Medicine, SUNYUniversity of Buffalo School of Medicine 2011, Mercy Medical Group, Methodist Hospital, 7500 Hospital Dr, Sacramento 95823 Sharon C. Sevilla-Bodine, MD, Pediatrics, University of Santo Tomas, Philippines 1991, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825 Kyle B. Stephens, DO, Family Practice Resident, Touro University 2014, Mercy Family Health Center, 7601 Hospital Drive, Ste. 103, Sacramento, 95823 Maria W. Sun, MD, Internal Medicine, UC Davis 2009, The Permanente Medical Group 2025 Morse Ave., Sacramento 95825 Scott K. Tanaka, MD, Orthopedic Surgery, Tulane University 2008, Summit Orthopedic Specialties, 6403 Coyle Ave., #170, Carmichael 95608 Tammy Woo, MD, Pediatric Resident, Keck School of Medicine 2012, UC Davis Medical Center, 2516 Stockton Blvd., Sacramento 95817
Rick N. Phan, MD, Internal Medicine/Hospitalist, St. George’s University, Grenada 2005, The Permanente Medical Group, 2025 Morse Ave., Sacramento 95825
Board Briefs January 15, 2015 The Board: Elected Rajiv Misquitta, MD, 2015 Secretary and re-elected Ruenell Adams Jacobs, MD, 2015 Treasurer. The remaining SSVMS officers are: Jason Bynum, MD, President; Tom Ormistion, MD, President-elect, and José Arévalo, MD, Immediate Past President. Approved the financial statements for the monthending November 30, 2014. Approved the appointments to the 2015 SSVMS committees. Approved that SSVMS, as a key stakeholder and convener, support stakeholder efforts to strengthen mental health crisis stabilization services in Sacramento County. Approved the Membership Report: For Active Membership — Carrieann Drenten, MD; Luis 34
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A. Juarez, MD; Anthony S. Setern, MD; Maria W. Sun, MD; Scott K. Tanaka, MD. For Resident Membership — Shideh Chinichian, MD; Ngoc-Truc Thuy Duong, MD; Devon E. Ganter, MD; Jeffrey Gaston, MD. For Reinstatement of Active Membership — Bruce Barnett, MD. For a Change in Membership from Retired to Active Membership — Robert Forster, MD. For Retired Membership — Lurlene Brown, MD; Erwin Eichhorn, MD; Carl Haller, MD; Franklin Li, MD; Robert G. Myers, MD; Russell W. Unger, MD. For Resignation — Smitha Agadi, MD (moved to New Jersey); Mary Chu-Yee, MD (moved to Washington); Jeremy N. Ciporen, MD (moved to Los Angeles); Sarah Takekawa, MD (transferred to Modesto); Brad J. Yoo, MD (moved to Oregon). Serving as the Member Board to BloodSource, the Board received the annual BloodSource report from Michael Fuller, CEO. The Board also approved the 2015 BloodSource Officers and Board of Directors.
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