2016-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2016

Success. It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

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Request your free electronic or hard copy today! 800-356-5672 | CAPphysicians.com/Value

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Medicine 2 3

2016 Education Series PRESIDENT’S MESSAGE Not as Smart as We Think

Like a Kid in a Candy Store

Bob LaPerriere, MD

Electronic Health Records Part I – User Misery

Ann Gerhardt, MD

Thomas W. Ormiston, MD EXECUTIVE DIRECTOR’S MESSAGE Physicians Must Register for CURES 2.0 by July 1

Aileen Wetzel, Executive Director

The Death of Fee-for-Service Medicare

Gerald Rogan, MD

Controlling Substances − A Proactive Approach to Prescribing

Lee T. Snook, MD

Classified Advertising

BOOK REVIEW Medical Muses: Hysteria in NineteenthCentury Paris

Jack Ostrich, MD

The Telephone Game

Caroline Giroux, MD

Pain Doctor

Caroline Giroux, MD

Reflections on Medical Advances in Your Lifetime

Early Pain Management and Anesthesia

Kent Perryman, Ph.D.

Community Unites to Help Uninsured

Liza Kirkland, Director, CSERF

Rise of the Recyclopath

Nathan Hitzeman, MD

Welcome New Members

Board Briefs

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

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx The cover image of the heart, and the image of the brain in the article on the Consumer Electronics Show (CES) in this issue, are through the generosity of WhiteClouds, the largest full color 3-D printing company in the world. The images demonstrate one aspect of the future of 3-D printing in the medical field. Such 3-D models, developed from CT scans (the heart) and MRIs (the brain), enable both better patient communication and planning for surgical procedures. Once used only at a handful of hospitals, the models are now becoming a staple of pre-surgical planning at many major academic medical centers, including UC Davis. Story on page 17.

May/June 2016

Volume 67/Number 3 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. 2016 Officers & Board of Directors Thomas Ormiston, MD, President Ruenell Adams Jacobs, MD, President-Elect Jason Bynum, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Vijay Khatri, MD Darin Latimore, MD Christian Serdahl, MD District 3 Thomas Valdez, MD District 4 Alexis Lieser, MD

District 5 Rajiv Misquitta, MD Paul Reynolds, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Anne Neumann, DO

2016 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Ruenell Adams Jacobs, MD José A. Arévalo, MD Barbara Arnold, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD

District 1 Anissa Slifer, MD District 2 Don Wreden, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Kevin Jones, DO Thomas Kaniff, MD Vijay Khatri, MD Sandra Mendez, MD Armine Sarchisian, MD Joseph Sison, MD John Tiedeken, MD Vacant Vacant Vacant Vacant Vacant Vacant

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more informa�on or to register, visit www.cmanet.org/events , or call (800) 786‐4262 May 4: Contract Registra�ons: How to Get Past “No” with a Payor 12:15 – 1:15 p.m. When submi�ng a request to renego�ate, many prac�ces fail to present a business case, which o�en results in a quick reply from the payor indica�ng that they are not in a posi�on to renego�ate at this �me. This webinar will cover steps prac�ces can take to build their best business case to prevent the “auto‐reply” and present a though�ul renego�a�on request. May 13 — 15: Western Health Care Leadership Academy (Conference) The 2016 Western Health Care Leadership Academy, will be held at the Hilton San Francisco Union Square. Speakers include Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; Donna Bra‐ zile, Al Gore’s campaign manager and Democra�c Na�onal Commi�ee Vice Chair; Atul Gawande, MD, renowned surgeon, writer and public health re‐ searcher; and ZDoggMD (also known as Zubin Damania, MD) internist, founder of Turntable Health and comedian. Leadership Academy is the West Coast’s premier opportunity for physicians, prac�ce managers, and other health care leaders to learn about the leading‐edge trends and devel‐ opments in the rapidly changing health care marketplace, access infor‐ ma�on and tools to help ensure the viability of medical prac�ce, and ac‐ quire the leadership skills needed to successfully manage change. June 8: How to Increase Workers Compensa�on Revenue 12:15 – 1:15 p.m. Workers' compensa�on payors can substan�ally reduce your revenue by systema�cally downcoding evalua�on and management codes and pay‐ ing the wrong reimbursement due, per California’s Official Medical Fee Schedule. This webinar explains how to easily appeal reduced payments, provides the correct reimbursements for popular CPT codes, and breaks down the new mandated appeal process into easy step‐by‐step instruc�ons. If you treat injured workers, this webinar will make it easy to know whether your payments are correct and how to appeal downcoded and incorrect payments.

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President-Elect Ruth Haskins, MD

CMA Vice Speaker Lee Snook, MD

AMA Delegation Barbara Arnold, MD

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.

Richard Thorp, MD

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.

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS III George Meyer, MD Sean Deane, MD Jillian Millsop, MD Adam Doughtery, MD Steven Nemcek, MS I Ann Gerhardt, MD John Ostrich, MD Caroline Giroux, MD Mary Pauly, MD Sandra Hand, MD Gerald Rogan, MD Albert Kahane, MD Robert LaPerriere, MD Glennah Trochet, MD John Loofbourow, MD Lee Welter, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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. ©2016 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

Not as Smart as We Think By Thomas W. Ormiston, MD HAVING ACHIEVED MY lifelong goal of becoming a curmudgeon, I am tempted to look back at the changes in our profession over my career and perhaps speculate on the future. Which is what we curmudgeons do. When I finished medical school in 1979, our profession was entering a new phase. Physicians previously had exclusive access to medical knowledge, and were expected to make health care decisions for our patients. But that was changing. Patients were quite appropriately demanding authority over their medical care. But we physicians still controlled the information. Here and there a medical book for lay persons appeared, but they were not widely used. Then the internet arrived. Medical information, some of it quite detailed and accurate, is everywhere. We physicians are no longer custodians of medical knowledge. We still control access to treatment, but how long will that last when all the information needed to determine the best treatment is widely available? On the flip side, could the explosion of available medical information actually enhance the role of the physician, if we embrace our role as counselors and advisors to our patients? Our training, if properly applied to the care of our patients, will become more essential if we understand the information and tailor it to the individual needs of each patient. A medical school professor once told me that only half of what we were learning was true. The problem was we did not know which half. There has been research in the interim that at least improves the accuracy of my professor’s assertion. The most suspect information, of course, would be expert opinion unsupported by high-quality research. Two studies cataloguing multiple research trials confirm expert opinion about 60 percent of the time and refute it the other 40 percent. Though better than my professor thought, it’s hardly reassuring to be

wrong just a bit less than half the time. One might think randomized, controlled trials are more accurate. But, here again, the evidence is not always comforting. A consortium of psychology researchers recently tried to reproduce 100 studies from the four top psychology journals. They were unable to replicate the original findings of 65 of the 100 studies (including one study done by the lead author of the replication effort). Amgen attempted to replicate 53 of the reported research studies they were using to develop cancer treatment. They could only replicate six of the 53. (A footnote here. There is vanishingly little fraud involved. These are complex data sets with analysis issues affecting the reported results. The research community is taking action to enhance reliability and transparency of research results.) It also turns out that human biology and pathology is much more complex than we would like. Take p53, the iconic tumor suppressor protein. It was the Science magazine molecule of the year in 1993. p53 mutations are present in about half of malignancies. After 23 years and references in 79,000 articles listed in PubMed, there are no drugs targeting p53 or its gene. The biology is just too complex for our current understanding. With so much information available, and even the highest quality information suspect, how do we maintain and enhance the value of our profession to society? I think we continue the tradition of our predecessors: listening to our patients, understanding their needs, understanding the art and science of medicine, applying our best effort for each patient’s circumstances, acknowledging uncertainly, and, above all, having the humility to share our limitations. tom.ormistonmd@dignityhealth.org May/June 2016

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

Executive Director’s Message

Physicians Must Register for CURES 2.0 by July 1 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.

UNDER CALIFORNIA LAW, ALL individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances, and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate), must register for the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016. In January 2016, the Department of Justice (DOJ) launched an upgrade to CURES – commonly referred to as “CURES 2.0.” The upgraded program promises a significantly improved user experience and features a number of added functionalities, including the ability to delegate report queries and new practitioneridentified patient alerts. The final roll-out was delayed six months while DOJ and the Department of Consumer Affairs worked with the California Medical Association (CMA) over its concerns with browser requirements that could have potentially cut off access for thousands of prescribers and dispensers. Physicians still using older browsers will be routed to the old CURES 1.0 interface, which will remain available for an indeterminate period during the transition. Also, beginning January 8, 2016, a streamlined registration process was implemented for new users. This fully-automated process enables licensed health care prescribers and pharmacists to request access to CURES and to validate their credentials entirely online using a secure web browser. CMA will continue to monitor and provide updates to members about any future CURES-related developments. To register for access to CURES 2.0, visit

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http://oag.ca.gov/cures. The DOJ website contains user guides and training videos to help with navigating the new system and understanding CURES 2.0 features. You may find these educational materials at https://oag.ca.gov/cures/ publications. On March 16, 2016, CMA hosted a webinar with DOJ staff to give physicians an overview of the registration process and key features of the newly upgraded system. The recorded webinar can be downloaded for free by visiting www. cmanet.org and clicking on “News and Events.” Physicians who experience problems with the new system should contact the DOJ CURES Help Desk at (916) 227-3843 or by email at cures@doj.ca.gov. Providers are also encouraged to report these technical issues to CMA’s member help line by calling (800) 786-4262 or by emailing memberservice@cmanet.org. awetzel@ssvms.org

SSV Medicine Editor, Dr. Nathan Hitzeman, is on vacation and will return for our next issue.

The Death of Fee-forService Medicare By Gerald Rogan, MD WILL TRADITIONAL Fee-for-Service (FFS) Medicare survive or will most beneficiaries choose managed care via Medicare Advantage (MA)? Currently MA is steadily and relentlessly replacing FFS. This article explains some reasons. There are two Medicare Programs: B and C. FFS Medicare (Medicare B) is the national plan in which the U.S. Treasury takes all the risk.1 MA Plans (Medicare C) consist of private health plans operated as private businesses that are organized to take risk yet remain viable.2 The Medicare beneficiary assigns his/her benefit to the MA Plan he/she chooses. The U.S. Treasury then pays the plan a fixed monthly amount for each enrolled beneficiary. Costs in excess of the government’s payment and any savings from low cost patients accrue to the Plan. For the Beneficiary, Medicare C is cheaper than B. For FFS Medicare, supplemental (MediGap) insurance averaged $183 per month in 2010.3 For the 80 percent of seniors not on Medicaid, 72 percent must buy their own MediGap. Employer-sponsored retirement plans furnish MediGap for the remaining seniors. The average premium for MA plans in 2014 was $35 per month.4 MA plans require modest out-ofpocket copays for visits, and depending on the plan, for imaging, and lab tests. MA plans offer non-face-to-face visits at no charge. In FFS, any patient request for service will motivate a visit because, otherwise, the provider works for free. These financials help explain why, in 2014, 30 percent of beneficiaries elected to enroll in MA, the highest ever.5 Mr. Glenn Hackbarth, Chairman of the Medicare Payment Advisory Committee (MedPAC) writes: “Medicare Advantage plans…often have lower premiums

and richer coverage than the government plan [FFS Medicare], saving money through limited provider networks, benefit design, and caremanagement programs focused on high-cost patients.”6 Medicare is expensive. In 2013, we spent $576 billion for the Medicare Program out of a total federal expenditure of $3,450 billion (17 percent)7 of which $680 billion was borrowed.8 There are 52 million Medicare beneficiaries, 43 million of whom are over age 65 with many more baby boomers to follow. Over the next six years, Medicare spending is expected to grow faster than the gross domestic product (GDP) (4.0 percent v. 3.7 percent) and twice as fast as the Consumer Price Index (CPI) (4.0 percent v. 2.1 percent). The CPI drives Social Security Payment increases. For patients in 2014, the Medicare B premium varied from $104.90 to $335.70 per month. For the national drug plan, Medicare D, the monthly average premium was $75.88.9 Annual out-of-pocket co-payments were as much as $4,550 additional, due to a large coverage gap called the “doughnut hole.” In some premium employer-sponsored Medicare Advantage (MA) plans, there are small co-pays but no coverage gap. On average, the annual beneficiary’s costs were 90 percent of the average annual cost for food. For 2016, Congress blocked the scheduled increase in the Medicare B premium, because Social Security payments did not increase, but Medicare costs did. Under FFS, cost control is delegated to eight local/regional administrative contractors, private companies that make coverage decisions

May/June 2016

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.

and conduct post-pay claims review but take no risk. Their tools are marginally effective to control waste and abuse, but do not prevent fraud. To help control FFS costs, CMS continually tweaks Medicare payment methods and amounts, such as by proposing to change the reimbursement of physician administered oncology drugs.10 But, as with Medicaid Plans, the main event is the transition game from FFS to MA. Curiously, Congress, at the behest of FFS Stakeholders, is hastening the death of FFS by encouraging CMS to pay for unnecessary use of resources, some of which MA providers can husband: 1. Maintaining carte blanche coverage for most anti-cancer drugs when administered for an off-label indication, thereby undermining robust collection of outcomes data so we may learn which drugs work the best; 2. Refusing to enact a new law in 2009 that would have allowed Medicare to continue to apply least-costly alternative payments for selected low-value drugs: a defacto group purchasing authority that Medicare contractors had applied for more than a decade until an appellate court overturned their authority (However, on March 8, CMS proposed a new payment method called “reference pricing” which would test the practice of setting a standard benchmark payment rate for a group of therapeutically similar drug products.);11 3. Blocking CMS from adopting the USPSTF’s current recommendations for breast cancer screening; 4. Allowing a hospital to charge Medicare a hospital outpatient facility fee because the physician’s office is located in a “hospital outpatient” building that is not part of the hospital; 5. Maintaining the formula-driven overpayment which allows hospitals to charge higher co-payments for tests compared to those performed in a physician’s office; 6. Refusing to block direct-to-consumer advertising for prescription drugs and industry-sponsored, physician-directed

Over the next six years, Medicare spending is expected to grow faster than the gross domestic product…

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“infomercials;” 7. Failing to set up a federal agency to investigate the root cause of “medical disasters” when repeatedly substandard hospital-based medical care is documented by a successful Qui Tam lawsuit; and 8. Refusing to implement anti-fraud methods that are as effective as those used by banks and credit card companies. The result: FFS Medicare is plagued by the tragedy of the commons12 and fraud. Managed Care delivery systems have developed methods to mitigate drivers of wasted resources by: 1. Creating drug formulary control; 2. Prescribing generic and less-costly drugs; 3. Isolating group physicians from pharmaceutical sales forces; 4. Developing physician-driven internal utilization controls; 5. Delivering care in the most cost-effective sites of service; 6. Providing urgent care outside an emergency department; 7. Sharing office space; 8. Supporting real-time physician interaction to improve diagnostic skills; 9. Assigning sub-specialists for common highrisk surgery, like total joint replacement; 10. Assigning complex low-volume surgery to only one hospital in the network; 11. Providing close patient follow-up via ancillary providers; 12. Providing virtual appointments via email and phone calls; and 13. Soliciting patient feedback. CMS promotes Accountable Care Organizations (ACOs). ACOs include FFS physicians and hospitals which organize themselves into integrated delivery systems that can accept financial risk and rewards. Like MA Plans, ACOs may reduce unnecessary use of resources, improve the quality of their collective services, and efficiently manage chronically-ill, high-cost patients.13 Is Private Practice Viable? The shift toward MA and ACOs may be a blessing for physicians. The complexity of owning and

running a FFS health care business is daunting and interferes with a physician’s focus on patient care. Private practice requires detailed repetitive attention to changes in coding and reimbursement, insurance contracting, business and employment law, OSHA requirements, and personnel and financial management. Many docs realize it is easier to be free from distractions by joining a large group to work for a salary and bonus. Let the group hire trained professionals to manage the business aspects of medical practice so the docs may focus on medical science and patient care. At a recent meeting of first year medical students, only 2 in 14 indicated a preference for private practice. Physicians are best suited to know what their patients really need and which services are unnecessary; services intended to run up the bill or test the worried well. A stated financial goal of FFS providers is to maximize reimbursement. To mitigate, FFS providers who are traditionally individualists must develop system-think so

that collectively we may avoid the tragedy of the commons. In summary, in order to control their respective costs, patients and CMS are driving the change to Medicare Advantage. Those FFS hospitals and physicians that evolve into ACOs also may thrive. jerryroganmd@sbcglobal.net 1 http://bit.ly/1Zt2CEa 2 http://bit.ly/1Mma9Cz 3 http://kaiserf.am/1Mmabdz 4 http://kaiserf.am/1Mmabdz 5 http://1.usa.gov/1uR1T2H 6 http://bit.ly/1Mma9Cz 7 http://kaiserf.am/1Mmabdz 8 http://bit.ly/22FHAE7 9 http://go.cms.gov/1VF1M70 10 http://1.usa.gov/1RgMeEI 11 http://go.cms.gov/1RyRC24 12 The tragedy of the commons is an economic theory of a situation within a shared-resource system where individual users acting independently and rationally according to their own selfinterest behave contrary to the common good of all users by depleting that resource. 13 http://go.cms.gov/25n8p20

NOTE: Dr. Rogan was board certified in Emergency Medicine. He owned a private urgent care and family practice for 18 years and administered Medicare FFS in California for six years.

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May/June 2016

Controlling Substances A Proactive Approach to Prescribing

By Lee T. Snook, MD, Vice Speaker, California Medical Association

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 CALIFORNIA MEDICAL ASSOCIATION (CMA) and the Sierra Sacramento Valley Medical Society (SSVMS) have long been active in efforts regarding pain treatment, opioid overdose, and controlled substance prescribing. Our support of guiding principles and best practices of the treatment of pain has set policy that help guide agencies such as the Medical Board of California and the Division of Workers’ Compensation. In 1990, SSVMS published “The Painful Dilemma: The Use of Narcotics for the Treatment of Chronic Pain,” a white paper that was subsequently endorsed by the American Academy of Pain Management and the CMA. Then, and now, we support a well-balanced approach to opioid prescribing and treatment that considers the unique needs of individual patients. More recently, CMA published, “Prescribing Opioids: Care and Controversy,” a white paper that includes an extensive discussion about the nature and treatment of pain. In addition to recommendations from CMA’s Council on Scientific Affairs, the white paper advocates that the treating physician should have a thorough knowledge of chronic pain. The white paper can be downloaded at http://bit.ly/1RDRhLg. In November 2014, after an extensive public process that included feedback from health care practitioners who treat pain in diverse settings, the Medical Board of California (MBC) released

its revised “Guidelines for Prescribing Controlled Substances for Pain.” Largely derived from CMA’s white paper, the Medical Board’s opioid guidelines are now the state go-to resources for educating physicians on appropriate prescribing practice. The guidelines can be downloaded at http://bit.ly/1BphgDZ. This issue is not without controversy. The CDC recently reported that national overdose deaths are in the range of 18,000 per year. Although one overdose death is one too many, it is important to put into perspective the number of chronic pain sufferers who may benefit from medication management. The principles of quality medical care support the concept that the people of California have access to appropriate, safe and effective pain management. SSVMS and CMA will continue to be proactive on this important issue at the state and local levels. With education and implementation of treatment guidelines, the current “epidemic” of opioid use and abuse, in so far as physician prescribing practices are involved, will be radically reduced. Most importantly, SSVMS supports the bolstering and funding of treatment for mental health that includes the early diagnosis and adequate treatment for Substance Use Disorder. LSnook@pain-mpmc.com

CLASSIFIED ADVERTISING Office Space for Lease Corner of 39th and J Street, 675 sf, fully serviced. Contact R. J. Frink, MD at (916) 801-5276 or email at rjfrink@surewest. net. See photos on Craigslist Sacramento: rental real estate section.

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Book Review

Medical Muses: Hysteria in Nineteenth-Century Paris By Asti Hustvedt; Publisher W.W. Norton & Co.; First Edition (2011); ISBN-13: 978-0393025606

Reviewed By Jack Ostrich, MD

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

LATE IN THE 16TH CENTURY, a Parisian gunpowder factory near the Bastille was relocated to a more commodious site on the other side of the Seine in what is now the 13th Arondissement. The factory was called “La Salpetriere” because saltpeter (potassium nitrate) was, and still is, a major component of black gun powder. In 1670, Louis XIV issued a decree that the main Salpetriere building was to be converted to a huge public hospital. In her book, Medical Muses: Hysteria in Nineteenth Century Paris, author Asti Hustvedt gives us a brief history of the hospital, now called “Hopital Pitie Salpetriere,” and describes it as it was around 1850: Located on Paris’ Left Bank...it housed approximately 5,000 patients and included more than 100 structures... [it was] a selfcontained city with its own narrow streets, sidewalks, courtyards and even a small trolley. It had a vegetable garden, orchard, reservoir, stables, post office, firemen and a cemetery. Patients provided much of the labor that kept the institution running...women worked in the kitchens as cooks...and did laundry in vast washrooms that served not only the Salpetriere, but all the public hospitals in Paris. There was a Protestant and a Catholic church, a school [as well as] a gymnasium and a library. Almost all the patients were women, and almost all had been confined due to what are now called psychiatric disorders. In 1795, Philippe Pinel, a statue of whom stands outside

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the modern Salpetriere, was appointed chief physician. He gained fame and public honor for establishing rules for the humane treatment of the mentally ill, most of whom had previously been shackled and “treated” with bleedings and purges. In 1852, 26 years after Pinel’s death, a 27-year-old physician named Jean-Martin Charcot joined the staff at the Salpetriere. Where others saw “a grand asylum of human misery,” Charcot recognized that he was “in possession of a kind of museum of living pathology whose holdings were virtually inexhaustible.” Since he had married a wealthy widow, he was able to forego the temptation of a lucrative private practice and was able to work full time at the hospital where he was captivated and fascinated by the numerous female “hysteric” patients. He became determined to study, define and treat what was apparently a common condition. When he was appointed chief physician at Salpetriere in 1856, he quickly established a pathology laboratory and created separate wards to house patients whose symptoms were similar to one another. He insisted that careful daily clinical notes be kept. Real-time drawings, some done by Charcot, but most by others, were done to document this or that characteristic pose or facial expression or physical defect. Many of these sketches and photographs are in Ms. Hustvedt’s book. Careful autopsies were done. Charcot’s interests lay mainly in diseases of the central nervous system, so he and his staff looked most

assiduously at those parts. He was the first to describe accurately the distinct pathology of amyotrophic lateral sclerosis. He attracted a coterie of bright and energetic students. A large (290 by 430 cm) painting by Andre Brouillet, done in 1887, now hangs in the medical museum at the University of Paris Descartes Medical School. It is titled, “A Clinical Lesson at the Salpetriere.” Charcot stands in the right foreground, dominating the picture. To his left is a young woman who appears to be swooning, her arms limp, eyes closed, neck extended with her head turned left toward the viewer. She is supported by the strong arms of Joseph Babinski, the hospital’s chief resident. Sitting close in front of Charcot, leaning forward attentively, is Georges Gilles de la Tourette. To Charcot’s right sits Pierre Marie (Charcot-Marie-Tooth) and sitting to Tourette’s left is Henri Parinaud (Parinaud’s syndrome) along with D-M Bourneville (Bourneville’s disease, now called tuberous sclerosis). In 1885, Sigmund Freud, who then had an interest in hypnotherapy, came from Vienna to study Charcot’s use of hypnosis in the treatment of his “hysteric” patients. Freud greatly admired Charcot and named his firstborn son, Jean Martin, in Charcot’s honor. He later obtained a 38 by 54 cm lithograph copy of Brouillet’s painting and permanently hung it over the “therapeutic couch” in his Vienna office, and later in his home in London. But Charcot is not, however, the only major figure in Hustvedt’s book. Rather three of his “star” patients also are: Blanche, Augustine, and Genevieve. There were dozens of flamboyant hysteriques at Salpetriere, but these three were the most reliably spectacular, malleable and eager to perform. It is Blanche, born Marie Wittman, who is pictured swooning, having been hypnotized by Charcot, in Brouillet’s painting. Charcot thought that he would eventually find an anatomical basis for hysteria, and believed for a while, as did many of his contemporaries, that it resided somehow, somewhere, in his patients’ internal genitalia.

He never found a specific lesion at autopsy, and once revealed to Sigmund Freud that “behind every hysteric there is an intimate secret.” Hustvedt writes, “He legitimized the disease by defining it as a neurological disorder, not madness or malingering.” It is not surprising that Charcot’s critics accused him of improper exploitation of young women who were able to find some fame and even fortune by feigning madness and seizures, or by assuming grotesque facial and bodily positions, sometimes for hours. Charcot’s clinical demonstrations and lectures were often open to the public and were very popular. One Paris journal complained that those events caused troublesome traffic jams in the Salpetriere neighborhood. Charcot’s lectures were memorable events. They began with a dramatic entrance: the master would arrive in silence, flanked by his students, and then the patients were brought in. Pierre Janet, who would become head of the Department of Psychology at the Sorbonne, wrote: Everything in his lectures was designed to attract the attention and captivate the audience by means of visual and auditory impressions. Freud noted Charcot’s “positively fascinating” teaching techniques and added, “Each of his lectures was a little work of art in construction and composition.” Blanche, Charcot’s first celebrity patient was nicknamed “the Queen of Hysterics.” She spent over half her life in the hospital, having entered at age 18 and leaving in 1905. She never again exhibited any signs or symptoms of hysteria after Charcot’s death in 1893. She stayed at Salpetriere as an assistant and technician in the newly established radiology department, and in 1905 she was hired as a lab assistant by Marie Curie. Blanche died eight years later, probably as a result of radiation poisoning. Curie, herself, died at age 66 in 1934 as a result of aplastic anemia, no doubt caused by chronic radiation exposure, as well. Augustine, born Augustine Gleizes, was soon to eclipse Blanche as the most famous continued on page 15

May/June 2016

Blanche in a state of catalepsy.

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The Telephone Game From “Indifference to Trauma” to “Undifferentiated and Paranoia”

By Caroline Giroux, MD IN MEDICINE, ESPECIALLY in psychiatry, we have to rely on a patient’s narrative and the notes from colleague predecessors, and a “telephone game” effect can occur where the original story morphs into something completely different. Electronic Medical Records (EMR) can amplify this effect. In 2012, during a regular medication management visit, I met a patient for the first time, Amanda. She seemed to be doing so well; there was not much to be done at first glance besides inquiring about medication side effects and refilling her medication regimen. Throughout the months, I should have listened to my recurring doubt. Every time I saw her, she would emphasize how clozapine had been lifesaving for her. This therapeutic trial could have, therefore, been a confirmation of the diagnosis she received in her thirties, rather atypical, even for a woman. Even less typical, in my mind, was her ability to function relatively well, taking classes, raising her teenage son. She looked as high-functioning as you and me. Then I thought, “She must be one of the few to ‘recover’ from schizophrenia (if such a thing is possible, but the textbook says so…).” This severe diagnosis was printed on her chart on my first encounter with her, as I was taking over a panel of a provider who had left. I was also amazed at her level of insight and the range of affect that would go through her harmonious face. She had a noticeable baseline anxiety, a discomfort sometimes when I had a medical student, for instance. Also, when not feeling well or under stress (e.g. when she felt overwhelmed with classes), she tended to present paranoid thinking. For instance, she could be convinced that someone had entered her apartment and

manipulated her personal items, like clothing. At that point, we decided to optimize her clozapine and she responded well to it. She was happy to tolerate the medication, despite some weight gain, and the white blood cell count was monitored monthly for agranulocytosis. Time went by, and at each visit she would request her same medication, yet my mind was not quite at peace. But in the middle of a busy day, among patients who present as much more fragile or on the verge of decompensation, I brushed it off, refreshed to see an incarnation of “modern medicine success.” Then, BOOM. In the context of applying to the Department of Rehabilitation for employment opportunities, she inquired about her diagnosis. I asked her if she had any concerns. She was wondering about the “paranoid versus undifferentiated” sub-types that were both evoked in the past. Finally, I decided to take time to play detective and systematically question her prior diagnosis. After all, I had never done the initial evaluation on her and had just assumed the previous doctors were right. And with the EMR since 2013, I had no access to her paper chart anymore, including her initial evaluation. It took the 45-minute session to uncover the telephone game. She sounded too specific upon voicing the learned vocabulary pertaining to psychosis. “I was psychotic, I was hearing voices.” She was evasive about the content, but she mentioned “judgmental,” so I thought about obsessive-compulsive disorder. Eventually, after I attempted finding out about stressors and the chronology of her symptoms (I was baffled that she had been able to keep the same job for 17 years until her first “episode” at 35), she said she saw a psychologist in her late twenties. Upon mentioning the clinician’s impresMay/June 2016

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. 13

NOTE: To protect my patient’s privacy, the name I use throughout the article is fictitious.

sions, I asked her if someone had done anything to harm her in the past. “Well, I was in an abusive relationship.” Later on, she added, very matter-of-factly, “I was also raped a couple of times… but I have worked through this. I’m fine now.” This important information had not been disclosed to her counselor or to the rest of the team before. I was stunned. And somehow − as shocking as it may sound − relieved. This bright, kind 43-year-old woman sitting in front of me might not have a persistently severe mental disorder after all. Her high functioning prior to the “mental breakdown” went against it. She seemed to have no issues up until she was molested at 13 by the father of a child she was babysitting. (Again, matter-of-factly, she proceeded to say that she had told the school and her parents, “but nobody believed me,” unfortunately, a too pervasive reality). She was raped in her late teens (and diagnosed with “schizophrenia” at 17, as was discovered later in the older chart, but without specific details), and later on, by her abusive partner. Throughout the years, she had coped by being under-responsive, or shutting herself down, until she could no longer take it at the age of 35. But patients with a true schizophrenia would be more prone to psychotic decompensation after a trauma, and such a long period of occupational functioning, as in Amanda’s case, isn’t the typical course. I was so overwhelmed with emotions, including some guilt of not having done this investigation much earlier, that I couldn’t write her progress note that night. While I ordered her old chart from storage, I decided that something about the way we practice and teach medicine and psychiatry has to change. Trauma awareness should be a priority among our peers and trainees. A disproportionate emphasis is put on schizophrenia. But we are talking about only one percent of the population affected, as opposed to at least roughly 10 percent in trauma-related disorders. In her old chart, despite concerning symptoms in the past (“command voices” and suicidal ideation after having been diagnosed

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She was raped in her late teens (and diagnosed with “schizophrenia” at 17…)

with schizophrenia and due to the fear of passing it on to her son), she consistently maintained a high level of functioning, displayed a remarkable insight and was responding “extremely well” and rapidly to treatments in an inpatient setting. As we are learning more about posttraumatic stress disorder (PTSD), we observe paranoid behavior (which is legitimate, this manifestation being an expression of intense hyper-vigilance and based on reality factors), and also perceptual disturbances (a lot of my patients who have been abused see shadows, hear their names or people crying). Yet, they are not psychotic, per se, as their contact with reality is intact. Dissociation, a common mechanism in PTSD, must be distinguished from confusion or visual hallucinations or other unusual perceptual experiences. Those affected by trauma-related disorders can also be suicidal. All of these manifestations, if taken out of their context, can unfortunately lead to a premature diagnosis of schizophrenia, if we strictly rely on a checklist approach. Of course, psychotic disorders should always be ruled out. But once this is accomplished, a thorough history of trauma and adverse childhood experiences should be conducted, as they can potentially lead to an unquestionable diagnosis of depression, agoraphobia or PTSD. In fact, now I use less liberally the diagnosis of depression with psychotic features, as the syndrome seems to be a response to a traumatic experience. Most people, often women with past history of trauma, will present as depressed. Moreover, catatonia (which Amanda, per her report, presented at the time of her initial diagnosis of schizophrenia) is more frequently found in depression. I don’t even want to try to imagine the number of women (and men, too) who have been institutionalized or lobotomized (among the 40,000 in this country, until last century) based on PTSD symptoms after being raped or traumatized. Biases, prejudices, and remnants of patriarchy create filters amplifying the distortions during a highly damaging telephone chain.

Thankfully, I have not witnessed any cognitive deterioration with Amanda and she hasn’t had a “psychotic episode” since the age of 35. Perhaps it is time to broaden our search of the truth and to shift the treatment approach, allowing people like Amanda time to heal, and to be more vigilant about the “telephone game” that can occur in medical handoffs, but also the anchoring heuristic (what leads people to stick with initial impressions once they are consolidated)1 and the framing effects of our

sometimes misleading “review of systems.” Amanda started attending a trauma education group and finds this helpful. We are also exploring more appropriate pharmacotherapies. Hopefully, this eight-year delay in expanding the diagnostic understanding of Amanda’s story has not caused diabetes or loss of opportunities. Medicine is a unique field. We are all lifelong learners.

Reference: 1. Redelmeier DA, The Cognitive Psychology of Missed Diagnoses, Ann Intern Med. 2005;142:115-120.

cgiroux@ucdavis.edu

Medical Muses continued from page 11 hysteric in Paris. By the 1870s, photography had replaced clinical sketching and drawing, and Augustine was photographed hundreds of times and always seemed eager to pose for the camera. Her “seizures” and contortions were more spectacular than Blanche’s, and she was more photogenic. One picture shows her apparently asleep, supine, rigidly suspended with only her neck and ankles supported by the backs of two wooden chairs. She ceased having “attacks” about a year and a half before she surreptitiously left Salpetriere in 1880. No one is sure if Charcot counted her as a “cure,” and her fate is unknown. The last of Charcot’s famous trio of hysterics was Genevieve Legrand. She was from Loudun, a small town in west central France that was the site in 1633-34 of “demonic possessions” at an Ursuline convent, witchcraft trials and public exorcisms that went on for three or four years. Genevieve, wrote one of Charcot’s assistants, is “our patient whose plastic poses and passionate attitudes have the most regularity.” Her “ecstatic” and “melancholic” posturing, as well as her penchant for self-mutilation, reinforced Charcot’s “conviction that demons and saints, from the past to the present, were hysterics.” Genevieve had visions of Christ and the Virgin Mary, and reported unwanted intimate nocturnal encounters with imagined intruders. Charcot’s student, Bourneville, wrote that, had

Genevieve lived two centuries earlier, she would have certainly been labeled as “possessed” herself, and probably burned at the stake. She was abruptly discharged from Charcot’s clinic in 1878 after an argument with another patient who may have been upstaging her. She never again displayed any hysteric symptoms and so, Hustvedt wonders, “perhaps Charcot inadvertently cured one of his star patients.” So, here we are in the 21st Century with a superabundance of psychiatric diagnoses and numerous drugs meant to ameliorate them. How would we code for Blanche, Augustine and Genevieve? What would we prescribe? Would we do better than Charcot and his chief resident Babinski? In 2012, French director, Alice Winocur, created a feature-length movie titled “Augustine” that explored the relationship between the famous patient and her famous doctor. If you do an online search for “Alice Winocur’s Augustine/ Fiction and films for French historians,” you will find a brief and readable history of Augustine, as well as some film clips that give a sense of what it must have been like at Charcot’s Salpetriere. Now, as noted earlier, the place is called Hopital Pitie Salpetriere, a modern research and teaching hospital with about 1600 beds serving the people of Paris and France.

Blanche, Charcot’s first celebrity patient, was nicknamed “the Queen of Hysterics.”

jmost119@aol.com

May/June 2016

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Like a Kid in a Candy Store A Review of the 2016 Las Vegas Consumer Electronic Show, Part I

By Bob LaPerriere, MD AGAIN I FELT LIKE A LITTLE KID let loose in a candy store as I attended the Las Vegas Consumer Electronic Show (CES) for the third time in January. With over 170,000 other attendees from more than 50 countries, looking at 3,800 exhibitors was a little overpowering, so the products below are only a small sampling of what I saw. In addition to the exhibits, there were lecture series including a two-day Digital Health Summit. Part II of my review will feature more details of some items, along with additional developments. Many of these products will not be available until later this year. BLUETOOTH − Bluetooth uses short-range radio waves (short range generally transmits to approximately 30 feet, though in some instances can go up to 100 feet), enabling communication between electronic devices, such as a smartphone and a speaker. It allows wireless connections to the “Internet of Things” (IoT). Development over the past several years of low-energy Bluetooth (BLE) allows some items to work for months or even years on a tiny battery; and Bluetooth is built into almost all smartphones, tablets and computers. It requires a simple procedure known as “pairing” to work. VIRTUAL REALITY (VR) − Several exhibits of virtual reality were tempting enough that once I realized my iPhone was a source for VR, I ordered a VR headset from Amazon. For a $35 investment (I already had a good set of stereo headphones), I can now enjoy numerous apps available for virtual reality, from “spooks” to news programs to dinosaurs. In virtual reality, you are, essentially, in the middle of the “site.” You can look 360 degrees around you, or look up and see the ceiling or the sky. You are truly immersed in the situation. More expensive and complex units are becoming available that

use other sources for the programs and have a built-in screen in the headset rather than using a smartphone for the video and audio source. 360-degree cameras are now showing up, such as the Giroptic 360cam; and Samsung has started marketing their unit. 4K/8K TELEVISIONS − Lots of televisions were evident, showcasing both the 4K, which are now readily available, and the 8K, to be available later this year. 4K means there are four times the number of pixels than in a standard HD television, so there is a four-fold increase in clarity. 8K actually has 16 times the number of pixels as standard HD. The clarity is incredible, with resolution looking sharper than “nature,” and at times, almost artificial. LG (Life’s Good) had a gigantic showroom with over 100 4K TVs synced to produce one large image. 4K broadcasting is in its infancy, though 4K content is available through streaming services, and 4K Blue-Ray players are now available, though they are currently in the $200-$400+ price range. SMART HOME − There was a proliferation of companies dedicated to the “smart home,” featuring all imaginable ways to control every aspect of your home remotely, including lighting, HVAC, and even door locks. Quickset showed a wide variety of new electronic locks. 3-D MEDICAL PRINTING APPLICATIONS − One company, WhiteClouds (www.whiteclouds. com), produces 3-D models from MRIs and CAT scans. These demonstrate the appearance of pathology, or other aspects of anatomy, in a true 3-D anatomical model. WhiteClouds is the largest, full-color, 3-D printing lab in the world with over 50 printers currently servicing medical, entertainment, gaming and architecture markets. 3-D medical models assist in the handling of complex surgical cases through May/June 2016

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. 17

3-D models, such as this brain, assist in the handling of complex surgical cases through improved pre-operative planning and evaluation.

improved pre-operative planning, evaluation, measuring, and patient education. The Mayo Clinic has their own 3-D printing lab and recently sponsored a three-day seminar on medical applications. Even now, though in their infancy, are advancements such as titanium 3-D printed joints that will be a perfect fit for the patient (see: http://3dprint.com/10743/3d-printed-hip/) and various 3-D printed tissue components (see: www.wakehealth.edu/Research/WFIRM/Projects/3D-Printing.htm). WhiteClouds was recently highlighted (see: http://3dprint.com/118418/superbowl-3d-printed-brace/) in the Super Bowl for 3-D printing a protective arm brace for Thomas Davis of the Carolina Panthers. With only days to act, WhiteClouds received a scan of Davis’ arm to 3-D print an exact fit brace. The future of medicine is exciting with unlimited 3-D printing technologies for various applications on the horizon. FITNESS TRACKERS − Every year there are more and more fitness trackers, though after several years, most of the features are fairly standard, and in addition to new companies, ones such as Fitbit that produced some of the first units, are developing new, more complex (and expensive) ones. BLINK − I found Blink (http://blinkforhome. com), a surveillance camera, to be both innovative and affordable, and of potential interest to many people. It requires a smartphone running either iOS or Android. Blink is easy to use and reasonably priced (approximately $99 for a sync

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module and camera, and $60 for additional cameras.) The camera is entirely wireless and claims to run a year on the two included AA lithium batteries. The only “wired” connection is the sync module that plugs into an AC outlet. It features 720p resolution and has a built-in microphone. It will detect motion and record up to a 10-second clip, and alert you via your smartphone when this occurs. With its Live View feature, you can check in on your home anytime, anywhere. There is no monthly fee, and the clips are stored on their cloud. Planned upgrades include temperature alert (it currently includes a temperature monitor), USB storage for video clips, the ability to program when the camera is armed (able to take video clips) and a weatherproof version. HANDY ITEMS − There is an increasing number of flash drives that are compatible with the iPhone, both through their own wi-fi connection or a direct plug, and a plethora of batteries for charging your pads and phones. INNOVATION − An exciting new development is the production of very small fuel cells. A novel one is run by magnesium and it will be used in drones to extend their flying time by a factor of 3 to 4. CARDIAC/VASCULAR MONITORS − Several “patch type” single lead units were evident that transmit an EKG to a smartphone. These include BC1 Heart Monitor System by xyzlife (www.xyz-life.com) and Qardio (getquardio. com). MyECG (https://www.bewell-connect.com/ product/myecg/) is a small unit that has both a minscreen to view the EKG and uses two thumb contacts. It also features Bluetooth transmission to a smartphone and recently was registered with the FDA, in addition to receiving an Innovation Award at the CES. iHealth Rhythm (ihealthpro. eu) measures parameters for screening, diagnosis and prevention of peripheral arterial disease. HEALTH/MEDICAL − •Seal Shield (www.SealShield.com) for several years has been producing electronic-related products, such as keyboards, and protectors for products to allow washing and disinfection. They now have a Portable UV Disinfection Device (MoonBeam3) using UVC light and two

UV sanitizers for mobile devices. • Captureproof (www.captureproof.com) is a HIPAA secure photo and video sharing program especially for telemedicine. • SmokeWatchers (www.smoke-watchers.com) is an app to support stopping smoking. • ADAMM (www.healthcareoriginals.com) is an electronic sensor and app to help monitor patients with asthma. • ORCAM (www.orcam.com) is now available. This is a small eyeglasses-mounted camera for people with poor vision, such as those with severe macular degeneration. The person points to text (book, menu, street sign, etc.) and the unit will audibly read the text to them. • EVE ROOM (www.elgato.com/meet-eve) is a module that tracks air quality and sends it to a smartphone. • SPUN (www.SpunUtensils.com). You first photograph your plate and image recognition records your food items. A fork and knife then weigh each bite of food.

GENERAL − Qkey (https://www.qkeysecurity. com/) – a USB “key” used to secure online payments. CUJO (www.getcujo.com) – a module and smart device to help prevent hackers, unauthorized access, etc. FLIC (https://flic.io) – a small wireless button (from Sweden) that uses Bluetooth and can be programmed to perform multiple functions on a smartphone (iOS or Android). Each button can be programmed to perform three functions by doing a click, a double click, or holding the button, including tasks such as operating the shutter release for the camera, making a phone call, ringing your phone to locate it or sending a distress message. And as you can imagine, with almost 4,000 vendors, this is only a sampling of the wondrous developments and “toys” we will soon be seeing. ssvmsedcom@gmail.com

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May/June 2016

Electronic Health Records Part I – User Misery 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.

AN INPATIENT SUFFERS a cardiac arrest at 2 am when his nurse is on break. The intensivist running the code blue logs on to the EHR, searches through five James Gardners for the right one, chooses a justification in the drop-down menu for accessing his information and dispenses with a best practice alert (BPA) asking her if the patient still needs a urinary catheter. The latest physician progress note contains a template physical exam and an assessment duplicating the admission ICD-10-based problem list which contains diagnoses that aren’t active this admission. There is no verbiage about hospital course or current condition. It takes three clicks to see one five-inch monitor strip, two more to exclude prn from active medications and too much time to make a graph showing deteriorating vitals. It’s all there, but takes too much time and misses the big picture. In 2004, President George Bush set a goal for every American to have an electronic health record (EHR) by 2014, to improve quality and reduce health care cost. His administration set up the Office of the National Coordinator for Health Information Technology and the American Health Information Community to oversee this new policy. EHR programs then were mostly clunky attempts to re-create the paper chart for outpatient offices. Physicians were slow to sign on, but that changed with 2009 legislation that prodded doctors to do so with financial incentives and enticed buy-in by administrators who, increasingly, run the business of medicine. Deep down, we all know that EHRs are here to stay. Politicians put up $30 billion to incentivize physicians to adopt digital medicine as a means to measure quality, improve

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safety, facilitate coordinated care (called interoperability) and move payment schemes away from volume-based care. Administrators worship them as a means to capture better reimbursement, prove compliance with best practice guidelines and enable them to survive quality reviews. Physicians appreciate the ready access to test results and, if the stars align properly, enable retrieval of remote patient data. Patients like the ability to see their results online without waiting three weeks to see the doctor. Public health analysts and scientists like the access to big data to assess changing health patterns and to generate new knowledge. However, current EHRs have serious problems, making them targets for criticism and parody, encapsulated in the “EHR State of Mind” YouTube video by LetDoctorsBeDoctors. com’s ZDoggMD at http://bit.ly/1UntKos. This Alicia Keys’ song parody makes a hilarious and pithy plea for an EHR that works better for patient care. My favorite line is, “Just a glorified billing platform with some patient stuff tacked on.” Practicing physicians know that the stars haven’t aligned, and we are far from achieving medical electronic utopia. A 2005 (pre-widespread EHR use) study of outpatient doctors indicated that simple programs which computerized progress notes were wellaccepted. Fast forward to 2016, where EHRs are more complex and designed to meet regulatory requirements and improve revenue stream. Docs flee into retirement or come to grips with the fact that it will take more time to get to know their patients less well.

The major problem is that EHRs use computer geek-administrator-number-cruncher logic, not the patient or problem-oriented flow of a medical mind. An EHR company executive told me, “So far it is technically impossible for EHR programs to link what we would consider to be related components of a person’s health record.” Since medical professionals are no longer the target users, and EHR logic doesn’t match medical logic, even computer-savvy clinicians have a difficult time adapting. A recent RAND study documented remarkable EHR-induced distress and concluded that, “No other industry, to our knowledge, has been under a universal mandate to adopt a new technology before its effects are fully understood, and before the technology has reached a level of usability that is acceptable to its core users.” They compare it to what would happen if the aviation industry sold new airplanes without pilots having extensively tested them. I tried to find out who had beta-tested various EHR products, without much success. Cerner, the largest company worldwide, never responded to my query. Others said Cerner is exceptionally configurable, to suit an institution’s needs, but what works for one individual may drive another crazy. EPIC responded, but didn’t give me much information. No one assured me that busy, non-tech-savvy primary care doctors were testers and convinced that EHRs are conducive to good patient care. The Department of Defense (DOD) could have changed the whole paradigm with their new EHR system. Instead, it awarded its $9 billion contract for the entire defense/VA health system to a Cerner/Leidos /Accenture coalition. The goal was to “integrate activities” and improve efficiency with a commercial product that would require “minimum modifications.” The request for proposals had emphasized interoperability, including with private health care systems. It made no mention of using medical logic or maximizing physician efficiency or patient satisfaction. Off-the-shelf means that current idiocy is perpetuated, not corrected.

Interoperability Has So Far Failed Health systems and providers buy different programs that just don’t communicate. Denise Petrovich, of GE Healthcare, makers of picture archiving and computer software (PACS), says that different programs use digital formats that don’t mesh with other programs. There is a board of engineers that meets to set IT format standards for all EHRs, but so far they have only developed them for tiny pieces of the record. For example, each EHR documents demographic items in a standardized format, like how a birth date is displayed, but lab data can’t mesh between EHRs because those formats don’t match. Not only are the mechanics of it tough, but some vendors have balked at interoperability and kept their system closed in attempts to increase profits. EHRs don’t save health care dollars. Reality rather than hype has led number-crunchers, using more extensive EHR data, to debunk the cost-saving argument. Theoretically cost-saving should result from less test duplication, because results require only a click to see. But doctors who have spent too much time on clicks and BPAs don’t take the time to review past testing to prevent repetition. This incurs more, not less, cost to society. EHRs make billing easy by requiring that doctors generate a problem list from ICD codes. A complete problem list with lots of codes makes the patient sound very sick. Padded coding generates better reimbursement for the provider, but more cost to someone else paying the bills. More “documentation,” with passivelyimported medical and social history, test results and complete exam template that wasn’t necessarily performed, makes it look like a lot of work was done. This “justifies” a higher E&M code, which numerous analysts call E&M “creep,” but increases health care cost. EHRs reduce efficiency. Recent reports find that most doctors complain of hours of data entry unrelated to patient care and workflow disruptions that waste time. Excessive data entry required for billing and meaningful use requirements slows down caregivers. It takes

May/June 2016

EHRs don’t save health care dollars.

…the average ER physician in a community hospital makes up to 4,000 mouse clicks per 10-hour shift.

time to try to find which of the inadequate drop-down diagnosis options most closely approximates a real, live, nuanced patient. Some outpatient doctors choose to spend time talking with and examining their patients, but end up completing their chart notes at night and on weekends. They’ve given up personal time for computer time. Hill, et.al., found that the average ER physician in a community hospital makes up to 4,000 mouse clicks per 10-hour shift. Not only are there clicks, but there are also searches – for stuff that is hidden or isn’t where it should be. The screen for a reference lab result is full of print, but the number you seek, as well the test name and collection date/time, are submerged somewhere among details of specimen acquisition, insurance coverage, laboratory location, and result release – like all of it is equally important. Woe to the doctor who orders a test with words in the “wrong” order or adds an “s” to reticulocyte. Whether it’s a code blue or a busy day, clicks, drop-down menus, searches and trying to read the computer’s mind add up to wasted minutes. That time might have been spent listening to the patient, doing a decent exam, arriving at a diagnosis without expensive testing, discussing alternative treatments and educating.

EHRs Don’t Improve Quality of Care EPIC overrode my effort to set my transplant patient’s cyclosporine dosing schedule at 6 am and 6 pm, so that a 5:30 am drug level would be a true 12-hour trough. Unaware of the default to 9 am and 9 pm dosing, I was about to adjust the dose when the nurse alerted me to the change. Digitizing orders, notes and data does not improve quality, especially if pieces of information are in illogical locations and the defaults don’t fit the patient. BPAs may alert doctors to potentially concerning problems, but they are so numerous and frequently so inconsequential that doctors suffering from “warning fatigue” click “override and accept” automatically. Canned ICD diagnoses don’t communicate knowledge of a particular patient. Adding descriptors to specify degree of severity, active or resolved, recent or

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remote and precipitants takes time and most doctors aren’t doing it. Doctors use time-saving measures like cut-and-paste notes and template reviews of systems and physicals as a survival mechanism. This fulfills E&M requirements at the expense of accuracy, and often leaves the patient unrecognizable. It certainly whitewashes patients. Handwritten exams were becoming homogeneous also, but at least we had the option of drawing a picture. It’s possible to draw an EHR picture of areas of pain on an abdomen, but it’s onerous and rarely, if ever, done. Volumes of imported data bulk up notes, but discourages anyone from reading them, which begets even less pressure to make them useful. Absent communication hurts patients. Many doctors either spend a few minutes with a patient and leave to compile the note elsewhere, or complete the note with the patient but focus only on the computer. Either way, lack of eye contact really bothers patients – they feel irrelevant and the doctor-patient relationship suffers. Lisa Rosenbaum, MD, in a New England Journal of Medicine op-ed about EHRs writes, “We follow many ‘Best Practice’ measures that have no value to patients, while much of what patients do value, including our attention, remains immeasurable.” Is relief in sight? The AMA achieved some regulatory relief for doctors struggling to meet “meaningful use” (MU) criteria, an incentive program using bonuses and penalties to coerce doctors to use EMRs in “meaningful” ways. Most MU criteria sound OK, like drug allergy alerts, prescribing online and patients’ online access to results, but some are ludicrous or hard to implement. BreakTheRedTape.org is a network of physicians holding town hall meetings to further influence legislation and reduce federal regulations. In spite of all this, MUs aren’t going away: CMS only agreed to allow doctors to devise criteria that better suit their practice. These efforts may reduce regulatory pressure, but don’t lead to caregiver and patient-oriented EHR programs. Those goals can only be met by changing EHR programming. We know this and

complain, but that doesn’t get us anywhere. There are more than 300 EHR companies in the world, the top two being Cerner and Epic. The docs I know who have used both say both are bad. With their respective $2.67 and $1.5 billion annual revenues, they should be able to devise efficient programs that enable better patient care, and test them on thousands of busy, practicing doctors to make sure that they do. A tech company that makes end-users happy would do very well. The AMA just announced a partnership with Silicon Valley technology experts called Health2047. This “innovation company” will “conduct rapid exploration of transformational solutions” to challenges doctors face. Robert Mills from the AMA translated that jargon into “EMRs and other techy approaches to fulfilling common needs.”

We can’t wait for 2047. It’s time for physicians to stop complaining, take a commanding seat at the table, and demand user-friendly programs that don’t impede patient care and doctors’ efficiency. In Part II of this subject, I’ll discuss medico-legal issues that make this an imperative. algerhardt@sbcglobal.net References: Hill RG, et al., “4,000 Clicks: A Productivity Analysis of Electronic Medical Records in a Community Hospital.” Amer J Emerg Med. 2013;31(11):1591-4. DesRoches CM., Electronic Health Records in Ambulatory Care – A national survey of Physicians. NEJM 2008;35-:50-60. Wachter R., The Digital Doctor: Hope, Hype, and the Harm at the Dawn of Medicine’s Computer Age. New York, McGraw-Hill. 2015. Poissant L, et al., The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. J Amer Med Informatics Assoc. 2005;12(5):505-516. Rosenbaum L., Transitional chaos or enduring harm? The EHR and the disruption of medicine. NEJM 2015;373:1585-1588.

Pain Doctor By Caroline Giroux, MD There is a carved sign Wooden, pristine That spells my name But not the shadow of my pain

Revisiting my book, once bare There are scribbles only I can see I have always known them to be there, Like an old shame, a lesser me But also I read a time of gold Years of accumulated knowledge My own myths of survival, already so old Like an armor and a shield, or my personal pledge

I face the sign Like an invitation To map your aches Amongst rows of sakes

One day I will decide to not only look, but own One day a part of me will accept to own the pain To see it… yes, seeing won’t mean having deficiencies! But rather finding territories of marvels, anti-enemies

This was the entrance to my safe place Surrounded by bookshelves Printed wisdoms and benevolent elves That first prescription, just “in case”

It is the day I will wake up from this silent nightmare It is the day I will become a more capable healer No more captive, the resuscitated explorer A teacher, finally, because still and always a learner

So many textbooks swallowed to make it to MD A sparkle of magic glows from the sign I know I can do it I thought I could do it…

cgiroux@ucdavis.edu

May/June 2016

Reflections on Medical Advances in Your Lifetime Background: Medical advances seem to happen all the time. Which one has been a “game changer” for you? What do you consider to be “the most significant medical advance in your lifetime” that has influenced or will influence your practice of medicine? Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows:

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 greatest advance in medicine in my lifetime occurred when engineers learned how to combine MRI data with the ability to use 3-D printing to create patient-specific artificial joints, cardiac valves, and other prosthetic implants. The implications and uses of this are unlimited, and the relatively low-cost and increasing speed and accuracy of the designs will make this affordable for all potential recipients. −Roy Schutzengel, MD, MBA Already, it is clear that EMR will have the biggest impact on how I practice medicine. Goodbye to handwritten notes. As a prior EMT with the fire department and in the hospital, I have already seen the utility of easily-accessible patient records. These records are of particular importance when patients may be unable to communicate due to physical impairment. Though a computer will never replace the importance of patient-physician interaction, it is a powerful tool that can easily fit into the future generation’s doctoring bags. −Shah W. Steiner, MS II, MPH CT scanners for head injuries. Pelvic ultrasound for lower abdominal pain with a positive pregnancy test. −John Tucker, MD, The cell phone. This was the most liberating

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technology, bar none. And as apps like UpToDate become more universally available, this becomes an essential tool to medical care and quality. −Lydia Wytrzes MD Percutaneous Coronary Angioplasty by Dr. Andreas Gruentzig in 1977. In 1977, the first balloon angioplasty procedure on a coronary artery was performed in Zurich, Switzerland, by Andreas Gruentzig, a German-born physician. Building on the work of physician Charles Dotter, who had performed the first-ever angioplasty procedure in a leg artery over a decade earlier, Dr. Gruentzig began a revolution in the treatment of coronary artery disease. Truly a leader in his field, Andreas Gruentzig began a revolution in the treatment of coronary artery disease, a revolution that continues to bring new concepts into reality as the battle against heart disease goes on. −Arvin Arthur, MD The Affordable Care Act. This will have far more impact on the overall health of the nation than any technical advance or drug. −Jack Kashtan, MD The advent of EMR/EHR in the last 10 years is the single potential greatest and currently most cumbersome advance in medicine. The goal of having integrated data among physicians, hospitals, and labs, across a multitude of organizations over a lifetime was conceived to improve care delivery and efficiency and reduce duplication of tests, as well as to provide better accountability about care being rendered. In addition, attempting to reduce fraud and waste with better documentation. However, current systems impose more work, require hours of data entry, and provide few, if any, tangible benefits to the patients. The infrastructure and costs required to maintain an EHR system

continue to grow significantly. Current systems lack interoperability. Duplication of efforts is increased when needing to print and scan information. As EMR/EHR systems are likely not going to go away, I assume the potential benefit will manifest in my lifetime. −Rajan Merchant, MD I think there have been two medical advances in my lifetime that have impacted my practice and will shape the future of plastic surgery. The first is the development of laparoscopic surgery which led to the development of robotic surgery. As our technology and skill advance with this tool, we will be able to perform very challenging procedures with minimal scars. The other advance would be tissue engineering and the expansion of the use of stem cells. −Amy Wandel, MD I just turned 80, and for me, the most amazing advance in my medical lifetime occurred just this year when I toured the UC Davis Stem Cell Lab at the Medical Center. I was astounded how they are able to use, not just cord blood stem cells, but they also work with adult mesenchyme stem cells, (I didn’t know these existed before.) They can harvest and cultivate them, and then induce them to become tissue-specific cells – such as heart muscle, or nerve cells for example. They are just beginning to use these clinically for patients with a wide variety of afflictions: arthritic pain, Parkinson’s, macular degeneration, non-healing limbs in diabetics, Huntington’s disease, severe burns, and so on – all devilish problems we have failed to help before. Although my age group will not see much of this revolutionary therapy happen, I feel so blessed to have been introduced to the future of medicine at this amazing lab right here in Sacramento. I strongly encourage our membership to become familiar and to support it. −F. James Rybka, MD One of the benefits of having been in practice a long time, (I graduated from medical school in 1974) is the opportunity to have experienced many practice-changing advances that must seem like they have existed forever for younger physicians. For me, the development

of CT scanning (and later MRI) is the most remarkable. Prior to the development of CT, we evaluated head injuries with now archaic studies, like cranial ultrasound, looking for midline shift or referred a patient for exploratory laparotomy to investigate a possible abdominal mass. −Mark Blum, MD For me, the “game changer” has been trauma-informed care (TIC). TIC refers to the shift in practice from the symptom-oriented, detached question of “What’s wrong with you?” to the narrative-based, compassionate inquiry of “What happened to you?”, as well as “universal precautions” regarding trauma. The shift is based on mounting evidence that adverse childhood experiences comprise the single-most important upstream, preventable cause of non-communicable diseases, which are the biggest cause of disability and mortality. “Universal precautions” refers to reducing the risk of harming patients inadvertently by changes in policy, procedures and practices that may re-traumatize patients. In addition, TIC entails cultivating provider self-care through the recognition of our own histories of adversities and psychophysiological vulnerabilities. Finally, TIC is wholly congruent with and supporting of patient-centered care and cultural competence/ humility. As such, it’s grounded on patients’ strengths and resilience, and promotes personal responsibility, empowerment, recovery and wellness. −Andres Sciolla, MD The development and expansion of immunocytochemistry and molecular diagnostics have revolutionized my practice of anatomic pathology. While thorough morphological evaluation is required in the evaluation of all pathology accessions, selection of appropriate markers can greatly facilitate making the correct diagnosis. −Jeffrey Moore, MD When I think of the Gen X transformations, I think of computers, internet, and multimedia advances, but also increasing wealth disparities, automation of jobs, pyramid schemes, and business shenanigans. There are numerous technology examples in medicine, and the CT scanner and cardiac stents might top my list. In

May/June 2016

The advent of EMR/EHR in the last 10 years is the single potential greatest and currently most cumbersome advance in medicine.

The advances in human genetics during my short 23-year lifespan have been profound.

terms of wealth disparities, the increasing pay gap between primary care docs and specialists is unfortunate and unprecedented, and thwarts better population health. Perhaps the most far-reaching social/medical advance was the Roe vs. Wade decision that came out around the time of my birth. It empowered women to start a family when they were ready to do so, and brought more attention to contraception as well. Despite that, how long did it take Viagra to drop off the list of essential meds and contraception to be put on it? As more women gained reproductive freedom, they have been able to forge careers (medicine included), fight for other women’s health causes (cancer awareness, abuse, inequalities), and take unprecedented leadership positions (maybe even Presidential?). −Nathan Hitzeman, MD Conjugated vaccines for infants and toddlers (meningitis, sepsis, etc.) −Steven Dorfman, MD The CT scan − when it was invented, we became empowered to image the brain for acute trauma, replacing ultrasound which was not very helpful. The CT replaced skull films which were not very helpful, in fact less helpful than the history. Second, is the cardiac catheterization and its intravascular interventions. This created a new way to mitigate CAD. Third, are trauma centers – these improve the quality of trauma care. There have been remarkable anticancer drugs, drugs for HIV and HCV, better understanding of disease, like gastric ulcers, and other diagnostic aids, like portable ultrasound. Safer needles protect the health care workers. More immunizations protect the children of educated parents. It is no wonder that health care costs more and patients live longer. When I started practice, Emergency Medicine was about to become a specialty. We had no cell phones, iPods, or home computers. Only 10 percent of my classmates were women. The birth control pill had been on the market for only eight years. Abortion had been legal for four years. The “war on drugs” had yet to fail. −Jerry Rogan, MD The most significant medical advance in my lifetime is the evidence-based medicine revolution which was based on work in the early 1990s by Dr. Gordon Guyatt, Dr. David

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Sackett, Dr. Brian Haynes and others at McMaster University in Hamilton, Ontario, Canada. This tidal wave of change is responsible for a whole new level of discipline in clinical research, outcomes-based research, and in scientific publication. It also was entirely responsible for most of my scientific journals getting much thinner. −Alan R. Ertle, MD The advances in human genetics during my short 23-year lifespan have been profound. In 2003, the Human Genome Project was declared complete. A few implications of this achievement are below: By understanding the genetics of bacteria and viruses, new antibiotics and vaccines can be developed. By understanding mutations in the genetic code for common genetic illnesses, we can begin to understand the functions of vital proteins in the human body which will lead to a greater understanding of human physiology and a greater understanding of how to prevent and treat these conditions. By understanding the genetics of plants and animals, we can alter crops to grow larger and healthier, to become pest-resistant and to stay fresh longer. This will bring down the cost of food and help alleviate hunger globally. By sequencing the genetic mutations in tumors, we can continue toward the age of individualized medicine in which we select treatment regimens based on the patient’s specific needs. By sequencing the genetic differences in certain brain receptors, we can better understand the genetics of mental illness, from addiction to Schizophrenia. By harnessing extraordinarily-powerful genomic editing techniques like CRISPR, we can do all of the above with greater precision. Each of the above technologies have progressed rapidly, even in the last 5 to 10 years. I am excited to be entering the field of medicine at the cusp of what is sure to be a revolutionary improvement in its practice. −Steven Nemcek, MS I

Book Review

Early Pain Management and Anesthesia A Look Back at Mandrake Root, Mulberry, Hemlock and More

By Kent Perryman, Ph.D. THE EXTENDED LIFE SPAN of humans can be attributed to the discovery of anesthesia and germ theory. Humankind has been burdened with pain and suffering from injury and disease for millions of years. The Christian view of pain and suffering attributed it to God’s will! However, medical science discovered that treating pain with analgesics and employing anesthesia during surgical procedures was the humane way of managing pain. Pioneers in the use of anesthesia include such notable characters as Connecticut dentists, Horace Wells and William Morton, and Boston chemist, Charles Jackson, in the 19th century. However, pain management associated with surgery extends much further into the past.

Pre-19th Century Pain Management The first use of anesthesia goes back to archeological evidence in South America. Allegedly, Inca shamans would use flint knives to bore holes in the skull to release bad spirits. This technique was also the first recorded use of the surgical technique of “trephination.” The shamans may have had patients chew coca leaves to numb the bored hole pain, as well as apply a coke-resin-spittle substance to the drilling site. Many pain killing remedies from the ancient Greeks included the consumption of wine. The Greek physicians also believed that the roots of mandrake plants had magical qualities, including the ability to induce sleep. The Greek physician, Dioscorides, used mandrake potions mixed with wine to produce anesthesia on

surgical patients. This was the first known use of the word anesthesia, which is Greek for “without feeling.” To relieve surgical pain, early medical practitioners in India and China used marijuana and hashish made from hemp plants, while North American aborigines inhaled smoke from the Jimson weed. Most of these early anesthetics did not function very well for mitigating pain, and none of these substances met the major attributes of general anesthesia to produce unconsciousness in a surgical patient. During the Middle Ages, there were virtually no scientific medical advances in pain management. Alchemists concocted an anesthetic formula in the 1200s, consisting of coal tar mixed with wax from a dog’s ear. This concoction was supposed to induce sleep for days. Swallowing soap was also a common practice to alleviate pain. By far, the most popular anesthetic during this time was “spongia somnifera” (Latin for “sleeping sponge”). An anesthetic stew of mandrake root, mulberry and hemlock was placed on a sponge and held to the patient’s nose. Many of these early pain remedy herbal mixtures also included opium, which was later employed as an intravenous anesthetic in 1659, and even later in 1805, modified into morphine. It wasn’t until the Renaissance era that inhalation anesthetics were first experimented with as a form of general anesthesia. The German physician, Valerius Cordus, synthesized diethyl ether in 1540 by distilling ethanol and sulphuric acid into what he called “sweet oil of May/June 2016

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.

vitriol.” Raymond Lullus, a Spanish physician, was experimenting with ether on animals during this same period. Three hundred years later, Theoprastus Bombastus von Hohenheim (Parocelsus) continued Lullus’ experimentations with ether anesthesia on chickens. Parocelsus claimed that sweet vitriol “quiets all suffering without any harm and relieves all pain.” It was the German chemist, Frobenius, who gave sweet vitriol the name ether, meaning “heavenly.” In 1772, another historically prominent anesthetic, nitrous oxide (N2O), was first introduced by the English clergyman and chemist, Joseph Priestley. However, it wasn’t until 1798 that patients in Clifton, England, were first treated with the nitrous oxide by Humphrey Davy. The medical community in Europe, at the time, was under the illusion that nitrous oxide could be fatal when inhaled. Humphrey experimented with N2O on himself and discovered its capability of inducing episodes of laughter, whereby he coined the term “laughing gas.” Davy eventually became addicted to the euphoric effects of the substance during his experiments with cats and dogs. In 1800, Davy suggested in the publication “Researches, Chemical and Philosophical, Chiefly Concerning Nitrous Oxide” that nitrous oxide be employed more seriously in surgery. He failed to adequately convince the medical community of the beneficial anesthetic benefits from N2O at the time. Laughing gas would have to wait until later in the 19th century to be taken seriously by the medical community as an inhalation anesthesia. Other forms of anesthesia were also being This nineteenthcentury ether mask is one of many donations that are on display in the SSV Museum of Medical History.

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experimented with during the latter part of the 18th century. The English physician, Henry Hill Hickman, was experimenting with methods of anesthetizing animals for surgery by depriving them of oxygen, as well as employing carbon dioxide to induce sleep. Hickman went on to write “On Suspended Animation,” the first official work ever published on anesthesia. He submitted a copy to the Royal Society of London that was discredited by none other than Humphrey Davy, the society’s president!

19th Century Pain Management with General Anesthesia The average life expectancy in the 19th century was 35 years, due to epidemics and maternal mortality. Absence of germ theory contributed to unsanitary surgical procedures and sepsis. Apothecaries created wizard oils with claims to cure whatever ailed you. The only surgeries being performed during the first part of the 19th century were limb amputations, removal of superficial tumors and removal of bladder stones. The skill of a surgeon depended on the swiftness of the operation − the quicker the procedure, the better the patient’s chances of survival. Alcohol was usually necessary to help dull the pain as well as to clean the wound. Pain associated with poor dental hygiene was also prevalent during these times. Many physicians, who were also dentists, had to rapidly remove teeth and have the patient swallow some whiskey to dull the pain. The pain associated with these tooth extractions would discourage some patients from having additional teeth pulled, resulting in added health problems. During this time in the 1830s, there was a rediscovery of Humphrey Davy’s laughing gas as a form of entertainment. Nitrous oxide demonstrations were given at fairs, tent shows and meeting halls. Eventually, laughing gas and ether parties became popular forms of entertainment, referred to as “ether frolics.” It was during one of these frolics that Dr. Crawford W. Long observed that participants experienced no discomfort from bruises or lacerations and had no recall of their accidents. Long had

observed similar behavior when employing ether for surgical procedures. However, Long never received any credit for his promotions of inhalation anesthesia by the medical community. It was Horace Wells, a Connecticut dentist, who in 1844 also witnessed an injury at a laughing gas party where the participant was unaware of his injuries until much later. Wells subsequently underwent a dental extraction under nitrous oxide that convinced him of the beneficial anesthetic qualities of this substance. Well’s former student and business partner, William T. G. Morton, arranged for his mentor to demonstrate the use of nitrous oxide during a tooth extraction at Massachusetts General Hospital’s (MGH) Ether Dome on January 20, 1845. Unfortunately, Wells failed to provide the patient with sufficient N2O, whereby he regained consciousness in the middle of the procedure. Eventually, it was Dr. Morton who became the first person to successfully demonstrate the use of ether as general inhalation anesthesia at MGH. In 1846, Dr. Robert Liston performed the first amputation under ether anesthesia. Nitrous oxide as a general inhalation anesthesia never caught on during the 19th century, due to its inadequate delivery systems. The early oxide inhalers had no scavenger system and flow meter as well as no allowance to control for oxygen. Today’s use of nitrous oxide uses a relative analgesia machine to precisely deliver dosed and breath-actuated flows. The simplified dental version lacks a vaporizer and ventilator. Ether was also an unreliable form of general anesthesia at this time. The ether was dripped onto a cotton mask covering the patient’s mouth and nose. The amount and frequency administered was left up to the discretion of the surgeon. Ether had a tendency to cause coughing and to generate struggling. James Young Simpson, while attending medical school at Edinburgh, Scotland, began experimenting with chloroform in 1847 as an anesthesia agent during difficult childbirths. Chloroform had been around since 1831, but as an anesthetic agent was ignored.

Chloroform eventually became more of an adopted, mainstream anesthetic in Europe during the last half of the 19th century to the extent that Queen Victoria even used it in 1853 to give birth to her son, Leopold. The medical profession eventually discouraged the use of chloroform as a general anesthetic. Cardiac arrest and liver toxicity were common problems. As it turns out, nitrous oxide is much safer. Nineteenth century mask inhalation eventually gave way to direct laryngoscopy (endotracheal anesthesia) as a safe means to intubate the trachea in the 20th century. Shorter action, more controllable intravenous anesthetics, such as sodium thiopental, supplemented many newly-developed inhalation anesthetics. The technology for compressing gases into metal cylinders that insured a regulated flow of inhalation anesthetics was not available in the 19th century. The introduction of topical, local and regional block anesthetics was also a medical innovation of the 20th century. We are fortunate to live in a time when anesthetics are available for surgical procedures, as well as for reduced suffering during palliative care.

Dentist William T. G. Morton successfully extracts a tooth in 1845 under ether anesthesia at the Ether Dome.

kperryman@suddenlink.net References: Fradin, DB, We Have Conquered Pain: The Discovery of Anesthesia.1996; Margaret K. McElderry Books Snow, SJ, Blessed Days of Anesthesia: How Anesthetics Changed the World. 2008; Oxford University Press History of General Anesthesia https://en.wikipedia.org/wiki/History_ og_general_anesthesia Blatner, A, The Discovery and Invention of Anesthesia (Stories in the History of Medicine) www.blatner.com/consctransf/ historyofmedicine/4-anesthesia/hxanesthes.html

May/June 2016

Community Unites to Help Uninsured Care Coordination Prevents Blindness

By Liza Kirkland, Director, Community Service, Education and Research Fund

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.

MORE THAN ONE MILLION undocumented Californians are currently ineligible for health coverage through the Affordable Care Act, and cannot enroll in Medi-Cal or buy health insurance from Covered California. As of January 2015, the University of California, Berkeley, Labor Center estimates that the Sacramento region has close to 50,000 undocumented immigrants who could benefit from access to care. This population is forced to live in pain in the shadows because no other options are available to them. The Sierra Sacramento Valley Medical Society’s (SSVMS) Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) program meets some of the health care needs of this community by recruiting physician volunteers to provide free medical services to our region’s uninsured. No one should suffer from a treatable condition due to their immigration status. By providing access to care for our region’s undocumented residents, SPIRIT creates a preventative public health strategy by facilitating access to care for uninsured residents in a timely and costeffective manner, rather than having them wait for expensive emergency care. Uninsured patients, like Salvador in this article, are forced to visit the emergency room for care, making local hospitals the default setting for caring for these patients in the least economical way possible. Salvador came to this country alone at the young age of 15 to help his family in his native Jalisco, Mexico. He would

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see families in his town benefit from the money that was sent from relatives working in the United States, and seeing that made Salvador strive for it, as well. He dropped out of high school to pursue a better life for himself and his family in the United States. After arriving in the Sacramento area, Salvador started to feel ill, so he visited a local community clinic. It was there that he was diagnosed with diabetes. Luckily, being a minor at the time, Salvador was able to receive MediCal benefits to help with managing his illness. Unfortunately, this was only the case until he turned 18. Now at 34, Salvador has been selfmedicating since turning 18, finding syringes and insulin wherever he could to help manage his diabetes. “I felt hopeless, I was my own doctor,” he says. “I had not been to a doctor since I was 18. Being undocumented, I felt scared and did not know where to go for help.” It was not until Salvador’s vision started to change that he knew something was not right, and he needed to seek care. After visiting a local emergency room and being turned away because he was not experiencing a medical emergency, he was referred for help to the communitybased organization, and SPIRIT partner, La Familia Counseling Center. With the help of La Familia, Salvador was able to find a medical home and was referred to SPIRIT for assistance. Long-time SPIRIT volunteer and SSVMS member, Ophthalmologist Richard Jones, MD, reviewed Salvador’s retinal imaging and stressed that if he did not receive eye surgery within

the next three months, he would go blind. Dr. Jones suggested that SPIRIT staff reach out to his colleague, SPIRIT volunteer and SSVMS member, Tony Tsai, MD. Dr. Tsai generously donated all of the care for Salvador, and SPIRIT partner, Dignity Health, agreed to donate the surgery at Mercy General Hospital. Thanks to a new partnership with Sacramento Covered, Salvador was able to receive free transportation via Uber to and from his surgery. SPIRIT is now working with Salvador’s primary care physician to ensure continuity of care post-surgery to help manage his diabetes. This includes having Salvador participate in Dignity Health’s free six-week Diabetes Management class at La Familia. “Words cannot express how thankful I am for all of this wonderful care,” Salvador says. “I am very happy to know that there are programs like SPIRIT in my community helping those in need. Thanks to SPIRIT, I will not go blind and can now take charge of my health and my diabetes. I feel empowered to share my story, help others and tell them: Educate yourself, do not lose hope and always have faith.” Interested in volunteering? Interested in making a donation? Please call (916) 453-0254. The SPIRIT Program is part of the Community Service, Education and Research Fund (CSERF), a 501 (c)(3) that exists as a vehicle to involve physicians in the community. SPIRIT is a collaborative partnership with SSVMS, Kaiser Permanente, Dignity Health, Sutter Health, UC Davis Health System and the Sacramento County Dept. of Health and Human Services, that coordinates surgical and specialty services for uninsured individuals at local hospitals and ambulatory surgery centers.

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SSVMS member, Tony Tsai, MD, generously donated all of the care for Salvador, and SPIRIT partner, Dignity Health, agreed to donate the surgery at Mercy General Hospital.

May/June 2016

Rise of the Recyclopath 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.

FOR YEARS, I WOKE UP next to a recyclopath. Recently, in the quiet of the winter dawn, I realized, I am a recyclopath. A recyclopath is someone who recycles, obsessively. Recyclopaths also try to prevent overconsumption of resources in the first place (“Do I really need that? What will become of it later?”). Like many local recyclopaths, my wife and I converged upon UC Davis during the waning years of the last millennium. After some time there, I just assumed every city must have four different types of receptacles in front of each building. Upon my first summer abroad in Guatemala, I found out just how wrong I was. Somewhere, a mile high on a winding bus ride through the Central American Sierras, the bus driver did something unspeakable, which to this day, jolts me awake at night in cold sweats. He finished drinking a two-liter bottle of Pepsi, belched, and threw the bottle out the driver’s side window. With that, he smoked a cigarette, then threw the butt out the window. Over the next five hours, I and a lone figurine of Jesus Cristo on the driver’s dashboard watched in shock as the bus driver and passengers threw various bottles and packaging out the window. Where was law enforcement? Where were the $1,000 fine road signs? Who was going to clean this stuff up? Once we got out of the cliffs, I dared look down at the side of the road and realized: This has been going on for a while, and no one is cleaning it up. Fast forward a couple of decades. I live in a home with insulation and a low-energy house fan, a fuel-efficient vehicle, no more than two kids, chickens that eat our table scraps, barrels that collect rain, and a composter. Buckets reside in the shower. Reusable containers accompany us to restaurants (no take-home packaging please). We have a special rack to dry our Ziploc

Sierra Sacramento Valley Medicine

bags for reuse. An additional freezer allows saving portions so less food goes to waste. We did vermicomposting for several years, but when the worms were not fed on time, they escaped their housing, and I had to clean their dehydrated carcasses off the laundry room floor. They were also smelly, and sometimes the compost juice leaked. In our yard are “wicking bed” planters, contained systems where a water reservoir in the impermeable base wicks upward to water our herbs and veggies. (Thanks to the Aussies on YouTube for that one.) Throwing something in the trash in our house is like a surgical pause. My wife can hear the clank of a can hitting the wrong receptacle from a mile away. I spend a lot of time sorting materials on Monday nights. I think my recyclopath self-realization came with how happy I felt when plastic bags were banned in the City of Sacramento at the start of 2016. For years, we have toted our reusable grocery bags, first with the smugness akin to the first Prius owners in San Francisco, but later more so because it just bothered us to think where all those plastic bags go. So where does trash go? There are numerous documentaries and websites on the subject. According to the EPA’s most recent data, the U.S. generated 251 million tons of trash in 2012, but recycled or composted about 35 percent of it. As a sign of progress, compared to 1990, 11 million tons less trash are going into landfills each year. Still, you and I generate, on average, about 4.5 pounds of trash daily and recycle only 1.5 pounds of that. We recycle 76 percent of paper, 54 percent of aluminum cans, 34 percent of glass, and 30 percent of selected plastic containers. The other factor to consider is how many times something can be recycled, and how much

of what you recycle actually gets “recovered.” According to a November 2012 Huffington Post article, glass and aluminum containers can be recycled indefinitely, paper only several times, and lower-quality newspaper or cardboard maybe once. Plastics can be recycled once, at best, depending on the type. Still, all recycling leads to greenhouse gas reduction. The amount of paper/cardboard recycling in 2012 equated to taking 27 million cars off the road that year, but this number shrunk to 670,000 car-equivalents for plastic. And then there are the oceanic “garbage patches.” Much internet lore exists on this topic with tales of a garbage patch the size of Texas, or twice Texas, halfway between California and Hawaii. The National Oceanic and Atmospheric Association (NOAA) states that exact sizes are hard to quantify, but that six patches exist in major oceans worldwide, mostly consisting of millimeter-size “microplastic” particles rather than rafts of larger debris. Still, the microplastic takes 1,000 years to degrade and is gobbled up by wildlife. A video on commondreams.org shows researchers tracking the garbage flow through floating GPS devices, which I hope are recyclable. Photo galleries show oceanic birds autopsied to reveal large quantities of plastic pieces in their digestive tracts. So what should we do? For starters, reconsider buying those individual plastic bottles for your next house party. And how about those Capri Sun pouches after your kid’s soccer game? Forget about it! Those pouches are almost impossible to recycle, according to plasticnews.com, as they mix layers of metal and plastic. If you can’t use real serving ware, then at least go with a can, man! In medicine, there is much waste too, but also much hope. Hospitals are notorious for generating waste. Think of all those gloves you tear through, how many products go into starting a central line, packaging, gowns, chucks, incontinence pads. In clinic, we get tons of paper waste – Pharma advertisements, worthless legal and confidentiality notices from insurance companies, excessive/redundant paperwork from employers and medical equipment

suppliers, and various pseudo patient-advocacy materials. Still, there are success stories out there amongst us. UCSF was listed in Becker’s Hospital Review as one of the 50 greenest hospitals in the country in 2013 and 2015. Read about it at http://sustainability. ucsf.edu/1.399. They compost 90 percent of their food waste! Holy smokes! Closer to home, Kaiser Roseville and Dignity’s St. Joseph’s in Stockton have also made the top 50. Common themes seem to be using natural lighting or changing out to LED lights, decreasing water use, choosing greener cleaning products, using launderable gowns and pads rather than disposable, and rethinking materialintense areas like the EDs and ORs. Kaiser apparently aims to decrease their greenhouse gas emissions by 30 percent by 2020. The industrysponsored Healthcare Plastics Recycling Council (HPRC) has a pilot project underway at Stanford Medical Center and Kaiser, as well. About a quarter of hospital waste is plastic. Two states in Australia are recycling a quarter of their medical plastic waste into industrial hoses and nonslip floor mats. I anticipate elderly fall rates will drop precipitously there in the near future. Still, at the end of the day, as hip as I am with my reusable shopping bag strapped over my Patagonia jacket lined with recycled plastic fleece, I cannot escape the fact that no matter how much I conserve or recycle, I have depleted some of the Earth’s resources by my very existence and have left a trail of waste that will last centuries. But there are signs of hope. The plastic bag ban is one of them. (Oh yeah, and please recycle your SSVM. Thanks.)

Six oceanic garbage patches exist in major oceans worldwide.

hitzemn@sutterhealth.org

May/June 2016

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. — Chris Serdahl, MD, Secretary. Marisa H. Amaral, MD, Cardiothoracic Surgery Fellow, Albany Medical College of Union University – 2007, UC Davis Medical Center (Resident/Fellow Program), 2221 Stockton Blvd., Sacramento 95818 R. Afiba Arthur, MD, Obstetrics & Gynecology, Meharry Medical College – 2007, Woodland Clinic Medical Group, 1321 Cottonwood Street, Woodland 95695 Catherine O. Bakey, MD, Pediatrics, University of Pennsylvania Perlman School of Medicine – 2011, Pediatric Medical Associates, 650 Howe Avenue, Ste. 100, Sacramento 95825

Richard P. Detwiler, MD, General Surgery, Loma Linda University – 1974, Marshall Surgery Center, 1095 Marshall Way, Ste. 202, Placerville 95667

Joanne B. Kalish, DO, Internal Medicine, New York College of Osteopathic Medicine – 1988, TPMG, 1650 Response Road, Sacramento 95815

Vishnu D. Evuri, MD, Hospitalist, University of Health Sciences Vijaywad – 2002, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608

Akbar Khan, DO, Physical Medicine & Rehabilitation, Touro University College of Osteopathic Medicine – 2009, Woodland Clinic Medical Group, 1321 Cottonwood Street, Woodland 95695

Allison C. Freeman, MD, Family Medicine, University of California, Irvine – 2012, Sutter Medical Group, 2210 Del Paso Road, Ste. A, Sacramento 95834

Theresa H. Kim, MD, Pediatrics, University of California Davis School of Medicine – 2012, TPMG, 10725 International Drive, Rancho Cordova 95670

Christopher O. Bayne, MD, Orthopedics, Harvard Medical School – 2008, UC Davis Medical Center, 4860 Y Street, Ste. 3800, Sacramento 95817

Glenn R. Gookin, MD, Family Medicine Resident, University of Central Florida – 2015, Mercy Family Medicine Residency Program, 7601 Hospital Drive, Suite 103, Sacramento 95823

Wanda J. Blaylark, MD, Occupational Medicine, University of Arizona – 1988, Woodland Clinic Medical Group, 632 W. Gibson Road, Woodland 95695

Karina S. Gookin, MD, Family Medicine Resident, University of California Irvine – 2015, Mercy Family Medicine Residency Program, 7601 Hospital Drive, Suite 103, Sacramento 95823

Andrew C. Bozdech, MD, Family Medicine, Rosalind Franklin University of Medicine & Science / The Chicago Medical School – 2005, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608

Gina M. Gregory, DO, Family Medicine, Western University of Health Sciences – 2004, TPMG, 1650 Response Road, Sacramento 95815

Michael S. Brandon, DO, Emergency Medicine, Western University of Health Sciences – 2011, Mercy General Hospital, 4001 J Street, Sacramento 95819 Kevin J. Burnham, MD, Internal Medicine/Sports Medicine, University of California San Diego – 2009, UC Davis Medical Center, 4860 Y Street, Ste. 400, Sacramento 95817 Dove Cai, DO, Family Medicine, New York College of Osteopathic Medicine – 2008, TPMG, 1001 Riverside Avenue, Roseville 95678 Cameron S. Carter, MD, Psychiatry & Neurology, University of Western Australia School of Medicine – 1980, UC Davis Medical Center – Imaging Research Center, 4701 X Street, Sacramento 95817 Lisa Chai, MD, Internal Medicine – Hospice and Palliative Medicine, Touro College of Osteopathic Medicine – 2005, TPMG, 1825 Bell Street, Sacramento 95825 Teresa Cone, MD, Psychiatry & Neurology, Michigan State University – 2007, TPMG, 2008 Morse Avenue, Sacramento 95825 Angelina M. Crans Yoon, MD, Allergy & Immunology, Woodland Clinic Medical Group, 632 W. Gibson Road, Woodland 95695 Richard A. Cross, MD, Psychiatry, University of Texas School of Medicine at San Antonio – 1997, UC Davis, 2230 Stockton Blvd., Sacramento 95820

Michael J. Heiby, MD, Emergency Medicine, University of Virginia School of Medicine – 2012, Methodist Hospital, 7500 Hospital Drive, Sacramento 95823 Harel A. Ho, MD, Family Medicine, Rosalind Franklin University of Medicine & Science / The Chicago Medical School – 1995, TPMG, 1955 Cowell Blvd., Davis 95618 Natalie S. Hoover, MD, Emergency Medicine, Saint Louis University – 2012, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608 Robert O. Horst, MD, Child & Adolescent Psychiatry, University of Colorado Health Sciences Center School of Medicine – 1999, UC Davis Medical Center, 3331 Power Inn Road, Ste. 140, Sacramento 95831 Kevin E. Hsieh, MD, Neurosurgery, Vanderbilt School of Medicine – 2002, Capital Neurological Surgeons, 1430 22nd Street, Sacramento 95816 Rajeswari Jayaraman, MD, Internal Medicine/ Hospitalist, Dr. M.G.R. Medical University, Chengalpattu – 2007, Mercy Folsom, 1650 Creekside Drive, Folsom 95630 Aditee Jodhani, MD, Emergency Medicine, Chicago Medical School at Rosalind Franklin University – 2012, Methodist Hospital, 7500 Hospital Drive, Sacramento 95823 Benjamin D. Jones, MD, Emergency Medicine, Oregon Health Sciences University School of Medicine – 2012, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608

Sierra Sacramento Valley Medicine

Richard S. Lloren, MD, Pediatrics, University of California Davis – 1987, Pediatric Medical Associates, 650 Howe Avenue, Suite 100, Sacramento 95825 Zinmar Ma, MD, Pediatric Resident, Texas Tech – 2015, UC Davis Medical Center (Resident/Fellow Program), 2315 Stockton Blvd., Sacramento 95817 Lynne Dee Malain, MD, Internal Medicine, Rosalind Franklin University of Medicine & Science / The Chicago Medical School – 2009, Woodland Clinic Medical Group, 632 W. Gibson Road, Woodland 95695 Melissa C. Matthews, MD, Psychiatry, Vanderbilt University School of Medicine – 2010, TPMG, 1660 E. Roseville Parkway, Building C, Roseville 95661 Jessica B. McCoy, MD, Psychiatry, University of Pennsylvania School of Medicine – 2005, UC Davis Medical Center – Department of Psychology, 2230 Stockton Blvd., Sacramento 95817 James M. Montoya, MD, Emergency Medicine, Ohio State University College of Medicine – 2011, Sutter Medical Center, 2825 Capitol Avenue, Sacramento 95816 Soheil Nafeei, MD, Emergency Medicine, Shahid Beheshti University of Medical Sciences and Health Services – 1998, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608 Stephen T. Nowicki, MD, Pediatrics, University of Florida – 2000, Woodland Clinic Medical Group, 1207 Fairchild Court, Woodland 95695 David A. Posner, MD, Family Medicine, University of Michigan Medical School – 2012, Sutter Family Medicine – Dixon Care Center, 125 N. Lincoln Street, Suite G, Dixon 95620 Jennifer M. Prigge, MD, Emergency Medicine, Rosalind Franklin University of Medicine and Science – 2012, Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael 95608 Ed W. Redard, MD, Family Medicine, University of California Davis – 1987, Mercy Medical Group, 8220 Wymark Drive, #200, Elk Grove 95757

Danielle A. Scholtze, MD, Pediatric Resident, University of Wisconsin -- 2005, UC Davis Medical Center, 2315 Stockton Blvd., Sacramento 95817 Mark E. Servis, MD, Psychiatry, Yale University – 1984, UC Davis Medical Center – Department of Psychiatry, 2230 Stockton Blvd., Sacramento 95817 Rafiq A. Sheikh, MD, Gastroenterology, Kashmir University Medical College Srinagar – 1979, Woodland Clinic Medical Group, 1321 Cottonwood Street, Woodland 95695 Hong Shen, MD, Child & Adolescent Psychiatry, Shandong Medical University – 1987, UC Davis Medical Center, 2230 Stockton Blvd., Sacramento 95817 Sudershan J. Singh, MD, Internal Medicine/ Infectious Disease, University of Washington School of Medicine – 2007, Woodland Clinic Medical Group, 1207 Fairchild Court, Woodland 95695 Thomas W. Smith, MD, Cardiovascular Disease, University of California San Diego – 2002, UC Davis Medical Center, 4860 Y Street, Ste. 2820, Sacramento 95817 Matthew F. Soulier, MD, Psychiatry, University of Utah – 2002, UC Davis, 2230 Stockton Blvd., Sacramento 95820 Sydney L. Supit, MD, Internal Medicine, Manila Central University College of Medicine – 1986, Mercy Medical Group, 3000 Q Street, Sacramento 95816 Timmy C. Thomas, MD, Occupational Medicine, University of Debrecen Medical and Health Sciences Center – 2006, TPMG, 2016 Morse Avenue, Sacramento 95825 Paula Wadell, MD, Psychiatry, University of California Davis School of Medicine – 2009, UC Davis, 2230 Stockton Blvd., Sacramento 95820 Cheryl K. Walker, MD, Obstetrics and Gynecology, Elica Health Centers, 1860 Howe Avenue, #440, Sacramento 95825 Nancy Joan Williams, MD, General Preventive Medicine, University of Utah – 2005, El Dorado County Public Health Officer, 931 Spring Street, Placerville, 95667

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May/June 2016

Board Briefs March 14, 2016 The Board: Received an update from Donald Lyman, MD, Chair, Public & Environmental Health Committee. Approved the endorsement of Resolution 106-16, CMA White Paper on Gun Violence, co-authored by Paul Phinney, MD. Approved the 2015 Year-End Pre-Audit Financial Statements and the 4th Quarter Investment Reports. Serving as the Board of Directors to the Community Service, Education and Research Fund (CSERF), approved a revision to the investment policy for the CSERF with the primary objective in the investment management of the fund’s assets to be capital preservation and moderate longterm growth of capital. Approved SSVMS opposition to a proposed CMA dues increase to be considered by the CMA Board of Trustees in April. Approved the endorsement of the California Healthcare, Research and Prevention Tobacco Tax Act of 2016. Approved the nomination of Barbara Arnold, MD as Delegate At-Large to CMA’s Delegation to the AMA. Approved Policy 100-05, Medical Student Outreach Funds for the California Northstate University College of Medicine, which establishes the guidelines for SSVMS to administer the funds for the SSVMS/CMA/AMA Medical Student Section Chapter. Approved the Restatement of SSVMS Qualified Employee Retirement Plan to incorporate all regulatory changes as mandated by the Pension Protection Act. In accordance with SSVMS and CMA Bylaws, approved the termination of members who had not paid their dues by the March 1, 2016 deadline.

Sierra Sacramento Valley Medicine

Approved the February 22, 2016 and March 14, 2016 Membership Reports: For Active Membership — R. Afiba Arthur, MD; Catherine O. Bakey, MD; Christopher O. Bayne, MD; Wanda J. Blaylark, MD; Andrew C. Bozdech, MD; Michael S. Brandon, DO; Kevin J. Burnham, MD; Dove Cai, DO; Cameron S. Carter, MD; Angelina M. Crans Yoon, MD; Vishnu D. Evuri, MD; Allison C. Freeman, MD; Gina M. Gregory, DO; Michael J. Heiby, MD; Harold A. Ho, MD; Natalie S. Hoover, MD; Robert O. Horst, MD; Rajeswari Jayaraman, MD; Aditee Jodhani, MD; Benjamin D. Jones, MD; Akbar Khan, DO; Richard S. Lloren, MD; Lynne Dee Malain, MD; Jessica B. McCoy, MD; James M. Montoya, MD; Soheil Nafeei, MD; Stephen T. Nowicki, MD; Jennifer M. Prigge, MD; Ed W. Redard, MD; Mark E. Servis, MD; Rafiq A. Sheikh, MD; Hong Shen, MD; Sudershan J. Singh, MD; Thomas W. Smith, MD; Sydney L. Supit, MD; Tammy Yick-Shin Woo, MD; James N. Worledge, MD; Jon Y. Zhou, MD. For Reinstatement to Active Membership — Richard P. Detwiler, MD For Probationary Membership — Kevin E. Hsieh, MD For Resident Membership — Marisa H. Amaral, MD; Glenn R. Gookin, MD; Karina Gookin, MD; Zinmar Ma, MD. For a Change in Membership from Active to Resident/ Fellow — Danielle A. Scholze, MD For a Change in Membership from Active to Active 65/20 — Ralph E. Koldinger, MD For Retired Membership — John Bissell, MD; Ralph DeVere White, MD; Charles D. Moore, MD; Leon Owens, MD; Jeffrey J. Rabinovitz, MD; Lloyd H. Smith, MD; Stewart Teal, MD; John D. Warren, MD. For Transfer of Membership — Javier R. Rangel, Jr., MD. For Resignation — Derek A. Ailes, MD; David Berman, DO; John Brothers, MD; John Chin, MD; Daniel A. Egerter, MD; Erin E. Forest, MD; Lynne Hackert, MD; Jeanne Kim, MD; Charles Maas, MD; Alicia Paris-Pombo, MD; Anne M. Prentice, MD; Marilynn Price, MD; Julie Steiner, MD.

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