2018-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2018

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MEDICINE 2

2018 Education Series

Our Tour of Cuba

PRESIDENT’S MESSAGE Firearms and Our Role

Gerald Rogan, MD

Exotic Fruits – Nutrition Trove or Hype?

Rajiv Misquitta, MD

Ann Gerhardt, MD

EXECUTIVE DIRECTOR’S MESSAGE SSVMS/CMA Advocacy

Chance Encounter

Stephen L. Mandaro, MD

Aileen Wetzel, Executive Director

GUEST EDITORIAL “Are You Pro-Life?”

Elisabeth Mathew, MD

Where Did Time Go?

Caroline Giroux, MD

The Intangible Sought After

Caroline Giroux, MD

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

Do Good and Feel Good

Lindsay Coate, Director of Programs, SSVMS

American Women’s Hospitals Service

Karen Poirier-Brode, MD

Snake Oil and the Placebo Effect

Reflections on Strangest Medical Complaints

Kent Perryman, Ph.D.

IN MEMORIAM Daksha Shah, MD

Bad Luck… Good Luck… Bad Luck

Bob LaPerriere, MD

Board Briefs

Welcome New Members

26 Tuberculosis

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.

Matthew Huh

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 While on a cycling trip around Hawaii’s Big Island, Dr. Ann Gerhardt encountered an exotic fruit that looks like an urchin. Even its white, pulpy flesh is creepy. Why would one eat it, except out of adventure? With no obvious vitamin content, nutrition is no motivator. Should we should just take a picture and devour a banana? Dr. Gerhardt writes about this intriguing fruit, called rambutan, and other exotic plant foods on page 18. By the way, rambut means hair, rambutan means hairy, in Bahasa Indonesian.

May/June 2018

Volume 69/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

Sierra Sacramento Valley

MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2018 Officers & Board of Directors Rajiv Misquitta, MD, President Chris Serdahl, MD, President-Elect Ruenell Adams Jacobs, MD, Immed. Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD John Wiesenfarth, MD District 6 Carol Kimball, MD

2018 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 Ruenell Adams Jacobs, MD Barbara Arnold, MD Natasha Bir, MD Richard Gray, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Chris Serdahl, MD Don Wreden, MD

District 1 Harmeet Bhullar, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Richard Bermudes, MD District 5 Armine Sarchisian, MD District 6 Christopher Swales, MD At-Large Megan Anzar Babb, DO Helen Biren, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Ernesto Rivera, MD J. Bianca Roberts, MD Ajay Singh, MD Vacant Vacant Vacant Vacant Vacant

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA Immed. Past President Ruth Haskins, MD CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD Editorial Committee John Paul Aboubechara, Sean Deane, MD Maria Garnica, MS II Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD

MS III Steven Nemcek, MS III John Ostrich, MD Karen Poirier-Brode, MD Neeraj Ramakrishnan, MS II Gerald Rogan, MD Glennah Trochet, MD Lee Welter, 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. ©2018 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

Firearms and Our Role By Rajiv Misquitta, MD OUR COMMUNITIES ARE NOT just affected by biologic illnesses; complex social issues can also cause great harm to our patients. Firearms-related injury or death is a major health concern. It seems that there is breaking news of a gun-related incident almost every day. The recent Parkland shootings brought the deadly impact of gun violence to the forefront for most Americans. The numbers involved in gun-related deaths are quite sobering. The New York Times’ Nicholas Kristof was quoted to say, “More Americans have died from gunshots in the last 50 years than in all of the wars in American history.”1 Numerically, that translates to more than 1.5 million gun-related American deaths since 1968, according to data from the U.S. Centers for Disease Control and Prevention. By comparison, only 1.2 million service members were killed in all wars in U.S. history, according to estimates from the Department of Veterans Affairs.2 In 2015, there were 34,997 deaths in the U.S. caused by firearms.3 I recently spoke with a local expert, Dr. Garen Wintemute, the Director of the Violence Prevention Research Program at the University of California at Davis. He commented on the mythology and misunderstanding of the firearms problem. He reminded me that mass shootings appear to have accounted for no more than 1 to 2 percent of deaths from firearm violence in recent years.4 In the nation, fatalities in regards to gun deaths are primarily from self-harm, and suicide outnumbers homicide by nearly 2 to 1.5 In a comprehensive white paper on firearms violence prevention, the CMA clearly outlines the facts.6 In California, suicide was the 10th leading cause of death in 2015, and firearms accounted for almost half of those deaths, with older white men at the highest risk. Homicide

is the leading cause of death for male and female African Americans aged 10–34 years, and firearm-related homicide is highest among young African American men.7 Physicians and other health personnel come face to face with the tragic sequela of gun violence quite often, and we have an important role to play in reducing these tragedies. Professional societies like the American College of Physicians, have recommended that talking about firearms is important for physicians to do.8 We need to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present.9 As a nation, we do a lot of research on diabetes and heart disease, with almost no federal funding spent on firearms research and how to prevent fatalities. As physicians, we can also support the need for more research in this area, like we do for other major public health issues. rajiv.misquitta@gmail.com REFERENCES 1 Kristof, N (2015, August 27). Kristoff: Lessons from the Virginia Shooting. The New York Times. p. A23 2 https://www.va.gov/opa/publications/ factsheets/fs_americas_ wars.pdf 3 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/injury/wisqars. [Accessed May 5, 2017] 4 Wintemute GJ. What You Can Do to Stop Firearm Violence. Ann Intern Med. 2017;167:886–887. 5 Ibid 6 http://www.cmanet.org/issues-and-advocacy/cmas-top-issues/ firearm-violence 7 Ibid 8 Weinberger SE, Hoyt DB, Lawrence HC, III, et al. Firearmrelated injury and death in the United States: A call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162(7):513–6. 9 Wintemute G, Betz ME, Ranney M. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med. 2016;165(3):205–13.

May/June 2018

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

EXECUTIVE DIRECTOR’S MESSAGE

SSVMS/CMA Advocacy Equals Priceless Return on Investment

By Aileen Wetzel, Executive Director

Contact me directly for a free financial impact worksheet that will help you calculate how much CMA’s Modifier 25 advocacy saves your practice.

RECENTLY, A PHYSICIAN asked me to quantify SSVMS/CMA membership dues’ return on investment. CMA’s recent victory against Anthem Blue Cross provides the answer – our advocacy potentially pays for a lifetime of membership dues. This past Fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. CMA quickly jumped into action and coordinated with the American Medical Association and the American Association of Dermatologists, along with many other state and specialty organizations, to push back on the proposed change. In response to the Anthem policy announcement, CMA successfully introduced a resolution to the AMA House of Delegates, asking AMA to “aggressively and immediately advocate through any legal means possible, including direct payer negotiations, regulations, legislation, or litigation, to ensure when an evaluation and management (E&M) code is appropriately reported with a modifier 25, that both the procedure and E&M codes are paid at the nonreduced, allowable payment rate.” The adopted policy paved the way for increased pressure on Anthem to halt implementation of its policy. As the result of organized medicine’s overwhelming opposition, Anthem recently announced they will not proceed with its policy to reduce payments for E&M services reported with modifier 25. Had the policy been allowed to take effect, the financial loss to physicians in multiple specialties would have been staggering.

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Members Only Benefit:

There have been a number of serious concerns raised recently regarding Anthem’s policies on the retrospective denial of payment for emergency room visits, restrictions on advanced imaging in hospital outpatient facilities, and the denial of payment for monitored anesthesia care or general anesthesia for cataract surgery. CMA and SSVMS are aggressively pushing back on these misguided policies. Despite existing California law that prohibits unfair health plan payment practices, many of them continue to circumvent the law. Regulatory agencies have been slow to address provider complaints and have taken few enforcement actions against health plans that unlawfully underpay providers. For this reason, CMA is sponsoring AB 2674 (AguiarCurry) to increase penalties on health plans that engage in unfair payment patterns. The bill would require regulators to investigate provider complaints that a health plan has underpaid or failed to pay the provider as required by state law (under the Knox-Keene Act of 2000). If the regulator finds that a health plan has unlawfully underpaid a provider, AB 2674 would require a penalty amount at least equal the amount of the underpayment plus interest. SSVMS and CMA are on the front lines battling the health plans to ensure patients have access to care and that physicians are reimbursed quickly and appropriately for services provided. The return on investment of SSVMS/ CMA membership dues? Priceless. awetzel@ssvms.org

GUEST EDITORIAL

“Are You Pro-Life?” By Elisabeth Mathew, MD Guest Editorials are welcome, as are comments regarding the editorials themselves. THEN WHY DON’T YOU HONK?” she said. I had just pulled out of the furniture showroom and stopped at the exit from its parking lot to enter Butano Drive on my way home. A lady, carrying a placard that said, “Abolish Abortions, honk if you are Pro-life,” walked over to my front passenger window and asked me this question through the slit between the window and its frame. I thought for a moment and replied. Me: What are you protesting? She: Abortion ... being done at that murderous location there, pointing to a neighboring building. I’m a Christian. I decided I wanted to give her a comprehensive answer to her question and explain why I would not honk. I pulled back into the parking lot, parked and got out of the car, and after cordial introductions with the lady protester, the following conversation ensued. Me: Have you done any follow up on the mother and the baby you saved and found out as to what happened to them? She: Not really. Me: Have you arranged for any child that was opted to be carried to term at your urging, been adopted or cared for by you or any of your church members? She: Not that I know of. Me: Would you kill the doctor and the assistants, if you cannot stop them from continuing to perform abortions? She: Yes. If we have to. It’s a small evil for the greater good. Me: Wow!!! (Taken aback). So, you just want these babies alive and not aborted, but after that, you don’t care? She: Hmm!

Me: What about gun control, stricter gun laws for owners and the banning of all military weapons of war from the streets and daily living? She: I’m for the Constitution. Sad about all the shootings. Me: So you are OK with war? I’m against ALL wars. Peace is much more endearing to me. Negotiations and other nonviolent techniques need to be mastered. She: Oh! Mmm. Me: What about the death penalty? She being silent; I continued. Me: – Euthanasia ... Or doctor-assisted suicides? – Terminating futile medical care continued insistently on a dying or already dead patient/ person? – Preventing suicides, homicides, spousal abuse and child abuse? – Abolishing nuclear weapons and annihilating usage of technology? – Environmental protections ... Clean air? – Banning reckless toxic dumping and fracking? I can go on ... But, I won’t. By the way, not only am I pro-life, I am also pro-choice, but that’s a whole other conversation. So, I am sorry that I cannot honk, as my definition of pro-life includes all that I listed and then some, and I am also pro-choice as there are situations where abortion is indicated and needs to be done. I believe in the freedom of choice; so a woman can choose what she wants to do with her body. She: WOW! Thank you for talking to me, that was interesting and food for thought for me. Me: Good luck with your protest. waterfallsdown2u@gmail.com May/June 2018

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. 5

Do Good and Feel Good By Lindsay Coate, Director of Programs, SSVMS

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

THE RESEARCH IS CLEAR: doing good for others will support your mental and physical wellbeing.1 With more than half of physicians reporting significant professional burnout, the Sierra Sacramento Valley Medical Society (SSVMS) has taken on the task of providing local physicians with tools designed to help providers reclaim the joy in practicing medicine. Last year, we successfully launched the Joy of Medicine program to nurture physician wellbeing through resiliency education, access to life coaches and counselors, and connection with peers. In addition to the Joy of Medicine offerings, volunteering can provide an escape from the pressures that physicians experience through paid positions2 and increase one’s sense of gratitude. SSVMS’ SPIRIT program can provide a fulfilling volunteer pathway for physicians looking to make an impact in the Sacramento Region. For almost 25 years, SSVMS’ Sacramento Physician’s Initiative to Reach out, Innovate and Teach(SPIRIT) program has depended on the generosity of specialty physicians in the Sacramento Region to volunteer their time and expertise to help patients without adequate access to care. SPIRIT volunteer physician, Maryann Johnson, MD with Mercy Medical Group states, “…I am reminded every time that it is a privilege to practice medicine and to give back to those that can’t otherwise afford medical care.” Despite the passage of the Affordable Care Act, many hardworking locals do not have access to health insurance, and therefore, specialty health care. Federally Qualified Healthcare Centers (FQHC) are available to patients without insurance to handle their primary care needs. However, specialty consultations and non-life-threatening surgeries, such as cholecystectomy, hernia or cataract repairs are not available to these patients.

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At right is Barton Bradshaw, MD, with a SPIRIT patient at Sutter Auburn Ambulatory Surgical Center.

Services provided by SPIRIT volunteer physicians can give people back their dignity, allowing them to return to work to lead healthy, productive lives. For example, one patient (a janitor and mother of five children) experienced severe gallbladder pain resulting in five trips to the emergency room over a two-year span. Thankfully, she received a life-changing surgery from SPIRIT volunteer, Dr. Adnan Din at Sutter Elk Grove Surgery Center in 2017 and was able to go back to work pain-free. Stories like these are why physicians continue to donate care to the SPIRIT program. Last year, the SPIRIT program volunteer base grew 61 percent to 91 specialty physicians who wish to provide care to the community’s uninsured. Dr. Yekaterina Axelrod, a neurologist with The Permanente Medical Group, encourages other physicians to consider volunteering with SPIRIT because, “…you don’t have to travel abroad on a mission to rediscover a great mean-

ing of becoming a doctor.” Thanks to specialty physicians like Dr. Axelrod, SPIRIT provides consults to uninsured patients at no cost in dermatology, ear nose and throat, gynecology, pulmonology and urology. There are also volunteer surgeons that will provide consults and outpatient procedures in gastroenterology, ophthalmology, retinal care, orthopedic and general surgery. In 2017, there were over 1,000 patients who received consults, resulting in 57 surgeries performed for over half a million dollars of donated care. SSVMS physician leadership, staff, program partners, patients and community members are all thankful to the physicians who can donate their time and expertise. Volunteer physician, Dr. Ruth Haskins, an OB/ GYN in private practice says it best, “I’ve been enriched by volunteering with SPIRIT because it feeds my spirit and fuels my passion as a volunteer.” Even with the enormous surge of volunteerism this past year, the SPIRIT program still has a large waitlist. If you are interested and want to find more joy in your practice of medicine, SPIRIT patients need access to consultations with allergists, gastroenterologists, neurologists and urologists. If you would like more information about volunteering in general for other SSVMS Community Programs, please contact me. We need you! lcoate@ssvms.org REFERENCES 1 Stukas A, Hoye R, Nicholson M, Brown K, Aisbett L. Motivations to Volunteer and Their Associations with Volunteers’ Well-Being. Nonprofit and Voluntary Sector Quarter. 2016;45 doi: 10.1177/0899764014561122. 2 Mcgeehan L, Takehara MA, Daroszewski. Physicians’ Perceptions of Volunteer Service at Safety-Net Clinics. Perm J. 2017;21. pii: 16-003. doi: 10.7812/TPP/16-003.

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American Women’s Hospitals Service The First 100 Years

By Karen Poirier-Brode, MD THE “WAR TO END ALL WARS,” ironically did not. It did, however, spark an organization known as the American Women’s Hospitals Service (AWHS), which celebrated its 100th anniversary in 2017. During World War I, and most all military engagements, military and civilians have needed medical personnel to tend to casualties of conflict. ‘’The First World War was a horror of gas, industrialised slaughter, fear, and appalling human suffering,” declared Nick Harkaway in the article, “On Poppy Burning,” published in The Huffington Post in 2012. In 1915, a group of 300 female physicians met in New York to hear a lecture presented by Dr. Rosalie Morton about the work of women doctors in the then year-old war. At that time, the United States and allied countries tended to deny medical women any active role in the war effort. The needs in the conflict were tremendous, and attitudes, though not those of

the U.S. military, quickly changed by the time the United States entered the action. Even if opinions had not changed, Dr. Esther Pohl Lovejoy would later write: “Our Government provided for the enlistment of nurses, but not for women physicians. This was a mistake. It is utterly impossible to leave a large number of well-trained women out of a service in which they belong, for the reason that they won’t stay out.” Lovejoy was the founding president of the Medical Women’s International Association. She was a president of the American Medical Women’s Association in its early years and served the AWHS in Europe during World War I and for many decades afterward. Lovejoy’s book, Certain Samaritans, is available on the AMWA website. She details physicians’ experience encountering war, treating grave human pestilences like typhus, smallpox, and influenza, and observing the tragedy of refugees 100 years ago. An American Women’s Hospitals Committee of the Medical Women’s National Association, now AMWA, organized to pursue a twofold mission – “the relief of suffering through medical care and the advancement of women in the medical profession.” The War Services Committee began in 1917 to report on the activities of the work of the medical women during the war. One report featured on the AMWA website indicates that the committee attempted to recruit continued on page 12 May/June 2018

At far left are Rosalie Slaughter Morton and Anne Morgan in 1918. At near left is Mary M. Crawford alongside one of her patients during the First World War.

Reflections on Strangest Medical Complaints Background: Recently, the SSVMS Editorial Committee discussed some unusual patient complaints. We thought it might be interesting for our readers to share a case or two of “The strangest medical complaints I have encountered as a physician, and what was the final diagnosis?”

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.

As a gynecologist, a patient came to the office complaining of a vaginal discharge. She said it “smells like low tide at Pismo Beach.” Diagnosis: Trichomoniasis vaginitis –Douglas Hershey, MD One morning in clinic, the pediatrics department sent up a 4-year-old with a “piece of dirt” stuck on his eye. They were unable to wash it off. Mom said it had been there a couple of days. The eye wasn’t inflamed. When I used the in-office microscope to look at his eye, I told Mom, “That piece of dirt actually has six legs.” Turned out it was a tick adhering to the conjunctiva. After using ointment to basically smother it, it was easily removed with a Q-tip. So much for “a piece of dirt.” –Robert Bellinoff, MD Pheochromocytoma– A 26-year-old man, new to my Walnut Creek general practice, complained he repeatedly vomits a few minutes following running for a BART train. Typically, he would leave the train at the next stop to throw-up in a trash can. He denied headaches and related symptoms. On ultrasound, his otherwise negative abdominal work-up showed a 1 cm ovoid density next to the aorta just above the bifurcation. Exercise test failed to show a change in blood pressure. A 24-hour “evoked” urine, during which period he ran a few blocks, showed elevated levels of catecholamines. His pheochromocytoma was excised at U.C.S.F.

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Elective Unconsciousness– A 45-year-old female arrived by ambulance to my San Joaquin County Hospital emergency department. She appeared unconscious, surrounded by a concerned and frightened large family, a few bottles of pills lain next to her on the gurney. Noticing her eye lids fluttered, I stroked them with a pencil. Her eyelids twitched. I announced to her she was faking and could wake up now to explain how many pills she had taken. Suddenly, she awoke, slapped my hand holding the bottle of pills and stated, ”I can be unconscious if I wanna be!” Exercise is Therapeutic– Summertime, 2 am, Walnut Creek, California. A 25-year-old female was brought to our emergency department for an acute mental health behavioral disorder. During our interview, she suddenly ran out the emergency department exam room, through the hospital door, and across the parking lot. As a young, energetic ER doc, I chased her. Arriving next to her, as we jogged along I asked, “So, where do you want to go?” She stopped running, and we walked back to the ED. –Gerald N. Rogan, MD I got a call at 2:30 AM the day after a breast augmentation surgery that the patient’s breasts were itching. I told her to scratch them and go back to bed. –Terry Zimmerman, MD It was not necessarily a strange complaint, but my partner and I were at the office one Saturday; he seeing patients, me cleaning the fish tank. One of the local FPs called about a rash his patient had. He described it and we both looked at each other in horror; it sounded like it could be meningococcus or worse. We told him to send the patient right over. The patient arrived and we both hurried into the room, looked at the rash and burst

out laughing. It was EXACTLY as he described it and nothing like what we imagined. We had to apologize to the mom for the laughter, but when we explained, she thought it was pretty funny. I don’t remember the dx, but it was very benign. –Jeff Rabinovitz, MD One pleasant summer evening in 1976, I found myself at work in the Adult Medicine Walk-In Clinic at Kaiser Hospital in Hollywood. At that time, we used paper charts. I am sure many of you remember them. Physician’s office notes were almost all handwritten. The charts were bound in flexible cardboard covers, and on the inside of the front cover there was printed a column of numbered lines where clinicians would enter “active” diagnoses. We would dutifully make a Lawrence Weed approved “S.O.A.P.” note for each complaint, and then, if necessary, update the problem list inside the front cover of the chart. My patient appeared to be healthy and he was pleasant. Why are you here this evening?

He said he was very worried because, over the past month or so, he had noticed, when he went out for his daily walk, that he would be rapidly disabled by abdominal pain and watery diarrhea. But he found that, if he wore a hat, no such symptom complex would occur. I wondered briefly (very briefly) if this might be some previously undescribed pineal-colonic interaction. My exam was normal, and a review of his chart revealed stability of lab tests and vital signs, and there were no hints of major psychosocial troubles. And so, I reassured him, urged him to wear his hat on sunny days, wrote a concise “S.O.A.P.” note, and scribbled a new diagnosis on the inside front cover of his chart: “Gets diarrhea when goes out in sun w/o hat.” –Jack Ostrich, MD A man was wheeled urgently into the emergency room. He was lethargic and bluish in color. The persons bringing him to ER reported that he just completed an international flight and looked like this after coming off the plane.

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May/June 2018

They were worried he was having a heart attack. The patient’s O2 sat was 100 percent, heart and lung exam were normal. Closer physical exam revealed that the bluish color rubbed off and his breath smelled of alcohol. The patient slowly became less lethargic. He reported getting drunk

on the plane and sleeping under a blue airline blanket, which rubbed off on him during the flight. Ultimately discharged with recommendations to avoid alcohol when traveling. –Michael Conroy, MD

American Women’s Hospital Services continued from page 9 all 5,000 female physicians in the country to take part with at least one hour per week of war service “gratuitously or for an especially considerate ‘Soldier’s Rate.’” AWHS established a hospital in France in 1918. A brief video documenting the AWHS war efforts, “The American Women’s Hospitals in World War I France: ‘Across Battlefields and into Villages,’” is available on the AMWA website. A 15-minute documentary, “At Home and Over There: American Women Physicians in World War I,” premiered at the Embassy of France, Washington, District of Columbia in November 2017 and was screened at the AMWA 103rd Anniversary Meeting, March 22-25, 2018 in Philadelphia. It is possible to make arrangements to view this production at other venues. World War I may not have ended all wars; however, it provided the impetus for a dedicated group of women physicians who have relieved suffering for over 100 years. AWHS did not confine its activity to war. It remained to serve in postwar Europe and then established clinics worldwide. Despite little public recognition, AWHS soldiers on. It continues its mission

today, both in underserved communities in the United States and in locations abroad such as Haiti, Nepal, Uganda, and the Amazon. You can find an online exhibition of artifacts and stories about the American Women’s Hospitals Service and other ways women physicians found to contribute their skills during World War I at https://www.amwa-doc.org/ourwork/american-womens-hospital-services/. Arrangements to host a screening of “At Home and Over There: American Women Physicians in World War I” may be made by email to wwi@amwa-doc.org. poirierbrodekaren@gmail.com REFERENCES American Women Physicians in World War I Exhibition https://www. amwa-doc.org/wwi-exhibition/, March 12, 2018 American Women’s Hospital Services https://www.amwa-doc.org/ our-work/american-womens-hospital-services/, March 12, 2018 Wikipedia Entry - Gen. George S. Patton’s Speech to the Third Army https://en.wikipedia.org/wiki/George_S._Patton%27s_speech_to_ the_Third_Army, March 12, 2018 Harkaway, N. (2012, November 12). On Poppy Burning http://www. huffingtonpost.co.uk/nick-harkaway/poppy-burning_b_2116037.html, March 16, 2018

CLASSIFIED ADVERTISING PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

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Bad Luck… Good Luck… Bad Luck 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.

DR. OBED HARVEY WAS ON the Central America, a Gold Rush-era ship, when it sank in 1857. Fortunately for the evolution of our region, he did not go down with the ship and its treasure of gold. He was born in New York in 1825 of Scottish ancestry. His grandfather and one of his grandfather’s sons both died on a prison ship during the Revolutionary War. Dr. Harvey studied medicine in New York and then in Illinois, graduating with honors. After two years of practice, he was lured to the land of golden promise and, coming overland, arrived at Hangtown (Placerville) in August 1850, where he practiced medicine until 1869. While in El Dorado County, he was actively involved in politics and was elected to the State Senate for three terms and later to the State Assembly. In 1857, he planned to attend the American Medical Association meeting in the east representing El Dorado County, only the second time that a delegate from California had participated. Dr. Harvey took a ship from San Francisco, the Sonora, to Panama, crossed the Isthmus, then booked passage on the Central America, a prestigious, top-of-the-line side-wheeler that carried 477 passengers and 101 crew members. Mountainous waves and a heavy, hurricaneswept sea swamped the Central America and it went down off Cape Hatteras, near North Carolina, on September 12, 1857. Dr. Harvey stayed with the men to the last, assisting the crew in their desperate effort to get the longboats with the women and children away before the stricken ship went down. Suddenly, the waves crashed mercilessly over

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the deck and washed Dr. Harvey into the water. He struggled to keep afloat. Finding a piece of floating debris, he clung to it desperately for nine long hours. He had almost given up hope, death seeming a certainty, when he saw a distant light that seemed to be moving and coming closer. It was the light in the top rigging of the Ellen, a Norwegian sailing ship. Harvey feared it would pass him by and he called out, but there was no reply. In one last desperate effort, he started swimming toward the light, calling out as he approached the ship. At last, the crew heard his call in the darkness, and the Ellen swung about and soon was alongside the tired and thankful Obed Harvey. He grasped a thrown rope, but his strength gave out and he dropped back into the water. Twice more they tried, but he could not hold the rope. The crew then lowered the ship’s ladder. Dr. Harvey somehow managed to tangle himself in it and was finally raised to safety. Once told of the tragedy, the captain of the Ellen searched the area for survivors and found 49, including Harvey, and took them to New York. The unlucky others, approximately 425 of them, drowned. Upon his arrival in New York, the Medical

Department of the University of New York conferred upon him an honorary degree. His appearance on the floor of the American Medical Association meeting, as the delegate from the State of California, drew a standing ovation from this gathering in Washington, DC. In 1869, he moved to Sacramento County, where he obtained 3,500 acres. He relinquished his medical practice and devoted his time and energy to his large and varied farm interests including dairying, grain, stock, orchards and vineyards. Settlers bought ranches throughout the valley, and large land owners such as Obed Harvey, John McFarland, Andrew Whitaker, and John McCaulley prospered. A portion of John McFarland’s property is now the McFarland Living History Ranch. In 1869, Dr. Obed Harvey was successful in getting the Central Pacific Railroad to lay track near his property. At the time the railroad track was laid there was no town in the immediate area. Liberty was the nearest town. Since it was a mile south, and the railroad didn’t go through, Dr. Harvey saw a need to build a town along the right-of-way of the railroad track. Dr. Harvey built his town according to the laws of 1869, which stated that anyone could create a town by having the area surveyed and selling lots. The Central Pacific surveyors surveyed and laid it out for him. The town needed a name, so John McFarland was given the privilege of naming it after a town in Canada, Galt, Ontario. Mr. McFarland, a successful rancher, was also a builder who built some of the first brick buildings in Galt. One such building is located on the corner of 4th and B streets and is still in use today. Dr. Harvey took an active part in raising funds for the erecting of schools, churches, and the establishing of other improvements in San Joaquin Township. In 1878, he became director of the State Asylum for the Insane in Stockton, and filled many other positions of honor and responsibility prior to his death in 1894, at the age of 69. He is buried at the Sacramento Historic City Cemetery. Making this story even more fascinating, the

The Central America, a Gold Rush-era ship that sank in 1857, was carrying at least 6,000 pounds of gold from California’s gold fields.

Central America was estimated to be carrying at least 6,000 pounds of gold from California’s gold fields. It was salvaged in the 1980s, at a depth of 8,000 feet. One coin was valued at $100,000 and one gold bar sold for $8 million. And, the story is still in the news. An article in The Sacramento Bee from January 30 of this year referred to the 3,100 gold coins, 45 gold bars and more than 80 pounds of gold dust with an estimated value of at least $50 million. The sinking and loss of so much gold caused an economic panic at the time. Still, today, the ship’s bad luck persists. According to The Bee, the investors in the recovery never received proceeds from the original sale of much of the gold, and the treasure hunter who located the ship is in jail. You can personally share in the excitement of the Central America. The story is extremely well described in the book, Ship of Gold in the Deep Blue Sea. The first part of the book describes the ship and its sinking; the second part details the recovery of the treasure. A beautiful coffee table book entitled America’s Lost Treasure was also published in 1998. ssvmsedcom@gmail.com REFERENCES https://en.wikipedia.org/wiki/SS_Central_America https://commons.wikimedia.org/wiki/File:Wreck_of_the_Central_ America.jpg Gold treasure from sunken ship gets its moment in the sun, Sacramento Bee, 2018-01-30 http://www.columbia.edu/~dj114/SS_Central_America.pdf https://www.findagrave.com/memorial/110505453 https://www.pcgs.com/news/bob-evans-chief-scientist-of-ss-centralamerica-ship-of-gold-coin-project https://www.pcgs.com/shipofgold

May/June 2018

Our Tour of Cuba By Gerald Rogan, MD Con los pobres de la tierra Quiero yo mi suerte echar: El arroyo de la sierra Me complace más que el mar. With the poor of the earth I want my luck to cast: The streams of the mountains It pleases me more than the sea Excerpt from the song “Guantanamera” developed from the poems of José Martí.

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.

DURING FEBRUARY 2018, our tour group of 24, mostly from Sacramento, visited members of Cuban synagogues as part of a people-topeople cultural and gift exchange. Our tour guide was Ileana Sarria of Havana, a lawyer and single mom who speaks fluent English. She explained Cuba’s history and current status while showing us many of its sites. Eleven million people live in Cuba, including about 1,100 Jews (one-hundredth of 1 percent). Jews arrived with Columbus in 1492, the same year the Catholic rulers of Spain expelled them. Shortly after the Spanish arrived in Cuba, all the indigenous people died, mostly of smallpox and other European infectious diseases. Under Spanish rule, its capital city, Havana, strategically located near the Gulf Stream and with a defendable harbor, became Spain’s major port to transship gold from its South American colonies. Local production focused on tobacco and sugar cane. African slaves provided the labor, supplanted by Chinese males after Spain abolished slavery in 1888. The U.S. helped Cuba and Puerto Rico gain independence from Spain via the SpanishAmerican War in 1898, which was promoted

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to the public using fake news and yellow journalism. Defeating Spain, we took control of Cuba and Puerto Rico. Cuba became an independent country while Puerto Rico remains a U.S. protectorate. Starting out as a democracy, but with an 85 percent illiterate population without skills in self-governance, Cuba became dominated by dictators. During the 1950s, supported by criminals, Cuban President Fulgencio Batista y Zaldívar (1901–1973) developed hotels, roads, and factories. But most Cubans remained destitute. After the success of the 1959 revolution, the new government of Cuba became communist and expropriated most private property without compensation, except for a kosher butcher shop. Most of the Cuban business class emigrated with understandable bitterness. The U.S. government forbade U.S. commerce with Cuba and attempted to defeat the new Cuban government. Cuba received economic support from the Soviet Union. When the Soviet Union collapsed in 1991, Cuba lost its financial subsidy. Electricity was not available at night. Sarria could not sleep without air conditioning. She decided to study English at night so her economic life could improve. Beginning in 2000, Venezuela has provided Cuba with low-price oil in exchange for Cuban physician and other services. Cuba sold half for foreign exchange. Petroleum shipments peaked in 2008 and are steadily declining. Now Cuba must ration its energy. The poet and revolutionary José Martí, (1853–1895) inspired Cuba’s independence. He wrote the words which became the song “Guantanamera.” He is revered today as the father of Cuban independence. Public monuments honor revolutionary heroes: Fidel

Castro (1926–2016), Raul Castro (b. 1931), Camilo Cienfuegos Gorriarán (1932–1959), and Dr. Ernesto (Che) Guevarra (1928–1967). The Museum of the Revolution in downtown Havana, converted from the former Presidential Palace, documents the efforts of the CIA to assassinate Fidel Castro, invade the country, and poison Cuba’s economy during the 1960s. Today the Cuban people are a rainbow of skin colors: a mixture of genes mostly from West Africa, Iberia, and East Asia. Sarria says Cubans are without racism. Cuba’s society is reported to be egalitarian – all are equally poor. Extreme wealth, such as we find in corporate America and in managers of other people’s money, is contrary to the Cuban government’s philosophy. Cubans are encouraged to report wealth outliers to the government. Physicians may not own their medical practices. Home ownership is limited to two houses. Private restaurants may serve no more than 60 people concurrently. Cars are too expensive to import, but family members may transfer vintage automobiles (e.g., 1957–58). Taxicabs are private businesses. The internet works. Cell phones work. Credit cards are not allowed. The Cuban government provides education, health care, food staples, and school childrens’ uniforms at no charge. Public transportation is

cheap because of government subsidies. Medical school is free. Martí would be pleased that poor people in Cuba are no longer economic slaves of a wealthy class. We stayed in one of the best hotels in Havana. A block away a sewer overflows. Trash is everywhere. Most of the 1950s’ era buildings show 59 years of deferred maintenance. Many buildings have no windows or doors. Plaster has fallen off facades. Nonetheless, Cuba is a fun place to visit. People are friendly, and the public spaces appear safe. The music and dance carry rhythms and moves native to sub-Saharan Africa. For foreign exchange, one can take U.S. dollars to Cuba, exchange them for Cuban convertible pesos (CUC$) for a 10 percent tax paid to the Cuban government. Expatriate Cubans may send U.S. dollars to their Cuban relatives. Raul Castro plans to retire in 2018. His retirement may allow Cubans the freedom to reconsider how much more free enterprise to permit in exchange for the greater risk of creating a wealthier class of entrepreneurs. Those whose property was stolen after the Revolution might receive some compensation for their losses if Cuba becomes more prosperous than it is now. Maybe then the U.S. and Cuban governments will be able to work together for the benefit of all concerned. jerryroganmd@sbcglobal.net

May/June 2018

Above, a market vendor offers handmade items for sale. Below is the Riviera Hotel in Havana, and behind author Gerald Rogan, MD, is a likeness of Dr. Ernesto (Che) Guevarra.

Exotic Fruits – Nutrition Trove or Hype? By Ann Gerhardt, MD

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

RAMBUTAN LOOKS LIKE AN alien’s egg that might hatch and kill us all. While on a cycling trip around Hawaii’s Big Island, I encountered the fruit and discovered that even its white, pulpy flesh is creepy. Why would one eat it, except out of adventure? With no obvious vitamin content, nutrition is no motivator. Should we should just take a picture and devour a banana? Until the nutrition community, and subsequently the rest of the population, woke up to the notion that plant foods contain healthy polyphenols, vegetables like iceberg lettuce and celery didn’t get much respect. A list of celery’s nutritional content, were it to have a label, looks bleak. A whole stalk has essentially no fat, minerals or protein and only 2-3 percent of the Daily Value recommended for Vitamins A and C. By these standards, iceberg lettuce is even more useless. That changed when scientists identified plant foods’ polyphenolic health value. Vegetables like celery, containing flavonols, flavones, dihydrostilbenoids, phenolic acids, phytosterols and furanocoumarins, suddenly became healthy. Those unhealthy-sounding chemicals give the plant, and those of us who eat them, an anti-oxidant, anti-inflammatory and possibly anti-tumor and anti-bacterial boost. Some exotic/tropical fruits lack well-known nutrients, as seen in the Table, but internet websites often tout them as wonder foods. Miraculous health claims often derive from traditional herbal medicine and may or may not be justified. Doing the science to identify plant foods’ chemical components which confer health benefits takes much longer than does

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making a health claim based on anecdotal cause and effect. Science hasn’t necessarily analyzed the phytochemical content of every fruit to the same extent. What follows, therefore, probably woefully underreports the nutritional content of these fruits. Guava reigns as queen in recognizable nutrients. It also is a rich source of healthy carotenoids, anthocyanins and flavanols, and supplies moderate amounts of folate, magnesium and manganese. The juice has much less nutritional value than whole fruit but would at least retain the water-soluble vitamins. Mangos supply a veritable treasure trove of phytochemicals – carotenoids, catechins, tannins, terpenes, flavonoids, alkaloids and phenols. It’s unclear to me if we’ve found more of these nutrients in mango because it’s better studied or because nature actually packed it with more of them. Papaya contains considerable quantities of magnesium, folate, carotenoids, isothiocyanates, alkaloids and tannins. Kiwi fruit is rich in folate and anti-oxidant flavones and flavonols. Starfruit has a measurable amount of pantothenic acid (Vitamin B5), copper and potassium. It also contains beneficial flavonoids, alkaloids and phenols. As a rich source of oxalates, people with kidney stones should avoid it, which is not hard to do in the mainland U.S. It also potently inhibits the liver’s metabolism of medications and some chemicals, which might seriously change drug levels in the body of someone addicted to starfruit. The inhibition is even greater than that of grapefruit, which we routinely advise against for patients taking affected medications.

Passion fruit, which contains carotenoids, theobromine, alkaloids, flavones and a coumarin, might also affect drug metabolism. The alkaloids inhibit monoamine oxidase, important for metabolism of some anti-depressants and catecholamines like epinephrine. Theobromine and coumarin have medicinal effects that are likely insignificant unless one develops a passion for passion fruit. The edible part of purple mangosteen contains xanthones, tanins and catechins. In the early 2000s, purveyors of its juice made a lot of money after creating a mangosteen fad. Read my 2006 analysis of it at www.healthychoicesformindandbody.org/Medisense_Articles/06126Mangosteen_Mania.pdf. In addition to potassium and Vitamins C and B6, jackfruit supplies useful amounts of magnesium, manganese and carotenoids. Breadfruit contains anti-microbial phenols, but it’s not clear that they would be absorbed intact and exert an anti-microbial effect in a human body. Lychee and longan are related to rambutan. Lychee contains epicatechin (a polyphenol tannin like in tea), rutin (a flavonoid) and

some copper. Longan is either too obscure for anyone to analyze or it truly has no nutritional benefit. Though it has zero nutrients in a standard nutrition table, that hasn’t kept various websites from touting its “amazing benefits.” It’s hard to find accurate information about rambutan’s nutritional content. The pulp contains fruit sugar and the hairy skin contains some polyphenolic antioxidants, Vitamin C and fiber, but it’s too hard for most people to eat. Scientists probably haven’t fully analyzed rambutan’s phytochemical content, leaving an information void and no justification for claims of wondrous cancer-preventing, antiseptic, heart healthy and weight controlling properties. In my mind, only curiosity would drive consumption. So, we’d do well with apples, rich in a variety of bioflavonoids, and citrus fruits, rich in Vitamin C, but wouldn’t that be boring?

Rambutan’s pulp contains fruit sugar and the hairy skin contains some polyphenolic antioxidants, Vitamin C and fiber, but it’s too hard for most people to eat.

algerhardt@sbcglobal.net

May/June 2018

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Chance Encounter By Stephen L. Mandaro, MD PRACTICING MEDICINE AS a general practitioner in this day and age is often pretty routine. Situations occur once or twice a day that are out of the ordinary, but every so often a chance encounter can occur that is truly extraordinary and may be, as in this case, oncein-a-lifetime. It was springtime in 1992, and I was on weekend call. Saturday morning was pretty routine. I was taking care of some things around the house, and in late morning, I received a call from a local nursing home that was covered by our group practice. The nurse on the phone asked, “Can you prescribe some cough medicine for Doctor Smith as she has a dry cough.” I thought to myself that I thought she said “doctor” and then I asked her, “Did you say Doctor Smith?” She replied, “Yes.” She then went on to say, “Oh! Don’t you know Doctor Smith?” I said, “No I don’t know her. Tell me about her. What kind of doctor is she?” The nurse went on to explain: “Oh, she was a general practitioner who practiced in the South area for many years. She’s been a patient at the nursing home a couple of years, and she was rescued from the Titanic when she was a little girl.” I paused and thought for a second, then said, “Excuse me, did you say she was rescued from the Titanic?” She replied, “Yes Doctor.” I thought again for a few seconds, not believing what I was hearing, and I the replied, “I’m coming down to see her.” I headed to the nursing home and was in Doctor Smith’s room within 15 minutes. I introduced myself as a doctor on call and verified that she was Doctor Smith. Let me simply describe her as a pleasant, thin, elderly woman lying upright in bed, who was very gracious and most cooperative in answering any of my questions. I examined her and ordered the cough

medicine. I referenced the fact the nurse told me she had been rescued from the Titanic when she was a child, and she immediately began to recount her memories. She told me she was 5 at the time. Her chart said she was born in 1907, which immediately told me she would have been 5, and old enough to recount some memories of such a frightening event. To digress a moment, the RMS Titanic was a British passenger ocean liner that sank in 1912 on her maiden voyage while traveling from Southampton, England to New York City. The ship, while traversing the North Atlantic on April 14, 1912 collided with an iceberg causing the sinking of the ship and a loss of more than 1,500 people in one of the deadliest peacetime maritime disasters in modern history. Doctor Smith gave details of the events of that night with such clarity that I was convinced she was a survivor of the Titanic disaster, and here she was, sitting in front me, and I could speak with her. According to her, her parents were both professors at the University of Kansas. Her father was from Britain and her mother was American. They were on holiday visiting her father’s family in England. Only she and her mother were on the Titanic voyage, as her father stayed an extra week to spend time with his family.

Below, the RMS Titanic heads out to sea.

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. May/June 2018

She recalled the chaos that night on the ship as something was drastically wrong. There were people running about, loading lifeboats and the crew was assisting passengers. She remembered wearing a life vest, being very cold and the horrors of loud screams from people floundering about in and out of the water. She remembered subsequent silence while the life boat floated away. She remembered being rescued by a ship with her mother, and she also remembered how happy she was to be home in Kansas and reuniting with her father some time later.

Doctor Smith later graduated from the University of Kansas Medical School and moved to Sacramento in the early 1950s to begin a career in medicine as a general practitioner. She retired in the early 80s and led an active life. I subsequently visited her a couple of times at the nursing home, and with each visit she was as gracious as the last. The chance encounter with her will be a memory I will always cherish. It certainly turned a routine weekend into something special. smandaro@comcast.net

Where Did Time Go? By Caroline Giroux, MD Potatoes to peel over spilled milk Laundry to fold in the spring breeze Runny noses to wipe Falls and scratches to prevent Where did the day go? Sweat and sighs over homework Endless streets crossed hand in hand New clothes, pants already outgrown Repaired friendships at the playground Where did the week go? Celebrations, too much fun leading to disaster Leg in traction at the hospital Lonely nights, in a room that smells of bleach Tears of solitude, no one can hear Where did the month go? Resisting bullies at recess Becoming wiser and stronger What do I want to do with my life First love, first heart bleed… Where did the year go? Bills to pay, boundaries to set Power to assert, wounds to hide Work life, love life, And everything else between the two Where did mid-life crisis go?

Looking back Holding your breath, staying still Just to play a trick on this body betraying you It hurts to move, to make a step forward. Where did my life go? No more new beginnings, or spirited flavors, oh! so vivid Now days look more and more like night Company sounds like a monastery Clock secrets jealously kept, unrevealed Where did all the time go… In your fossilized hopes and dreams They inhabit you, still today Just as they did the day you held your diploma Or your wonderful, screaming, bloody newborn There is no other way to live Than the way you just do now Others, those new wonderers, are waiting for you To tell your stories and defy time Time, really Hasn’t escaped through your youthful folly You were able to catch it everyday As it offered itself to you, ever faithfully You can be thankful for your life No matter which suitcases were lost in the way You can still live life Even with this pain, the sign you still exist, at least another day cgiroux@ucdavis.edu

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The Intangible Sought After By Caroline Giroux, MD “ES-TU HEUREUSE?” I remember distinctly the dreaded question (are you happy?), as I was studying for the American licensing exam some 15 years ago. It led to a very unpleasant, not to say irritated, feeling from being interrogated on this very taboo subject by a person who had seemed so far removed from such a reality. Happiness was this cruel concept that I thought was reserved to a lucky few, and to feel happy, I always had to work extra hard at it before achieving such an outcome, to prove to the world that I deserved it. Conversely, any phase of unhappiness made me feel like a failure. To be with my fiancé, I had to take this additional exam, to expand my possibilities in a country where he was going to medical school, and I could only perceive, behind my mother’s fateful question, her palpable reluctance of seeing me migrate, echoing my own apprehension. I felt terrified about living in this neighbor country, where medieval practices such as capital punishment were still in place, where racial tensions were rampant, where guns were featured in the weekly advertisement leaflets, where consumerism made me nauseated just thinking about it. This land of exile didn’t exactly represent a fertile ground for enchantment. When Nan, our managing editor, asked if I could write about a happiness-related topic, a similar hint of reluctance cohabited with my sincere desire to explore this issue for her.

I tended to be suspicious of people who claimed to be “happy”… I don’t think I emulated Zen as a child or even young adult. Perhaps out of loyalty for my mother who was deeply affected by a divorce, I deserted my own emotions because hers

were already too painful to witness. I thought this had scarred me forever and through some irrational belief, I couldn’t believe I had the right to be happier than my mother. Ever. So I pushed away this notion of happiness and gave it other names: love, fulfillment, spirituality. An obsession at best, I was unable to consider happiness as a valid framework. In fact, I tended to be suspicious of people who claimed to be “happy,” thinking “What’s wrong with them?” For happiness is gone the minute you realize your state of bliss. As a psychiatrist, I was very soon confronted with this pursuit, often futile, in people who are looking for a happy pill, or quick fix to their torments. Ironically, years ago I was offered the project of developing a module on mood disorders for the medical students, and I felt once again terrified by what I had been trying to avoid: my own recurrent unhappiness. Because, even though I answered “yes” to my mother back then to avoid another tirade of inquiries, I knew, deep down, that it was much more complicated than DSM codes. Happiness couldn’t be determined based on a binary approach or some emoji chart. Nonetheless, looking more closely at spectacular mood experiences provided me with a good distraction. It forced me to view emotional states on a spectrum, to read about famous people’s own torments, and to take another look at my ghosts from a distance. Eventually, a dissection of melancholia gave me an opportunity to exorcise my own avoidance. Going against the current of dismissal of my pain, ignoring my surroundings’ pressure to feel happy, I paid close attention to the load of concrete landing on my stomach whenever I experienced a sense of alienation. I started to connect body sensations to my blues to decode the mechanisms leading to unhappiness in the May/June 2018

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. 23

Happiness doesn’t mean constant joy but rather aliveness, or the complex co-existence of sometimes contradictory emotions…

hope of outsmarting them. I discovered that regular mindfulness practices are effective in increasing wellbeing. To better understand happiness, we also must question some common pervasive myths: “Sadness means unhappy.” Sadness has been equated with depression, while, in fact, depressed people are often unable to experience emotions. They lose this sense of aliveness, they feel they barely exist. Looking back, I realize I was happy even during times I was deeply nostalgic: at six years old, crying myself to sleep because I missed a boy named Karl who lived two hours away and who instantly became my soul mate that summer when I visited my aunt. The year I got married, I experienced deep gratitude (and sorrow) listening to my beloved and terminally ill grand-papa Georges-Etienne sing at the big dining room table a beautiful song as he was expressing he was going to miss us. I was elated (and frightened) to connect with my husband, an amazing birth partner, every time my “origin of the world” ejected a quintessential screaming boy who landed in my arms. Happiness doesn’t mean constant joy but rather aliveness, or the complex co-existence of sometimes contradictory emotions, yet culminating in a sense of deep serenity. “Happiness is pleasure.” Although senses (or some kind of perception) play a significant role in happiness, it is the intersection between pleasure and meaning that creates the most optimal “happiness quotient.” The notion of happiness has been distorted by the industry: a specific brand of clothing, car, or anti-aging cream won’t lead to happiness, but an illusion, or a very transient high. We also live in a culture that creates a pressure to be happy. But it seems more realistic to embrace a life full of meaning. Then, happiness often ensues. Happiness is not like a bank account: it is not about the accumulation of stuff, experiences, etc. “The best things in life are not things,” wrote American humorist and columnist Art Buchwald. A minimalist lifestyle teaches us to find luxury in new places. While studying for exams, joy had become the sacred meal, the

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winter Olympics on TV or the delightful shower between two half-days of intensive textbook reading. I experience wonder when I taste a silent morning to watch the sunrise, or when I find a picture of a memorable trip hidden in the pages of a beloved book. Connection with nature, exercise and socialization are pillars of well-being. A book caught my attention as it talked about sustainable living and mentioned enoughness.1 What a beautiful word! Why not be content with a “happy enough” life, just like the concept of “good enough parent” is all a child needs. And true happiness cannot be a self-centered quest, nor can it happen in isolation or at the expense of others. Think about the greediest person you know, and there is no way this person is genuinely happy. Plus, the chances are that such a person wastes resources and, in doing so, deprives others of basic goods. Craving for material items or status is never going to satisfy a person. It is enslavement. I cringe when I hear patients admitting they spend their days going to their medical appointments or watching TV (screens seem to be afflicted by the same obesity epidemic, getting bigger and bigger, as a mirror image of the effects of sedentary lifestyle or dystopian feedback mechanism). But a sense of purpose beyond life maintenance chores is essential to living well and fully. People who look at the days being wasted are waiting to die. And this is not happiness. This is not sustainable either. I prescribe an activity, anything not harmful that makes them want to get out of bed every day. And I praise those who do this naturally. I have a patient with a jocular personality who is quite gifted for happiness, and he strives to put a smile on every person’s face he meets by complimenting, offering assistance or cracking jokes. Happiness, like love, can’t be chased, but it can be found… in an unexpected invitation to lunch, in a poem like “Song of Childhood,” in a friend’s comforting words at the right time, in a little hand in mine as I walk with my children. Then, it is up to us to cultivate it. With trial and error, we learn to accept less blissful moments,

transcend them, and stay away from toxicity. Once I understood I was the designer of my own life, I experienced more satisfaction and less time to wonder, “Is that it? Is that what life is about?” Leaving a positive legacy has become a goal, canceling that type of question while causing happiness as a side effect. Today, I am better able to take responsibility for my happiness, by removing the obstacles that prevent me from seeing it. I can often say I am “happy enough.” The fact that I can talk about it more openly probably means that I am also less threatened by its occasional absence. With time, we know ourselves better, and we also become more of ourselves, therefore getting closer and closer to the intangible sought after. The beauty of aging, I guess!

I truly believe there is a strong,

be totally myself, with only kindness as a filter. I am blessed with so many friends and colleagues in a country I never thought I would come to appreciate. If we pause, practice mindfulness, and embrace even the sorrows, this voice can have some room. It can indicate a path to a happier living. Even if we can’t fully grasp happiness, most of us can know to a certain degree when we see it. When I read the Valentine’s day message Nan received from her husband Bob, who is in hospice in this phase of their life where they still try to meet while keeping regrets at bay, I can’t help but think it is shared happiness right there, no specific formula needed. I am pretty sure they pay attention to their inner whisper every day, live the present to the fullest and choose happiness over everything else. What a liberating feeling it is to see each new day as a bonus full of opportunities.

insistent whisper in each of us that we often spend a lifetime to ignore… The answer or recipe doesn’t lie in books, even if I read a few philosophers and inspirational self-help books. I truly believe there is a strong, insistent whisper in each of us that we often spend a lifetime to ignore, for the sake of approval, of external forces that do not even care about our happiness. Listening to this attuned murmur connects us to our true self, the guardian of our potential to experience joy. The lack of pressure from a sadistic superego allows a more spontaneous life, filled with joy and acceptance of what is. Children and people with intellectual disabilities seem to be more prone to joy, probably because they are not succumbing to the torturing to-dos that come with a life of algorithms and multilayered responsibilities. My voice has always told me to dream, work with the passion of my heart, become a mother, create, travel and write. My choices led me to that. My voice always applauds when I press pause on the scenario of my life to have passionate conversations with friends who validate my “right” for happiness. Healthy relationships are the ones where I am allowed to

cgiroux@ucdavis.edu REFERENCE 1 Sarah van Gelder and the staff of Yes! Magazine. Sustainable happiness: live simply, live well, make a difference. BerrettKoehler Publishers, Inc. Oakland, CA. 2014

May/June 2018

Tuberculosis By Matthew Huh Editor’s/SSVMS Museum Curator’s note: This is the third article in a series by Mira Loma High School student Matthew Huh, featuring diseases that were common and often fatal at the time of the inception of our Medical Society in 1868. Many people, including physicians, came from the east to California because our weather was more favorable for patients with tuberculosis. One estimate showed one-third of those coming to California came for their health. Fresh air and altitude were common components of treatment. In the early to mid-20th century, several TB sanitariums were located near Sacramento, including Colfax and Weimar.

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.

TUBERCULOSIS (TB), a very ancient malady, has been identified in skeletal remains as far back as the Neolithic period and in Egyptian mummies. During the Neolithic period (10,0007000 BC), humans first discovered agriculture and the domestication of cattle. Because TB has not been found in remains prior to this, scientists believe that the TB bacteria originated in elephants (approximately 2000 BC) and then moved to cows, and then finally jumping to humans during domestication of cattle. TB is a disease caused by the bacterium Mycobacterium tuberculosis. TB can either be active or latent. More than one-fourth of the world population is estimated to have latent TB, which means they are infected but do not show any type of symptoms or spread it to others. Alternatively, active TB can affect different parts of the body. The most common type of TB is pulmonary TB (affecting the lungs). This type causes severe coughing and chest pain while TB, in general, causes weakness, weight loss, chills, and fevers. TB was first known as “phthisis” by Hippocrates, which means “decaying” in Greek. Much later in the middle ages, phthisis came to be known as the “King’s Evil” because it

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was said that scrofula, glandular swellings in the neck associated with TB, could only be healed by the “royal touch,” a power gifted by God only to kings. Since the 5th century, certain kings of Britain and France even set up ceremonies in which infected peasants could get this royal cure. This practice continued for centuries until 1825 when monarch Charles X stopped the ceremony. By this point, the name of TB changed from phthisis to Consumption, to describe “the wasting away.” The mortality rate of Consumption was very high. Rene Dubos, a 20th century microbiologist who studied this “Great White Plague,” asserts that in the 18th century more than 40 percent of deaths in London were primarily due to this disease. Mortality rates improved somewhat in the next century. Dr. Austin Flint, in his treatise published in 1865, wrote “Statistics show that of the population of England, France, Germany, and Russia, amounting to 230 million, the annual deaths from this disease are 869,000; and that of the people inhabiting the globe, amounting to 968 million, 3 million die each year with this disease.” German professor of medicine, J.L Schönlein, studied patients with TB and later renamed the disease from Consumption to Tuberculosis, because of the tubercles, lesions in the lungs or other tissues, which he found to be a characteristic sign of TB. In 1882, Dr. Robert Koch, a German physician and microbiologist, definitively proved that Mycobacterium tuberculosis was the cause for TB. He is considered the founder of modern bacteriology. In 1890, Koch presented a substance he named Tuberculin, which was supposedly the cure for TB, to the Tenth International Congress of Medicine. This was a glycerin extraction from Mycobacterium tuberculosis. However, this was seen as a great scandal by Koch in an

attempt to get money as it did not treat TB as he claimed. However, Koch’s substance was not a total failure. Another 19th century physician, J.A. Villemin, proposed a theory that bovine TB and human TB strains were essentially the same. This theory, paired with Koch’s Tuberculin, led to Albert Calmette and Jean Guerin (of the Pasteur Institute), producing a vaccine for TB in 1906. This was named the BCG vaccine (Bacilli-Calmette-Guerin) and was first used to vaccinate calves. Two decades later in 1924, its use was extended to humans. The first large application of the BCG vaccine was in 1928 when 116,000 French children received it. Definitive treatment of Consumption during and before the 19th century was widely unknown and false treatments like leeches, radon, alcoholic beverages, and even heroin were suggested. Another, more dangerous, treatment was to inject silver nitrate into the lungs through the larynx and trachea, as silver exhibits antimicrobial properties. In the early 1800s, an English physician, James Carson, injected air into the pleural cavity to collapse the lung in hopes of “healing the lung.” Other surgeons also did a procedure to collapse the chest wall, fill the pleural cavity with inert material like ping pong balls, and raise the diaphragm by crushing the phrenic nerve. Sanatoriums or sanitariums, where patients were exposed to trees, fresh air and good nutrition came into fashion for a short while. The

discovery of penicillin led to the discovery of Streptomycin and in 1944, the first patient was treated with it with dramatic results. Like other bacteria, TB has become more and more resistant to the antibiotics that are used. In non-resistant strains of TB, there are currently multiple antibiotics which are usable to treat it, the two most potent being Isoniazid and Rifampicin. Strains of TB called MDR TB (multi-drug resistant TB) and XDR TB (extensively drug-resistant TB) which are resistant to both Isoniazid and Rifampicin are becoming extremely problematic. March 24th marked the annual World TB Day which celebrated the anniversary of when Koch discovered the relationship between the TB bacteria and the disease.

At left is a pneumothorax device from our Museum of Medical History that was used to inject air and collapse a lung. At right are children who were patients at the old Weimar sanitarium.

matthewdhuh@yahoo.com REFERENCES Cooper, Joel D, et al. Pearson’s Thoracic & Esophageal Surgery. Edited by F. Griffith Pearson, 3rd ed., vol. 1, Churchill Livingstone/ Elsevier, 2008. Flint, Austin. A Treatise on the Principles and Practices of Medicine. 4th ed., Henry C. Lea, 1873. Kang, Lydia, and Nate Pedersen. Quackery: a Brief History of the Worst Ways to Cure Everything. Workman Publishing, 2017. Kennedy, Michael. A Brief History of Disease, Science, and Medicine: from the Ice Age to the Genome Project. Asklepiad Press, 2010. Strumpell, Adolf von, et al. A Text-Book of Medicine for Students and Practitioners. D. Appleton, 1892. “Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Feb. 2018, www. cdc.gov/tb/default.htm.

May/June 2018

Snake Oil and the Placebo Effect Sometimes the worst cures can heal us.

By Kent Perryman, Ph.D. SNAKE OIL IS USUALLY associated with quackery, which is defined as the practice and promotion of intentionally fraudulent medical treatments that have no merit. The term “quack” comes from the Dutch “kwakzalver,” or “quacksalver,” meaning “hawker of salve.” During the middle ages the term came to mean “shouting” the sale of wares at the marketplace. It is possible that some of these fraudulent medicines and practices had therapeutic efficacy due to the powerful placebo effect as noted today in some scientifically controlled studies.

Patent Medicine Quackery

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.

During the 1893 Chicago Columbian Exposition, a pitchman by the name of Clark Stanley began promoting what would turn out to be a financial boom for him. Clark was boosting an elixir he claimed would remedy any number of maladies including sciatica, lumbago, gout and rheumatism. This concoction consisted mostly of mineral oil, beef fat, red pepper and turpentine with a little oil from a boiled rattlesnake: Hence, the trademark “Clark Stanley’s Snake Oil Liniment.” During the construction of the transcontinental railroad, the Chinese immigrants brought with them their own snake oil made from Chinese water snakes, a popular topical ointment for relieving muscle aches associated with hard labor. The Chinese version, which contained omega-3 fatty acids, turned out to be an effective anti-inflammatory until they resorted to using American rattlesnakes rather

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than water snakes. (Clark’s remedy was eventually removed from the market by the Pure Food and Drug Act in 1906.) We only have to look back over the course of medical history to see the many liniments, tonics, nostrums, bitters and elixirs believed to cure many maladies. “Believe” was the key. Quack medicines were prevalent in the British Empire prior to the American Revolution, at which time they were eventually adopted as patent medicines and herbal cures. Mark Benvenuto, a chemist at the University of Detroit Mercy in the 1950s, analyzed many of the 19th century patent medicines and found them to contain some medically-beneficial ingredients, such as calcium and zinc, in addition to vegetable compounds. Lydia E. Pinkham’s vegetable compound was one of the more popular patient medicines of the 19th century marketed as an herbal remedy for female complaints. This trusted medicine contained no Calomel (mercury) found in other remedies. Paine’s celery compound contained 19.8 percent alcohol and was considered to be a digestive aid as well as a laxative. Carter’s Little Liver Pills, successfully sold up until the 1950s, contained bisacodyl, while Ayer’s sugar-coated cathartic pills were made from a vegetable compound. Sarsaparilla, marketed by both Ayer’s and Hoods, and containing alcohol, dandelions and juniper berries, was a popular patent medicine, and Sarsaparilla was also a popular type of root beer in the Southern United States where it was

made from a blend of birch oil and sassafras (the dried root bark of a sassafras tree). However, Ayer’s Cherry Pectoral, concocted by Dr. James C. Ayer in the 1840s, was not so benign. Products marketed for children and containing opium could be fatal. Both Dr. Wistar’s Balsam of Wild Cherry, used to cure coughs, and Mrs. Winlow’s Soothing Syrup for teething infants also contained opiates. The easy availability probably resulted in self-dosing and, combined with high alcohol and opiate levels, these were not some of the benign patent medicines. The incredible power of the human desire to live drove consumers to believe these treatments may cure them. However, up until the execution of the 1906 Pure Food and Drug Act, there were no limitations on the recommending of patent medicines containing elements like mercury, antimony and arsenic, as well as ingredients derived from plants such as opiates, strychnine, tobacco and alcohol. This act was subsequently repealed in 1911, only to be reinstated the following year by the Sherley Amendment which prohibited labeling medicines with false therapeutic claims intended to defraud the public. Several years later, Congress passed the Harrison Narcotic Act which imposed limits on narcotics available to the consumer, and required a prescription for medicines exceeding these limits. Many of these early “patent” therapies were employed as emetics and cathartics to balance the humors by purging disease processes from the body. The “patent” did not refer to any government approval, but rather to proprietary concoctions. If they were actually patented, the manufacturer would have needed to reveal the ingredients.

lution of the 1880s when much of Europe and the United States were converting to electricity for their domestic lighting, communications, heating and industrial needs. Very little was understood at the time of the relationship between electricity and medicine. Our country was undergoing a revolutionary transition from a rural agricultural and cottage industry economy to an urban, factory-oriented manufacturing nation. This change in lifestyle led to long, strenuous hours of labor that many were not accustomed to. One of the purported health benefits of these electrical instruments was their restorative virtues. The late 19th century physician, George Miller Beard, developed the bogus medical theory of “neurasthenia,” proposing that the body had a fixed amount of energy in one’s lifetime that could be depleted by things such as educational demands and urbanization. He believed there was an epidemic of “wasting” disease associated with the industrial revolution during the late 19th and early 20th century. Many entrepreneurs realized the opportunity to develop and promote fraudulent electrical devices that they claimed could provide the needed energy to sustain the demands of the

At left is a Violet Ray Generator, sometimes called an “ultra violet device.” These devices claimed to cure just about everything including heart disease, paralysis, wry neck and writers cramp. At right is an ad for Lydia E. Pinkham’s Vegatable Compound. Besides the five herbs in it, the formula also contained drinking alcohol.

Electrotherapeutic Quackery During the 19th century, patient medicines were not the only fraudulent means employed to heal the ailing public. Electrical cures were being developed during the second industrial revo-

May/June 2018

The first documented use of a placebo effect dates back to 16th century Europe when the Catholic Church employed false holy objects to discredit demonic possession.

factory employees after long, strenuous, 12-hour work shifts. The early medical quackery instruments marketed in the late 19th century relied on hand-turned electro-magnetos to produce intermittent shocks, and galvanic cells (wet cell batteries) for direct current stimulation. Later, in the early part of the 20th century when homes were being electrified, more sophisticated instruments became available that operated on alternating current. Some of the more sophisticated devices were also promoted as capable of performing diagnostic evaluations. Many of these were marketed through magazines, newspapers, catalogues (Sears & Roebuck and Montgomery Ward), and medicine shows. Most of the sales’ emphasis was on the home market, with the exceptions of some medical practitioners who employed these instruments for diagnostic and healing purposes. Electrotherapy was sometimes combined with light therapy, as exemplified by the successfully-marketed Violet Ray. Nikola Tesla first demonstrated this device at the World’s Columbia Exposition in 1893 using a high voltage, low current delivered through a glass electrode to stimulate and warm the skin’s surface. These high-frequency oscillators were extolled for their beneficial treatment of skin disorders such as acne, eczema, and psoriasis. Even though there were many anecdotal claims through testimonials, the device was eventually removed from the marketplace in the 1950s. Naturopathic practitioners promoted its healing properties through increasing surface circulation for the treatment of rheumatoid arthritis. Some of these early instruments may have been the precursors to diathermy and transcutaneous electrical nerve stimulation (TENS) eventually used by the medical community for muscle relaxation, pain relief and physical therapy. The placebo effect may have played a significant part in the perceived benefits from these treatments.

The Placebo Effect Placebo derives from the Latin “placebo,” meaning “I Shall Please.” Placebo is any

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substance or treatment with no active therapeutic effect. The 1811 Hooper’s Quincy’s LexiconMedicum defined placebo as “any medicine adopted more to please than to benefit the patient.” It’s administered to deceive the recipient into believing that it is a treatment that functions as an active cure and, in scientific studies, functions as a control. Cultural anthropologists have emphasized the importance of ritualized healing in many primitive societies throughout the world. Many of these sham medical practices are beneficial and defy contemporary western medicine. Placebos were employed for a long time by medical professionals to placate anxious patients using sugar pills, inert tonics and saline injections. Many physicians were convinced that the alleged therapeutic benefits from placebos were artifacts in scientific studies. The first documented use of a placebo effect dates back to 16th century Europe when the Catholic Church employed false holy objects to discredit demonic possession. Later, in the 18th century, John Haygarth, a British physician, demonstrated the placebo effect of a popular treatment, ”Perkins Tractors,” purported to draw out disease due to the metal they were made from. He accomplished this by using dummy wooden tractors that were just as effective as the metal tractors. French pharmacist, Emile Cove, while working in an apothecary at Troyes between 1882 and 1910, advanced the use of placebos in his text, “Self-Mastery through Conscious Autosuggestion.” Medical researchers during the 1950s were convinced that placebo effects were no more than the results of Pavlov’s classical conditioning, where recipients were responding to inert stimulus symbols of medicine. Dr. Henry K. Beecher published one of the first clinical studies in 1955 in JAMA, demonstrating that placebos can cause measurable changes in physiological functioning that exceeded pharmacological actions. Beecher’s results also implicated idiosyncratic response factors: Personality traits may also play some role in contributing to the success of placebo outcome measures. The respected physician, historian and

author, Arthur K. Shapiro, proposed that the patient’s physician is an important factor in the placebo effect. He also suggested that, after an extensive historical review, “The history of medical treatment is essentially the history of the placebo effect.” Of the recorded 4,785 drugs and 16,842 prescriptions for ancient remedies, all were placebos. During a double-blind control, neither the investigator nor the recipient is aware of who is receiving the active ingredient and the placebo until the conclusion of the experiment. In some studies, there is an additional “crossover” procedure where the various recipient groups are switched at some point to receive the placebo without their knowledge: These are the most rigorously-controlled studies to ensure the effectiveness of the treatment. The majority of all peer-reviewed medical research studies that are funded by the National Institutes of Health or the National Science Foundation must include placebo controls. Many drug trials fail to demonstrate effective outcome results statistically, either due to a successful placebo effect or a lack of treatment effect. However, a number of scientific studies have demonstrated the power of a placebo effect on outcome measures. During the 1960s, researchers were able to alleviate asthmatic symptoms using inhalers that contained only water vapor. Another study conducted in the 1970s with dental patients having their wisdom teeth extracted showed they experienced no discomfort when receiving a placebo they believed was pain medication. It was during the 1970s, with the discovery of endorphins, that neuroscientists heralded the importance of placebos as important mediators of pain management: Naloxone was reportedly able to block the beneficial effects of a placebo on endogenous opioids, and the placebo-endorphin link has become a scientific mainstay. The science behind the placebo effectiveness is not very well understood due to a lack of knowledge concerning the neurophysiological relationships between the body and brain. Functional brain imaging revealed that success-

ful placebo effects are linked with enhanced dopamine production and mu-opioid activity, and also has demonstrated reduced painrelated neuronal activity in the spinal cord. (Opioids exert their pharmacological actions through three opioid receptors, mu, delta and kappa.) The placebo effect has also been noted to influence physiological changes of heart rate and blood pressure in the treatment for pain management, depression, anxiety and fatigue. Some researchers believe there may be a genetic component underlying the placebo effect. Our regulatory genes (IEGs) are believed to be controlled by environmental influences as well as by “mindset” (beliefs and feelings). “Open-labeled” placebos have demonstrated the most convincing evidence of effectiveness. In open-label, both the researcher and the participant know the treatment the participant is receiving. Studies have demonstrated the effectiveness of open-label treatments when the patients were fully aware they were receiving an inert medication for irritable bowel syndrome (IBS), low back pain, attention deficit hyperactivity disorder and tremor associated with Parkinson’s disease. The effectiveness of these placebo treatments is not the result of deception, but rather the individual perception and expectation that the treatment will be beneficial in relieving the illness.

The science behind the placebo effectiveness is not very well understood…

Conclusion Much of the marketing success evident through repeated sales of patent medicines and electrotherapeutic devices during the 19th and early 20th centuries can probably be attributed, at least partially, to a placebo effect. Customers who repeatedly purchased these nostrums and repeatedly used devices like the Violet Ray generators believed in their effectiveness. kperryman@suddenlink.net REFERENCES The list of sources used in this article is available upon request from the author.

May/June 2018

IN MEMORIAM

Daksha A. Shah, MD 1940–2018

IT WAS 6:15 AM ON a Monday morning in January 1983. I was walking to the women’s surgical changing room at the Kaiser Permanente Sacramento’s surgical suite. I was 20 feet away from the door to the room, when I heard a clear, Gujarati-accented, English-speaking voice in animated conversation with someone who I couldn’t hear behind the door. I knocked on the door and entered the room and was greeted by a 4-foot 10-inch, energetic woman with a loud, “Hello! Welcome. You must be Dr. Mathew E.N.T.” I attempted to reply, but she continued, “I am Daksha Shah, OB-GYN.” After a brief exchange of pleasantries, I found my assigned locker which had five handwritten names stuck on it Daksha A. Shah, MD and no lock. Daksha decided that this locker was too crowded and that I needed one for myself without having to share with anyone. She walked me over to the Head Nurse, Inga, and said in her classic style, “Inga, Dr. Mathew is a very busy surgeon and will be here most of the time, day and night; she needs a locker for herself with a lock. Give it to her.” A request and an order in one breath! I got a key and a locker assignment immediately, which I used for the next 25 years. We became instant chums and remained friends over the years. We even lived within a few blocks from each other in Carmichael. Once again, it was the middle of January 2014. I was walking out of my office to see a patient in the clinic, when the phone rang. I picked it up, and the unmistakable voice of Daksha said, “You’ve got to help me.” She sounded urgent and frustrated. She continued, “I’ve been having trouble with my left leg for the last few months, and now I feel my right foot is

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doing the same thing, and I am not getting any answers from the docs I have seen.” I suggested that she come in and let me examine her, but most of all to talk about what was going on. She agreed, and did come in. After examining her, we had a serious chat about what to do, and a few weeks later, she was diagnosed with Amyotrophic Lateral Sclerosis (ALS). This was the beginning of her battle with this progressive and fatal disease. During the next four years, I visited her every alternate Sunday on my way home after church. I interviewed her each time I visited her, mindful not to tire her, to find out the composition of this “dynamite” of a person. Daksha was born on May 4, 1940 to Vidyaben and Dadiyabhai Mehta. Because she was very premature, she spent the first 1½ months in an incubator. Her father was a successful businessman and a prominent organizer of the Andolan, the non-violent Freedom movement from British rule headed by Gandhi. He had been jailed for the 18th time for participating in the protests for Freedom when her mother was pregnant with her. Daksha met him for the first time when she 2½ years old after he was released from jail. She was the fifth child and had two older sisters and two brothers. India achieved freedom nonviolently from British rule on August 15, 1947. At the time, Daksha was 7 years old and in the 2nd grade. She was chosen to sing solo the Indian National Anthem at her school festivities on that day. Her early education was in the vernacular Gujarati, and she graduated from high school as the class valedictorian. Her undergraduate college education was at the Gujarat State College in Ahmedabad. She was among the top five in the state at the qualifying exam for entering medical school and given a secure seat

at the B. J. Medical College in Ahmedabad. Her class was composed of 51 percent females. She went on to get her medical degree with honors in 1963 and chose for her postgraduate specialization, Obstetrics and Gynecology at the Wadilal Municipal Hospital and College. She was the only candidate to pass the boards at the first attempt. She practiced on the academic staff as a Senior Lecturer until her “arranged” marriage with Arvind Shah, a chemical engineer and a citizen of the USA, on March 10, 1969. (They were married almost 49 years at her passing.) Two months following marriage, she joined Arvind in New Jersey; after passing the ECFMG and FLEX exams she began her New Jersey Medical Center residency, passing the OB-GYN Boards in 1972. Daksha was a staff physician in Pennsylvania until 1978. She joined the staff at Kaiser Permanente, Sacramento in 1979 as she wanted to live in warmer weather. She was a very active and busy obstetrician and gynecologist and took care of a very wide range of diagnoses, but infertility was her deepest interest, and she helped numerous couples with her successful skills and talent.

“The world is a kinder place because Daksha was in it.” She was a personable and compassionate physician, and her patients loved her. She was certainly a pioneer Permanente woman physician, as there were not many female physicians in 1979. Dr. Greg Herrera, who worked with her in New Jersey, Pennsylvania and the OB/ GYN Departments at The Permanente Medical Group in Sacramento, remarked with wet eyes, “The world is a kinder place because Daksha was in it.” She was one of the pioneer volunteers for the Medical Society’s Adopt-A-School and County Clinic volunteer programs, which were established in 1989 (now the SPIRIT program). As a volunteer in both programs, she was very enthusiastic and diligent. Through the Adopt-

A-School program, she helped educate students on sexually-transmitted diseases. She retired in 2004 after a remarkable 25-year service at Kaiser Permanente and over 40-plus years as an obstetrician and gynecologist. In spite of an extremely busy work schedule, she raised her two successful children, a daughter, Neha, an attorney, and a son, Cyril, a politician. Daksha was very friendly, kind and generous to everyone she met. You never had to make an appointment to visit her at home. If you were at her home, she would never let you leave until she had stuffed you with her instantly cooked, delicious meals and then packed some of the food for you to take home, even if you said no. This experience was described by friend and colleague, Dr. Sajjad JanMohammed, as “someone who was heard, although not seen,” and someone who “force fed” you as her sign of affection for you.” She was very involved in her religious center at the Ramakrishna Mission, and participated in many of the social activities there. She was an active member of an Indian classical vocal group called the Vasundara Choir, and performed with them around California. She was also a very energetic Indian folk dancer. I had the pleasure of dancing the “Dandya Raas” at her daughter’s wedding, after which she declared, “You pooped me out, Elisabeth, let’s sit and take a breather.” I took the breather, and she continued to chatter, non-stop. As my visits continued, I saw this “Energizer Bunny” of a woman being forced to give up her activities one after the other, losing her mobility, nonstop “chatterbox” talking, laughing, eating, drinking, and eventually becoming an immobile, rigid body with the inability to blink, and finally, to even breathe. She passed away with her family members surrounding her as they had been through the entire four-year ordeal. Daksha is survived by her husband, Arvind, daughter Neha, son Cyril and four grandchildren who were her pride and joy. Rest in peace, dear friend. You have been set free to dance and sing across the Heavens. –Elisabeth Mathew, MD, FACS

May/June 2018

Board Briefs March 12, 2018 The Board: Received an update regarding activities of the Emergency Care Committee from Peter Hull, MD, Chair. The committee consists of the emergency department medical directors of all hospitals in the Sacramento region. The committee has taken the lead on seeking solutions to issues that impact patient care in the emergency department. Received a report from Alana Freifeld, MS II and Neeraj Ramakrishnan, MS II, medical students from California Northstate University College of Medicine, regarding their findings in the research project X-Waiver Provider Project. The study identifies provider practices, attitudes and barriers toward buprenorphine prescription. Appointed J. Bianca Roberts, MD, to the SSVMS Delegation to the California Medical Association representing Alternate-Delegate Office 8. Approved the 2017 Unaudited Year-End Financial Statements, the 4th Quarter Investment Reports and Recommendations. Approved the termination of membership for 106 physicians for nonpayment of 2018 dues. Approved the Membership Report: For Active Membership – Jose F. Abad, MD; Fernanda DaSilva, MD; Terri Ferrari, MD; Jeffrey Gaston, MD; Angelique Green, MD; Kyi Kyi Htein, MD; Munir Janmohammed, MD; Melissa Johnson, MD; Shahnawaz Karim, MD; Hema Manickam, MD; Abhilash Nair, MD; Dan Parker, MD; Kristina Paulantonio, MD, Rodica

Sierra Sacramento Valley Medicine

Petrea, MD, Aaron Rosenberg, MD; Debby Sentana, MD; Alicia Silva, MD; Sara Teasdale, MD; Kit Tittiranonda, MD; Kasandra White, MD; Meghan Wood, MD; Jerrod Writt, MD. For Reinstatement to Active Membership – Venugopal Bellum, MD; For Resident Physician Active Membership – Trang Le, MD; David Roldan, MD. For a Change in Membership Status from Active to Resident Physician Active Membership – Elizabeth Pontarelli, MD. For Retired Membership – Allan Au, MD; Evan Bloom, MD; Scott Budd, MD; Gary Cederlind, MD; Dermet Fong, MD; Randall Hepworth, MD; Carol Lee, MD; Marion Leff, MD; James Moorefield, MD; Esther Novak, MD; Mary Pat Pauly, MD; Ronald Tamaru, MD; Bryce Tanner, MD; E. Michael Thelen, MD; For Transfer Membership – Robert M. McCarron, DO (to Orange County Medical Association). For Resignation – Sandar Aung, MD; Bruce Barnett, MD (moved to Massachusetts); Fernanda DaSilva, MD; Anne Kern, MD (moved to Los Angeles); S. Khizer Khaderi, MD (moved to Los Angeles); Gundrum Kungys, MD; Steve Lalliss, MD; Kathleen Larkin, MD (moved to Saratoga); Daniel Lavery, MD (moved to Oregon); Steven Marcum, MD (moved to Tennessee); Nadir Qazi, MD (moved to Los Angeles); Archan Shah, MD (moved to Arizona); Marshal Snyder, MD; Tamara Taber, DO; Trevor Winter, MD (moved to Half Moon Bay); Qais Wahidi, MD; Kenneth Wiesner, MD; Natasha Zohuri, MD (moved to Los Angeles). For Termination of Membership – George T. Wong, Jr., MD (license expired).

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. — Carol Kimball, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP: Jose F. Abad, MD, Family Practice, University Massachusetts Med School – 2003, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815 Venugopal Bellum, MD, UHS Vijayawada Kakatiya Medical College – 1998, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670 Fernanda DaSilva, MD, Hospitalist, Eastern Virginia Medical School – 1996, Mercy Medical Group, 3939 J Street, Sacrameto, CA 95819 Terri Ferrari, MD, Ob/Gyn, University of Washington School of Medicine – 2013, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815 Jeffrey Gaston, MD, University of Miami School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Angelique Green, MD, UC Davis School of Medicine – 1993, Mercy Medical Group, 3000 Q St., Sacramento, CA 95816

Melissa Johnson, MD, Ob/Gyn, University of California School of Medical - San Diego – 1995, Sutter Medical Group, 3 Medical Plaza Ste 260, Roseville, CA 95661 Shahnawaz Karim, MD, Neurology, Acharya Shri Chander College of Medical Sciences – 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Hema Manickam, MD, General Medicine, Dr S N Medical Coll, Rajasthan University – 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Kristina Paulantonio, MD, Ob/Gyn, Tulane University School of Medicine – 2007, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758 Rodica.Petrea, MD, Neurology, University of medicine and Pharmacy ‘Carol Davila’ – 1995, Mercy Medical Group, 1730 Prairie City Rd # 120, Folsom, CA 95630 Debby Sentana, MD, Hospitalist, Loma Linda University School of Medicine – 2012, Mercy Medical Group, 3000 Q Street, Sacramento, CA 95816

Alicia Silva, MD, General Surgery, UC Davis School of Medicine – 1993, Sutter Medical Group, 2030 Sutter Pl # 1100, Davis, CA 95616 Sara Teasdale, MD, Internal Medicine, UCSF School of Medicine – 2012, UC Davis Medicine Group, 4150 V Street, Suite 3100, Sacramento, CA 95817 Kasandra White, MD, Ob/Gyn, Michigan State University College of Human Med – 2010, Mercy Medical Group 3000 Q Street, Sacramento, CA 95816 Jerrod Writt, MD, Family Practice, University of California Irvine - CA College of Med – 2013, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento, CA 95825 APPLICANTS FOR RESIDENT ACTIVE MEMBERSHIP: Trang Le, MD, UCD Medical Center Resident/ Fellow Programs – 2020, 4150 V Street Suite 1200, Sacramento, CA 95817 David Roldan, MD, UCD Medical Center Resident/ Fellow Programs – 2020, 4860 Y St Ste 1600, Sacramento, CA 95817

Munir Janmohammed, MD, Cardiology, Ross University School of Medicine – 2002, Mercy Medical Group, 3941 J Street, Suite 230, Sacramento, CA 95819

Interested in Shaping Health Policy? THE SIERRA SACRAMENTO Valley Medical Society (SSVMS) has vacancies on its Delegation to the California Medical Association (CMA) House of Delegates. The CMA House of Delegates convenes annually to establish broad policy of the organization on current major issues affecting the practice of medicine and public health as determined by the Speakers of the House and the Committee of Delegation Chairs. Policies adopted by the House of Delegates are implemented by the CMA Board of Trustees either at the state level or referred for national action or legislation. Delegates and Alternate-Delegates are responsible for representing their colleagues in the House

of Delegates by attending and actively participating in Delegation caucus meetings and all sessions of the House of Delegates. In 2018, the House of Delegates will meet in Sacramento October 13-14 at the Sacramento Convention Center. SSVMS reimburses all of its Delegation members for transportation and hotel accommodations. A daily meal allowance is also provided. Delegation members must stay for the entire meeting (Saturday-Sunday) in order to be eligible for reimbursement. For more information contact: Chris Stincelli, Associate Director, cstincelli@ssvms.org or (916) 452-2671.

May/June 2018

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Insurance Services Mercer Health & Benefits Insurance Services LLC Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, and Cmacounty/insurance.service@mercer.com more... www.countyCMAmemberinsurance.com Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.

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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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Celebration Saturday, May 5, 2018 6PM - 8:30PM Sutter’s Fort, Sacramento

Experience the history of SSVMS and Sutter’s Fort with food, beverages, live pioneer music, games, & prizes Free Family-Friendly Event for Physician Members and Guests RSVP by April 27th with Mei Lin at MJackson@ssvms.org or call 916-452-2671

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