2017-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

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MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2017

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MEDICINE 2 3

2017 Education Series PRESIDENT’S MESSAGE A New Appreciation for Treating Chronic Pain

Ruenell Adams Jacobs, MD

GUEST EDITORIAL They’re Getting Away With Murder

Babak Nouhi, MS II

RX Safe Physicians – Physicians Take the Lead

Lindsay Coate, Director of Programs, SSVMS

Supervised Injection Facililties: Less Disease

Fat Emulsion Breakthrough

Ann Gerhardt, MD

Hospice – No One Walks Alone

Kayla Sheehan, MS I

Transgender and Gender Non-Binary Health Care

Christopher Swales, MD

Hot Air Sauna Burns

Glennah Trochet, MD and Ann Gerhardt, MD

Cannabis – A Drug That is Also a Medicine

Bob LaPerriere, MD

George Meyer, MD

Cannabis for Your Dog?

Student Garden Aims to Combat “Food Deserts”

Sandra Hand, MD

Neeraj Ramakrishnan, MS I

A Posit on Fee-for-Service Single-Payer Plan

A Tour of the UCD Veterinary School

Board Briefs

John Loofbourow, MD and Bob LaPerriere, MD

Welcome New Members

Civil War Medicine Part I – The Antebellum Health Care Environment

Kent Perryman, PhD

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 Of the 620,000 soldiers who died in the American Civil War between 1861 and 1865, two-thirds of their deaths were due to disease processes. Medical knowledge and diagnosis were not up to the task of adequately treating the legions of wounded and diseased. Due in part to the ineffective and prevalent practice of “heroic” medicine, such as blood-letting, illnesses like cholera, measles and smallpox spread among troops in encampments and hospitals. Kent Perryman, PhD., explores Civil War medicine in the first of a two-part essay on page 17. Our cover photo, which accompanies his article, shows an American Civil War Ambulance corps transferring the wounded to a nearby field hospital. − kperryman@suddenlink.net

May/June 2017

Volume 68/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. 2017 Officers & Board of Directors Ruenell Adams Jacobs, MD, President Rajiv Misquitta, MD, President-Elect Tom Ormiston, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD Christian Serdahl, MD Vacancy District 3 Thomas Valdez, MD District 4 Alexis Lieser, MD

District 5 Sean Deane, MD Cynthia Ramos, MD Paul Reynolds, MD John Wiesenfarth, MD Eric Williams, MD District 6 Carol Kimball, MD

2017 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 Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Don Wreden, MD

District 1 Anissa Slifer, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Megan Anzar Babb, DO Natasha Bir, MD Helen Biren, MD Arlene Burton, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Sandra Mendez, MD Robert Peabody, MD Armine Sarchisian, MD Eric Williams, MD Vacant Vacant Vacant

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President Ruth Haskins, MD

CMA Speaker Lee Snook, MD

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Editorial Committee John Paul Aboubechara, Sean Deane, MD Adam Doughtery, MD Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD

MS III Steven Nemcek, MS II John Ostrich, MD Neeraj Ramakrishnan, MS I Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD Jon Yan Zhou, MD

Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2017 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

A New Appreciation for Treating Chronic Pain By Ruenell Adams Jacobs, MD MOST OF US ARE AWARE of the opioid problem in this country. Starting in 1999, the number of opioid prescriptions written increased astronomically. This change in prescribing practices was in response to medical information that determined that medical providers were undertreating patients with pain conditions, particularly chronic pain. Many of us can recall the numerous CME seminars we needed to complete in order to meet the 12-hour education minimum that was required in order to renew our medical licenses. At one point, hydrocodone became the number-one prescribed drug in America. As a result of increased availability of opioids, the number of deaths from opioid overdoses quadrupled in the decade that followed.

Many health plans have restrictions on the number of tablets/ capsules/patches that can be dispensed in a 30-day period. Fast forward to 2014, when federal laws for prescribing changed dramatically. Now there is a database we can access to help cut down on overprescribing. Many health plans have restrictions on the number of tablets/capsules/ patches that can be dispensed in a 30-day period. Pharmacies have strict protocols for when the prescribed medication can be filled. The use of the electronic medical record and health information exchange computer

systems has aided in this endeavor. Pain is common, and being a primary care physician means that I see several patients a day who are experiencing a pain condition of some type. The descriptions from patients vary. The pain may be of acute, intermediate or long duration, may vary from mild impairment to severe disabling impairment and may or may not be due to known or unknown causes. It can be quite a challenge to determine a cause and find an effective and appropriate treatment without contributing to the opioid addiction problem we face. Since I am also human, I have had my share of painful conditions, and have some personal insight on pain and suffering. Fortunately, most of my experiences were either of short duration or not severe enough to intrude too much into my life. Until now. Recently, I developed a pain condition that was of sudden onset. As far as I know, I did not do anything to cause this pain. It may have developed as a complication from a routine procedure or not (the procedure had been done a few months ago and the pain developed in that area). Since the cause of the pain was not immediately apparent, however, treatment was delayed for several days until more symptoms developed. The new symptoms eventually helped point my provider in the right direction and, once treatment was begun, my condition gradually improved over the next several days. In the meantime, I suffered − and I mean suffered. This pain was a lose- your-mind kind of pain: constant, severe, debilitating. The

May/June 2017

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.

nature of the pain was, at times, sharp or throbbing, localized or radiating. It interfered with everything: sleeping, eating, working, social interactions, concentrating. Taking naproxen and acetaminophen around the clock barely touched it. Tylenol #3 did almost nothing, so I gave up after three doses. When I wasnâ&#x20AC;&#x2122;t focusing on ways to manage the pain, I was spared a few minutes to think and empathize with what some of my patients go through on a daily basis. I decided to really think how my personal experience might potentially be of value in the care and management of my patients going forward. Here are some of the things I found helpful: 1) The right diagnosis and treatment; 2) My husband, who brought me soup, tea, sympathy and picked up the slack around the house; 3) The care and empathy of my provider

who knows me well, returned my calls and really listened; 4) My family, friends and office staff who texted or called to commiserate; 5) The distraction of starting this article, breathing exercises, doing the laundry and washing my hair; 6) Getting out of bed and getting dressed every day; 7) Finally, refusing to despair while my provider was trying to figure it out. I am thankful my problem was temporary because I am not sure how I would be able handle something like this on a chronic basis. So the next time I see one of my chronic pain patients, it will be with a renewed appreciation for the challenges they face in their lives as they struggle with this very real condition. adamsr78@comcast.net

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Visit bloodsource.org or call 866.822.5663 to learn more about the best way(s) you are able to help others. Schedule an appointment at a BloodSource Donor Center or mobile blood drive soon. Together, we do save lives.

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GUEST EDITORIAL

They’re Getting Away With Murder By Babak Nouhi, MS II Guest Editorials are welcome, as are comments regarding the editorials themselves. HOW DID ONE ophthalmologist in South Florida bill Medicare over $11 million for injections of a single drug in 2012? How is it that pharmaceutical companies are able to spend more money on lunch buffets than on research and development? And, why has Big Pharma’s main lobbying group, PhRMA, outpaced any other in total spending devoted to lobbying? The answer is simple: The rules and regulations put in place by our elected officials have completely set the board in the drug companies’ favor. Market exclusivity and an inability for national health programs and government entities to negotiate drug prices are the two biggest reasons for why the pharmaceutical industry has outperformed other major sectors for the better part of the past decade. Unfortunately, unlike the financial fiddlers on Wall Street, Big Oil, and the tobacco industry, Big Pharma has advertised to the American people a mission statement as altruistic as the ones placarded by medical schools around the country: “We’re doing it for you.” In September 2015, Martin Shkreli became the “The Most Hated Man in the Country” when he obtained the manufacturing license for the anti-parasitic drug, Daraprim, and raised its price from $13.50 to a whopping $750 per pill. His reasoning? “Research and Development.” R&D, as it’s been referred to, has long been used by pharmaceutical companies to justify hiking drug prices. Though these companies do pay enormous sums of money to pass a drug through the FDA, a number of factors weigh

against this rationale for the high prices. For one, the proportion of revenue made by these large companies that is actually invested back into R&D is just 10-20 percent. Secondly, the most important innovation for these new drugs is often performed at academic institutions and supported by grants from public entities, such as the National Institutes of Health (NIH). In fact, more than half of the 26 most transformative drugs of the past 25 years have had origins in publicly-funded research. Furthermore, in 9 out of the 10 largest pharmaceutical companies, more money is spent on advertisement than actual R&D. Pharma companies explain that non-negotiated prices are essentially a mechanism put in place to subsidize their research and development. What seems truer is that taxpayers are subsidizing the $24 billion they spend on physician advertisement every year instead. A recent JAMA report from Harvard Medical School concluded in a meta-analysis that: “… there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.” Think about it. As a taxpayer, not only are your dollars going towards research-oriented government initiatives such as the NIH, but they are going towards subsidizing the latest Xarelto commercial − you are essentially paying for a completely monopolized drug twice. Hiking drug prices are only part of the story. The number of tricks and tactics that pharmaceutical companies have under their sleeves to maximize profit is unbelievable. For the treatment of Wet Age-Related Macular

May/June 2017

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.

Following my uncle, who is a physician, into pharmaceutical conferences was always fun for me. Free all-you-caneat buffets, cool bags of goodies... What’s not to love?

Degeneration (AMD), there are currently two drugs available. Both have virtually the same mechanism of action, both cost about the same to manufacture, both have nearly identical clinical outcomes, and both are made by the same exact company. The difference? One costs $50 for each injection (Avastin), the other costs $2,000 for each injection (Lucentis). Both of these drugs are injectable antivascular endothelial growth factor (anti-VEGF) drugs. They are literally miracle workers for patients suffering from AMD, as they are known to restore vision in those destined for blindness. However, Avastin was originally manufactured by Genentech to treat various forms of cancer whereas Lucentis − which is basically Avastin with a few cosmetic changes − was specifically rolled out by Genentech as a treatment for AMD. When ophthalmologists began realizing that Avastin had very similar clinical outcomes as Lucentis, Genentech’s alarm bells went off. They went through practically every measure possible to ensure doctors stopped using Avastin − a drug that they created − on patients with AMD. For one, Genentech began aggressively marketing Lucentis as the sole treatment option for AMD, stating that it lasted a few weeks longer in the body than did Avastin. Secondly, the company refused encouragement from the FDA to seek approval for using Avastin in eye ailments, according to unpublished internal FDA documents. Thirdly, and perhaps most disturbingly, the company packaged Avastin in doses far to too big for use in ophthalmology, meaning that the drug needed to be repackaged by other companies for use in the eye. Genentech then proceeded to argue that, because third parties were forced to repackage this medicine, there would be risk for contamination. For this reason and the fear of being sued for using off-label medication, there are still those ophthalmologists who administer Lucentis. John Thompson, a Baltimore ophthalmologist who is president of the American Society of Retinal Specialists, noted that, “If Genentech decided to get FDA approval and make Avastin available in small quantities for the eye…the American Society of Retinal

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Specialists would applaud.” Unfortunately, Avastin still hasn’t been FDA-approved for eye ailments, and Genentech is still soaking up the revenue from over the roughly 40 percent of ophthalmologists who still prescribe Lucentis. Following my uncle, who is a physician, into pharmaceutical conferences was always fun for me. Free all-you-can-eat buffets, cool bags of goodies, and incredibly beautiful women in their twenties speaking to you about a drug that could save millions of lives. What’s not to love? The truth is, these pharmaceutical companies are no different than a pooling company; they have only one agenda and that’s to make as much money as humanly possible. They don’t care about you, your health, or even if their drug is better than the last iteration. Yet, when Martin Shkreli was pressed on the massive price hike on Daraprim, he said, “I can see how it looks greedy, but I think there’s a lot of altruistic properties to it.” It’s funny, as medical students we carry around a copy of First Aid as if it contained a higher being’s commands, treating each word like scripture. In it, it defines altruism as, “alleviating negative feelings via unsolicited generosity.” The example provided is that of a mafia boss making large donations to charity. So in a way, I suppose Martin Shkreli is right, the pharmaceutical companies are like a mafia, one that has been getting away with murder for much too long. Babak.Nouhi6995@cnsu.edu NOTE: In an effort to lower the skyrocketing cost of prescription drugs, a drug importation amendment was advanced during the January budget resolution vote in the Senate. It was rejected because it contained no language guarding against unsafe drug importation from unknown sources. In late February, Senators Cory Booker (D–NJ), Bernie Sanders (I–VT), and Bob Casey (D–PA) introduced stand-alone legislation that would allow Americans to import safe medicine from Canada. Reps. Elijah E. Cummings (D–MD) and Lloyd Doggett (D– TX) introduced a companion bill in the House. It was voted down in March.

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RX Safe Physicians − Physicians Take the Lead By Lindsay Coate, Director of Programs, SSVMS IT DOES NOT DISCRIMINATE against age, sex, ethnicity, income bracket, profession or geographic region. It could be your patients, friends, neighbors, co-workers, family or even you who is shaken. The issue is, of course, the prescription opioid and heroin epidemic that has swept our nation, and the patients in the Sacramento region. In the four-county Sacramento Region, prescription opioid and heroin overdoses took the lives of 133 residents in 2013, with prescription opioids accounting for almost 85 percent of the incidences.1 There were numerous situations where an opioid overdose led to non-fatal emergency room visits with: 487 cases in Sacramento County, 47 cases in Yolo County and 51 cases in El Dorado County. Statewide, there were 1,934 deaths and 11,683 cases of non-fatal emergency room visits due to opioid overdose.2 To understand the full scope of the issue for the entire Sacramento Region, below is a chart with figures per county.

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

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A Brief History of Prescribing In 3,400 BC, the Sumerians in Mesopotamia first cultivated the poppy plant, otherwise known as the “Joy Plant.” In the 19th and 20th centuries, morphine and later, heroin, were discovered and actively marketed to citizens and physicians to relieve pain. However, at the time, most physicians felt that long-term opioid use to assist with non-cancer pain was outweighed by the risk of addiction.3 Heroin, originally capitalized and trademarked as “Heroin” by Bayer in Germany in the late 19th century, was promoted as a safe and non-addictive pain reliever and cough suppressant. The pain medication, Talwin, which debuted in the 1960s, was also supposed to be non-addictive. Before the 1990s, opioids were reserved for moderate-to-severe acute pain or end-oflife pain. Unfortunately, the start of the decade ushered a huge change in the way opioids were perceived by both physicians and patients, leading to a quadrupling of sales in the United States between 1999 and 2000. Thanks to legislation and aggressive pharmaceutical campaigns, many patients expected to live painfree lives. The under-treatment of pain became a common theme with the Medical Board of California (MBC) and other professional guidelines that encouraged physicians to actively treat non-cancer, chronic pain with opioids.4 In fact, the MBC required physicians to take a course to make sure they were not underprescribing to patients experiencing chronic pain. Many would argue that this change in the understanding of opioids was due to

the marketing efforts of pharmaceutical companies, with the main culprit being Purdue, and their drug, OxyContin. Primary care physicians were targeted by the pharmaceutical industry to prescribe the drug for problems such as backaches or minor knee pain. The drug was developed, tested and FDA-approved to relieve pain in 12-hour dosages. However, study after study have proven that OxyContin’s efficacy is eight hours or less for most patients, regardless of the dose size. The prescribing practices for OxyContin that were pushed by Purdue to physicians were a recipe for addiction. In 2007, Purdue and three of their top executives pleaded guilty to fraud and were ordered to pay $635 million in damages for downplaying OxyContin’s risk of addiction. The lawsuit covered the company’s marketing campaign to doctors that suggested that OxyContin was less addictive than other painkillers, but did not address the inaccurate proclamations of the 12-hour dosage effectiveness.4 To address this epidemic on the national level, many lawmakers are pushing for Congress to further investigate Purdue for falsifying the longevity of OxyContin’s effects, thereby dramatically increasing the chances for addiction.

Physicians Taking the Lead To address this important public health issue, the Sierra Sacramento Valley Medical Society (SSVMS) engaged with the Sacramento County Opioid Task Force and is the lead for the Engaging the Medical Community and Overdose Prevention subcommittee. Through this subcommittee, SSVMS has provided educational programs and promoted safe prescribing guidelines to physicians throughout the Sacramento region. Led by SSVMS member and pain special-

ist, Dr. Lee Snook, these CME programs reaffirm the physician’s professional obligation and ethical duty to provide appropriate medical care, based on the physician’s training, experience and clinical judgement, while at the same time reducing the risk of opioid addiction and misuse. According to Dr. Snook, “Managing pain sometimes requires the use of opioids. Over many centuries, this class of medications has proven indispensable in relieving pain. Physicians must be proficient and knowledgeable about the MBC Treatment Guidelines.” To find out more about safe prescribing guidelines, visit www.mbc.ca.gov. To request a Safe Prescribing Program for your medical staff or group, contact SSVMS at lcoate@ssvms.org. To further educate physicians on safe prescribing, SSVMS has launched a new program, RX Safe Physicians. In addition to providing resources to physicians, SSVMS has created a patient safety initiative entitled, “Got Pain? There is No Magic Pill.” The purpose of this campaign is to encourage a conversation between the physician and the patient regarding the use of opioids and alternative therapies to manage pain. SSVMS will be providing our member physicians with free posters and handouts for physicians to utilize in waiting and clinical rooms. In addition, we will be publishing a safe medication guideline brochure for patients. This resource will include education regarding opioids, how to recognize addiction, how to identify and assist someone who is experiencing an overdose, and a list of locations in the Sacramento Region to safely dispose of medication. If you would like to learn more about our efforts or would like to display these free materials, please contact me.

REFERENCES 1 CDPH Vital Statistics Death Statistical Master and Multiple Cause of Death files 2 California Office of Statewide Health Planning and Development, Emergency Department Data 3 “Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions,” Rosenblum, Marsch, Joseph, Portenoy, 2009 4 “Prescribing Opioids: Care amid Controversy,” California Medical Association, 2014 5 “YOU WANT A DESCRIPTION OF HELL?’ OXYCONTIN’S 12-HOUR PROBLEM,” LA Times, May 5, 2016

lcoate@ssvms.org

May/June 2017

Supervised Injection Facilities: Less Disease By George Meyer, 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.

AT THE END OF JANUARY, I had the opportunity to visit the first North American Supervised Injection Facility (SIF), Insite, in Vancouver, BC, which was established in 2003. I understand that because this SIF could not handle all the injectors who wished to attend, one other has recently been approved by Vancouver City, while there are several other facilities in Vancouver that offer supervision without the approval of the city. I will share my impressions of my tour, which was set up as a visit, not an interview. Interviews might lead to publications, for which the SIF has strict rules. I arrived a few minutes before my scheduled appointment at 7:45 AM on a Friday; the open hours of the SIF are 9–3 and, due to an agreement with Health Canada, no one from the outside is allowed in during business hours except their clients. (I thought it was 9 am–3 pm, but it was 9 am–3 am.) For three days in January, they were open for 72 consecutive hours on the three days/nights that follow welfare check issue day; there are more ODs at that time. I actually arrived early at 139 E. Hastings Street in a part of town obviously impacted by poverty, homelessness and addiction. There were numerous homeless persons camped out along the walls of the buildings in the area. Some were socializing, others were huddled under their covers. A few people showed no signs of street entrenchment. I looked at the sidewalk in front of the entrance to Insite and saw several discarded insulin syringes. I was told later that the city is expected to keep the sidewalk clean, and during open hours, Insite is quite proactive at keeping the storefront tidy.

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There are two shifts with two RNs and five others present during the injection times. The SIF has 12 little booths where clients can prepare their own drugs (they purchase drugs on the street so quality is not assured). In fact, as we have noticed in the U.S., a lot of the street drugs now seem to be laced with fentanyl and carfentanyl (carfentanyl is 100 times the concentration as fentanyl, and is used in veterinary medicine.) Recently, the SIF has noted many more overdoses than in the past. One day they had to rescue 14 ODs in four hours. Obviously, they use antagonists, apply airway management, and a call to the EMTs to take the client to the hospital. The SIF provides sterile cups to prepare their fixes sterilely; the package also has a filter to decrease the injection of solid materials. I was told the sterile cup and filter are acquired from France, but are made in the Slovak Republic. The

SIF also has sterile water and vitamin C for their clients. The vitamin C allows the crack cocaine to go into solution. Apparently, this replaces lemon juice or vinegar which carry more risk when injected. There is a needle exchange, but it is not just one syringe for a used one. The nurse in charge told me, “They can have a full box if they want them.” Male and female condoms are also available at no cost to the client. The injection area is locked so clients may not enter until their name comes up on the computer − first come, first served. They sign in at the desk in the front room of the building, usually giving a code name or “handle.” This anteroom is often jam-packed, and many clients cannot wait to access the shooting area, Patrons await the offering SIFs in their cities. In my opinion, so they go outside and shoot. Occasionally, opening of Insite, Sacramento should investigate this system as a a person ODs right outside the front door. the first supervised public health benefit. Thirty thousand clients each year are unable injection facility in North America, to access the injection area because it is too located in geowmeyer@icloud.com busy. After injecting, and once stable, each Vancouver, BC. client is encouraged to join others in a recovery area, where coffee is available. Counselors are available to make referrals to drug and alcohol services. Insite has a 12-room detox unit on the second floor, called Onsite. Clients interested in getting clean are admitted for up to two weeks to help As a trusted partner to businesses and families across generations them quit and/or get them started on since 1919, Baird has seen investors through many market cycles. a program like Methadone. There is And the insight we’ve gained from this experience informs all we do a long waiting list for this program. today as we strive to create great outcomes for our clients throughout Clients are restricted to this area their financial lives. during detox, so meals are provided Put Baird’s time-tested expertise to work toward your long-term goals. and there are counseling, yoga and exercise activities. Once they have Patty M. Estopinal, CIMA®, CDFA successfully detoxed, they may have Director access to the third floor where a few Private Wealth Management more rooms are available while the 916-783-6554 . 877-792-3667 client finds a job and other shelter. pestopinal@rwbaird.com Data collected show that their pattyestopinal.com clients have many fewer cases of hepatitis B and C and HIV. Based on Investment Management Consultants Association is the owner of the certification mark “CIMA®” and the service marks “Certified Investment Management AnalystSM,” “Investment Management Consultants the success of this facility, another has AssociationSM” and “IMCA®.” Use of CIMA® or Certified Investment Management AnalystSM signifies that the been approved by the city. Montreal, user has successfully completed IMCA’s initial and ongoing credentialing requirements for investment management consultants. Toronto and other Canadian cities ©2016 Robert W. Baird & Co. Incorporated. Member SIPC. MC-48079. Robert W. Baird & Co. does not provide are looking into the possibility of tax or legal advice.

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May/June 2017

Student Garden Aims to Combat “Food Deserts” By Neeraj Ramakrishnan, MS I IN RECENT YEARS, the city of Sacramento has undergone tremendous growth. The city’s unemployment rate has become lower than that of the entire State of California as job and business opportunities have surged. Even Sacramento’s culture has undergone a transformation of sorts with the emergence of a modern and vibrant atmosphere in the area. However, despite all of this growth, Sacramento continues to face a major problem: food insecurity. More than 240,000 people in the greater Sacramento area have inadequate access to affordable and nutritious food. Food deserts have emerged in areas such as South Sacramento, where unhealthy fast-food chains dominate the landscape, and grocery stores are incredibly scarce. Moreover, people of a variety

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of racial and economic backgrounds, ranging from teachers out of work to nursing home residents, are affected by this crisis. As problems like food insecurity arise, the Internal Medicine Group of the California Northstate University College of Medicine (CNUCOM) strives to help and support its surrounding community. A particularly powerful way in which the Internal Medicine Group has done this is through its partnership with the Sacramento Food Bank and Family Services Organization. The food bank serves as an invaluable resource for people living in food deserts such as South Sacramento. In fact, for many of these people, their monthly trip to the food bank serves as one of their only opportunities to access fresh fruits and vegetables. In light of this, the Internal Medicine Group wanted to do more than just send its members to volunteer at the food bank. Consequently, Brendan Kim, MS II, President of the Internal Medicine Group, came up with the idea of starting an organic community garden. Current second year medical students at CNUCOM, Glenn Geesman and Howard Capone, also stepped in and took leadership to run the garden. Since its conception, our community garden has made great strides. A variety of produce such as zucchini, kale, tomatoes, mustard greens, beans, corn, tomatoes, and watermelon is currently grown at the garden. The produce grown here varies quarterly, depending on the season, and is donated to the food bank. In turn, the food bank distributes these fruits and vegetables to those in need. Our garden is poised to have an encouraging

future as it received funding from the California Medical Association Foundation last November. These funds have already been used for endeavors such as building fertilizer beds and buying seeds for a variety of crops. The Internal Medicine Group at CNUCOM is committed to supporting its community through difficult times. Yet, it is important to acknowledge that its partnership with the food bank through the community garden symbolizes something more than just this. It is a passion to care for people holistically, rather than just treating them in the confines of a hospital or clinic. We, as aspiring physicians, would like to foster a way of practicing medicine that empowers patients. As the burden of disease in our modern society has shifted from infectious to chronic illnesses, we must teach our patients healthy habits so that they can properly care for themselves to lead happy, fulfilling lives. Food insecurity remains a significant problem in our surrounding area and does, indeed, contribute heavily to debilitating conditions such as diabetes and heart disease. By acknowledging this problem through donating organic produce to the food bank that the community can incorporate into its diet, we can potentially set a positive, powerful foundation for the future of our patients by allowing them to modify their own lifestyles. Targeting food security in our community through the community garden is only the start for us. We hope to expand this project through endeavors such as teaching nutrition and gardening classes to children affected by food deserts, so that they can learn to grow their own produce and acquire healthy habits during difficult and trying times. Moreover, the Internal Medicine Group is looking to become even more connected with its community by working with nursing homes and homeless shelters in the surrounding area. Medical students and physicians should not just be known for their ability to treat patients. They should be regarded as the ultimate advocate for their patients and community.

Students at CNUCOM proudly tend their organic garden and donate regularly to a local food bank.

neerajramakrishnan178@gmail.com

May/June 2017

A Tour of the UCD Veterinary School By John Loofbourow, MD and Bob LaPerriere, MD

John Loofbourow, MD

EARLIER THIS YEAR, Dr. Rob Warren, Communications and Marketing Officer for the UC Davis School of Veterinary Medicine, guided a small group of physicians on a fascinating tour of the Veterinary Medical Campus. Colleague, Dr. Mark Blum, had organized the tour of the campus, a facility probably not recognized and appreciated by many locals, that has been located in Davis since 1948. In general, physicians and veterinarians are family, so it is worth knowing more about one another. We are within a few miles of the world’s premier veterinary school, making a visit easy and informative. There is much to learn and much to share.

Timeline

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• 1948 - The first class consisted of all men. Now 80 percent of students are women. The curriculum was focused on large animals, whereas the current caseload is more than 80 percent small animals. • 1950s - The first hip replacement was done. • 1970 - The Veterinary Medical Teaching Hospital opened, and the first residencies were established. Now, there are more than 30 disciplines with over 100 residents, the most in the U.S. • 1980s - Named top veterinary school in the U.S.; Tulare Research Center established. • 1990s - J-5 mastitis vaccine developed, hemodialysis unit started and beginning of Oiled Wildlife Care Network. • 2000s - PhD-DVM degree offered. Shelter medicine program and autism research began. • 2010-15 - Jawbone regrowth in dogs and

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Bob LaPerriere, MD

genome project for foodborne diseases initiated. • This is only a partial list. For additional history see www.vetmed.ucdavis.edu/history. The veterinary school is devoted to the diagnosis and treatment of any animal species, excepting the one that Swedish zoologist and physician, Carl Linnaeus, in 1758 may have considered wise: Homo sapiens. But, it becomes ever more clear that aspects of genetics, physiology, sociology, psychology, behavior, and even language are variably shared among all animals. To judge from the use of technology, pharma, diagnosis and clinical interventions, small animal medical care is quite similar to people care. There are, however, some significant differences. For one thing, veterinarians do not deal with insurance companies; animal owners do. For another, some veterinarians provide for large numbers of animals (herd medicine) which requires consideration of scale, outcome, and cost. And, although herd medicine is quite different from people medicine, it may be a consideration in human medicine.1

The UCD Veterinary Hospital There are only 30 veterinary schools in the U.S., and only one other in California that is a private school in Pomona. The UC Davis veterinary hospital is one of the three largest in the U.S. in terms of caseload – the others are Boston and New York. But only a small number of specialties are available for residents in these other facilities. At first, large animal medicine predominated at UCD, in concert with the needs of the State of California’s livestock industries. Later, small and companion animal medicine became responsible for most of the later exponential growth, consistent with changing public attitudes about our human kinship with all animals, especially our pets. The faculty today, under Dean Dr. Michael Larimore, numbers more than 300 with approximately 120 associated directly with the hospital. Many of the 145+ annual graduates go directly into a private practice. Sub-specialty training programs require one year of internship prior to 2-4 years of residency, depending on the specialty. Currently, the school trains 108 residents, in addition to graduate students, in PhD and Master of Preventive Veterinary Medicine programs. The teaching hospital opened in 1970 and since then, by many measures including the number and variety of specialty training programs, it has become an integral part of the number-one ranked veterinary school in not just the U.S., but in the world, according to QS World University Rankings. Residents at the UC Davis Veterinary Campus have come from 39 states and 32 foreign countries. When the hospital opened, about 5,000 patients were admitted yearly. Now, annual total patient admissions and visits approaches 55,000; the majority are small animals. Society has begun to value animals more highly in recent decades, especially in regard to pets, which can become beloved and loving companions, with all of the implied emotional attachments. Consequently, the school pays attention to the emotional well-

being of patients, their owners, and students. In considering student applicants, compassion for animals is important, and during training, “Compassion Fatigue” is common among students. The school places a high emphasis on student health, and counselors are readily available.

When the hospital first opened, about 5,000 patients were admitted yearly. Now, annual total patient admissions and visits approaches 55,000; the majority are small animals.

...there is usually a lower accumulated debt incurred for veterinary students than for students in medical school. The decision to become a veterinarian is often made between age 10 and 16. You have to have at least a 3.8 grade point average and hope you are one of the 145 accepted out of approximately 1,000 applicants. The average yearly cost for a student is $34,000, but thanks to financial aid, there is usually a lower accumulated debt incurred for veterinary

May/June 2017

The UC Davis Veterinary School is devoted to the diagnosis and treatment of any animal species. Many of the 145+ annual graduates go directly into a private practice.

students than for students in medical school. With financial aid factored in, UC Davis is the 8th most affordable veterinary school in the country. Although, in general, veterinary and human medicine have much in common, consider these contrasts between animal and human health care: • Because State financial support for the school is minimal, the rapid growth and

the coming expansion largely depend on provision of private animal care and donations. • Pet insurance is not common in the U.S. Approximately 5 percent of patients − in this case meaning the owners − are covered. In Europe, 40-70 percent of animals are covered by insurance, and in Australia, the same company that is the equivalent of Medicare also provides animal/pet insurance. • The relationship between animals and humans is a primary consideration, including aspects of zoonotic disease, sociological or psychological interactions, commercial and industrial herd medicine, and the ecology of wildlife. In summary, the diversity of this institution is amazing. In addition to diagnostic and treatment modalities common in human medicine, they have unique clinicians: a veterinarian who specializes in fish, two nutritionists in the hospital (one of the world’s few residencies in nutrition), and the Gorilla Doctors Group, www.gorilladoctors.org, one among many international projects. They maintain a large food safety lab and are involved in screening for 36 viruses in 34 countries. They have the most advanced linear accelerator in any veterinary hospital, and have a modern integrative medicine unit as a separate department providing physical therapy, acupuncture and laser treatment. An extensive expansion of facilities has begun, with groundbreaking set to begin soon. john@loofbourow.com ssvmsedcom@gmail.com REFERENCE 1 See an earlier SSVMedicine essay, most readily accessible online at: https://nwalmanac.wordpress. com/ 2013/ 08/24/ herdmedicine-3/. When we referred to those aspects of herd medicine which seem important in proposing Universal Health Care, that comparison was not well received because, clearly, herd animals are raised to be sacrificed, in stark contrast to the thrust of small animal and human medicine. Yet, to provide medical care to more than 300 million people, cost, outcome, and scale are such vital considerations that any affordable universal medical care must consider them.

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Civil War Medicine Part I − The Antebellum Health Care Environment

By Kent Perryman, Ph.D. OF THE 620,000 SOLDIERS who died in the American Civil War between 1861 and 1865, two-thirds of their deaths were due to disease processes. Medical knowledge and diagnosis were not up to the task of adequately treating the legions of wounded and diseased. Due in part to the ineffective and prevalent practice of “heroic” medicine, such as blood-letting, illnesses like cholera, measles and smallpox spread among troops in encampments and hospitals. Germ theory and antisepsis were unheard of. Most of the high mortality rates in both armies can be partially attributed to an inadequate health care environment as detailed in this article, Part I. Part II will be devoted to the inadequate medical treatments for injured and ill infantrymen.

Antebellum Health Care The United States had a minimal health infrastructure (medical training, staff and hospitals) when the Civil War broke out in 1861. Most health care took place in the home by female family members and amounted to helping the patient with eating and drinking, empting bed pans, and changing bed linens. Herbal remedies handed down by generations, nutrition, and decent hygiene through bathing and clean linen were employed to comfort and heal the infirmed. In more severe illness, a family physician might be called if the distance was not too great. Most of the physicians in private practice and hospitals received their medical education as apprentices, in lieu of formal schooling. Regular physicians were referred to as “allopaths.” Earlier, in 1847, the American Medical Association had been established to deal with other forms of

medical practice, including homeopathy and botanical practitioners. Even physicians, who were formally trained at the few existing medical institutions, received little surgical instruction to prepare them for the horrors of war. The average medical curriculum was two years and provided no clinical experience or laboratory instruction. Harvard University, for instance, did not own a single stethoscope or microscope until after the war. Until tuition was instituted in 1871 at Harvard, salaries of medical school professors were raised through the sale of lecture tickets. There was also an extremely high attrition rate for those attending a formal medical institution, such as Albany Medical College. Students, who wanted to refresh their medical knowledge, often did so by purchasing tickets to lectures sponsored by practicing physicians. The few hospitals that existed during the antebellum period were generally reserved for the insane, and the almshouses housed the poor.

Civil War Nursing Care With the outbreak of the Civil War, clothing, shelter and medical care became the responsibility of the military. Most military surgeons came from civilian practices without experience in organizing an army medical system. The concepts of sanitation and nursing care that developed during the Civil War were primarily responsible for saving many lives in both the Union and Confederate armies. Between 1861 and 1862, skilled women began to staff field and general hospitals as nurses. It was due to their efforts that hospitals became more healing environments, mimicking the home sickroom. Nurses were instrumental in providing sufficient food, potable water, and

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An early Union army field hospital located near a Southern farmhouse.

clean clothing and bedding that helped reduce fatality rates. Nostalgia or homesickness often resulted in melancholia or major depression that lengthened the recovery period. Depression was considered a “moral cause” that could lead to malingering and desertion due to a “decline of mental strength.” A treatment for depression was to encourage letters from home, and the nurses were able to help the soldier correspond with his family. An example from one New York infantryman: “A letter from a mother or sister or any true friend brings visions of home and its comforts and joys. Pleasures which come clustering around the heart like doves that cheer the despairing heart.” Physicians were certain that strength of will was important in recovery. Music was played to encourage singing, along with stage entertainment. Historians generally concur that the women nurses provided a nurturing atmosphere that promoted healing. The newlyestablished United States Sanitary Commission (USSC) was responsible for providing steamer transportation of the wounded, as well as the delivery of medical supplies to field hospitals. The USSC was also responsible for recruiting many of the Union’s nursing staff, as well as for promoting the importance of camp hygiene and the use of disinfectants. A major contribution recognized for reducing mortality rates was stricter sanitation

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regulation by the nursing staff. This can best be exemplified by comparing mortality rates in various combat engagements. In the earlier Mexican-American War (1846-1848), seven men died from disease for every man killed in battle. In the Crimea War (1853-1856), their ratio was four to one, while in the Civil War, only two Union soldiers died of disease for each one who died of battle wounds. This evolutionary reduction in disease mortality can be attributed to enforced improvements in sanitary conditions at field and general hospitals. Nurse Florence Nightingale promoted improved, systematic applications of sanitary principles, regulating the disposal of wastes and providing patients with clean, airy hospital wards. Location of privies at a distance from sickroom tents and potable water sources was a major improvement.

Civil War Hospitals The soldiers wounded on the battlefield often lay unattended overnight until the arrival of fresh troops to push back the attacking force. At the beginning of the war, the wounded were carried out to a nearby field hospital individually on litters (stretchers), or on improvised wheeled carts. In 1862, Jonathan Letterman, a Union surgeon with the USSC, established a dedicated ambulance crew to be assigned to each regiment, along with ambulance wagons. However, there were many times when the wounded could be transferred off the battlefield only at night by the ambulance corpsmen to dressing stations. These stations often were no more than old barns or farmhouses where surgeons could control bleeding and pain. The surgeon arrived on horseback with limited medical supplies, and hopefully later, a medical supply wagon to transport the wounded to a field hospital. At times, there were fewer than 14 surgeons to care for more than 3,200 wounded. It could take up to a week for the injured to be evacuated, during which time many died of exposure and infection. Regimental field hospitals were set up as temporary sites close to the front lines, which was advantageous for rapidly returning the

infantrymen, who were less severely injured or ill, back to service. However, the primary function was to further stabilize the wounded infantryman by preventing additional blood loss, and by administering to the needs of the acutely ill. Amputations and bullet removals were common procedures, as well as temporary treatment, for some diseases until the patient could be transported. Every morning at “sick call,” the enlistees could present their complaints to the surgeons. Usually, after a few days of convalescent care, a soldier could be returned to his regiment. In the early days of the war, the “furlough” practice evolved whereby a man could be sent home for treatment if his injuries required 30-90 days to heal. This system benefitted the army financially, but was eventually discontinued due to the large number of desertions once a solder returned home. The field hospitals were composed of several canvas tents for the officers and their supplies, as well as a kitchen and sickroom tent with enough room for eight cots covered with army blankets. In warm weather, tent sides could be raised to increase air circulation. Medicines stocked at the field hospitals were limited to opium, morphine, Dover’s powder, quinine, Rochelle salts, castor oil, tinctura opii (tincture of opium or laudanum), camphorate and whiskey. Most medication was either in powder or liquid state. Surgical supplies consisted of chloroform, ether, brandy, ammonia spirits, bandages, adhesive plaster, needles and silk thread. Amputating cases were supplied with catlins (double-sided amputation knives for cutting in both directions), artery and bone forceps, scalpels, scissors, bullet probes and a tourniquet. The larger Civil War general hospitals were located behind the lines near more populous areas such as Washington, Philadelphia, Louisville, and St. Louis, where the wounded and diseased had extended periods of recovery. These hospitals were believed to better approximate the home health environment and demonstrated a much lower mortality rate

than the field hospitals. Many were in large warehouses, almshouses, and schools near rivers and rail lines. Later, as the war continued, newlyconstructed hospitals could accommodate thousands of patients. Philadelphia’s Satterlee Hospital could house more than 5,000. Due to their location in major metropolitan areas, these medical facilities were under constant scrutiny that resulted in more pleasant, sanitary and orderly conditions. Due to the efforts of the USSC, these hospital patients received the benefit of nutritious food and skilled nursing care which promoted recovery. Later in the Civil War, some of the newly-constructed hospitals were modeled on the European, pavilion-style promoted by Florence Nightingale. The pavilion plan placed an emphasis on light, air and ventilation to prevent the accumulation of foul odors, as well as on providing an adequate water supply and abundant sunlight. Wards were 30 feet wide and 100 feet long with a 16-foot-high ceiling with ridge vents to keep air circulating, and were interconnected by covered walkways. William Hammond, the Union Surgeon General at the time, was instrumental in replacing many of the Union’s older general hospitals with newly-constructed buildings based on the pavilion architecture. His premier facility was constructed in West Philadelphia, and in June of 1863 was named the “Satterlee” in honor of surgeon Richard S. Satterlee. Sickroom tents were sometimes set up on the adjacent grounds for overflow, and were also used to separate

May/June 2017

A larger Northern Union army hospital, above.

epidemics of gangrene, as well as to isolate black troops. There were separate buildings for kitchens, laundries, post offices and chapels in some of these Union general hospitals. A few had such amenities as a library with reading room and a smoking room with billiard tables. The individual wards had their own stove for heating, and a water closet to receive waste matter. Hot water was also available for bathing and for laundry facilities to supply clean linens and clothing for the thousands of patients. At Satterlee, medical “cadets” (medical students) were brought in from the University of Pennsylvania Medical School to perform basic orderly duties in exchange for the opportunity to learn medical practices from attending physicians. Although there were no statistics at the time, the health care community was convinced that these wards were more conducive to faster recovery rates, due to regimented nursing care and sanitation procedures. At the end of the Civil War, the general

hospitals were decommissioned. Unlike their Northern brethren, the South lacked the financial resources to afford their wounded troops the same medical care provided by the Union’s general hospital. In conclusion, even without the benefits of “germ theory” and antibiotics, health care during the Civil War underwent a revolution, decreasing mortality rates for the wounded and diseased troops due to improvements in nursing care, sanitation, nutrition, and hygiene, both in the field and general hospital settings. Part II will provide an historical account of Civil War medicine that covers the specific beliefs and treatments for injuries and diseases that challenged the military health care community during this period of our history. kperryman@suddenlink.net REFERENCES Humphreys, M. Marrow of Tragedy: The Health Crisis of the American Civil War. 2013,The Johns Hopkins University Press Schroeder-Lein, GR. The Encyclopedia of Civil War Medicine. 2008, M.E. Sharpe The Regimental Hospital. www.civilwarhome.com/ regimentalhospital.html

What’s on your mug? This coffee mug is a favorite of Nate Hitzeman, MD. If you have a favorite of your own, send us a photo in high resolution and we may use it.

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Fat Emulsion Breakthrough Another Chapter in Parenteral Nutrition History

By Ann Gerhardt, MD AFTER 41 YEARS OF USING a single intravenous fat emulsion (IVFE) in parenteral nutrition (PN), we finally have a new one, and it’s called SMOF. It’s not necessarily an ideal emulsion, but is a definite step in the right direction. The history of IVEFs is complicated. In 1678, William Courten administered olive oil intravenously to dogs, who promptly died from pulmonary fat emboli. In 1873, Edward Hodder treated three cholera patients with intravenous milk, two of whom inexplicably survived. Subsequent use caused significant side effects, so that approach died along with the patients. Paul Friedrich tried to subcutaneously infuse a mixture of fat, peptide, glucose and electrolytes, which was too painful to continue. Recognizing that fat must be emulsified to keep it from separating from waterbased plasma, scientists added amphipathic phospholipids. These mix with triglycerides to make an emulsion with globules similar to chylomicrons. The greater the ratio of phospholipid to triglycerides, the smaller the emulsion particle size. That might sound desirable, but too much phospholipid tends to be pro-inflammatory and creates abnormal atherogenic lipoproteins. A small molecule was added to make the emulsion isosmotic with plasma. The first commercial IVFE with this general formula was developed in the U.S. in 1957. Lipomul consisted of cottonseed oil, soy phospholipid and poloxamer. It was taken off the market because of serious side effects, including anaphylaxis and thrombocytopenia. Having been burned once, the FDA wouldn’t approve another IVFE until 1975, even though

Europeans succeeding in developing safe IVFEs in the 1960s. Meanwhile, IV nutrition had become a reality. In 1967, Stanley Dudrick, MD, a surgical resident in Philadelphia, first infused a parenteral glucose and amino acid mixture into dogs that didn’t kill them. By 1968, he had successfully nourished babies who had gastrointestinal failure. The first PN contained only amino acids, dextrose and the micronutrients that were known then to be essential. Over time, shortbowel patients on PN who ate no food didn’t do very well, leading to the discovery of new, essential micronutrients. Without fat calories, patients had trouble with essential fatty acid deficiency and meeting their caloric requirement. Since the goal was to promote anabolism, we wanted to spare amino acids for building protein. That left dextrose as the only calorie source. Unfortunately, humans have a limited capacity to oxidize glucose, and sick patients have insulin resistance that limits that capacity even further. PN came to be called hyperalimentation because we gave excessive dextrose calories to achieve weight gain, thinking that weight was lean mass. Instead, the non-oxidized glucose was stored as fat in the liver and skin, even as the patient remained catabolic. Intralipid, a soybean oil, egg phospholipid and glycerol emulsion in just the right ratio, was invented by Swedish physician and scientist, Arvid Wretlind, in 1961 and used safely in Europe thereafter. It wasn’t approved for us in the U.S. until 1975. Once we had a usable IVFE, we could finally meet caloric needs with a mixture of fuels that would spare amino acids

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Physicians often blamed IVFE for liver abnormalities in adults, but the problem was usually too much sugar, not the infused fat.

for anabolism. AND we could prevent essential fatty acid (EFA) deficiency. Sixty-one percent of soybean oil’s fatty acids are EFAs, so it’s easy to prevent deficiency without having to infuse a ton of fat. The not-so-nice thing about soybean oil is that all those EFAs are the ω6 type and unsaturated. Humans turn ω6 fatty acids into pro-inflammatory arachidonic acid, prostaglandins and leukotrienes, and the unsaturated bonds are ripe for peroxidation. Soybean oil also contains phytosterols that cause liver damage when infused parenterally. Neonates had the most trouble with those properties of Intralipid, often developing liver failure. (Physicians often blamed IVFE for liver abnormalities in adults, but the problem was usually too much sugar, not the infused fat.) Europeans have led the experimental charge to develop IVFEs without those problems. They’ve synthesized special “structured” lipids by attaching EFAs and non-inflammatory fatty acids to glycerol, but IVFEs using them have not yet become reality. Most new formulae use a mixture of natural oils. Soybean oil is still used to supply EFA, though safflower oil, with a higher percentage of EFA, has been tried. Fish oil is an attractive choice because it has no phytosterols and contains about 50 percent long chain ω3 fatty acids, which are converted to anti-inflammatory mediators. It also has inflammation-resolving substances called maresins, protectins and resolvins, which might be useful in inflammatory conditions, including systemic inflammatory response syndrome, but this hasn’t been proven in critically ill patients. Coconut oil, with mostly medium-chain fatty acids, is metabolized quickly for energy. Olive oil, with 80 percent oleic acid (an ω9 fatty acid with only one unsaturated bond) is another reasonable, non-inflammatory energy source. I’m told that European companies balked at the hurdles they would have to jump to meet the FDA’s requirements for approval. Lipomul’s shadow stretched long into the 21st century. In 2013, there was a severe Intralipid shortage. Baxter Healthcare succeeded in getting approval for Clinolipid, an 80 percent olive

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oil and 20 percent soybean oil emulsion. For reasons unclear to me, they didn’t market or distribute it in the U.S. For two years, we severely rationed Intralipid, often to patients’ nutritional detriment. Fresenius Kabi has been the only European company willing to tackle the FDA’s requirements for approval of a new IVFE. They got their feet wet with the process by getting FDA approval of a 3-in-1 pre-mixed PN formula, containing soybean oil emulsion, glucose, amino acids, minerals and electrolytes. That took seven years, but gave the company and the FDA experience with each other. Ta-Da!! SMOF lipid approval took only three years. SMOF stands for Soybean (30 percent), MCT (medium chain triglycerides) (30 percent), Olive (25 percent) and Fish (15 percent) oils. Soybean oil provides the EFAs. MCTs supply quickly oxidized calories. Olive oil’s 82 percent oleic acid is an energy source with less peroxidation potential. Fish oil, with anti-inflammatory components, hopefully reduces some of Intralipid’s side effects. So far neonates are the ones to show significant, demonstrable benefit from SMOF, in the form of less liver failure. Adults receiving SMOF have lower levels of inflammatory interleukins and metabolic intermediates. It’s not yet clear how that has translated into health and outcomes. There has been a trend to reduced length of ICU stay and liver enzymes don’t rise as much as with Intralipid. There are fewer EFAs in SMOF, compared to Intralipid. This isn’t a problem in patients on daily PN containing lipids. During the shortage years, however, we got into the bad habit of infusing lipids only two or three days a week to supply EFAs. This obviously ignored the calorie balance problem described above, and often left people short of usable calories. Sick in-patients need daily lipids. Short bowel syndrome out-patients on long-term PN are a different issue. Folks who can eat and have some absorptive capacity often get by on intermittent IVFE in their PN, maybe two or three days a week. To supply the 2 percent of calories they continued on page 24

Hospice – No One Walks Alone By Kayla Sheehan, MS I I HAVE A SONG I LIKE to think of as my anthem. It’s from an old musical, “Carousel,” and its title is a not-so-subtle nod to my philosophy surrounding patient care: “You’ll Never Walk Alone.” It’s a nice thought, and I wish it were more true. Unfortunately, a major portion of our patient population is pushed aside, neglected, ignored, not only because of our own cultural ineptitudes surrounding death and dying, but also because we fail to properly educate future physicians on how to navigate end-of-life care. A group of us at California Northstate University College of Medicine is working to change that. As medical students, the wealth of information we are expected to internalize is astounding. From physiology and biochemistry to diagnostics and pharmacology, we learn nearly every angle caused by our future patients’ ailments. For example, we know how to recognize acute lymphoblastic leukemia by its histology, we learn its associated antigens, and we know that one gene translocation t(12;21) has a good prognosis, while the other t(9;22) has a poor one. We learn that, and then we turn the page. We don’t learn what to say to that patient with the poor prognosis. We don’t learn what kind of care we can continue to provide them as they navigate their illness. We don’t learn how to interact with their family and support systems. We don’t learn this because the current curriculum has no room for it. We leave these patients “walking alone” during what is often their darkest hour. We forget or fail to realize that there is a difference between curing and healing, and in doing so, we rob these patients

of the potential to be healed in their final days. And what’s more, we rob ourselves of what I believe to be one of medicine’s deepest privileges − standing sentinel as a patient passes peacefully. It is true that this specific field of medicine may not be for everyone, and that is okay. I, for example, would make a terrible surgeon. But the difference is, I know the role of a surgeon; I am taught in medical school when to call for a surgical consult, and I learn which pathologies require surgical intervention. The role of hospice and palliative care is shrouded in a mysterious fog of morphine and DNRs. It’s associated with “giving up.” It isn’t mentioned in our Step 1 prep books or lectures. We learn about diseases so rare that the only place we are likely to see them is on our exams. But when it comes to death, something we will absolutely have to face throughout our careers, the conversation either does not occur, or is related to prognosis alone. We all suffer as a result of these shortcomings. End-of-life care is our biggest health care expense by far. Patients choose expensive treatments that severely compromise the quality of their lives in the hope for a marginal increase in the quantity of months or (if they’re lucky) years they have left. Hospice increases life expectancy in many terminally ill patients, but the connotations associated with hospice and palliative care are so centered around an immediate death sentence that many patients don’t feel comfortable pursuing those services. And many physicians feel equally uncomfortable suggesting them. Additionally, physician grief over patient

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The role of hospice and palliative care is shrouded in a mysterious fog of morphine and DNRs.

death is a contributing cause of physician burnout. Nowhere in our training are we given the tools we will need to cope with the loss of patients. Death is often considered a failure − an intervention that didn’t work, or a missed diagnosis. In medical school, we never talk about giving patients a “good” death, or about what happens after a patient has died. And then, after years of intense training, we encounter the first patient our schooling did not prepare us to heal. Someone whose illness is too far progressed for curative treatment, or someone who, after years of intense chemotherapy, no longer wants to treat their cancer, or someone with an incurable disease such as ALS, who only has palliative options to begin with. We have not been taught how to help these people. I think it’s time we were. At CNUCOM, the Hospice and Palliative Care Group meets every month to discuss endof-life issues, how to have difficult conversations with patients, bereavement, and much more. Our group consists of members interested in specialties ranging from Emergency Medicine to Orthopedic Surgery. But each of us realizes that we will, at some point, encounter a patient who would benefit from hospice and palliative medicine. We want to be ready to handle these situations with grace. In addition to our monthly meetings, many of us are currently undergoing training

to volunteer with Kaiser Hospice throughout the Sacramento area. Our volunteering will not be in any “medical” capacity − we won’t have our white coats or stethoscopes. What we will have is the opportunity to relieve caregivers, and thus better understand the context of a patient’s illness. We will have the privilege of sitting with the dying, and learning what it means to be present for a patient. We will have the chance to work with the interdisciplinary team, and to fully understand the role of each member. Most importantly, we will see firsthand that just because a life is ending does not mean it cannot be changed. Death is a difficult thing, but patients and their loved ones should not have to suffer even further because physicians are ill-equipped to handle its intricacies. Receiving a terminal diagnosis can be a profoundly isolating experience, and rather than chaperone these patients through their final phase of life, we often leave them walking alone on their path, largely because we were never taught how to do otherwise. It is our hope that CNUCOM’s Hospice and Palliative Group can help prepare future physicians to heal patients at all stages of life. No one walks alone. kayla.sheehan1253@cnsu.edu

Fat Emulsion Breakthrough continued from page 22 need as EFA, they may need more SMOF than they were getting with Intralipid. Hospitals often choose their default product based on price, so you may not have a choice about which IVFE to use, but at least some hospitals have it available as an alternative. SMOF costs a few dollars more than Intralipid, but both are amazingly inexpensive compared to many other intravenous pharmaceuticals. If there is a choice and the patient is a child,

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the logical choice is SMOF. A sick in-patient theoretically might benefit from SMOF. If a PN-dependent adult on Intralipid is not doing well at home, or there is a liver problem while not receiving excessive sugar calories, a trial of SMOF is a reasonable option. If a patient is doing well on Intralipid, there is no evidence that switching to SMOF would make life better. algerhardt@sbcglobal.net

Transgender and Gender Non-Binary Health Care By Christopher Swales, MD “I AM TRANSGENDER.” Those three words were imbued with such fear and anxiety from the first trans patient I had, as he sat in my exam room, sitting close to a friend he brought for support. Having scanned his chart prior to him coming in, I knew that he had a poor experience with the provider before me, due partially to lack of understanding and a cultural disparity that only worsened an already delicate situation. I simply answered, “Ok. How can I help?” While I had only a very basic understanding of transgender care, I knew that this was someone I could help. After research, calls with other transgender providers, and some hands-on experience with the Gender Health Center (GHC), a local transgender advocacy center in Sacramento, I now feel more confident than ever to treat transgender patients.

I was lucky to have a patient who was able to advocate well, and came armed with information on his care... Through my exposure and education in transgender health, I learned just how hard it can be for these patients to access care. I was lucky to have a patient who was able to advocate well, and came armed with information on his care and a willingness to educate me as a physician. It is somewhat embarrassing to me that this patient felt like he had to teach me about transgender health, after all, I had gone through medical school and residency, but with

no exposure or education on this subject. This experience, and recent local and national news, have ignited a new passion, one for transgender health education, advocacy, and education. It is important to understand the definitions for transgender and gender non-binary, to have a greater understanding of these patients’ struggles. Transgender refers to people whose internal senses of self with regard to gender, do not match their external or assigned sex at birth. A transgender man, then, is a person assigned female at birth due to external genitalia, but feels that he is a man in regard to his gender and how he views himself. Gender non-binary is a broader, catch-all term for persons who either do not regard themselves as either gender, or who identify as both genders. This is often more difficult to understand for us as providers, as it is more outside the norm of gender as we often perceive it, but equally more difficult for the person to accept and feel accepted. There are three pieces of advice that I would give for the care of transgender patients: First, and most important, address the patient by his, her or their preferred gender and name. If you don’t know, or aren’t sure, just ask the patient directly, as this establishes a base level of trust and will make interaction much smoother. Second, train all staff to be aware of, and sensitive to, transgender patients, as anyone who contacts the patient has the ability to make either a good or bad impression. Third, be open with your patient about your personal level of comfort with regard to his, her or their transgender status, and continued on page 27

May/June 2017

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.

Hot Air Sauna Burns By Glennah Trochet, MD and 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.

A FRIEND RECENTLY SUFFERED 3rd degree leg burns after falling asleep in a sauna. The SSVMS Public and Environmental Health Committee wondered if this were a problem worth attention. The Committee delegated to us the task of researching the subject in our community. This is what we found. Sauna burns and deaths are a big deal for those afflicted by them. We don’t know how many people are injured or burned in saunas in the U.S. Apparently, not many Americans die in them. In Sacramento County, the burn unit at UC Davis has not seen a hot air sauna burn in recent memory, and not in the past three years. The few reported cases in the United States consist of an inebriated 61-year-old woman expiring in a sauna with no timer, three who died in an Arizona cult sweat lodge, and a 68-year-old man, alone in a malfunctioning sauna, found with charred skin, chunks of which were lying on the floor. Finland, site of the World Sauna Championship, tops the world for most reported sauna burns and deaths. There, one sauna burn a day requires hospitalization, usually related to touching the heater or a hot surface, and one out of four burns in the country is sauna-related. In the championship, the temperature starts at 110 degrees, then is increased with water thrown on the heater every 30 seconds. In 2010, two people fainted at six minutes, one of whom died. (As a result of these incidents, the championship was discontinued and has not resumed). Some mutant holds the record for lasting more than 16 minutes. According to a 2008 study, Finland has about 2 million saunas for a population of 5.2 million people. The annual sauna-related death rate is less than 2 per 100,000 inhabitants. Half were inebriated. Twenty-five percent of

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Glennah Trochet, MD

Ann Gerhardt, MD

deaths were due to heat exposure, and fifty-one percent died of “natural causes.” The cause of the remaining deaths is unclear, but it could be trauma – for example, a man in Germany died after falling face first onto a sauna stove. Other than the trauma of falling onto a stove, or head trauma when a skull hits the floor, what usually kills people is related to dehydration and high body temperature. We normally dissipate body heat by sweating and peripheral vasodilation. Saunas induce water weight loss from sweating, leading to dehydration. Dehydration leads to reduced ability to disseminate body heat and causes peripheral vasoconstriction, further reducing the body’s ability to adjust its temperature. Extreme sauna humidity reduces sweating and dehydration, but eliminates sweating as a mechanism to dissipate heat. The brain is particularly sensitive to heat. This may prevent an appropriate response to discomfort, especially in a person whose judgement is already impaired by alcohol. The combination of alcohol and heat can also cause a person to faint. The vasoconstricted extremities are particularly prone to hot air damage, incurring full thickness skin burns, loss of blood supply, deeper tissue damage and rhabdomyolysis. There may not be many reported sauna problems in the U.S., and California does not have any regulations for saunas, as opposed to hot tubs. However, most sauna manufacturers provide timers with their saunas, cutting off the heat after a predetermined time. For those who like to use a sauna, taking a few common-sense precautions will help one enjoy the benefits without the dangers: Keep temperature at or below 180 degrees. Set the timer, if available. Take breaks and drink water. Don’t have metal

items in the sauna or wear jewelry or clothing with metal in them. Don’t drink alcohol and sauna. Don’t sauna alone. Make sure someone checks on you if you don’t leave the sauna after 15 to 20 minutes. Don’t leave a drunk alone in a sauna. Sauna isn’t a macho competition: When it feels uncomfortable or the brain is sleepy, leave. We recommended to the Public and Environmental Health Committee that no further action was necessary. trochetg@gmail.com Algerhardt@sbcglobal.net REFERENCES Koljonen V. Hot air sauna burns- review of their etiology and treatment. J Burn Care Res 2009 30(4);705-10 Abstract: Kenttämies A1, Karkola K. Death in Sauna. J Forensic Sci. 2008 May;53(3):724-9.

Transgender continued from page 25 either research and educate yourself, or refer to another provider who can help the patient more appropriately. Transgender people are less likely to engage in health care, and have more fears about their treatment and care, so it is up to us to reach out and show that we respect them, and their transgender status. Since last fall, I have given several lectures on Transgender and Gender Non-Binary patients throughout the local Dignity Health System. While I don’t have as great a level of expertise as some of the physicians at the GHC, I am striving to continue learning and spreading that knowledge. I encourage all providers, primary care and specialty, to look into transgender care, as you likely have several trans patients in your practices. I offer myself as a resource if you have any questions, and want to let you know about other local resources. The GHC provides social work and legal assistance, and has a free hormone clinic though one of the UCD student-run clinics, the JVMC. They have been invaluable for assistance with

legal name and gender change forms, as well as letters for insurances. I recently learned about www.SacGender.org, a resource page for transgender patients and providers, run, in part, by Dr. Carol Milazzo, a pediatrician in Roseville. Lastly, I encourage everyone to read the free guidelines from the UCSF Center of Excellence for Transgender Health that are available online at http://transhealth.ucsf.edu/protocols, and, should you be inclined, the World Professional Association for Transgender Health (WPATH) guidelines, available online at www.wpath.org. These WPATH recommendations are considered Standard of Care for Transgender and Gender Non-Binary Patients. Christopher.Swales@DignityHealth.org NOTE: See also in the Jan-Feb 2016 issue of SSV Medicine an article on transgender care by Laura Brimberry, RN (https://issuu.com/ssvmedicine/docs /1601-ssvmed/1?e=5422997/32143294)

May/June 2017

Cannabis – a Drug That is Also a Medicine By Bob LaPerriere, 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.

I RECENTLY ATTENDED a CME course on Medical Cannabis, sponsored by United Patients Group (https://unitedpatientsgroup.com) that does consulting and education related to Medical Cannabis, cannabis being a preferred term to marijuana when discussing its medical applications. Northstate University Schools of Pharmacy and Medicine hosted the talk by Bonni Goldstein, a Southern California pediatrician who has been involved with medical cannabis for two decades. It was not only fascinating, but also extremely illuminating. Dr. Goldstein reviewed case histories of children, including those with cancers and seizures, and adults with a wide variety of disorders, who all dramatically benefited from cannabis. Unfortunately, scientific studies in the U.S. are lacking, as cannabis is a Schedule I drug. But other countries are doing extensive studies. The various components of cannabis were discussed, including the main two used medically, THC (tetrahydrocannabinol, the main psychotropic) and CBD (cannabidiol). CBD has many medical benefits, but essentially no psychoactive property, and the ratio or balance of THC and CBD is an important aspect of therapy. There is work on hybrids which can produce various ratios of the active components (leafly. com). Many other products are found in cannabis, not only the 100+ other cannabinoids, but also numerous compounds, especially terpenes and terpenoids which are similar, and the terms are often used interchangeably. They have multiple medical benefits, including anti-inflammatory

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effects, and are related to the fragrance and taste of different cultivars. The entire plant has importance, as all these compounds work synergistically. The fact that humans have cannabinoid receptors (the endocannabinoid system), and produce chemicals that link with them, should also be a stimulus for intensive research. A friend recently loaned me the catalog from the Cannabis Museum (www.cannabismuseum .com). The museum highlights the use of cannabis from 1850 through the early 1900s, until its prohibition in 1937. Its curator is Don Wirtshafte, an attorney, who has been involved for three decades with this medicinal plant. He developed his amazing collection of bottles during his research, disputing the argument that cannabis was never accepted as a medicine. From Don’s Collector’s Statement: A hundred years ago, these drugs were popular simply because they worked and were known to be safe. For sixty years running, Cannabis was the third most used compound in medicine. Physicians of the day found it beneficial for a wide variety of indications; indications that match the claims being made by the proponents and patients of medical Cannabis today. I had the pleasure of meeting Don when he visited our Museum of Medical History in February. This stimulated me to search our “bottles,” and subsequently our museum now has a small exhibit featuring the three bottles I located (shown on page 30). As marijuana is now legalized in California and other states, it is important for physicians to be more familiar with, and open minded about, this “drug,” a drug continued on Page 30

Cannabis for Your Dog? By Sandra Hand, MD IF YOU THINK IT IS difficult for physicians to be up to date regarding the many clinical uses of cannabis, then imagine how it is for our veterinary colleagues? Like us, our pets have pain, suffer the problems of old age, have seizure disorders and cancer. The problem for veterinarians is even more of a legal and professional mess than for physicians. While cannabis remains a Schedule I drug and illegal under federal law, in California since the 1990s and in a number of other states, we can at least recommend it where it seems appropriate for our patients. Physicians can fill out a State form to provide access for our patients to medical cannabis dispensaries. The legal environment continues to change for California, and research on cannabis done in other countries is available. User experience is also a guide to dosage and effectiveness. However, according to several articles on veterinary cannabis in SFGate in October 2015, and on March 8, 2017 (available online), veterinarians are forbidden from even recommending it. The ASPCA, the FDA and the American Veterinary Medical Association are critical of its use. If you ask a California veterinarian, most of them will say they just donâ&#x20AC;&#x2122;t know and you try it at your own risk. Despite this, Dr. Don Duong, a Los Angeles veterinarian trained at A&M in Texas, created VetCBD. He markets his product only through medical cannabis dispensaries within California. A bottle contains 115 mg of cannabidiol (CBD) in olive oil with suggested dosing based on weight. He has a very informative website, VetCBD.com. He uses the flowers from cannabis cultivars that are bred to produce mostly CBD, which is nonpsychoactive, with little THC. CBD can also be obtained by extraction from the whole hemp plant, and some producers use

hemp because of the gray zone in the law that allows industrial hemp products, if the THC is very low, less than 0.3 percent. It is, however, inferior to cannabis flower as a source. So, here is the story of two old dogs. When my 12-year-old Miniature Pinscher, Angel, began to show signs of joint pain, we knew it was serious. Dogs, as a rule, when there are other dogs around (and we have three), do not demonstrate weakness, as the other dogs will take advantage of them. Angel began to totter on her back legs and refused to weight-bear on her right front leg. She was no longer jumping up into laps or dancing for a treat on her hind legs in that typical Min-Pin bipedal strut. The veterinarian prescribed an antiinflammatory for her arthritis. It turned her stools to water and she ceased to eat. So we stopped it, and took her in for something else. Another drug was given with the same result. By this time she was mainly staying in her bed and had to be carried upstairs at night. No longer did she merrily jump up on the bed and snuggle down near our feet. We were losing our dog. I complained to a friend of mine that the next step seemed to be expensive, deep tissue

12-year-old Angel seemed to benefit from cannabis used to treat her joint pain.

May/June 2017

laser treatments and might not work. He suggested we try VetCBD. I knew very little about it, but knew his 16-year-old Chihuahua, Gus, had been dwindling in a similar fashion for a while and appeared to be doing better lately. He told me he was giving it to Gus. He had heard about it through word of mouth at the dispensary where he got his own medical CBD from for his back injury. So he bought some for me, and we tried it. It was like a miracle had occurred! In three days, she stopped

limping. Her appetite returned. In a few weeks, she was dashing up the stairs and laughing at me with her whole body wiggle and grin that showed how delighted she was to have beat me up the stairs. She began to play again with our other dogs. She showed no sedation. She looked and acted like a much younger dog. When we accidentally ran out of medication, she began to flag within a few days and seek her bed more. A few days after restarting it, she was back to her new “old self.” We continued to give her the medication in her dinner without fail. We recently lost her at age 14 to a lung cancer. She was happy and eating well and running upstairs until her last day of life. Gus lived until he was 18. Check out the VetCBD.com website for more information. smh9142@comcast.net

Cannabis continued from page 28 that indeed is also a medicine. It is important that more accurate and defined preparations become available for medical use, though the inability to do this − and the vital research that is necessary − is restricted until the government moves it out of Category 1. Of note, the CMA has a policy recommendation that cannabis be These old bottles of cannabis and heroin remedies are on display in the SSVMS Museum of Medical History.

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made Schedule II, so that scientists can study and verify the medical aspects of it more. ssvmsedcom@gmail.com OTHER RESOURCES: https://www.medicaljane.com https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/

A Posit on Fee-For-Service Single-Payer Plan “A fee-for-service single-payer health plan sponsored by a state government (vs. national) is financially impossible.”

Background: Remember single-payer universal health care? It nearly passed in California in a 2004 referendum which the CMA sponsored. Then it passed the legislature when Arnold Schwarzenegger was governor, but he vetoed it. He claimed, “socialized medicine is not the solution to our state’s health care problems.” He emphasized that such a measure would “cost the state billions and lead to significant new taxes … without solving the critical issue of affordability.”1 Senator (now Mayor) Darrell Steinberg said in a public meeting last year that there is a limit to how high one can raise taxes. According to an article in the February 17 Sacramento Bee, State Senator Ricardo Lara, D-Bell Gardens, intends to reintroduce legislation for single-payer health care in California. The article states that he “envisions a system that would cut out insurance company waste and duplication that currently exists… no more out-of-control co-pays and high deductibles.” Single-payer is an insurance system in which the funding all comes from one source – usually the government, but providers and health care organizations remain private. Canada and Taiwan have single-payer systems. The UK is often considered single-payer, although not as purely so. Vermont passed single-payer legislation in 2011, but abandoned it in late 2014, ostensibly due to tax burdens on small businesses and a struggle to divert federal funds to support it. In 1997, the leader of the National Health Service Bureau in Taiwan, Dr. Mei Shu Lei, visited the California Medicare Contractor

because the cost of the Taiwan system was out of control. Dr. Mei was searching for a solution. Fee-for-service payment via Medi-Cal is being abandoned because fee-for-service is too expensive. Read more here: www.sacbeecom/news/ politics-government/capitol-alert/article133279459. html#storylink=cpy 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. States cannot afford the cost independently. The goal is to control the delivery system and then to control costs completely independent of the true costs of care. This will be done by regulating various reimbursements to a common low amount and limiting care, especially highcost care, and encouraging “death with dignity.” New technology and treatment approaches will be evaluated by cost, not benefit. If allowed, concierge medicine will expand greatly as people will try to secure access to doctors who will likely leave the state. With free college and tax-free professions, taxes will need to increase substantially and with Calexit, we’re on our own. –John Young, MD I believe that health care should be a basic right, like education. Most countries in the world support this belief. The issues are access and financial support. Massachusetts and the ACA have made good steps in terms of access, but fail to control costs. Studies show that the cost of care for people age 65 and older is much less

May/June 2017

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.

Somehow, almost every other developed country has instituted some form of singlepayer health care that costs less and works better than ours.

than for people under age 65. This is due to the private insurance companies’ profit motivations and administrative costs. California Insurance Commissioner, Dave Jones, is supporting the CA single-payer bill (SB562) and would not allow insurance companies to write health insurance in California. The current Medicare system is not socialized medicine, and adding a “single-payer” for under 65-year-olds would still allow choice. –Barbara Livermore, MD. Agree. It seems like most grand political and public works projects happened after WWII. The building of large dams and bridges, putting a man on the moon, transportation infrastructure. I guess there was more of a national unity and feel-good spirit then. As time goes on, there are too many special interests and fear of political blow-back to do anything grand and gutsy anymore, and single-payer health care would be gutsy! Health care is complicated, and there are so many entities to point our fingers at, and so much fear that can be mongered on the general population, who are generally clueless as to how health care works or is financed. I can see an initiative possibly passing, but we would never get funding at the federal level to make this work. It’s too bad because I am a fan of single-payer. Rising health care costs will continue to bleed other sectors of the economy. Stagnant wages, potholes in the roads, sin taxes on cigarettes and sodas, medical-induced bankruptcies. Shake your fist in the air at our health care system. It’s the driver. –Nathan Hitzeman, MD Agree. The State of California can’t even pay physicians appropriately for Medi-Cal with the Feds’ help. –Katherine Gillogley, MD Agree that single-payer is expensive and will drive business out of California if enacted! – Reginald Rice, MD I disagree. It is the only possible workable solution nationally. And most doctors need to be on salary linked to the quality of outcomes, not volume. Fee-for-service is becoming archaic and too inefficient. –Pat Hardy, MD NO SINGLE-PAYER GOVERNMENT HEALTH CARE!!!!!!!!! (Jeez, haven’t we had enough government interference in our

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industry?!?!?!) –Peter T. Skaff, MD The idea of a single-payer system looks good in theory and fails at a practical level every time. Competitive Marketplace is essential for an efficient system. The goal should be Universal Coverage, not Single-Payer. −Kuldip Sandhu, MD Government management (whether Federal or State) is inefficient, costly and worsens quality. (The VA for everyone.) Better to reduce regulations and data demands on physicians and increase competition between insurers and hospital systems. Instead of 60 percent of health care dollars to bureaucrats and administration, and 40 percent to providers; it should be much more to actual providers and much less to nonproductive regulators. Regulation-free “Direct Medical Practice” is an innovation proving satisfying to many primary care providers. –Richard Park, MD This “Posit” is a gross oversimplification of a complex situation. I disagree. −Joy Melnikow, MD It’s hard to imagine anything worse than America’s current inefficient, incoherent health care systems. Somehow, almost every other developed country has instituted some form of single-payer health care that costs less and works better than ours. An HMO/”fee-forservice” single-payer health plan at the State or Federal level is obviously possible − but it will take a lot of work and willpower to get it right. −Robert Meagher, MD Disagree. It makes sense because it gets the insurance companies out of the picture. −Elaine Silver, MD Disagree. Most of us agree that all humans should have access to health care, yet in the U.S. we ration health care based on ability to pay, which is a cruel and unjust way of doing so. With appropriate federal waivers and political will, California would show the rest of the nation how to ensure that all its residents have health care coverage. Single-payer proposals cut out wasteful administrative overhead and can control costs. The State of California could easily negotiate much better prices for medications and medical devices. I would much rather pay

taxes to a system that covers everyone than pay premiums to an insurance company that keeps denying me care and rations the care they do provide irrationally. −Glennah Trochet, MD It’s irresponsible not to have a single-payer system. If managed appropriately, it would be much cheaper, much less confusing, more accountable, and easier to navigate. −Maynard Johnston, MD I disagree! The savings from eliminating insurance companies is massive and could fund the whole thing. It would be like Medicare. California is big enough to make it work. − Stewart Teal, MD We already cover a third of our population with Medi-Cal. The Medicare population has coverage. Our exchange and employer-based insurance cover almost everybody else. If we converted all the private insurance/exchange patient funding toward single-payer, it could be done. If you take the profit out, it could be cost-effective. The tough nut to crack is how to run it efficiently and evidence-based. −Debra Johnson, MD Consider VAT as one source of financing. Everyone pays, but proportionally to their spending ability. −Padraig O’Neill, MD Agree. Will be bloated with government bureaucracy and costs. −Philip Messah, MD I passionately disagree. It is time for a change. The USA spends almost $3 trillion per year in a gangrenous system. The costs could reach $4.2 trillion annually, roughly 20 percent of our gross domestic product, within 10 years. Yet, this country ranks 53 (!!!) in terms of life expectancy. With such disastrous outcomes, how can we still trust the insurers? I come from a place (that ranks 12 for life expectancy) where there is a universal coverage, where “premiums, deductibles and co-pays” are intimidating terms relegated to the sphere of one’s car insurance. I admit that universal coverage is not perfect, but at least, it can lessen the burden on our saturated emergency rooms; people might be more tempted to go to well visits and take care of their health rather than waiting until they are on the verge of dying. Seventy-five percent of health care costs

are spent on preventable diseases that are the major causes of disability and death in our society. On the long term, prevention and health maintenance are less costly than waiting for catastrophes to happen. A universal or single-payer system would also free the mind of our patients in the most challenging times of their existence, when they are vulnerable from illness and have other things to worry about than whether or not their insurance will cover such and such test or treatment. The corporate interest has no place in basic medical care. Universal medical care is a fundamental right. Or does this resistance to disinfect our dysfunctional system a proof that this country treats its car industry better than its people? − Caroline Giroux, MD Medi-Cal is mostly managed care with claims paid by multiple payers: managed care entities. Xerox pays the remaining fee-forservice Medi-Cal claims. California Department of Health Care Services (DHCS) pays no claims. Medicare A and B claims are paid by eight Medicare Administrative Contractors (MACs). Durable Medical Equipment (DME) is paid by four MACs. Many pharmacy benefit managers (PBMs) pay pharmacy claims under part D. Most MACs are owned by health insurance conglomerates. CMS (Centers for Medicare and Medicaid Services) pays no Medicare fee-forservice claims. DHCS already decided (circa 2011) that single-payer for Medi-Cal is financially impossible. CMS has no plans to use one payment contractor for the entire country. Fiscally responsible payment requires competition. The VA has its own hospitals and clinics. I doubt CMS or DHCS want to run hospitals and clinics and hire doctors. Commercial plans do not provide care. They only pay claims. We are upset when there is only one insurer in a county. No one is moving to single-payer. Best we rework the ACA − a bipartisan creation at different times, using multiple payers and moving toward integrated provider delivery systems. “Universal access” is a more meaningful concept than “single-payer.” −Gerald Rogan, MD

May/June 2017

No one is moving to singlepayer. Best we rework the ACA...

REFERENCE 1 https://www.ncbi. nlm.nih.gov/pmc/ articles/PMC158 6096/

Board Briefs March 13, 2017 The Board: Approved the appointments to the Board of Directors of Cynthia Ramos, MD, representing District 5, Office 10, and Tonya Fancher, MD, representing District 2, Office 7, and accepted the resignations of Vijay Khatri, MD, who no longer represents District 2, and Darin Latimore, MD, who accepted a position at Yale University. Received an update regarding the Public and Environmental Health Committee from Glennah Trochet, MD, Chair, and approved the following recommendations from the committee: 1) That SSVMS communicate with state regulators the Society’s concerns regarding inadequate and incorrect provider networks and directors, and their impact on physicians and the patients they serve; 2) That SSVMS urge the Sacramento County Board of Supervisors to increase enrollment in the Healthy Partners Program to ensure that all residents of Sacramento County have access to care; 3) That SSVMS support the American Lung Association in California’s advocacy to continue implementation and enforcement of the Clean Air Act. Approved the 2016 Unaudited Year-End Financial Statements and the 4th Quarter Investment Reports and Recommendations. Received an update from Myel Jenkins, Program Director, Community Service, Education and Research Fund (CSERF), a 501(c) (3) organization of SSVMS. Ms. Jenkins reported that the SPIRIT Project is seeking physicians who can volunteer care, particularly for the following high-demand specialties: Dermatology, Gastroenterology, General Surgery, Gynecology, Neurology, Ophthalmology, Orthopedic and Urology. She noted that there is a waiting list of SPIRIT patients who are only able to access specialty consults through the services donated by SPIRIT volunteer physicians.

Sierra Sacramento Valley Medicine

Also, CSERF is engaging in social media campaigns to raise community awareness about their programs. Received an update from Lindsay Coate, SSVMS Director of Programs, regarding the Society’s participation with the Sacramento County Opioid Task Force and taking the lead for the Engaging the Medical Community and Overdose Prevention Subcommittee. In addition to ongoing educational programs and promoted safe prescribing guidelines to physicians in the region, SSVMS has launched a new program, RX Safe Physicians. The campaign will provide resources to physicians to help engage a conversation between the physician and the patient regarding the use of opioids and alternative therapies to manage pain. Approved, in accordance with SSVMS and CMA Bylaws, the termination of membership for members who had not paid their 2017 dues by the March 1, 2017 deadline. Approved the March 13, 2017, February 27, 2017 and January 23, 2017 Membership Reports. For Active Membership — Andrea Bates, MD; Aliyah Khan, MD; Alan Lee, MD; Pei-Hsui Huang, MD; Sarada Mylavarapu, MD; Ramiro Zuniga, MD. For Active Resident Membership — Joseph D. Hall, MD. For Reinstatement to Active Membership — David K. Roberts, MD. For Retired Membership — Colin Arnold, MD; Algimantas Balciunas, MD; Laurel Finta, MD; James Forester, MD; Michael McCloud, MD; David Moitoza, MD; E. Andrew Neal, MD; Jan Okimoto, MD; Katherine Rutherford, MD; Ron Sprinkle, MD; Jane Stoinoff, MD; Paul Zubach, MD. For Transfer of Membership — Maria Parayno, MD (to Los Angeles). For Resignation — Matthew Gargulinski, MD; Robert Ghrist, MD; Kusuma Hampapur, MD; continued on page 35

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. APPLICANTS FOR ACTIVE MEMBERSHIP: Andrea Bates, MD, Psychiatry, Jefferson Medical College of Thomas Jefferson University in Philadelphia – 1990, 316 California Ave #107, Reno, NV Pei-Hsui Huang, MD, Cardiovasular Disease, Emory University School of Medicine – 2005, Sutter Medical Group, 2800 L Street, Sacramento, CA 95816 Aliyah Khan, MD, Family Medicine, Eastern Virginia Medical School – 2011, Mercy Medical Group, 3000 Q St., Sacramento, CA 95816

Tracy Zweig Associates INC.

REGISTRY

PLACEMENT

FIRM

Physicians Nurse Practitioners ~ Physician Assistants

Alan H. Lee, MD, Orthopedic Surgery, University of Michigan – 2004, Mercy Medical Group, 1730 Prairie City Road, Folsom, CA 95630 Sarada Mylavarapu, MD, Anesthesiology, Guntur Medical College – 1978, Woodland Memorial Hospital, 1325 Cottonwood St, Woodland, CA 95695 David K. Roberts, MD, Cardiovascular Disease, Univ Miami – 1985, Sutter Medical Group, 2800 L Street, Sacramento, CA 95816 Ramiro Zuniga, MD, Family Medicine, Fac Medical De La Pontifica University Javeriana – 1989, CA Health & Wellness, 1740 Creekside Oaks Drive, Suite 200, Sacramento, CA 95823 APPLICANTS FOR RESIDENT MEMBERSHIP: Joseph D. Hall, MD, Psychiatry, UC Davis Residency Program – 2020, 2230 Stockton Blvd., Sacramento, CA 95817

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

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Board Briefs

Physicians for Judicial Review Committees

continued from page 24

The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego.

Paul Hayes, MD; Hollis Hopkins, MD; Herman Kensky, MD; Robyn Kimura, MD: Aaron Libet, MD; James Little, MD; Anne Marie McLellan, DO; Dennis Nguyen, MD; Anandray Patel, DO; Stephanie Radke, MD; Taffere Mihretu, MD. Deceased: Al Kahane, MD (2/15/2017); F. L. Don McClurg, MD (12/27/2016).

IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any of Special Consultant. Physicians will be paid on an hourly basis for their time and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq. org) if you may be interested.

S.S.V.M.S. 12-11-13

May/June 2017

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Advance Health Care Directive Kit California Physician's Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPAA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physician Orders for Life Sustaining Treatment Kit

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www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)

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