2019-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 2019

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MEDICINE 3

PRESIDENT’S MESSAGE On a Mission to Save Private Practice

Christian Serdahl, MD

EXECUTIVE DIRECTOR’S MESSAGE Bursting Big Soda’s Bubbles

Aileen Wetzel, Executive Director

A Calling, and a Call to Physicians

SSVMS Honors Medicine

Photos by David Flatter

For Medi-Cal Kids, You Can Make Every Smile Count

By Margaret Delmore, MD, DDS 22

Nathan Hitzeman, MD

Keep Your Eyes Open for New Sources of Lead Poisoning

Jeffrey Rabinovitz, MD and Olivia Kasirye, MD

OPINION An Addiction to Guns

Caroline Giroux, MD

PROFILE Dr. David Lubarsky Takes the Helm at UCD Health

First Uterine Transplant From Deceased Donor Offers Hope

Marissa Chinn, MS III

Saving Lives In Sacramento Through Collaboration

Ken Smith, Managing Editor

Preserving Humanism in An Age of Technology

William Bommer, MD Susan Ivey, MD

Obituary: James Knoblock Hepler, MD

Board Briefs

New SSVMS Members

Farsam Fraz, MS II

A Medical Student’s Take on Duty Hours

Elijah Abramson, MS III

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 SSVMedicine@ ssvms.org or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

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SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Cover photo: Sunflowers in Yolo County.

Volume 70/Number 3

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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

May/June 2019

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MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2019 Officers & Board of Directors Christian Serdahl, MD, President John Wiesenfarth, MD, President-Elect Rajiv Misquitta, MD, Immediate Past President District 1 Ashutosh Raina, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD

2019 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 Helen Biren, MD Richard Gray, MD Reinhardt Hilzinger, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Sen. Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD John Wiesenfarth, MD Don Wreden, MD CMA Trustees District XI Douglas Brosnan, MD

District 4 Ranjit Bajwa, MD District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD Roderick Vitangcol, MD District 6 Carol Kimball, MD District 1 Alternate Vacant District 2 Alternate Ann Gerhardt, MD District 3 Alternate Thomas Valdez, MD District 4 Alternate Richard Bermudes, MD District 5 Alternate Armine Sarchisian, MD District 6 Alternate Christopher Swales, MD At-Large Alternates Megan Anzar Babb, DO Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Adam Dougherty, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Anand Mehta, MD Leena Mehta, MD Rajiv Misquitta, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD Naomi Ross, MD Vacant

Sandra Mendez, MD

Editorial Committee Mustafa Bahramand, MS II Sean Deane, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD Steven Nemcek, MS IV

Eric Ovruchesky, MS I John Ostrich, MD Karen Poirier-Brode, MD Neeraj Ramakrishnan, MS III Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD

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Aileen Wetzel Ken Smith Melissa Darling

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Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about membersâ&#x20AC;&#x2122; 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. ÂŠ2018 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

On a Mission to Save Private Practice By Christian Serdahl, MD ccneye@sbcglobal.net ACCORDING TO THE 2018 SURVEY of American Physicians, only 31% of physicians identify as being in private practice. Looking back, the percentage was 33% in 2016 and 48.5% in 2012. Additionally, Merritt Hawkins’ most recent survey of graduating residents indicated that only 1% expressed a desire to go into solo private practice. These numbers are staggering and should be of concern to everyone. If private practice were to collapse, physicians’ financial “floor” would collapse along with it. There would be no competition and salaries would be impacted. In the movie “Saving Private Ryan,” the character portrayed by Tom Hanks and his special-forces unit are deployed behind enemy lines to bring home James Francis Ryan, the only surviving brother in a WWII family. We are also on a mission: Our medical society has developed a campaign called “Saving Private Practice” and is working behind the scenes to help private practice survive. Our staff understands the unique struggles and challenges facing physicians in private practice. Aileen Wetzel, our CEO, spent 12 years at the California Medical Association where she was one of the founding members of the Center for Economic Services. It is focused on defending physicians in all types of practice from health plan and regulatory abuses. Before her tenure at CMA, Aileen managed multiple large orthopedic practices in a number of states. And Physician Relations Manager Megan Sharpe previously worked as a medical assistant in a busy private practice. Last year alone, SSVMS helped physician members recoup almost $120,000 from payers. In the past 10 years, CMA’s Center for Economics

has recouped over $29 million on behalf of physician members. My own two-physician ophthalmology practice inadvertently missed a deadline to revalidate with Medicare, our primary revenue source. We learned of this when the Medicare contract intermediary Noridian suspended our ability to bill Medicare. Noridian notified our practice manager that it would take a minimum of 80-100 days for our revalidation to be approved. I called Megan, who elevated our plight to CMA’s Economic Services team. Noridian resumed our ability to bill Medicare within two weeks. Private practice medicine will never become extinct. Patients will always want choices and there will always be physicians who don’t fit in the large group practice model. Several studies have indicated that private practice physicians provide less expensive medical care compared to physicians practicing in large groups with a hospital affiliation. Private practice physicians also generate jobs that pay a living wage and are vital to the diverse economy of our region. Physicians in private practice with one to four doctors make up only 10% of the SSVMS membership. More than 70% of our members are from large group practices. When I joined in 1991, the numbers were reversed. Make no mistake, private practice is challenging but the rewards are immense. And while I appreciate all the good things a group practice has to offer, I would not trade places. But I am extremely grateful that our Medical Society supports physicians in all types of practice. All of us—doctors and our patients who want options—should be as well.

May/June 2019

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

EXECUTIVE DIRECTOR’S MESSAGE

Bursting Big Soda’s Bubbles By Aileen Wetzel, Executive Director awetzel@ssvms.org IN 2016, CALIFORNIA VOTERS approved CMA-backed Prop. 56 to increase the tax rate on cigarettes and tobacco products to help fund health care expenditures and facilitate access to care by increasing Medi-Cal provider rates. Today, California faces another health crisis. Over one-half of Californians already have diabetes or are likely to develop Type 2 diabetes during their lives. Twenty-five percent of Californians are obese and 38 percent of children are obese or overweight. Like the tobacco industry before them, Big Soda companies are targeting children, low-income and minority populations with deceptive marketing tactics. The California Medical Association and the Sierra Sacramento Valley Medical Society have joined the California Dental Association, health stakeholders and legislators in support of Assembly Bill 764 (Bonta), which would prohibit manufacturers of sugar-sweetened beverages from offering discounts or coupons for soda. When beverages make up nearly half of all added sugars in the American diet, it is no surprise that discounts on unhealthy products like soda make healthy diets for low-income families less likely. The soda industry uses a sophisticated multi-pronged strategy to reduce the price of its products and target certain consumers. Soda companies use “promotional and marketing incentives” to lower prices on sugar-sweetened beverages and increase consumption in communities where purchases of soda are down. In fact, a study in New York found that soda manufacturers supported discounts and promotional displays on their unhealthy beverages in correlation with the beginning of the month, when food stamps are distributed. AB

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

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764 ensures that Big Soda cannot continue to target communities with promotions and discounts that discourage healthy diet decisions. Taking on Big Tobacco has shown that limiting access and stopping predatory marketing schemes can help lower consumption, raise awareness, and help improve health outcomes. It’s time to take on Big Soda. If you would like to personally get involved in this advocacy effort, please contact me directly.

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A Calling, and a Call to Physicians End-of-Life Option Act Offers Patients Dignity in Death By Nathan Hitzeman, MD hitzmn@sutterhealth.org

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

SINCE CALIFORNIA ASSEMBLY BILL 15, the End of Life Option Act (EoLOA), was passed in 2015 and enacted in 2016, hundreds of patients with terminal illnesses have received lethal medications by physicians to end their suffering. Notice that I didn’t say “by their physicians.” Very few physicians are participating in the end-of-life services enabled by the bill, especially in senior-dense areas like Roseville and some outlying rural communities. In fact, the chance of one’s own physician participating is quite low. After involvement in about a dozen EoLOA cases over the last two and a half years, I am by no means an expert. But I have a wonderfully compassionate and resourceful colleague, Ryan Spielvogel MD, who has trailblazed this service for our family medicine clinic. Through him and others, I have seen many successes and bear traps along the way. Participating physicians in our Sutter Health clinic often get requests to travel to Roseville and other outlying areas because so few providers offer this service. I hope that my story might persuade you to consider adding this service to your practice. I have found it to be among the most rewarding experiences in my 14 years of practice. Any licensed physician may participate in the EoLOA process. Of course, in this era of Big Box Medicine, some physicians are limited by the policies of their institution, including any religious affiliation. But I suspect that most physicians just aren’t comfortable with prescribing lethal medication (“First Do No Harm”), that it might be perceived as too much

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paperwork or logistics, or that this is all just too new to jump into. It also doesn’t reimburse any more than an office visit, and there’s no sexy cutting-edge technology like robotic surgical arms, helipads, or catheters under fluoroscopy. It involves talking with patients and family. Yet it can be the final and most important touch we have in a patient’s life. Surprisingly, the EoLOA is a well-written bill with a process that is not hard to follow. A patient must be evaluated by the attending physician twice, at least 15 days apart. The patient must be a resident of California, have a terminal illness, be of sound mind, and be physically able to administer the lethal medication themselves whether by mouth, feeding tube, or rectal tube in a witnessed fashion. It cannot be administered by IV. A second physician needs to consult with the patient somewhere within this 15-day period and concur with the plan. For any significant mental health issues, a mental health provider must be consulted as well. The patient must consent in writing and verbally, and two witnesses must sign on; not more than one may be family, and not more than one may be from a health worker involved in the patient’s care. The various forms and templates to use for the process are available online through the California Department of Public Health (CDPH). According to CDPH, 632 patients in 2017 started the EoLOA process. Fifty-five died during the waiting period. Of 577 patients receiving lethal prescriptions, 86 did not ingest the drugs and died of the underlying illness, 363 ingested

and died from the drugs, and 128 had “undetermined outcomes.” The gold standard lethal cocktail is high dose secobarbital. Unfortunately, this costs several thousands of dollars and is cost-prohibitive to most patients. Although it often leads to unconsciousness in minutes and death in an hour or two, there have been cases of prolonged deaths. High-dose morphine alone is rarely used as many patients with a terminal illness are already opioid-tolerant. The current most popular and economical regimens contain various combinations of high-dose amitriptyline, diazepam, digoxin, morphine and propranolol. Patients are often pre-medicated with antiemetics and anxiolytics. I never really imagined myself doing this. I grew up in a religious home and went to religious schools. I consider myself Christian tempered by a little agnosticism. I volunteered in hospice during college. My parents were not thrilled to hear that I was participating in helping terminal patients end their lives when I first mentioned it over a holiday dinner (think awkward silence and silverware clinking). I would never want to harm a patient or break my Hippocratic Oath, but I see patients harmed every day by well-meaning medical intervention that just leads to more suffering. Most patients are able to die peacefully with hospice, but some do not. Some reach a state of

disability that they had hoped never to experience. I was first asked to be a consultant on an EoLOA case through a connection within SSVMS. A retired surgeon’s friend’s wife was dying of breast cancer and did not want to suffer anymore. Although she lived locally, her care was through a renowned medical center in the Bay Area Her oncologist and I discussed the case. He stated incorrectly that his institution must do an ethics review and that their palliative care service must sign off on the process. Despite the institution’s many helipads, no doctor could make the 80-mile trip out to do the home visit. My credentials were questioned (“You mean you’re not a palliative care specialist?”). Through persistence and frequent reference to the legislative source document—I’m a family doc and this is not my first rodeo—I was able to participate in helping the patient fulfill her wishes and the family was very grateful. My colleagues and I have had many interesting experiences since. Most have gone smoothly, but not all. One patient of mine, after getting the lethal prescription, waited a couple days for a family member to be present and became delirious the day he was to take it, and suffered several days longer until he expired from the illness. Another patient of mine became unconscious quickly but Continued on page 8

May/June 2019

End of Life Option Act Continued from page 7

took almost a full day to expire. Having your cell phone available to the family and hospice services involved is tremendously helpful in reassuring the families during this waiting period. The patient is almost always in a sleep-like and peaceful state. One of our clinic patients was a young lady with cancer, reminiscent of Brittany Maynard. We found prescribing for her emotionally hard for us, but she was sure of her decision. One patient had a horrible fungating oral cancer and simply couldn’t swallow medicine, but could use his G-tube. Another was on TPN with short gut syndrome and couldn’t take it by G-tube but could use a rectal tube. One patient with a hypercoagulable disorder had frequent strokes/TIAs and unfortunately became too debilitated to finish the EoLOA process because she couldn’t physically administer it. She did mercifully pass not too long after, however. The patient I saw who seemed to be suffering the most had ALS. He was in pure misery, and he and his family wasted not one second to get the prescription so he could pass. We’ve had patients from rural communities seek us out because they heard of a friend having the EoLOA service through us with good results for the patient and family. Many of the patients, interestingly, are from wellto-do backgrounds.

Let me be clear: We do not rubber stamp. One patient was severely depressed and just didn’t qualify. Another man refused dialysis and we tried to talk him into peritoneal dialysis, where he would have more control over the treatment, but he ended up refusing this too and went on to take the lethal medication. Interesting family discussions and dynamics have come up, as one could imagine. One patient’s daughter gave me some wonderful advice to take an oral history from your parents, something that proved invaluable to me when my own father passed away a few months ago. One can learn a lot about life through death. We often consider death a failure in our profession. But through many of my home visits and experiences over the years, I am amazed by the amount of suffering that goes on behind the closed doors we drive past every day. Indeed, my last EoLOA patient marveled that we sometimes treat pets better than humans when it comes to ending their suffering. EoLOA is not the right path for most patients, but it’s an important option for some. And don’t we all like options? It’s always good to First Do No Harm, but sometimes patients want the Harm undone, and now we have a merciful way to complement hospice services to do just that.

SSVMS Spring and Summer Upcoming Events MAY 15

Saving Private Prac�ce: Key Strategies for Prac�ce Success

MAY 23

Balancing Life Today & Dreams For Tomorrow Webinar

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Conﬁdent Re�rement, Re�ring on Your Own Terms Webinar

AUG 22

Market Vola�lity & Outlook Webinar

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3rd Annual Joy of Medicine Summit Save the Date!

To RSVP contact Mei Lin Jackson at mjackson@ssvms.org or (916) 452-2671.

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SSVMS Honors Medicine Acknowledgments February 28, 2019

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OPINION

An Addiction to Guns By Caroline Giroux, MD cgiroux@ucdavis.edu

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

JUST OVER A YEAR AGO, my boys went to a birthday party. One of the highlights of their day was when they received a Nerf gun. I didn’t think much of it at first, because usually festivities surrounding the aging of children in this country get really overwhelming and dizzying for me. So my stress response systems, easily activated by the apprehension of having to find a polite way to decline the cake and its proverbial icing, were already overloaded. Well, overload, loading, unloading. Click, followed by the poof-poof-poof sounds of foam making contact… the remnants of romanticized cowboyism had contaminated my family. The next morning, upon hearing my children enjoying this novelty, it dawned on me that this toy could have been invented by the National Rifle Association to create future gun addicts. Just thinking of that possibility made my blood boil. I felt a surge of revolt, wanting these evil gadgets out of my house. What a loaded topic. Is this what such a pervasive obsession is about in this country: a dopaminergic surge at aiming accurately? In sum, just another form of addiction? My definition of addiction is the investment of a disproportionate amount of thought, time and energy on a specific item, whether it is a drug, alcohol, gambling, sex, money… or guns. Just like money, or drugs, the addicted brain never seems to have enough, and always wants more, more, like those infamous mass shooters who were later discovered to have dozens of firearms in their possession. I suspect that for some people pulling a trigger could become an addictive experience like a video game. Stimulus, response. Action, immediate result. The vending machine syndrome. Sensation at all costs over moral sense. Therefore, it makes me grin cynically when Sierra Sacramento Valley Medicine

people try to find the cause after a mass shooting, what led a person to do such damage. The blame on the killer’s medication (valium, for the mass shooter who killed people in Las Vegas) is misguided. Although I agree that this medication is evil in part because it is highly addictive, it is just another indication that this person was prone to addictions. And just like tolerance and the need to increase the dose develops for a substance, the need to increase the capacity of a firearm seems to increase as well. If it is not an addiction, how should we understand the clinginess of a lot of Americans to their “constitutional right” to own a gun? What does it say about a country whose people make that a priority over universal health care and education, for instance? Some family members above the border were as shocked as I was to learn about the page fully dedicated to guns in the weekly flyer we receive in my neighborhood, along with advertisements for pizza places. This is still quite surreal to me. And if this addiction is so pervasive and severe, is it possible that one of its roots would be early age exposure? It outrages me when people trivialize this: “Boys are boys, there’s nothing wrong with that, they’ll outgrow it!” Well, clearly, some don’t. Should we still take the risk? And, the fact that there are no “victims,” that’s it’s only a “game,” is another poor argument. Would any parent see it the same way if their kids were playing games like “rape and pillage” or “drug dealer”? Even if it is only a game, wouldn’t they be uneasy about exposing youth to such atrocious and macabre scenarios? I think we have to re-examine the potential impact of propaganda. Kids are too often the targets of corporations. And the peer pressure and trivialization by certain communities exac-

erbate their destructive impact. The synergy between capitalism and nationalism is a toxic product called gunism. Owning a gun doesn’t solve problems. It just reinforces the culture of fear and hatred that we live in. It interferes with healthy dialogue because when someone owns a gun and you don’t, then you become suddenly more vulnerable, and it perpetuates the cycle of fear, trauma, and violence. And unfortunately, if the victims die (which is more the rule than the exception, judging by the death toll, whether it is from murder or suicide), they can no longer advocate for themselves. The afflicted families are often too fragile and overwhelmed with grief to be effective in fighting to change the policies on gun ownership. And in all honesty, who does the public find the easiest to remember, the nicknames that almost glorify mass shooters or all the individual victims who perished? How can we avoid to repeat history if we forget the lost lives? If we look at the neuroscience of trauma, how people get stuck in a fight, flight or freeze response, we can understand why a gun in the wrong hands is concerning. Studies show that women tend to dissociate (“freeze” response) during a traumatic event and upon being triggered (no pun intended), whereas men—it is unclear if it may be due to testosterone and cortisol levels—tend to respond more aggressively (the so-called “fight” response). Knowing that trauma is such a pervasive experience, that the majority of Americans will have experienced at least one traumatic event before the age of 18, the odds for a

gun owner to have hypersensitized stress or fear response systems are high, which means that the cortical areas of the brain essential for impulse control, analytical thinking and executive functioning are shut down when experiencing a sense of threat, real or not. This person is more likely to respond in an irrational and extreme manner, bypassing the frontal “brake,” given that fear involves more primitive areas of the brain. Add shame, rage, obsession, misogyny or xenophobia with revenge to the mix, and you have a bloody disaster. I don’t think plastic guns are innocent toys. Just like plastic fruit help kids role play about a healthy diet, guns promote violence and normalize what is not in our nature. It makes its way through the subconscious, just as hearing about these school shootings enlivens the concept of America’s “gun culture” and how unhealthy sexual scripts normalize sexual misconduct. What does it say of a nation when our children’s brain power in schools is not used to learn about science, creativity, or empathy but instead regular practices of lockdowns and other drills? My attempts to create an atmosphere of emotional safety for my patients seem futile now. No safety is fully attainable with such a level of violence. The forces supposed to govern in the best interest of this country have been comatose for too long. Time to unplug the machine. Beyond the political ramifications of this debate, I think it is a serious, urgent public health issue and we as doctors should be at the forefront of the dialogue, educating the population, studying the impact of such exposure and requesting more stringent gun laws. Regardless of where we stand about the question to own a gun or not, I think we should agree that access to firearms is a critical calamity we should talk about as a society, instead of putting the blame on the mentally ill. I insist that it is about time that this country examines its core values. This problem is not going to go away on its own. Even a change of policy will take a while to shift the mentality, so better to start now (New Zealand Prime Minister Jacinda Ardern is my hero!). We have to stand and bear witness to the casualties and make this violence stop. And the shift should start within each household. Or at any birthday party. Note: A first version of this article was written over one year ago. Unfortunately, many mass shootings have occurred since. Nothing has changed, and doctors have been told to “stay in their lane.” Physicians—and anyone who cares about public safety—should not be kept out of the conversation.

May/June 2019

PROFILE

Dr. David Lubarsky Takes the Helm at UCD Health Partnership With Patients, Physicians, Health Systems a Priority By Ken Smith, Managing Editor ken@kdscommunications.com

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

DESPITE NOT FINDING THE CALIFORNIA sunshine he was expecting during one of the coldest and wettest winters in recent memory, David Lubarsky, MD is embracing his new role as head of the Sacramento region’s largest health care system. Dr. Lubarsky arrived last fall from Florida, where he was chief medical officer for the University of Miami Health System. An anesthesiologist, he stopped practicing the day before he left for Northern California. He is also armed with an MBA from Duke and an undergraduate degree in European intellectual history (“Yeah, I know,” he says) that plays a surprisingly large role in his current life as administrator of UC Davis Health and its over 1,000 physicians and $1.9 billion annual budget. “Existentialism, nihilism, ancient Russian philosophy, all of that came under the rubric,” Dr. Lubarsky said. “The reason it’s important is to understand the progression of thought and to understand human beings. European intellectual history is really a function of understanding human beings, their response to their situations, and the edifices of governance that are both functional and dysfunctional in Western Society. That actually has a tremendous amount of application to understand the underserved, the overprivileged and the role of government in health care.” Working for the University of California and the region’s only academic health center, Lubarsky has to apply the relationship between government and health care while navigating UC’s bureaucracy and helping to refine the UCD Medical Center’s role both in serving the community and shaping policy. Sierra Sacramento Valley Medicine

“I don’t really need to bring hardly anything, because the organization has it all,” he said. “It really is an amazing group of great practitioners, great research, and committed people for the social mission, but they really haven’t been working in concert. What I’m really bringing is the knowledge of how to create synergies between incredibly great existing talent and also to elevate the level of national attention to the high quality of care and amazing research we’re doing.” One of Dr. Lubarsky’s priorities is working with local providers and patients to make access to the Medical Center more available to them. New programs, such as centralizing access to

Dr. Lubarsky hits the trails after a visit to UCD’s health partner Tahoe Forest Hosital.

“I’m a firm proponent that organized medicine is the voice of physicians, and I’m a firm proponent that the voice of physicians is the voice of health care and actually the voice of patients.” Fit and confident, the 59-year-old Dr. Lubarsky was born and raised in the Bronx, graduated from Washington University in St. Louis, did his rotations at New York University and taught a business class on health care at Duke after earning his MBA there. Trading the warm winters of Florida for the dry summers in Sacramento wasn’t the only change he noticed in his move west and to an apartment in downtown Sacramento. He is an avid cyclist who regularly takes advantage of the American River bike trail, at least when the ongoing rain didn’t force him inside to use a spin machine. He started riding with some of the cycling groups and found

Photos Courtesy UC Davis Health

UCD’s extensive range of services and adding self-scheduling for patients and physicians, should help address many of the problems local physicians have experienced when referring patients to the Medical Center and UCD Health specialists. But he also wants to partner with other health systems in the area to make better use of the region’s resources so the Medical Center can focus on the sickest patients and most complex cases. “The major focus I have is about building partnerships,” Dr. Lubarsky said. “We were sort of a castle on the hill; we walled ourselves off, built a moat and didn’t welcome everyone in. We’ve torn down the wall, filled in the moat and sent out signs saying ‘Please come visit the castle.’ It’s not a castle anymore, it’s a welcoming abode and we’ve really enriched the partnerships with other health systems in the area.” Dr. Lubarsky, whose full title is Vice Chancellor of Human Health Sciences and Chief Executive Officer, says the new mantra at UCD Health is that “we’re not here to compete with other health systems, we’re here to complete other health systems.” By complementing other health systems’ resources with UCD’s technology, experience and research, he sees better outcomes for patients needing complex diagnostics and procedures that might be a one-off at other facilities. Conversely, by not pursuing other types of care he says can be addressed by other health providers “probably just as well as we can, and at a lower cost, we are also aiding society by focusing on what we do best.”

Dr. Lubarsky arrived in Sacramento after 14 years in Miami.“I hate to move,” he says.

that—“sadly,” he says, tongue in cheek—that there are some “really, really good bikers here.” “When I first came here and I was in shape before I started this job, I was out on a back stretch rolling through some farmland in the delta,” he said. “I was going 31 miles an hour and I got dropped like a rock”—left behind by other riders in the group—“and I’m thinking, nobody ever drops me! There are people going 34 or 35 miles an hour here! But I’m passionate about it because I have a need for speed and seeing the landscape roll by is just fantastic.” His true passion, though, is fixing systems, something that he said he has done since he was a kid and long before he even knew what organizational systems were. One in particular that is close to his heart is preventing physician burnout, largely as a result of an experience he had as part of a surgical team at NYU. Dr. Lubarsky had been up 32 hours straight and was doing a cranial-facial reconstruction on a child. “I fell asleep,” he recounted. “I woke up two minutes later but I still remember to this day that it was the scariest moment of my life.” The next day while he was off, he sat down and reorganized the entire schedule across NYU’s three hospitals. Continued on page 14

May/June 2019

Dr. Lubarky speaks at the UC Davis “Mini Medical School” in March.

When he presented his plan to the hospital chairman and was told it couldn’t be done, Dr. Lubarsky explained that if the hospital took the plan and revised shifts for nurses and residents, changed how many were on call and created a back up system, it wouldn’t cost any money. “He said OK. And from that point on, no one worked more than 24 hours at NYU in the anesthesia department.” Dr. Lubarsky has brought that passion for preventing physician burnout west. UCD Health recently committed to support and engage in SSVMS’ Joy of Medicine Program, which provides resources and services to Sacramentoregion physicians. Dr. Lubarsky recognizes that Florida and California are very different places politically, although he said Sacramento is somewhat more conservative than Miami. But Miami’s Dade County, he explained, is a blue island in a largely rural, conservative state. He welcomes the opportunity to help shape a more progressive health care policy in more receptive California, and he believes being in the state’s capital raises UCD’s ability to do that. But he added that it’s important to be active in both SSVMS and the CMA to be successful, and he has backed that up

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by bringing more than 800 physicians into SSVMS as new members this month. “I’m a firm proponent that organized medicine is the voice of physicians, and I’m a firm proponent that the voice of physicians is the voice of health care and actually the voice of patients,” he said. “The way the world works, people listen when you speak in unison.” Dr. Lubarsky said that although the hospital, which is financed 95 percent through revenues and just 5 percent by the state, is filled and making money, it is not his nature to be satisfied with the status quo. “We can be number one in primary care, we can be number 20 or 15 in research if we just organize ourselves. We don’t have to have six-hour waits in our emergency department, they should be cut to zero because that waiting time is useless. It’s bad for patients and for everybody,” Dr. Lubarsky said. “I really am a person who believes that every organization, especially ones that serve a social mission like we do, have an obligation to make themselves not only as good as they are, but as good as they possibly can be.”

ACOG ESSAY WINNER

Preserving Humanism in An Age of Technology By Farsam Fraz ffraz@ucdavis.edu Editor’s Note: This is the winning essay from ACOG’s 2019 medical strudent essay contest. This year’s prompt: “How do we preserve humanism and ethics in medicine in a time of rapidly developing technology?” “MEDICINE CANNOT HEAL IN A VACUUM; it requires connection,” Dr. Rana Awdish says in her book, In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. As health care providers, we are granted the honorable privilege of healing. Our patients allow us to take care of them in their most vulnerable moments, welcome us into their lives, entrust us with their secrets. In a time where we are increasingly depending on rapidly developing technology, with that privilege comes grave responsibility. Responsibility to preserve humanism and ethics in medicine. In her book, Dr. Awdish speaks about her experience going from an ICU physician to a patient in the ICU of her own institution. She writes about having the best possible tools and technology fighting to keep her alive, but amongst it all, she experiences the lack of both humanism and ethics from her providers. Instead of forming a relationship with her as a patient, they form a relationship with her pathology. She describes feeling invisible and unseen and ultimately shares with us about how her experiences helped her become a better physician. Reading Dr. Awdish’s book and attempting to address the question in this prompt, I have reflected a lot about my own approach to taking care of my patients—understanding that my approach will evolve as I move forward in my career. Since I have not begun my third-year clerkships, my clinical experiences have been limited to volunteering at Shifa Community Clinic, a non-profit student-run clinic in the

heart of Sacramento, CA. At Shifa, our doors are open to the underserved and uninsured population of Sacramento—people who often have nowhere else to go. We operate out of three combined apartment buildings that have been transformed into a small, but mighty, clinic that serves over 800 patients. Although we cannot provide our patients with the newest health care technology, we can provide them with extra time for them to share their stories with us, tell us how they got to where they are. I believe these small moments where we stop and learn more about our patients, and take care of them outside of their pathologies, is how we can maintain these fundamentals of medicine. Although we do not get the same luxury of time with most of our patients from third year and beyond, I do believe that we can take some of the fundamentals we learn in these beginning clinical experiences throughout the rest of our career. That instead of seeing technology as a divider amongst physicians and patients, we utilize it as a tool to even better the relationships we maintain with our patients. Allowing technology to do its job of making some aspects of our role easier to allow us to free up time to be better providers for our patients. Because at the end of the day, no type of technology can replace the encouragement from an entire room full of people while a mother is in labor. Or the sheer moment of joy when a physician hands a newborn baby to their mother for the first time. Nor the empathy and comfort, during moments of grief and illness that only a person can provide another person. If we always remember our patients as people first, rather than as pathologies or “learning opportunities,” I am confident that we will always preserve the essentials of humanism and ethics in medicine no matter how advanced the technology gets. May/June 2019

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

A Medical Student’s Take on Duty Hours By Elijah Abramson, MS III elijahabramson@gmail.com

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

on wellness at each level is important, perhaps no more so than at the resident level. In 2003, ACGME limited resident workweeks to 80 hours and shifts to 30 hours. Changes made in 2011 limited shifts to 16 hours for first-year residents. Current ACGME requirements limit residents to an 80-hour workweek with a maximum of 24 hours in one shift, and if a resident has a 24-hour shift it must be followed by 14 hours free of clinical work. Whether all programs follow these guidelines is open to speculation. One active study that tests these limits is the controversial iCOMPARE study at Johns Hopkins. Early results published in the New England Journal of Medicine measuring the impact of “flexible” (longer than 16 hours) shifts show “no significant difference in the proportion of time that medical interns spent

Photo: California Northstate University

THE DEMAND OF RESIDENCY WORK HOURS is well known to medical students and much of the general population. Forty-eight-hour shifts and 100-hour workweeks are among the most infamous hazing aspects in medicine. The good news is that awareness surrounding medical student, resident physician, and practicing physician wellness has bellowed its way to the forefront of the national dialogue. My medical school, California Northstate University College of Medicine, has a dedicated Wellness Committee. Nationally, the Accreditation Council for Graduate Medical Education has tinkered with duty hour restrictions. Kaiser has instilled wellness initiatives for their physicians. At each level, from pre-medical student to practicing physician, challenges and sacrifices of work-life balance are necessary. But a focus

California Northstate University offers yoga classes through its student wellness program.

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on direct patient care and education.” While program patient outcomes, which is why it is unsurprising why directors were more satisfied using flexible hours than a New York study found that violation of duty hours is with standard duty-hour programs, interns were less most prevalent in surgery. Lost in the concept that more satisfied with their longer shifts and overall educational training equals better physicians is that it also means fewer experience. physicians: a 2017 publication in JAMA Surgery found Prior to the recent attention to wellness, patient care the attrition rate to be 18 percent among general surgery and physician performance were the only metrics considresidents and higher than for other specialties. ered. While these are intuitively critical factors to training Medical students have uncountable external forces physicians, wellness is required for—and not separate in deciding their specialty. My personal preference is for from—patient care and physician performance. Work-life a hands-on, tangibly rewarding practice with excitement balance is important unless we prefer to neglect morbidity and technical skill. Naturally, like many others with a (burnout) and mortality (suicide) in medical professionals. similar preference, EM and surgery are at the top of my We are making headway in acknowledging the differential. One factor I must consider is the minimum problems of resident duty hours and resident wellness. 20-hour per week discrepancy between EM residents and Thoughtful studies and ACGME modifications are imporsurgery residents. tant ways of optimizing resident wellness. We have reached The right shifts in the medical professional culture near-unanimous agreement that 100-hour weeks “because are occurring. The effort to maximize the wellness of that is how it is” are not logical. The goal is to train future trainees who face emotional and physical demands—both physicians to be the best physicians possible, not to subject inside and outside of medicine—unlike almost any other them to endurance tests. profession needs to continue for the benefit of patients Prior to medical school, I educated K-12 and college and future physicians. The growing emphasis on workstudents in a variety of settings from one-on-one tutorlife balance means many bright and talented people ing to classroom teaching. Nowhere outside of medical may choose to forego the arduous hours of training and education are hours for the sake of hours instilled so prematurely step away from a career in surgery, which is a instrumentally. Educational performance is undoubtedly loss to patients and our profession alike. maximized when students are truly in a good place physically, emotionally, and academically. INC. So how do residency duty hours apply A R E G I S T R Y & P LACEMENT FIRM to me, a third-year medical student, and the choices ahead? I am on the cusp of choosing my pathway Physicians forward and currently deciding between emerNurse Practitioners ~ Physician Assistants gency medicine (EM) and surgery. Similar to other students with the same dilemma, the difference in hours will have an impact on my decision. EM is an increasingly competitive field in part due to more progressive attitudes toward resident wellness, including the American College of Emergency Physicians recommendation of 60-hour work weeks for Locum Tenens ~ Permanent Placement resident physicians. Surgery, by contrast, remains one of the V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 more “traditional” specialties when it comes FA X : 8 0 5 - 6 4 1 - 9 1 4 3 to work hours. The FIRST Trial, published in

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the New England Journal of Medicine, highlighted that fewer restrictions on work hours for surgical residents did not result in worse

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m

May/June 2019

SSVMS Honors Medicine The Sierra Sacramento Valley Medical Society honored medicine at a gala event February 28 at the Tsakopoulos Library Galleria in Sacramento. Comedian Jack Gallagher had a room full of 250 physicians, medical students and guests laughing to start the evening, but the night focused on honoring SSVMSâ&#x20AC;&#x2122; 2018 award recipients. The evening raised over $10,000 to support SSVMSâ&#x20AC;&#x2122; SPIRIT program and Medical Student Scholarship Fund. It was wonderful to honor medicine as a community. Thank you to everyone who attended!

SSVMS Pre

Eric Tepper, MD and Rick Jones, MD

From left: SSMVS President Christian Serdahl, MD; Golden Stethoscope recipient Denise Satterfield, MD; CMA Trustee Margaret Parsons, MD Lydia Wytzes, MD, Alicia Abels, MD, Craig Senders, MD (Senders Wine)

SSVMS Board Members Drs. J. Bianca Roberts, Vanessa Walker, Rajiv Misquitta, Vijay Rathore, Sean Deane, Christian Serdahl, Ranjit Bajwa, John Wiesenfarth, Paul Reynolds, Roderick Vitangcol

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Margaret Parsons, MD, Medical Honor recipient David Herbert, MD, SSVMS President Christian Serdahl, MD

esident-Elect (and auctioneer extraordinaire) John Wiesenfarth, MD SSVMS Medical Student Scholarship award recipients (from left) Lisa Teixeira, MS I, Cristina Monterroza, MS III, and Kayla Sheehan, MS III are joined by Margaret Parsons, MD

Above: Cache Yorke (left) and Stacie Walton, MD; below, Adam Dougherty, MD and April Dougherty

Photos by David Flatter (flicker.com/davidflatter)

Society for the Blind was honored with the Medical Community Service Award

May/June 2019

For Medi-Cal Kids, You Can Make Every Smile Count By Margaret Delmore, MD, DDS margaretdelmoremd@gmail.com

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

CAVITIES ARE ALMOST 100 PERCENT preventable, yet dental problems are the reason that more than half a million of California’s school-aged children miss at least one school day per year. In Sacramento County, approximately 47 percent of oral health-related emergency department visits for children from newborn to age 20 in 2016-2017 were for preventable conditions. The oral health of our child patients can be dramatically improved with a physician’s help. Because children are more likely to access medical care than dental care, with well-baby visits generally beginning soon after birth and continuing throughout childhood, as the medical provider you have the opportunity be on the front lines of assisting young children and their families in preventing dental decay. The Dental Transformation Initiative, a federally funded component of California’s Medi-Cal 2020 waiver, aims to address the state’s position as having one of the lowest utilization rates in the country for dental care services by Medicaid (Medi-Cal) beneficiaries ages 0-20 years. This is being done by incentivizing continuity of dental care, increasing reimbursement rates for specific preventive dental procedures for Medi-Cal dental providers and through the implementation of local dental pilot projects. This funding and support demonstrate that our federal and state governments view access to dental care as critical to achieving better overall health outcomes for Medi-Cal beneficiaries, particularly children. Sacramento County is one of 13 entities in California to be funded by the California Department of Health Care Services to participate in a local dental pilot project. Every Smile Counts!, Sacramento County’s project, is impleSierra Sacramento Valley Medicine

menting three pilots over the course of threeand-a-half years to reinforce good oral health practices and increase utilization of dental services by 5 percent annually: • A “virtual dental home,” in which providers such as dental hygienists and registered dental assistants work under the auspices of a dentist to provide dental care in places where people work, play, attend school and receive social services. • Community outreach and parent education, in which community health workers reach out to families to provide oral health education and help them gain access to the services they need, and • A medical-dental partnership that provides more opportunity to identify and prevent oral health problems. Of the three pilots, the medical-dental collaboration pilot is the one in which physicians should take particular interest. It aims to engage medical professionals in providing oral health education, stressing prevention, brushing, flossing, and advising parents to take their child to a dentist when their first tooth comes in or by their first birthday. “First tooth or first birthday” is an especially important mantra that all medical providers should follow by encouraging families to have a dental check by the arrival of the child’s first tooth or first birthday, whichever comes first. Physicians can also play the important roles of applying fluoride varnish in a medical setting twice per year, referring children on Medi-Cal to their assigned dentist, and conducting a caries risk assessment that looks at the positive and negative behaviors that influence the likelihood of dental disease. I know what you are thinking: Just what

Photo: Mei Lin Jackson

Dan McCrimons, MD conducts a wellness visit that includes a look at the child’s oral health.

I need, more to add to my already crammed schedule. But Children Now, a statewide advocacy, policy and research organization focusing on children’s issues, can help. Children Now will train primary care physicians and their staff on how to educate children and families about oral health, navigate children and their families to the appropriate dental facilities, and administer and bill for preventive dental services such as dental screenings, caries risk assessment and fluoride varnish. Integrating a dental professional into your medical team can also foster the bilateral transfer of learning. The medical-dental collaboration pilot program became operational in July 2018 at clinics owned by River City Medical Group (RCMG), one of the area’s largest Medi-Cal dental providers. RCMG employs, through DTI funding, a support services navigator who coordinates dental services and an oral health educator who explains the importance of regular dental visits and follows up with the family after a visit. Additional state funding also supports the hiring of two part-time registered dental hygienists in alternative practice to enhance the medicalcollaborative team. As a physician, you can be an important part of ensuring patients, and especially children, maintain their oral health. Look at the teeth, gingiva and soft tissues of all patients to perform oral health screenings and help identify factors impacting oral health and overall health. (I’m always impressed with the physicians that know the numbers of the teeth. By the way, it’s letters for primary or baby teeth.) If there is a problem, communicate with the patient’s dentist. We don’t bite.

Ask patients and parents if they have a dentist. If not, direct them to Sacramento Covered at (866) 850-4321 for assistance finding insurance and a dental provider. You should also educate families on “first tooth or first birthday” and how cavities and dental disease are preventable. Encourage them to promote oral hygiene by brushing twice a day for at least two minutes and choosing water instead of sugary drinks. (Just remember the phrase, “Rethink your drink.”) SSVMS members can access information on how to make a dental appointment for their patients and educational materials for parents in many languages at first5sacdental.org/esc.resources. As the immediate-past president of the Sacramento District Dental Society, I implore you to call us if you need help and to join SDDS on its mission to enhance the oral health of the community. As Nelson Mandela said, “There can be no keener revelation of a society’s soul than the way in which it treats its children.” Children are indeed our most valuable future resource, and we can’t let them suffer from dental neglect. Consider adopting the medical-dental partnership protocol in your office. For more information on the medical-dental pilot program, contact Katie Andrew at Children Now at (916) 379-5256, extension 134 or email her at kandrew@childrennow.org.

El Dorado Smiles El Dorado County’s year-old version of Every Smile Counts!, dubbed El Dorado Smiles, is placing its initial focus on children’s oral health. Less than 1% of El Dorado County MediCal children under a year old and 17% of children between age one and two had a dental visit for any procedure during the measurement year (2016). Pediatricians and family medicine providers interested in additional information regarding El Dorado Smiles or integration of oral health into their primary care practice may contact Cathy Larsen at El Dorado County Health and Human Services, (530) 621-6313 or at cathylarsen@edcgov.us.

May/June 2019

Keep Your Eyes Open for New Sources of Lead Poisoning Immigrant Remedies, Cultures Present New Challenges By Jeffrey Rabinovitz, MD and Olivia Kasirye, MD jjrabinovitz@gmail.com, kasiryeo@saccounty.net

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to SSVMedicine@ ssvms.org.

MOST PHYSICIANS ARE AWARE of the dangers of environmental lead, and many of us were trained to consider the risks of exposure to lead from old paint chips or from soil contaminated by gasoline additives. But as the demographics of our society change, there are new, and surprising, sources of lead exposure that deserve the attention of all providers, especially those who treat children. The most common source of lead exposure was from lead-based paint seen in homes built before 1978, when its use was banned. Exposures continued to occur for years, due to improper repair or renovation activities in the home. Over time, there has also been a marked reduction in the amount of lead in car and truck fuel, and this has had a positive impact on environmental lead exposure. However, lead in aviation fuel persists as do other environmental and occupational sources. Blood lead levels (BLL) above 5 ug/dl are traditionally considered to be elevated, but studies show that there is no safe BLL. With BLL above 5 ug/dl, a child may experience an IQ deficit of 6 points. One-half-million children 1-5 years old have BLL over 5 ug/dl. According to the Centers for Disease Control, lead exposure can also lead to ADHD, juvenile behavioral issues, delinquency, and hearing and speech problems. This is clearly a serious problem to which many of us have not paid enough attention. There are blood lead testing mandates in California, and all children on Medicaid are required to be tested at ages 12 to 24 months regardless of any other risk factors. We often assume that these are children in low-income families who live in older homes

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Surma, used in many cultures as eyeliner, may be contaminated with lead.

where they are more likely to encounter peeling paint, water contaminated by lead service lines, lead solder in pipes, or brass fittings and faucets containing lead. But many other children not covered by Medi-Cal who also live in older homes, espÂecially in midtown and downtown, are at risk. New challenges are presented by our immigrant population, and we should follow blood levels in this population more closely. Immigrants from India, Southeast Asia, China, the Middle East, or Hispanic countries may be exposed to ceramics, medicinals, cosmetics, spices, and other items that have high lead content and are potentially dangerous. We should consider testing all immigrants, refugees, and international adoptees for in utero exposures from their birth countries, as well as for specific post-natal exposures. We must have a high index-of-suspicion

when we find our patients have been given traditional folk remedies for gastrointestinal upset and other symptoms. For example, Mexican folk remedies for gastrointestinal illnesses may include lead oxide-containing products such as azarcon and greta. These may also be used for teething babies. Daw Tway, shown in samples to contain as much as 970 parts per million of lead, is used for colic in Thailand and Myanmar. In general, items imported from home countries present the greatest risk. In Arabic and Middle Eastern countries, traditional home remedies and cosmetics (including some for religious ceremonies) may also be contaminated with lead. These include (in transliteration): surma, esfand, ghutti, zarchoba, zagafel, khakshir, alkohl, sattarang, bokoor, ceruse, and cerrusite. In South Asia, products of concern include surma, sindoor, ghasard, bala goli, and kandu. The Hmong use pay-loo-ah, a red powder for fever or rash. Imported personal care products such as mustard seed and almond oil for hair may be contaminated. Dollar Tree makeup and some Vichy face creams have also been found to contain lead. So, what do we do? We make sure we are aware of these and other sources of lead. Questionnaires have been created, including by the Sacramento County Department of Public Health, to help with lead poisoning prevention. These should be given to those in high risk populations and could prompt us to check a blood lead level in a child where exposure may not have been suspected. If the level is elevated, Public Health should be notified so steps can be taken to remove the source of lead.

• Lead can affect children’s brains and developing nervous systems, causing reduced IQ, learning disabilities, attention problems, executive function disorders and behavioral problems. • No level of lead in the blood is safe. Low level exposure which causes no symptoms at the time of the exposure can result in cognitive deficits later in childhood. • Lead has been found in folk remedy powders and tablets given for arthritis, infertility, upset stomach, menstrual cramps, colic and other illnesses. • Greta and azarcon are Hispanic traditional medicines taken for an upset stomach, constipation, diarrhea, and vomiting. They are also used on teething babies. Greta and azarcon are both fine orange powders with lead content as high as 90%. Sources: CDC, California Department of Public Health

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May/June 2019

MEDICAL INNOVATION

First Uterine Transplant From Deceased Donor Offers Hope By Marissa Chinn, MS III Marissa.Chinn8874@cnsu.edu MORE THAN SEVEN MILLION AMERICANS used infertility services from 2011 to 2015, according to the latest figures from the Centers for Disease Control, driving growth in research to seek new answers for women and families who desire children. Uterine infertility, which was previously labeled as the only type of untreatable infertility, has now become a subject of extensive research. The primary etiologies include malformation, infection, andâ&#x20AC;&#x201D;most commonlyâ&#x20AC;&#x201D;unexpected hysterectomy. For approximately one out of every 500 women who face infertility, uterine infertility is the cause. Prior to 2013, women with uterine infertility only had two options for childrearing: adoption or surrogacy. But research on uterine transplantation, which began with live donors and has now progressed to using deceased donors, gives women with uterine infertility another option. In December, the University of Sao Paolo in Brazil reported the first case of a baby born from a recipient of a deceased donor. Although the results were only recently published in Lancet, the birth actually occurred in December 2017, four years after the first successful birth from a uterus that was transplanted from a live donor in Sweden. Swedish doctor Mats Brannstrom, who pioneered uterine transplants, has delivered eight children from women who received wombs from family members or friends. Two babies have also been born at Baylor University Medical Center in Texas and one in Serbia as the result of transplants from living donors. Prior to this success in Brazil, there were ten failed attempts with a deceased donor in the Czech Republic, Turkey and the U.S. The patient in Brazil who successfully gave birth was described as a 32-year-old woman who was 24

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born without a uterus due to Mayer-RokitanskyKuster-Hauser Syndrome, or MRKH, which affects one in 4,500 newborn girls. In MRKH Syndrome, women will have a female chromosome pattern, normally functioning ovaries and external genitalia, but the vagina and uterus may be underdeveloped or absent. The cause is unknown. Some cases of MRKH Syndrome affect other organs outside of the uterus; however, this patient had no cardiac, renal or bone structural abnormalities. Four months prior to transplantation, in-vitro fertilization produced eight cryopreserved blastocysts. The uterine donor was 45 years old, had three previous vaginal deliveries and died of a subarachnoid hemorrhage. She was a multiple organ donor: heart, liver, kidneys and uterus. During the transplantation, the explanted uterus endured just under 8 hours of ischemia, approximately twice what had been reported with cases of live donors. This was longer than planned due to priorities in coordination and retrieval sequence of organs. This case also reduced the amount of time between surgery and embryo transfer. The Swedish studies waited one year between transplantation and embryo transfer, whereas the goal for the case in Brazil was six months. However, the procedure was postponed by one month due to inadequate thickness of the endometrium. Overall, the total time of immunosuppressive therapy was shortened leading to decreased total cost and lower risk of side effects in the patient. Total operating time for the recipient was 10.5 hours. It is expected that the length of uterine transplant surgery will decrease in the future, as was the case for other organ transplants, with advancements in technique and experience.

After having just celebrated her first birthday, baby and mother are both healthy, and the child’s growth parameters are normal. The baby girl, who weighed 2,550 grams, was born by cesarean section at 35 weeks and 3 days with APGAR scores of 9, 10 and 10 at one, five and 10 minutes respectively. The timing of the cesarean section, between 35 and 36 weeks gestation, follows the recommendation of the Swedish study. During the cesarean section, the transplanted uterus was removed. Unlike transplants of other organs, the donated uterus is not intended for lifelong use and may be taken out after delivery, ceasing the need for immunosuppressive drugs. Uterine transplantation remains a fairly new concept, and surgical techniques and protocols require further refinement. However, there is great promise for continued Member Testimonial success in the future. Currently, a team at the Cleveland

Clinic is working with deceased donors while a team at Baylor is working with both live and deceased donors to further study uterine transplantation. Research in uterine transplantation may also provide a better understanding of pregnancy and the uterus. The birth in Brazil was unlike any that came before. It was a milestone for the medical community, the new mother, and all who will be affected by its future implications. It offers new optimism to women who otherwise would not have the opportunity for pregnancy and deceased donors can theoretically provide transgender women with the opportunity to become pregnant. The novel treatment could provide welcome opportunities in family planning—and a greater sense of hope—for many people in the future as research in the field continues to grow.

“Being part of organized medicine is imperative for any physician. You are connected with many helpful physicians who have been in your shoes at one point or another and can help answer any questions. SSVMS takes pride in seeing that physicians’ needs are met.” Drs. Anand and Leena Mehta

Med Students Make Capitol Visit to Support Vaccinations

Medical students from UC Davis and California Northstate University attended a press conference in March to show support for SB 276, a bill by State Senator Richard Pan, MD (center) to strengthen the medical exemption process. Dr. Pan said some schools are reporting that 20 pecent of their students have received exemptions from vaccination, placing students at risk of being needlessly exposed to disease. SB 276, co-authored by Assemblywoman Lorena Gonzalez, would require state-level public health approval of all exemptions.

May/June 2019

Saving Lives In Sacramento Through Collaboration By William Bommer, MD and Susan Ivey, MD wbommer@gmail.com, sivey@berkeley.edu THE 2018 SACRAMENTO COUNTY Health Status Report shows that an average of 1,609 people died each year from coronary heart disease (CHD) from 2014 through 2016, and that another 636 deaths occurred as a result of stroke. Together, that means there were 2,245 Sacramento deaths annually that could have been prevented. Sacramento’s age-adjusted mortality rates of 103.2 per 100,000 for CHD and 41.7 per 100,000 for stroke are significantly higher than the age-adjusted average death rates for both diseases statewide (89.1 per 100,000 for CHD, 35.3 per 100,000 for stroke). Similarly, Sacramento rates have not improved over time in parallel with other counties in our state. A number of international, national and regional models have been put forward that could lower Sacramento County’s higher heart attack hospitalization, CHD and stroke death rates. Million Hearts from the U.S. Department of Health and Human Services, South Carolina’s Hypertension Initiative, Canada’s Ontario Primary Care Education Program, and Maine’s Franklin County communitywide Cardiovascular Disease Prevention Collaboration have all been associated with

both a reduction in cardiovascular risk factors and lower hospitalization and mortality rates for CHD and stroke. Within California, the Right Care Initiative has implemented countywide physician organization learning collaboratives called University of Best Practices (UBP). Launched by the UC Berkeley School of Health, the first UPB was in San Diego County, where major health care systems and physician organizations shared best practices in managing cardiovascular and cerebrovascular risk factors. In a recent effort to assess the success of UBP San Diego, a UC Berkeley study compared age-adjusted heart attack hospitalizations in San Diego to four other California counties using Office of Statewide Health Planning and Development hospitalization data. The difference-in-difference analysis showed that heart attack hospitalizations were dropping more rapidly in San Diego County compared with other counties in the state (including Sacramento) with a 16.5% drop in acute MI hospitalizations. A nearly 20 percent reduction was seen in San Diego’s rate of hospitalizations for heart attack beginning in 2010 co-incident with the start of the San Diego UBP program.

Sacramento heart attack rates climbed from 2010 through 2014… Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.

Myocardial Infarction Hospitalization Rate, 2010-2014

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An economic analysis concluded that the reduction in heart attacks provided a projected health care cost savings of $61 million over the four years analyzed. What can we do to reduce cardiovascular disease in Sacramento? We know it can be done. INTERHEART, a 2004 Canadian study, showed that only nine risk factors—smoking, hypertension, diabetes, obesity, raised lipid ratios, stress, diet, level of alcohol consumption, and lack of exercise—were responsible for 90-94 percent of the attributable risk for heart attacks. Elimination of these risk factors could eliminate most heart attacks. Although all of our health care systems and providers are aware of these risk factors, getting our patients to achieve the goal of eliminating them is often difficult. Right Care’s UBP explores educational and system management approaches that can enhance patient lifestyle changes and promote optimal medical treatment acceptance and compliance. In view of the high rates of CHD and stroke events in Sacramento and the UBP success in reductions of acute MI hospitalizations in San Diego, the UBP was expanded to Sacramento (2012), Los Angeles (2013), and San Jose (2018). Since 2013, Sacramento’s UBP programs have reviewed guidelines on lipids, stress, blood pressure, smoking cessation, and diabetes control with Right Care Initiative members and partners on a regular schedule. However, not all members and partners are actual providers. The Sierra Sacramento Valley Medical Society (SSVMS) provider members are really the boots on the ground for Sacramento County patient care, and its involvement is also critical to achieving the UBP guideline-directed patient goals of LDL<70-100, SBP<130, HbA1C<7-8%, BMI 18.5-25, smoking cessation, stress reduction, a diet rich in fruits/vegetables, and physical activity of 30 minutes per day at least 5 days each week. To help reach these individual providers, the Right Care Initiative has

developed a website with all of the educational guideline presentations. It can be found at rightcare.berkeley.edu. In addition to the website and monthly Sacramento UBP meetings, Right Care is now available to make presentations to area health care providers and community organizations about the proven ways to reduce cardiovascular disease (contact Hattie Hanley at hattiehanley@berkeley. edu). The possibility of reaching more providers and ultimately more patients improves our chances of reducing CHD and stroke events in Sacramento. Although lifetime risk reduction could eliminate cardiovascular events in almost all patients, clinicians are often faced with reducing events in patients with well-established cardiovascular disease. Unfortunately, the reversal of atherosclerosis is currently a slow process and despite the success of current therapies in reducing secondary cardiovascular events by 20-50%, there remains a 50% residual risk of events. This is because years of plaque buildup are not quickly reversed with even optimal lifestyle change or with medical or surgical therapy. Is there also hope for these patients? Revascularization combined with optimal medical therapy can also offer symptom relief in many patients and can be life-saving in acute coronary and stroke events. Promising new therapies are also on the horizon for atherosclerosis, including medications (anti-platelets, anticoagulants, anti-inflammatories, enzyme inhibitors, statins, PCSK9 inhibitors, omega-3 fatty acid esters, anti-sense oligonucleotides, triglyceride reducers, anti-glycemics), stem cells, nanotechnology, 3D printing, robotics, and personalized DNA-directed medicine. We can look forward to a promising future. But let’s not wait for the future. We have the knowledge and the tools to reduce heart attacks, strokes, and cardiovascular death. If we all work together, we can save lives in Sacramento today.

While San Diego County’s rates dropped and were significantly lower.

May/June 2019

Presenter: Mitzi Young California Medical Association Center for Economic Services

Saving Private Practice: Key Strategies for Practice Success Dinner Presentation

Wednesday, May 15, 2019 Registration & Dinner at 5:30pm | Presentation 6:00pm-8:00pm Sierra Sacramento Valley Medical Society, 5380 Elvas Ave. Sacramento, CA 95819 No cost for SSVMS Physician Members | Non-Members: $10 RSVP with Mei Lin Jackson at mjackson@ssvms.org or call (916) 452-2671

SSVMS Vetted Vendor Partners to Help You Thrive:

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OBITUARY

RESILIENCY CONSULTATIONS Recognizing the crushing stress and work load that physicians face today, SSVMS sponsors up to six (6) lifetime sessions with licensed and vetted psychologists and life coaches for physicians living and working in Sacramento, El Dorado, Yolo and Placer Counties. Counseling and coaching through this program are confidential, competent, convenient, and cost-free to physicians. Since the program’s inception, over 50 physicians have accessed the service with over 175 appointments. Currently, there are five psychologists and three life coaches available to any physician in the region. To access this service, visit October 11, 1936-March 14, 2019 www.joyofmedicine.org to schedule your appointment.

50+ physi 175+ sess

James Knoblock Hepler, MD

JAMES KNOBLOCK HEPLER, MD died peacefully of care. He was certified byJOY the American Board of- Obstetrics OF MEDICINE ON CALL pulmonary disease on March 14, 2019 in Sacramento and Gynecology and a member of the American College In September 2018, SSVMS launched Jo of Obstetrics and Gynecology and the Northern California California at the age of 82. Medicine - On Call, a podcast where we OB-Gyn Society Born October 11, 1936 in Mishawaka, Indiana, he the many paths physicians take to bring Usually the brightest person in the room, Jim was spent most of his early years, along with his siblings, of medicine. The podcast a alsotheir the practice most curious. His recollechelping his parents run the family andand increase accesswas to physicia tionpromote of history geography poultry farm. He graduated from by focusing on continued topics of mindfulness, man amazing, and he to take the Bremen School where he was stress and joy. Download and subscribe courses throughout his life, including valedictorian. Jim earned a B.S. in or classes your favorite app by searchi video at homepodcast from The Great 1958 from Purdue University and “Joy of - On Call”. Courses. HeMedicine attended the Renaissance received his MD at the University of Society at CSUS, studying everything Cincinnati Medical School in 1962. from Shakespeare to the iPhone. He interned at Sacramento County Behind that occasional gruff exteHospital from 1962-1963. rior was a kind and noble man who loved a good joke After his internship inANNUAL 1963, he served in the military JOY OF MEDICINE SUMMIT and an interesting conversation. hadlocal a long and loving at James Connally Air Force Base in Texas until 1965, SSVMS’ 2nd Annual Joy of Medicine Summit successfully providedHe 175 physicians with the to marriage, an outstanding career and a wonderful family. followed by his OB/Gyn Residency at Kaiser Foundation resources needed to cope with the stressors that are part of practicing medicine. This half-day sum Jim and Phyllis filled their home with their beloved cats, Hospital in San Francisco from 1966 to 1969. featured sessions on journaling, happiness and working with the EHR. Save the date for the 3rd A often strays, and many friends, both lifelong and new ones The Kaiser Permanente Medical Group in Sacramento of Medicine Summit scheduled for September 28, 2019. they cultivated through their varied interests. hired him in January, 1969. He was appointed to the In retirement he continued his life of service and clinical (volunteer) faculty of the University of California pursued his many interests. Jim was a wine enthusiast, a Medical School at Davis in February, 1972 and served history buff, and a lover of classical music, as well as an as Chief of OB/Gyn at Kaiser from 1972 to 1978 and outdoorsman and an athlete. He loved to fish and was an Assistant Chief from 1995 until his retirement in 1998. PHYSICIAN PEER GROUPS avid birder. He coordinated the OB/Gyn residencycollegiality program from its physicians To promote among fromA passionate cyclist, a road bike took the spot in the garage once held by his treasured Avanti. He took inception in 1978 and, “in the early days,” held weekly various health systems and practices in the spin classes (indoor cycling) with people half his age until classes, precepting and mentoring the Family Nurse Sacramento region, Physician Peer Groups monthly he was nearly eighty, and worked with a personal trainer Practitioner program. sessions are held in colleagues’ homes in Davis, and attended Pilates classes until weeks before his death. His wife of 50 years, Phyllis, was as lively and spirited Elk Grove, Newcastle, Carmichael andHe El was Dorado preceded in death by his wife, Phyllis, and his as Jim was intellectual and pragmatic. Jim adored this and Hills, with more the way. OverJim 60 will be dearly missed by his brother and sister parents. he was her devoted companion until her locations death in on 2013. physicians participate facilitated in Indiana, his many nephews and nieces, and all of those They had a wonderful life enjoying actively travel, the arts, and in these group interactions. To sign up for a peer group, lucky enough to call him a friend. their close friends and extended family. visit www.joyofmedicine.org. Per Jim’s request, no services will be held. Donations Jim was an exceptional physician, specializing in in his honor may be made to the SSVMS Medical Student high-risk pregnancies. He was respected by his peers and Scholarship Fund or the charity of your choice. the thousands of families he helped with his outstanding

ing f ne

www.JoyOfMedicine.org May/June 2019

Board Briefs March 11, 2019 Meeting The Board: Welcomed David Lubarsky, MD, MBA, Vice Chancellor of Human Health Sciences and CEO for UC Davis Health. Dr. Lubarksy shared his vision for UC Davis Health. Welcomed Senator Richard Pan, MD, representing Senate District 6 and Chair of the Senate Health Committee. Senator Pan provided a legislative update. Approved asset allocation investment policy changes for SSVMS General & Building Funds, the Community Service, Education and Research Fund, the Scholarship Fund, and the Employee Money Purchase Pension Plan. Approved an investment recommendation for the

Scholarship Fund utilizing a percentage of the portfolio with a smoothing method. Approved the Fourth Quarter 2018 Financial Statements and Investment Reports.

Approved the Following Membership Reports: January 28, 2019 For Active Membership — Rekha Cheruvattath, MD; Thomas Imperato, MD; Gilbert Luceno, MD. For Retired Membership — Weldon Jordan, MD; Dana Miller-Blair, MD; Sadha Tivakaran, MD; Gary Whiting, MD. For Resignation — Cesar Estela, MD; Joey Kenney, MD; Hailey MacNear, MD; Christina Ward, MD; Azeza Uddin, MD. March 11, 2019 For Active Membership — See the list of 764 UC Davis Health physicians approved for Active Membership under New SSVMS Members. For Reinstatement to Active Membership — William Bommer, MD; Emma Garforth, MD. For A Change in Membership Status from Retired to Active — Michael Lawson, MD; Thomas Nesbitt, MD. For Retired Membership — Thomas Atkins, MD; James Boggan, MD; David Bovill, MD; Marcia Britton-Gray, MD; Mitra Choudri, MD; Jean Cordalis, MD; Don Finegold, MD; Scott Gylling, MD; Steven Kelly-Reif, MD; David Kosh, MD; David Siegel, MD; John Struthers, MD. For Transfer of Membership — James Gehrig, Jr., MD (to San Diego). For Resignation — Martin DuFour, MD (moved to North Carolina); Hailey Macnear, MD.

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New SSVMS 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. New Active Members for May/June 2019 *Physician specialty abbreviated following name. Zachary Edgar Brewer, MD, CDS, Mercy Medical Group Eric Hodes, MD, AN, Dignity Health Jean Woo Lee, MD, HOS, Mercy Medical Group

Christel Dizon Miranda, MD, FP, Mercy Medical Group Patricia Sierra, MD, OPH, Sacramento Eye Consultants

SSVMS is pleased to welcome over 700 physicians from UC Davis Health:

Lily Chaput, MD, IM Gurtej Cheema, MD, RHU Ritu Cheema, MD, PDI Dillon Chen, MD, MSR Jenny Chen, MD, OPH Melissa Chen, MD, OBG Patricia Chen, MD, IM Jennifer Chen, MD, IM Mingyu Cheng, MD, PTH James Chenoweth, MD, EM Helen Chew, MD, HO Michael Chew, MD, HOS Yung-wei Chi, DO, CD Catherine Chia, MD, HOS Nipavan Chiamvimonvat, MD, CD May Cho, MD, HO Shelley Choi, MD, HOS Helen Chow, MD, HO Matthew Chow, MD, N Scott Christensen, MD, HO Katerina Christiansen, MD, IM Wendy Chu, MD, HOS Jong Chung, MD, PHO Shannon Clark, MD, OBG Cheryll Clark, MD, PD Samuel Clarke, MD, EM Julianna Clark-Wronski, MD, AN Raul Clavijo, MD, US Terry Coates, MD, R Christine Cocanour, MD, GS Daniel Colby, MD, EM Steven Colquhoun, MD, TTS Blair Colwell, MD, PCC David Cooke, MD, TS Angela Cortez, MD, SME Michael Corwin, MD, R Scott Crabtree, Jr., MD, IM Mitchell Creinin, MD, OBG Carroll Cross, MD, PUD Stephanie Crossen, MD, PDE Eric Crossen, MD, PD Brian Dahlin, MD, NR Marc Dall’era, MD, U Lorien Dalrymple, MD, IM Megan Daly, MD, RO Aaron Danielson, MD, EM Amanda Darling, MD, PAN Morgan Darrow, MD, PTH Dattesh Dave, MD Jon Davids, MD, OP Loren Davidson, MD, PM Brian Davis, MD, PM Molly Davis, MD, FP David Dawson, MD, VS Jonathan Dayan, MD, PD Ashok Dayananthan, MD, N Charles De Mesa, DO, PMD

Mehrdad Abedi, MD, HO Sonia Acevedo Espinoza, MD, FP Thomas Acton, DO, FP Jason Adams, MD, PUD Alaa Afify, MD, PTH Lia Africa, MD, HOS Oma Agbai, MD, D Sara Aghamohammadi, MD, PD Alicia Agnoli, MD, FP Shirin Ahmad, MD, RHU Jillian Ahrens, MD, ID Marcy Ahrons, MD, PD Thomas Alan, MD, IM Carol Albanese, MD, PM Timothy Albertson, MD, EM Robin Aldwinckle, MD, APM Amar Al-Juburi, MD, GE Robert Allen, MD, ORS Roblee Allen, MD, PUD Muna Alnimri, MD, NEP Elysia Alvarez, MD, PD Shadi Aminololama-Shakeri, MD, DR Ezra Amsterdam, MD, CD Shubha Ananthakrishnan, MD, NEP Dua Anderson, MD, AN John Anderson, MD, GS Emily Andrada-Brown, MD, PEM Kathleen Angkustsiri, MD, DBP Reuben Antony, MD, PD Suresh Appasamy, MD, NEP Michelle Apperson, MD,PhD, N Patricia Jean Applegate, MD, CD Tyron Arnott, MD, IM Paul Aronowitz, MD, IM Mili Arora, MD, HO Shawna Arsenault, MD, PM Sharon Ashley, MD, AN David Asmuth, MD, ID David Asseff, MD, AN Keerthi Atluri, MD, PM Huma Attari, MD, P Mark Avdalovic, MD, PUD Guadalupe Avila-Kirwan, MD, IM Smita Awasthi, MD, PDD Huong Bach, MD, IM Orode Badakhsh, MD, AN Amr Badawi, MD, IM Joanna Baginski, MD, HOS Runalia Bahar, MD, HOS Annie Baik, MD, OPH Stephen Banks, MD, RO Victor Baquero, MD, FP David Barnes, MD, EM Sarah Barnhard, MD, PTH

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Cyrus Bateni, MD, R Sara Baumann, MD, P Timothy Beamesderfer, MD, IM Craig Belon, MD, PAN William Benko, MD, PN Kristin Bennett, DO, AN Lars Berglund, MD, END Brigitte Berry, MD, IM Heather Bevan, MD, FP Arnaud Bewley, MD, OTO Anthony Bhe, MD, HOS Emilie Bhe, MD, PSM Jasjeet Bindra, MD, R Mary Bing, MD, MPH, EM John Bishop, MD, ATP Hugh Black, MD, PCC Alla Blinder, DO, IM Nina Boe, MD, OBG Christian Bohringer, MD , AN Richard Bold, MD, GS Victor Bonilla, MD, CD Alexander Borowsky, MD, PTH Robert Boutin, MD, DR Christopher Bowlus, MD, FPG Simeon Boyd, MD, MG Walter Boyd, MD, CTS Michael Boyd, MD, FP Alain Brassard, MD, D Alison Breen, MD, OBG Lisa Brown, MD, GS Ian Brown, MD, SCC Erin Brown, MD, GS William Brown III, DO, FP James Brunberg, MD, R Theresa Buckley, MD, SM Sara Bughio, MD, IM Radhika Bukkapatnam, MD, IM Thomas Bullen, MD, PD Barbara Burrall, MD, D Bhuvaneswari Burugapalli, MD, HO Lavjay Butani, MD, PN Robert Byrd, MD, PD Martin Cadeiras, MD, CD James Cafarella, MD, PD Ru Cai, MD, IM Michael Campbell, II, MD, GS Carolina Candotti, MD, IM Catalin Cantemir, MD, AN Robert Canter, MD, SO Noah Canvasser, MD, U Bianca Castellanos, MD, PD Daniel Cates, MD, OTO Puja Chadha, MD, P Eric Chak, MD, GE Cristina Chandler, MD, AN Jennifer Chang, MD, DR Jason Chang, MD, IM

Charles Decarli, MD, N Alison Delargy, DO, HOS Arthur DeLorimier, MD, PG Herman Devera, MD, AN Rajvinder Dhamrait, MD, AN Rodney Diaz, MD, OTO Gerald Diaz, MD, HOS Jacob Dima, DO, FP Constantine Dimitriades, MD, PCC Victoria Dimitriades, MD, PD Burl Don, MD, NEP John Dorsett, MD, PM Jennifer Draper, MD, IM Alexandra Duffy, DO, N Theresa Duong, MD, HOS Lilian Duru, MD, FP Denis Dwyre, MD, PTH Jonathan Eastman, MD, ORS Julius Ebinu, MD, PhD, NS Wetona Eidson-Ton, MD, OBG Daniel Eisen, MD, D Eva Escobedo, MD, R Christopher Evans, MD, U Maya Evans, MD, BIM Dali Fan, MD, CD Ghaneh Fananapazir, MD, AR Linda Farkas, MD, CRS Diana Farmer, MD, PDS Marcia Faustin, MD, FP Nasim Fazel, MD, D Terri Felix, MD, PD Joshua Fenton, MD, FP Erik Fernandez Y Garcia, MD, PD Jessica Ferranti, MD, P Nancy Field, MD, OBG Ellen Fitzpatrick, MD, ORS Neal Fleming, MD, AN Jonathan Ford, MD, EM Ruben Fragoso, MD, RO Kenneth Frank, MD, PD Peter Franks, MD, FP Marc Friedman, MD, AN Abigail Fruzza, MD, PDE Scott Fuller, MD, OTO Jamie Funamura, MD, OTO Joseph Galante, MD, GS Patrick Gamp, MD, CD David Gandara, MD, ON Mehul Gandhi, MD, NEP Nandini Gandhi, MD, OPH Regina Gandour-Edwards, MD, PTH Wendy Garabedian, MD, IM Jorge Garcia, MD, IM Juan Garcia, MD, GE Julie Gardner, MD, AN Amy George, MD, FPMRS Eugenio Gerscovich, MD, R Afshine Ghaemi, MD, FP Sepideh Gholami, MD, SO Adam Giermasz, MD, HEM Cherie Ginwalla, MD, PD Mauro Giordani, MD, ORS Fady Girgis, MD, NS Eric Giza, MD, ORS Nicole Glaser, MD, PDE Jocylen Glassberg, MD, OBG Eric Glassberg, MD, FP Vera Go, MD, IM Micaela Godzich, MD, FP Albina Gogo, MD, PD Alicia Gonzalez-Flores, MD, IM John Graff, DO, HMP Michael Greenberg, MD, AN Matthew Greer, MD, EM Jeffrey Gregg, MD, PTH Kelly Griffin, MD, FP Gary Gross, MD, OBG

Eric Gross, MD, EM Matthew Grow, MD, AN Ethelwoldo Guerrero, MD, IM Salvador Guevara, MD, CRS Dorina Gui, MD, ATP Delani Gunawardena, MD, IM Aili Guo, MD, END Asha Gupta, MD, GE Maria Gutierrez, MD, AN Noe Gutierrez, MD, FP Kelly Haas, MD, PG Maha Haddad, MD, PN Randi Hagerman, MD, PD Rosalie Hagge, MD, R Elilta Hagos, MD, FP Wissam Halabi, MD, CRS Allen Hall, MD, FP Rosemary Hallett, MD, AI Michelle Hamline, MD, HOS Moonjoo Han, MD, CCP Richart Harper, MD, PCC David Harrison, MD, ON Brian Haus, MD, ORS Nasim Hedayati, MD, GS Herman Hedriana, MD, OBG Heidi Henchell, DO, FP Mark Henderson, MD, IM Stephen Henry, MD, GM Oliver Hentschel, MD, HOS Kristin Herman, MD, PD Angel Herrera Guerra, MD, PD Donald Hilty, MD, P W. Ladson Hinton, IV, MD, P Shinjiro Hirose, MD, PDS Calvin Hirsch, MD, IM Hung Ho, MD, GS Jensine Ho, MD, IM Lisa Ho, MD, IM Rasmus Hoeg, MD, HEM Kristin Hoffman, MD, PD John Holcroft, MD, CCP James Holmes, MD, EM Zachary Holt, MD, IM Deborah Hong Lee, MD, AN John Hosoume, MD, IM Melody Hou, MD, OBG Poh How, MD, PhD, P Victor Huang, MD, D Thomas Hughes, MD, AN Christine Humphrey, MD, FP Misty Humphries, MD, VS Scott Hundahl, MD, SO Apeet Hundal, MD, IM John Hunter, MD, R Kendra Hutchinson, MD, HO Mook-Lan Iglowitz, MD, PLM Frank Ing, MD, PDC Julie Ingwerson, MD, PM Chetan Irwin, MD, PS Nancy Jaeger, MD, FP Fatima Jafri, MD, PLM Anita Jain, MD, PD Angela Jarman, MD, EM Yashar Javidan, MD, ORS Sumayya Jawadi, MD, AR Kuang-Yu Jen, MD, PTH Hanne Jensen, MD, BBK Rose Jensen, MD, FP Lee-Way Jin, MD, PTH Michael Jin, MD, DR Karnjit Johl, MD, IM Brian Jonas, MD, HO Russell Jones, MD, EM James Jones, MD, AN Jayne Joo, MD, D Nanette Joyce, DO, PM Ian Julie, MD, EM

Gregory Jurkovich, MD, SCC Michael Kadoch, MD, CTR Paul Kaesberg, MD, ON Anmol Kahlon, MD, IM Debra Kahn, MD, P Laura Kair, MD, PD Arundhati Kale, MD, PN Vaneet Kalra, MD, NPM Rory Kamerman-Kretzmer, MD, PD Veeraparn Kanchananakhin, MD, PD Trishna Kantamneni, MD, CHN Chrishanthie Karalakulasingam, MD, IM Anthony Karnezis, MD, PTH Pouria Kashkouli, MD, IM Sunpreet Kaur, MD, PG Robert Kaye, MD, AN Craig Keenan, MD, IM Kenneth Kelley, MD, EM Karen Kelly, MD, ON Bernadette Kelly, MD, FP Vanessa Kennedy, MD, GO Jeffrey Kennedy, MD, N Laura Kester, MD, PD Eunice Kim, MD, PD Edward Kim, MD, HO Kyeong Seon Michelle Kim, MD, AN Andrea Kim, MD, HOS Amanda Kirane, MD, SO Maija Kiuru, MD, D Norma Klein, MD, AN Anca Elena Knoepfler, MD, IM Nathalie Kolandjian, MD, HOS Karin Kordas, MD, IM Paul Kreis, MD, AN Christopher Kreulen, MD, ORS Robert Kriss, DO, PAN Jennifer Kristjansson, MD, EM Adam Krouse, DO, FP Nam Ku, MD, HMP Brooks Kuhn, MD, PCC Maggie Kuhn, MD, OTO Kara Kuhn-Riordon, MD, NPM Eric Kurzrock, MD, U Thaddeus Laird, MD, DR Philina Lamb, MD, D Ramit Lamba, MD, R Nancy Lane, MD, RHU Melissa Lao, MD, FP Primo Lara, Jr., MD, HO Richard Latchaw, MD, R Erik Laurin, MD, EM Martin Leamon, MD, ADP Benjamin Leavy, MD, FP Mirna Lechpammer, MD, NP Cassandra Lee, MD, ORS Stephanie Lee, MD, PLM Tennyson Lee, MD, CD Katherine Lee, MD, IM Mary Siy Leigh, MD, PD David Leshikar, MD, SCC Holly Leshikar, MD, OP Joseph Leung, MD, GE Eva Lew, MD, CCM Jennifer Li, MD, OPH Tianhong Li, MD, ON David Li, MD, AN Shannon Liang, MD, PN Christopher Lillis, MD, IM Huey Lin, MD, FP Yichun Lin, MD, AN Albert Liu, MD, OBG Hong Liu, MD, AN John Livoni, MD, DR Tehani Liyanage, MD, AN Thomas Loehfelm, MD, DR Susan Long, DO, ADL Continued on page 34

May/June 2019

New Members Continued from page 33

Lindsey Loomba-Albrecht, MD, PDE Antoinette Lopez, MD, FP Javier Lopez, MD, CD Samuel Louie, MD, PUD Sarah Louie, MD, FP David Lubarsky, MD, AN Rachael Lucatorto, MD, IM John Luke, MD, FP Zachary Lum, DO, ORS Scott Macdonald, MD, IM David Mach, DO, FP Sarah Maclean, MD, PAN John MacMillan, Jr., MD, PUD Stephen Macres, MD, PharmD, AN Niti Madan, MD, NEP Jaya Maewal, MD, PD Julia Magana, MD, PD Elizabeth Magnan, MD, FP Pirko Maguina, MD, FPS Gagan Mahajan, MD, AN Anjlee Mahajan, MD, HO Cydney Mahoney, MD, FP Mohammad Malaekeh, MD, PD Norika Malhado-Chang, MD, N Lindsey Malik, DO, CD Mathew Malkin, MD, AN Marcio Malogolowkin, MD, PHO Thomas Maney, MD, PD Archana Maniar, MD, IM Veena Manja, MD, CD Surinder Mann, MD, GE Eric Mao, MD, GE James Marcin, MD, CCP Rebecca Mardach, MD, PD Emily Marquet, MD, IM Sarah Marshall, MD, FP Kathleen Marshall, MD, P Ryan Martin, MD, NCC Madelena Martin, MD, PD Maria Martins, MD, PD Stephanie Mateev, MD, CD Mahan Matin, MD, PTH Karen Matsukuma, MD, ATP Emanual Maverakis, MD, D Soe Soe Maw, MD, IM Larissa May, MD, EM Crystal May, DO, R Gregory Maynard, MD, IM Anne Mcbride, MD, CHP Jenny McCormick, MD, EM Craig Mcdonald, MD, PM John Mcgahan, MD, R Heather McKnight, MD, HOS Amelia Mclennan, MD, OBG Heidi McNulty, DO, FP John Mcvicar, MD, GS Valentina Medici, MD, GE John Meehan, MD, ORS Juliana Melo, MD, OBG Dan Merck, MD, IM Trevor Mills, MD, EM Karen Mo, MD, FP Madina Mohammadi, MD, IM Jamal Maseel Mohammed, MD, SM Mithu Molla, MD, HOS Divina Monis, MD, PTH Arta Monjazeb, MD, RO Gertrudes Montemayor, MD, FP Elizabeth Moore, MD, R

José Morfin, MD, IM Mark Moriwaki, MD, END Lara Moser, MD, AN Ala Moshiri, MD, OPH Ramanjyot Muhar, MD, R Bryn Mumma, MD, EM Theresa Murdock-Vlautin, MD, PD Sima Naderi, MD, R Shaheen Najafi, MD, IM Natasha Nakra, MD, PD Kiran Nandalike, MD, PDP Joanne Natale, MD, PD Shannon Navarro, MD, R Bahareh Nejad, MD, OBG Kay Nelsen, MD, FP Daniel Neudorf, DO, PM Kwan Ng, MD, VN Hien Nguyen, MD, ID Stephanie Nguyen, MD, PD Hoa Nguyen, MD, HO Tan Nguyen, MD, FP Don Nguyen, DO, IM James Nichol, MD, FP Alison Nielsen, MD, AN Daniel Nishijima, MD, EM Denyse Nishio, MD, IM Donald Null, Jr., MD, NPM James Nuovo, MD, FP Robert O’Donnell, MD, HO Tyler O’Flahrity, MD, HO Daniel Okamoto, MD, HOS Justin Oldham, MD, PUD John Olichney, MD, N Kristin Olson, MD, ATP Peter O’Malley, MD, PD John Onate, MD, P Kelly Owen, MD, EM Arzu Ozturk, MD, NRN Clara Paik, MD, OBG Tina Palmieri, MD, GS Chong-Xian Pan, MD, HO Karen Panek, MD, FP Arun Panigrahi, MD, PHO Mamta Parikh, MD, HO Aman Parikh, MD, EM Jeanny Park, MD, PDC Katherine Park, MD, N Elizabeth Partridge, MD, PDI Gayatri Patel, MD, IM Roma Patel, MD, OPH Anjali, MD, PHO Sanyukta Pawar, MD, IM Andrew Pelech, MD, PDC Kristen Pellegrino, MD, FP Matthew Pena, MD, AN Margaret Penkala, MD, CD Clifford Pereira, MD, PS Richard Perez, MD, GS Pauline Ale Perez, MD, FP Paul Perry, MD, CTS Nayereh Pezeshkian, MD, CD Nancy Pham, MD, R Manh Pham, MD, FP Ho Hoang Phan, MD, TRS Chinh Phan, DO, PCC Sonal Phatak, MD, END Jenise Phelps, MD, OBG Jonathan Pierce, MD, GS Laura Pierce, DO, FP

Sierra Sacramento Valley Medicine

Rex Pillai, MD, IRDR Rogelio Pinon-Gutierrez, MD, HOS Brian Pitts, MD, AN Jennifer Plant, MD, PD David Pleasure, MD, N Christopher Polage, MD, PTH Richard Pollard, MD, ID Tommy Potti, MD, DR Francis Poulain, MD, NPM Scott Pritzlaff, MD, AN Lee Pu, MD, PS Nesser Ramirez, MD, FP Shyam Rao, MD, WM Lisa Rasmussen, MD, PD Mitch Ratanasen, MD, HOS Katherine Rauen, MD, PD Niroop Ravula, MD, PAN Jeremiah Ray, MD, OSM Siba Raychaudhuri, MD, RHU Gregory Redmond, MD, IM Balvinder Rehal, MD, D Bibiana Restrepo, MD, DBP Navdeep Riar, MD, HOS John Richards, MD, EM David Richman, MD, N Carol Richman, MD, HO Jonathan Riess, MD, ON Paul Riggle, MD, FP Peter Rinaldi, DO, ORS Rolando Roberto, MD, ORS Rachel Robitz, MD, P Eve Rodler, MD, HO Victor Rodriguez, MD, VS Michael Rogawski, MD, N Jason Rogers, MD, CD Kathleen Romanowski, MD, GS John Rose, MD, EM Jennifer Rosenthal, MD, HOS Baback Roshanravan, MD, NEP Jennifer Rothschild, MD, U Catherine Rottkamp, MD, NPM Nichole Ruffner, MD, OBG Rachel Ruskin, MD, GO John Rutledge, MD, CD Brenda Ruvalcaba, MD, HOS Payam Saadai, MD, FPR Junichiro Sageshima, MD, TTS David Sahar, MD, PS Edgardo Salcedo, MD, SCC Maha Sami, MD, HOS Ajay Sampat, MD, N Erin Sanchez, MD, IM Harbrinder Sandhu, MD, RHU Christian Sandrock, MD, PUD Chandrasekar Santhanakrishnan, MD, GS Souvik Sarkar, MD, GE Noriko Satake, MD, PD Candice Sauder, MD, SO Nicolas Sawyer, MD, EM James Saxton, MD, PD Daphne Say, MD, PG Verena Schandera, MD, EM Pieter Scheerlinck, MD, EM Michael Schick, DO, EM Michael Schivo, MD, IM Nina Schloemerkemper, MD, AN Eleanor Schwarz, MD, IM Charles Scott, MD, P Christian Sebat, DO, PCC

Joann Seibles, MD, FP Simran Sekhon, MD, R Alison Semrad, DO, END Soman Sen, MD, GS Viyeka Sethi, MD, CCP Hazem Shamseddeen, MD, GS Suma Shankar, MD, PO Mushfeka Sharif, MD, IM Shivani Sharma, MD, FP David Shatz, MD, GS Dana Sheely, MD, END Lucy Shi, MD, HOS Ruth Shim, MD, P Kaumakaokalani Shimatsu, MD, IM Chris Shin, MD, PM Parminder Sidhu, MD, ON Heather Siefkes, MD, CCP Kelly Siemens, MD, FP Eric Signoff, MD, HOS Jessica Signoff, MD, CCP Sabrina Silva-Mckenzie, MD, P Naileshni Singh, MD, PMD Amrik Singh, MD, AN Gagan Singh, MD, CD Siddharth Singh, DO, AN Voltaire Sinigayan, MD, HOS Joseph Sison, MD, CHP Raja Sivamani, MD, D Kurt Slapnik, MD, FP Blanca Solis, MD, FP Jay Solnick, MD, ID Jeffrey Southard, MD, IM Lane Squires, MD, OTO Kris Srinivasan, MD, FP Monica Srivastava, MD, HOS Uma Srivatsa, MD, CD Toby Steele, MD, OTO Mary Beth Steinfeld, MD, PD Rebecca Stein-Wexler, MD, R Merin Stephen, MD, HO Nicholas Stollenwerk, MD, PCC Jesse Stondell, MD, GE Elena Sudjian, MD, IM Sherzana Sunderji, MD, PDC Prasanth Surampudi, MD, END Lisa Swensson, MD, FP Arthur Swislocki, MD, DIA Robert Szabo, MD, ORS Patricia Takeda, MD, CD Kit Wah Tam, MD, HO Lionel Gayares Tan, MD, HOS Michael Sebastian Tanaka, MD, HO Schirin Tang, MD, CCA Timothy Tautz, MD, AN Priyanka Teckchandani, MD, IM Cecilia Terrado, MD, GE Suzanne Teuber, MD, AI Wayne Thom, MD, FP Suraj Timilsina, MD, RHU Cinthia Tirado, MD, AN Jeannette Tom-Lerman, MD, AN Alexis Toney, MD, PD Elisa Tong, MD, IM Susana Torres, MD, FP Michael Trifiro, MD, OBG Paolo Troia-Cancio, MD, ID Christoph Troppmann, MD, GS Kathrin Troppmann, MD, GS Trinh Truong, MD, PG Susan Tseng, MD, ORS Jye-Ping Tu, MD, IM Charles Tujo, MD, R Sarah Turgasen, MD, IM Joseph Tuscano, MD, ON Katren Tyler, MD, EM Leah Tzimenatos, MD, PEM Mark Underwood, MD, PD

David Unold, MD, BBK Eleasa Unold, MD, IM Shiro Urayama, MD, GE Garth Utter, MD, SCC Marissa Vadi, MD, AN Payam Vali, MD, NPM Elham Betts, MD, HMP James Bogaerde, MD, ORS Jeff Gundy, MD, PDC Cheryl Vance, MD, EM Narges Varnosfaderani, MD, IM Sandhya Venugopal, MD, CD Heather Vierra, MD, IM Amparo Villablanca, MD, CD Anastasia Waechter, MD, GE Lois Waetjen, MD, OBG Brandee Waite, MD, PM Jeffery Wajda, DO, EM Ben Waldau, MD, NS Sarah Waldman, MD, ID Tianyi Wang, MD, IM Robert Weiss, MD, NEP Nicole Weiss, MD, AN James Welch, MD, HOS Nancy Lynn West, MD, OBG Sage Wexner, MD, EM Vicki Wheelock, MD, N Charles Whitcomb, III, MD, CD Jean Wiedeman, MD, PD Lisa Williams, MD, PM Kimberly Williams, DO, IM Khine Win, MD, HO Garen Wintemute, MD, EM Barton Wise, MD, RHU Jessica Witkowski, MD, HOS David Wolf, MD, AN Eleanore Wolpaw, MD, IM Garrett Wong, MD, CD Granger Wong, MD, PS Linda Woo, MD, IM Tammy Woo, MD, PD Margaret Wooddell, MD, FP Debra Wright, MD, OBG Peggy Wu, MD, D Theodore Wun, MD, HO Guohua Xia, MD, P Ge Xiong, MD, N Jennifer Yang, MD, UP Clara Yang, MD, HOS Aubrey Yao, MD, U Alan Yee, DO, N Jay Yeh, MD, PDC Tisha Yeh, MD, HOS Kaicheng Yen, MD, OTO Maria Yen, MD, NEP Jane Yeun, MD, NEP Sophia Yi, MD, AN Amy Yip, DO, FP Glenn Yiu, MD, OPH Ken Yoneda, MD, PUD John Yoon, MD, END William Yoon, MD, VS Joseph Young, Jr., MD, GS Brian Young, MD, NEP Christopher Young, MD, FP John Youngblood, MD, FP Erik Youngdale, MD, P Jihey Yuk, MD, PD Amir Zeki, MD, PCC Holly Zhao, MD, PM Xiao Zhao, MD, RO Jason Zhao, MD, RO Yunli Zheng, MD, IM Chihong Zhou, MD, PTH Jordan Ziegler, MD, NS Lara Zimmermann, MD, N Marike Zwienenberg, MD, NSP

May/June 2019

Contact SSVMS to Access Your

Member Only Benefits

info@ssvms.org | (916) 452-2671 BENEFIT

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement.

CMA’s Center for Economic Services (CES) www.cmadocs.org/reimbursement-assistance | (888) 401-5911

Legal Services CMA On-Call, Legal Handbook (CPLH) and more…

CMA’s Center for Legal Affairs www.cmadocs.org/legal-resources | (800) 786-4262

Insurance Services Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, etc.

Mercer Health & Benefits Insurance Services LLC www.countycmamemberinsurance.com | (800) 842-3761

Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.

Prudential Travel Accident Policy & AXA Travel Assistance Program www.ssvms.org/Portals/7/Assets/pdf/AXA-travel-accident-policy.pdf

Career Center Member groups receive free basic job postings and access to the Career Center resume bank.

California Physician ™ Career Center www.careers.cmadocs.org

Mobile Physician Websites Save up to $1,000 on unique website packages.

MAYACO Marketing & Internet www.mayaco.com/physicians

Auto/Homeowners Insurance Save up to 10% on insurance services.

Mercury Insurance Group www.mercuryinsurance.com/cma

Car Rental Save up to 25% - Members-only coupon codes required.

Avis or Hertz

CME Certification Services Discounted CME Certification for members.

Institute for Medical Quality (IMQ) www.imq.org

Student Loan Refinancing Members receive a rate discount of 0.25% off the approved loan rate.

SoFi www.sofi.com/rate-discount-25

Healthcare Messaging Free secure messaging application

DocBookMD www.docbookmd.com/physicians

HIPAA Compliance Solutions Members receive a discount on the Toolkit.

PrivaPlan Associates, Inc www.privaplan.com

Magazine Subscriptions Members get up to 89% off the cover price of popular magazines.

Subscription Services, Inc www.buymags.com/cma

Confidential Physician Wellness Resources 24-hour confidential assistance hotline is free and will not result in any disciplinary action. Additional Physician wellbeing resources also available through SSVMS’ Joy of Medicine.

Physicians’ Confidential Line (650) 756-7787 www.cmadocs.org/confidential-line www.joyofmedicine.org

Medical Waste Management Save up to 30% on medical waste management and regulatory compliance services.

EnviroMerica www.enviromerica.com

Office supplies, facility, technology, furniture, custom printing and more… Save up to 80%

StaplesAdvantage

Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required

COLA (800) 981-9883

Security Prescription Products RxSecurity Members receive 15% off tamper-resistant security subscription pads. www.rxsecurity.com/cma-order

SSVMS Vetted Vendor Partners SSVMS’ Vetted Vendors are trusted partners of the Medical Society. Each business has gone through an application process and provided multiple physician references that can attest to their satisfaction with the business. Access Vetted Vendors 916-452-2671 or msharpe@ssvms.org. Cooperative of American Physicians (CAP) Medical professional liability protection to over 12,000 of California’s finest physicians.

Sotheby’s International Realty Mela Fratarcangeli is consistently ranked in the top 5% of all real estate agents in the Sacramento Valley serving the buyers and sellers at all levels in the Sacramento Region.

Crumley & Associates Drawing on more than 120 years of experience, Crumley & Associates emphasizes sound financial planning, along with a variety of personal financial services.

The Mortgage Company The Mortgage Company brings a wealth of experience to every purchase and refinance loan, and exceptional concierge level service.

Bank Card USA By eliminating the middleman, Bank Card USA is able to offer special pricing for our members.

www.ssvms.org/physician-resources/vendor-partners

If the road remains open, Everyone has a chance to win.

2019

RACE FOR THE CLINICS Sacramento, CA

SATURDAY, MAY 18

Join us for our 2nd Annual Race for the Clinics held near Downtown Sacramento. Our 5K/10K Run/Walk raises funds for safety-net medical clinics in the greater Sacramento Region. These clinics provide 250,000 visits per year to the under-insured and uninsured.

• Free Kids Fun Run (10 & Under) • 5K (3.1 miles) & 10K (6.2 miles) • Post Race Health Expo • Corporate Team option available • Entry includes a t-shirt & medal

serotoninsurge.org