2021-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley Serving the counties of El Dorado, Sacramento and Yolo

July/August 2021

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Sierra Sacramento Valley

MEDICINE 4

Professional Boundaries Hide Personal Pain

Ken Smith, Managing Editor

PRESIDENT’S MESSAGE

Carol Burch, MD

EXECUTIVE DIRECTOR’S MESSAGE

Volunteers Are the Heart of Our Success Aileen Wetzel, Executive Director

OPINION

Finding a Sense of Awe In Life and Death Caroline Giroux, MD

What Can You Do About Vaccine Hesitancy?

Want to Be Top of Your Class? Let YouTube Show You How James Zhou, MS II

Board Briefs

New SSVMS Members

Laminate? That's So Early 2021 Ken Smith, Managing Editor

SSVMS Medical Museum Begins to Reopen

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. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the Sierra Sacramento Valley Medical Society for permission to reprint.

Bob LaPerriere, MD

A Kitty Catastrophe Faith Fitzgerald, MD

Physicians Are Happier Here And We Can Prove it! Lindsay Coate, Vice President, Strategic Operations

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento The museum is gradually reopening. Visit our website at ssvms.org/museum for updates and virtual events.

VOLUME 72/NUMBER 4 Cover photo: Liang Liang, MD stands at the precipice at Yosemite National Park's Taft Point.

Photo by Ming Zhang

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx

July/August 2021

Sierra Sacramento Valley 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.

2021 Officers & Board of Directors

Carol Burch, MD, President Paul Reynolds, MD, President-Elect John Wiesenfarth, MD, Immediate Past President District 1 Jonathan Breslau, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD

District 4 Shideh Chinichian, MD District 5 Christina Bilyeu, MD Sean Deane, MD Farzam Gorouhi, MD Roderick Vitangcol, MD District 6 Marcia Gollober, MD

2021 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Anand Mehta, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD

At-Large Delegates R. Adams Jacobs, MD Barbara Arnold, MD Megan Babb, DO Helen Biren, MD Jonathan Breslau, MD Carol Burch, MD Amber Chatwin, MD Angelina Crans Yoon, MD Mark Drabkin, MD Rachel Ekaireb, MD Gordon Garcia, MD Ann Gerhardt, MD Farzam Gorouhi, MD Richard Gray, MD Richard Jones, MD Mohammad Khan, MD At-Large Alternates Christine Braid, DO Lucy Douglass, MD Karen Hopp, MD Arthur Jey, MD

CMA Trustees, District XI

Adam Dougherty, MD

AMA Delegation Barbara Arnold, MD

Editorial Committee

District 1 Alternate Brian Jones, MD District 2 Alternate Janine Bera, MD District 3 Alternate Toussaint Mears-Clark, MD District 4 Alternate Shideh Chinichian, MD District 5 Alternate Joanna Finn, MD District 6 Alternate Natasha Bir, MD

Steven Kmucha, MD Charles McDonnell, MD Leena Mehta, MD Sandra Mendez, MD Tom Ormiston, MD Sen. Richard Pan, MD Neil Parikh, MD Hunter Pattison, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD Lee Snook, MD Tom Valdez, MD John Wiesenfarth, MD Sam Lam, MD Taylor Nichols, MD Ashley Rubin, DO Alex Schmalz, MD Ashley Sens, MD Robert Oldham, MD Margaret Parsons, MD Sandra Mendez, MD

Megan Babb, DO Sean Deane, MD Caroline Giroux, MD Robert LaPerriere, MD Karen Poirier-Brode, MD Gerald Rogan, MD

Glennah Trochet, MD Kayla Umemoto, MS II Michelle Ann Wan, MS III Lee Welter, MD Eric Williams, MD James Zhou, MS II

Executive Director Managing Editor Webmaster

Aileen Wetzel Ken Smith Melissa Darling

Sierra Sacramento Valley Medicine

HOSTED BY LOCAL PHYSICIANS

Listen and subscribe to Joy of Medicine - On Call on your favorite Podcast App or visit joyofmedicine.org

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2021 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bimonthly 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.

| FEATURED CONTRIBUTORS |

Carol Burch, MD

Caroline Giroux, MD

Does professional detachment help us treat patients or does it just suppress the pain as we empathize with patients? Dr. Burch thought about the conflict within us as she sat next to her dying sister.

Awe is, well, awesome. Just as there is magic in a glowing sunset, embracing the mysteries of life—and death—before seeking the practical answers can help us experience awe, Dr. Giroux says.

A survey by SSVMS shows that physicians in the Sacramento region have a lower rate of burnout compared to other locations. Lindsay explains why there is more joy in medicine in our area.

James Zhou, Ms II

Faith T. Fitzgerald, MD

Bob LaPerriere, MD

It's time to play "Stump the Professor." Dr. Fitzgerald recalls a case involving a cat, a dead schoolteacher and how a California governor tried to hide a public health emergency.

Dr. LaPerriere, the curator of the SSVMS Museum of Medical History, provides an update on the museum's gradual reopening after the pandemic and the new additions to its collection.

carol.md.mba@gmail.com

james.zhou7143@cnsu.edu YouTube has become an everyday part of life, where you can go to learn how to make waffles or solve quadratic equations. James shows why it's an important resource for medical students as well.

Ken Smith

ken@kdscommunications.com

cgiroux@ucdavis.edu

ftfitzgerald@ucdavis.edu

Lindsay Coate

lcoate@ssvms.org

ssvmsmus@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.

Vaccine reluctance remains a problem, but the reasons why aren't as cut and dried as they may seem. Ken looks at what those who are skeptical are saying and what physicians should say to them.

July/August 2021

| PRESIDENT’S MESSAGE |

Professional Boundaries Hide Personal Pain L

ast year, my sister had to go to the ED because of abdominal pain. She ended up having a blockage and surgery, and the CT taken at the time showed a little something in the pancreas, but no one was concerned. The plan was that after she’d recovered from surgery, she would have it biopsied just to make sure it wasn’t cancer. Fast forward and after the first round of chemo did not work, she is in hospice. I have been able to spend time with her supporting her and her daughters. For much of our lives, we are in our professional role as physicians. We bring compassion and comfort to the bedside by listening to patients, by making recommendations, by answering questions. The focus is on meeting the patient’s needs. While this can bring us joy, it is not meant to meet our own emotional needs; we are there to serve the patient. This is the boundary they taught about in medical school. My school phrased it as not becoming “emotionally involved,” and it becomes habit to avoid an emotional give-and-take in therapeutic relationships. This way we are not overly hurt by angry patients or the slowly dying. We keep the distance to see the long game and help direct quality care no matter the emotional turbulence. Sitting in the wing chair in my sister’s room, she talks about her views on life and how she would rather have a shorter life that allows her to live each day fully, rather than more days sitting in the bathroom. I read a Pablo Neruda poem from one of her books to her that includes a line about how he wanted to open the door into a room of regret, but that the door was locked. She said she’d already walked through that room and had not found any need to return, life has been good. She wants to know if I’ve come to terms that I will lose her. Currently, I have decided to lose her in daily amounts rather than feel the full burden of a lifetime of loss all today. I will spread it out over a lifetime, a bit each day. (I have no idea if there is any basis for this concept, but it sounds good to me today.) 4

Sierra Sacramento Valley Medicine

By Carol Burch, MD carol.md.mba@gmail.com

Watching the thoughts going through my mind, I wonder if I’m putting up the therapeutic wall. I realize that family and friend relationships require an emotional give-and-take in order to be healthy and balanced. Each person needs to consider the other person’s state and work towards meeting each other’s needs. Was I retreating and protecting myself by being an emotional wallflower by not really engaging in her process with her? And why is it important to engage? It hurts to lose someone. If we avoid the pain by not engaging, what is the consequence? What we lose is a missed connection, missed growth. When we avoid that edge of the emotional spectrum, we also miss the other edge, which is joy. Feeling our emotional pain does several things for us that will make us better physicians. The first is that when we learn to notice our pain, we also start noticing our joy. Joy is the great antidote to the fatigue and disconnection that often comes with our profession’s long hours. Second, when we feel and acknowledge pain, it lessens in intensity. Being with your pain, just noticing it and feeling it, not trying to stuff it or numb it, but just watching, diffuses it. It may take time, but it lessens. I am not saying that it goes away or is cured, but it becomes bearable. This is important as it allows us to handle other stressors because we are not spending our energy trying to ignore the pain. We also become less afraid of emotions that are hard to deal with. Just as reading about a topic helps us understand it and talk about it, becoming better at dealing with difficult emotions helps us help others with their emotions. We have mirror neurons that enable us to often feel others’ emotions, which helps us bond and stick together as a group. When a patient is experiencing an emotional trauma, we experience it to a degree as well; being aware of that is the first step towards effective communication of bad news. Think about the first time you had to tell someone that they had cancer. I remember the first time I told a

patient he had mono and would probably be tired and nauseated for a long period. I could give him medication to help, but I could not cure it. I felt so disappointed and before I told him, I was afraid of saying exactly how bad it could be. As much as we talk about a therapeutic distance, we still have those mirror neurons and we still feel discomfort. “Never take away a person’s hope when delivering bad news,” I was told early on. I don’t remember exactly who that came from, but I’m sure I heard it from several of my teachers. We need to be realistic, and not give false hope. We need to give people the tools to understand the path in front of them. One tool that can help is our Honoring Wishes program, which provides you with guidance on how to conduct difficult end-of-life discussions and includes documents patients and their families can use to be clear about their end-of-life wishes. If you haven’t received information about Honoring Wishes or would like to learn more, contact Brandon Craig at bcraig@ ssvms.org. Listening to my sister’s oncologist, I could hear her discomfort. She said that without treatment, people in my sister’s condition live another four months on average, some longer, some shorter. It gave my sister a

framework of time, so she did not wait to revise some paperwork that she needed to do before she dies. She has had the conversations with her daughters about what will happen to the farm and how her estate should be split. She has gifted money now to her granddaughters to avoid estate taxes. She is happy to clean up messes and see people she hasn’t seen in years because she has clear information. It was hard on her doctor, but an important gift to my sister. I have seen doctors avoid the difficult discussion. My stepmother remained intubated for many hopeless days because the doctors said she would die if they extubated. My father was not told that she would be alive but, when she was roused, only aware of pain. Once he was told she would never again talk, never again feed herself, and that if she was allowed to wake she would feel her pain, he was able to let her go. We would all prefer not to have these end-of-life discussions, and to not feel the pain they cause. But it is a gift to us as physicians that we are the ones who can provide comfort to our patients at the most difficult time of their lives, and the clarity we can provide can also be a gift—as it was to my sister—to patients and families facing their fears as they prepare to make difficult choices for what lay ahead.

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July/August 2021

| EXEC UTIVE DIRECTOR’S MESSAGE |

Volunteers Are the Heart of Our Success

Community Programs, Committees Are Rewarding Personally And Professionally

love serving as your executive director and I make no secret of that. People often ask me what my favorite part of the job is and, hands down, my answer is that I enjoy getting to know our physician members as individuals. The second-best part? The programs, projects and committees we get to work on together. Our physicians are the heart of SSVMS, and your involvement in our volunteer programs and committees helps us to increase access to care for patients, support physician wellness and address the variety of challenges you face in your practice. One of our newest and most exciting programs is Future of Medicine. We’re exposing rising junior and senior high school students from lower income areas of the Sacramento region to careers in health care. Through interactive sessions with a wide variety of providers— including physicians, dentists, pharmacists, nurses, techs, and others—they get a better understanding of the opportunities available in health care and the support they need to pursue them. We are currently seeking physicians to serve as mentors or to host a student through our job shadowing. Your participation can help launch the careers of the next generation of health care providers we need to ensure that quality care remains available and accessible in our region. You can also encourage that next generation of physicians by supporting our Medical Student Scholarship Fund through a tax-deductible donation. Each year, we give out over $17,000 in scholarships to deserving students. The fund is administered by the Scholarship and Awards Committee, which I hope you’ll consider joining to help us recognize not just up-andcoming students, but also the physicians who have done so much for patients and the community over the years through the committee’s recommendations for honors 6

Sierra Sacramento Valley Medicine

By Aileen Wetzel awetzel@ssvms.org

such as the Golden Stethoscope and community awards. Our Sacramento Physicians Initiative to Reach Out, Innovate and Teach—better known as SPIRIT—is a longtime favorite of our members for community service. Since SPIRIT began, physician volunteers have provided over $12 million in free care to the uninsured, treated over 54,000 patients and performed over 1,200 surgeries. This program has literally been a life-saver to thousands of underserved—and under-insured—patients and provides physicians with a rewarding sense of giving back to the community.

Since SPIRIT began, physician volunteers have provided over $12 million in free care to the uninsured, treated over 54,000 patients and performed over 1,200 surgeries. Much of SPIRIT’s efforts has been in community clinic settings that can be limited in the services they provide. That’s why the current focus of the SPIRIT program is to find specialists who can donate care in their private practices or surgical services at a partner hospital or surgery center. Our staff makes it easy for you by coordinating volunteer schedules and providing case management services. To become a volunteer or offer your site for care, contact Adriana Aguiar, SPIRIT program manager at aaguiar@ssvms.org. What really makes SSVMS work is your participation on our committees that provide policy and procedure recommendations to the board of directors. If you haven’t served on a committee or have just thought about it, I encourage you to get involved. Our newest committee is tackling an especially important issue that is, honestly, overdue in addressing. The Health Equity Advisory Committee is focused on confronting racism and bias in medicine that affects

patients and physicians. This important committee is charged with developing best practices for medical groups, creating awareness among providers, providing resources to providers, and advocating for legislative policies to promote more positive outcomes for marginalized communities. We’re also very proud of our Honoring Wishes program that is helping facilitate conversations between physicians and patients facing end-of-life decisions. We need volunteers to help members of our community document their end-of-life wishes. If you have any doubts about the need for this program, I urge you to read Carol Burch’s president’s message if you haven’t already before turning to this article. There are committees that appeal to a wide range of interests. Our Editorial Committee helps set the direction for this magazine, and the Public and Environmental Health Committee makes recommendations on issues that affect the health and well-being of our community. There’s even a Historical Committee that preserves the history of medicine in our area. For a leadership opportunity within SSVMS, we currently have openings on our delegation to the CMA House of Delegates. The House of Delegates convenes annually to debate on issues affecting the practice of medicine and access to care. Delegate and alternate delegate positions are both available. If you are at a point in your medical career that you want to do something that is satisfying and of great service to your community,

Dr. Rick Jones with a patient who received eye care through the SPIRIT program, which serves uninsured and underserved patients. SSVMS provides opportunities for social and professional interactions with fellow volunteers and the public while supporting important community projects. We support fantastic causes, and with your help we can do more for our members

and our community. To find out how to participate on a committee, in a community program or as an SSVMS delegate, contact Dana Brooks at dbrooks@ssvms.org and we’ll take it from there.

The Medical Society's community programs are supported by grants and generous donations from the community. To become a volunteer or to make a tax-deductible donation, visit ssvms.org/community-programs and click on the volunteer or donate buttons.

July/August 2021

| OPINION |

Finding a Sense of Awe In Life and Death

Embrace Mystery to Find Meaning in Life, Medicine

hen I think of awe, what comes to mind is a blissful, elevating sensation like the one I experience every time I hear the heavenly opening bells of Fleetwood Mac’s “Everywhere.” Or the rush of dopamine from the ecstasy of a first kiss. Or any show or movie that allows me to time travel—like “Outlander” (please don’t judge me!)—that includes the inevitable scene of a woman in atrocious pain walking away from a breech delivery, triumphant and with a healthy newborn at her breast. Awe is any experience that is so majestic it dissipates my worries, such as when I was once blessed enough to see the northern lights from my hometown. It can be going to an observatory to rediscover through giant telescopes the venerable planets and stars that apparently gave birth to the dust we are made of (if you don’t believe we are made of stardust, please take an illustrated astronomy book and look at pictures of nebulae). My personal proof is that a close-up of the Ring Nebula looks exactly like my youngest son’s astonishingly beautiful green eyes. Life and nature mirror themselves in myriads of ways. Just as a legume is named after the kidney, a walnut that looks like two cerebral hemispheres is beneficial for brain health. A longitudinal cut of a strawberry reveals the chambers of the heart. But trying to reflect on the sense of awe within the practice of medicine, after having endured the trauma of medical school clinical rotations and specialty training, and even decades later with our corporatized medical field, was rather challenging when preparing my presentation for the fourth session of the Healer’s Art course. In the past, some faculty have gracefully discussed their almost mystical experiences in accompanying the dying. But since I am a psychiatrist, not a family doctor, an oncologist, critical care or palliative care physician, the only relevant encounters I could think of were 8

Sierra Sacramento Valley Medicine

By Caroline Giroux, MD cgiroux@ucdavis.edu

witnessing my grandmother’s last breath while I was a medical student or those awful night calls when, as an intern, I was brutally dragged from an already fragmented sleep by my pager with the request to walk to the palliative unit for the futile act of pronouncing death. Even though it was certainly a relief to see my grandmother being released from her coma after she suffered metastatic cancer, the sense of awe was not so obvious. But maybe it was there in my aunt’s beautiful and divine voice next to me, as she told her mother to “go towards the light, maman, go into the light.” Or in my younger brother’s tears, an unusual sight, that fell onto the bed and looked like crystals as the noon light shined through them when our grandmother no longer needed to contain her spirit. In psychiatry, with the exception of suicide, we deal mostly with symbolic dying processes: through depression, for instance, which I try to no longer view as entirely pathological but as the prelude to an essential transformation that often consists of the death of the ego or its illusions. The whole being slows down into an energy conservation mode as it prepares to take a leap and expand, like a state of hibernation before the spring and all its possibilities. In order to be reborn, everything must die. High temperature and pressure may destroy limestone but also leads to its beautiful metamorphosis into marble. Maybe it is easier to start with the mysterious— some would say supernatural—before seeking the practical in order to experience awe. For instance, the unexplained in seemingly miraculous recoveries or the unexpectedly positive outcome of a healthy baby after a stressful labor in a patient I assisted as a medical student. There is awe in the epiphany experienced by a survivor of trauma as she writes and shares her story in group, just as there was in the invisible form of the spirit leaving my grandmother’s body peacefully as she was surrounded

by family who could join just in time to witness her last breath. Viewing each death as an essential step of the birth-death-rebirth cycle also allows us to transcend

had nothing coming after. Hence the need to achieve status, accumulate possessions, make money, leave a trace of ourselves for eternity to deal with the fear of our own mortality.

If you slowly change the angle of Labradorite, beneath the dark gray surface appears the breathtaking iridescent light of its structure, as if the aurora borealis of the soul were no longer trapped. more easily the idea of death. The “dark goddesses”—the women of intuition and incredible gifts who threatened the powerful and who became the subject of witch hunts— were prominent and essential transmitters of such wisdom before patriarchy became the guiding structure of our world. Our brains evolved in parallel with the patriarchal institutions and with it, the idea of time and life as linear took hold, therefore creating the fear of death because it was assumed that we

Once we can view mortality as only a step in a bigger process, that the intangible is as real as (if not more than) the tangible, it is easier to accept. Hence, honoring the roles of the healers and dark goddesses or the return of the divine feminine—our nurturing, devotional, compassionate, loving and intuitive side—in all of us and seeing them as essential in guiding others walking through the portal of death helps with the development of a sense of awe. An ending will imply a new

beginning, which is certainly cause for celebration. To lead the seed talk that evening, I drew upon my experience doing group therapy for survivors of trauma. The theme of the concluding session of the 12-week curriculum is transformation and transcendence. Going from chrysalis to butterfly. The victim and survivor identity must die to make room for the newly empowered, healed, authentic soulful self. To demonstrate the need to look beyond darkness and zoom out of the difficult narrative to transcend, when the group used to be in person I passed around a piece of my favorite stone that was first discovered in my beloved Canada, a labradorite (found in Labrador). If you slowly change the angle, beneath the dark gray surface appears the breathtaking, iridescent light of its structure, as if the aurora borealis of the soul were no longer trapped and

July/August 2021

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suddenly allowed to shine through. When a being dies, the body disintegrates but I believe that the first law of thermodynamics applies: nothing is created and nothing is lost. The energy, chi or soul goes back to the soul of the world. To quote Jim Carrey, of all people, “My soul is not contained within the limits of my body; my body is contained within the limitlessness of my soul.” It is comforting to believe in the interconnectedness of all beings, a powerful murmuration of choreographed consciousnesses, a shared vibration that will change the world one co-existence at a time. After a while, we stop fooling ourselves into thinking we can capture and defy time. The Ouroboros with the serpent eating its own tail representing infinity reminds us so, as it stands erect as the silhouette of an hourglass. Eternity happens one second at a time. As we go through our own numerous symbolic birth-deathrebirth cycles, cultivating awe in life and in medicine and embracing mysteries have the potential to create meaning, accept impermanence and elevate consciousness. By being bigger than the self and by raising our spirit, awe compels us to share with others, nurturing connections which in turn will continue to foster well-being. But nothing sensational or grand with special effects is required to achieve such a state: being swept by the shining nebula of awe can even start in our own life, by noticing the stars shining from our eyes or the movements of light within the labradorescence of our own soul.

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| JOY OF MEDICINE |

Physicians Are Happier Here And We Can Prove it!

SSVMS Study Shows Burnout Rates Are Lower in Our Region, Even After COVID-19

he pressures of a complex health care system, long hours, and now COVID-19 have left many physicians feel that their role as healers is diminished. That’s also a recipe for physician burnout, which is more than just stress: it is severe emotional exhaustion, depersonalization, and the feeling of reduced personal accomplishment. But something is going right in Sacramento, because burnout levels are below the national average. Surprisingly, over the past pandemic year when physician experiences ranged from overworked to on the verge of losing their practices, burnout rates in the area dropped even further and physician satisfaction rose. Sacramento is a great place to practice medicine

By Lindsay Coate lcoate@ssvms.org

because the medical community has chosen to care for its physicians. In our survey, SSVMS found physicians in Sacramento experience higher levels of happiness and fewer report symptoms of burnout (34%) than physicians nationally (42%). Our Medical Society is passionate about physician well-being and addressing burnout. Our nationally recognized Joy of Medicine program encourages per sonal resilience, connection with colleagues, and collaboration with leaders to foster a culture of wellness in the medical community. Since 2017, Joy of Medicine has connected hundreds of physicians to counseling and coaching services, peer support groups and education events to increase their personal resilience.

Breaking the Taboo

John Chuck, MD, who chairs the SSVMS Joy of Medicine Advisory Committee, is a big believer in using wellness services. He's pictured here with his therapist, Marissa Pierce, LMFT. 12

Sierra Sacramento Valley Medicine

This is a continuation of a trend of physicians openly embracing well-being programs that were once considered nearly taboo as a sign of weakness or for which there were barriers to participation. It is particularly gratifying to see that in the 12 months ending September 2020, 56% of survey participants used at least one wellness service either through self-pay, services offered through their medical practice or their health system or hospital, or the SSVMS Joy of Medicine program. Based on these numbers, the stigma against physician mental well-being is clearly changing for the better. Since the incep-

2018:

35.7% of physicians reported experiencing burnout

2020:

Source: Joy of Medicine: A Regional Approach to Improving Physician Well-Being

33.7% of physicians reported experiencing burnout

Physicians in the Sacramento region are reporting a lower rate of burnout than in 2018, and the percentage of local physicians who say they have symptoms is significantly lower than the national average. tion of the Joy of Medicine program, there have been nearly 900 mental health care appointments accessed by area physicians. There are currently six psychologists and two life coaches available for up to six no-cost sessions for any physician who needs them. You can find out more about this service at joyofmedicine.org. Still, resolving the problem of community-wide physician burnout cannot focus on just individual wellness. The solution lies within improving local health systems and promoting a culture of wellness within physician organizations. Burnout takes a significant toll on our essential caretakers. Several national studies show physicians experience higher rates of suicide and depression compared to the general population. Because of burnout, many physicians leave the practice of medicine, resulting in

an annual cost burden of $4.6 billion on a U.S. health care system that is already short on physicians. Patients lose good doctors and access to essential health care as a result. SSVMS recommended improvements to regional health systems in a whitepaper based on our 2018 physician well-being survey. Committed to making continuous improvements, we followed up on our study with a 2020 Survey. The results, described in Joy of Medicine: A Regional Approach to Improving Physician Well-Being, show a surprising result: despite the negative impact the COVID-19 pandemic had on physician well-being, Sacramento physicians’ burnout levels improved rather than worsened. Implementation of SSVMS’s recommendations for improved care of physicians correlated with a decrease in physician burnout by 2%. July/August 2021

We surveyed physicians on what they felt were the key drivers of engagement that medical groups and health systems could use to prevent or reduce burnout. In each of the seven categories, there was growth in the level of satisfaction among the surveyed physicians compared to the 2018 survey. Positive feelings towards compensation, workload, and organizational culture continued to be above 70%. The remaining categories of efficiency and resources, social support, and control and flexibility rated between 53% and 64%; however, the positive assessment for each of these categories increased by at least two percentage points. Significantly, the work-life integration category scored a 10% higher positive assessment compared to 2018. Medical groups have clearly worked hard to improve engagement with their physicians, and we expect these results to continue their positive trajectory. These benefits will only last with continued dedication to improving physician wellness. Based on the data in our 2020 survey, SSVMS recommends regional health systems take more measures to improve physician work-life balance: offer flexible schedules and the option to work fewer hours, provide mental health resources and peer engagement activities, and hire assistants and scribes for increased administrative support. Health systems should also integrate a more efficient electronic health records system that supports in-person and remote scribes, voice recognition, and a more robust

Recollections of How Teaching and Learning Were Upended in 2020

Sierra Sacramento Valley Medicine

Understanding what drives physicians to become engaged can help medical groups and health systems reduce burnout. health information exchange. We plan on conducting this survey again in 2022 to continue monitoring successes and areas of improvement that medical groups and SSVMS should implement to continue advancing physician wellbeing scores. Following SSVMS’s

To read the full report, Joy of Medicine: A Regional Approach to Improving Physician Well-Being, visit tinyurl. com/smest4dz or scan the QR code with your camera.

recommendations, Sacramento can continue to build health systems’ values to better care for its physicians and thus provide better outcomes for their patients. Lindsay Coate is vice president, strategic operations at SSVMS.

Source: Joy of Medicine: A Regional Approach to Improving Physician Well-Being

Driving Engagement to Reduce Burnout

CONNECT WITH COLLEAGUES

IN-PERSON! JOY OF MEDICINE SUMMIT

Saturday, September 25, 2021 Capitol Plaza Ballrooms, Sacramento, CA

8:30 - 12:00 PM

Emcee John Chuck, MD

Featured Topics 9:00 AM - Does Anyone Have a Case? The Balint Group Experience Would you like to improve your rapport with your patients? Explore how to enhance patient-physician relationships with peer-to-peer Balint groups. Facilitated by Rochelle Frank, MD and Marissa Pierce, MFT.

10:00 AM - Overcoming Toxic Stress: Biography of a Wounded Healer You are invited to discover the other side of Adverse Childhood Experiences (ACES) in physicians by reframing their impact from a resilience angle. Presented by Caroline

Full Breakfast

Giroux, MD.

Exploring Gratitude

11:00 AM - The Psychology of Wellness

Lightning Rounds

Workshop

CME Available

In a world of many challenges, how can we overcome them? Discover methods to improve our relationships with ourselves and with others. Presented by Amy Ahlfeld, PsyD.

| VACCINATING AMERICA |

What Can You Do About Vaccine Hesitancy?

Start By Understanding What Makes Patients, and Even Communities, Reluctant

esitancy toward—or even outright rejection of—COVID-19 vaccines is a frustrating and often puzzling problem for physicians. Each of the vaccines available has shown efficacy rates that are several times those for flu shots and and have been credited for the sharp drop in cases that has enabled life to return to something resembling a pre-pandemic normal. Americans accepted the vaccinations for polio and smallpox with a patriotic fervor to wipe out these diseases. But while tens of millions of COVID-19 vaccines have been injected into the arms of Americans, some groups have been the most prominent holdouts even if the reasons are far more diverse than their demographics.

The Same but Different

My neighbor Randy (his last name is being withheld for privacy) is a great guy. A former air traffic controller, he has a booming voice that has led to a second career as a voiceover talent and a laugh that can be heard a block away. He is also white, Republican, a staunch conservative and attends an evangelical church. Taken together, these characteristics form one of the country’s leading demographics for people who are either opposed to vaccines or at least skeptical. The day I got my second shot, I ran into Randy and told him what I had just done and how happy it had made me, feeling like I had been given armor to fend off what I envisioned as COVID snipers who could strike anywhere, anytime at a random target. Randy said at the time that while he wouldn’t dissuade anyone from getting the shot, he didn’t see a need to get one himself; he hadn’t gotten sick and didn’t expect to, so why put something that he still considered “experimental” in his body? It’s easy to dismiss his reluctance to his demographic, but the truth is much more nuanced. In fact, he has 16

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By Ken Smith ken@kdscommunications.com

since gotten his first shot; whether he gets the second shot is a bit up in the air at the moment but probably unlikely. Despite his hesitancy to get fully vaccinated, Randy isn’t cavalier about his health. In fact, the opposite is true: he extensively researches and follows nutritional approaches he believes work to build a healthy immune system, and takes a regimen of supplements that include vitamins C and D along with zinc. It’s also clear, however, that he believes these natural approaches, which some studies say offer benefits against COVID-19 while others say they are modest at best, are as good or better than the vaccine. He says health concerns that he lives with daily, not any religious or political opposition, give him the most pause. “How do we know this isn’t going to make my tinnitus worse, that was one thing. Factor two, I had three strokes, and those three strokes were precipitated by a supplement I took that was developed by a cardiologist,” he said. Reports of blood clots and what a doctor told his daughter-in-law, who recently gave him his first grandchild through a difficult birth, also weighed on him. “The doctor said no more kids, no COVID vaccine.” Still, there is a certain element of defiance to how he approaches COVID. Before any vaccination, Randy and his wife visited a cafe in El Dorado County several times where patrons weren’t allowed to wear masks, and a trip to Louisiana also included a setting that risked exposure. That only reinforced his opinion that he has resistance to the virus, either from his nutritional regimen or a possible early exposure last year that produced mild symptoms. “I honestly don’t believe that if you don’t get the vaccine, you’re going to get COVID and infect other people,” he says. “I just don’t believe it. I don’t believe it because I have gone two years, I’ve been in so many situations where I’m very confident that I’ve probably

been exposed.” That may be part of the thought process, says psychiatrist Caroline Giroux, MD. She likens intentionally placing yourself into a situation that increases the risk of getting COVID-19, such as visiting a restaurant or event where people refused to wear masks, as something that produces the same type of thrill adrenaline junkies get from extreme sports. “Dealing with uncertainty is unbearable to the human mind,” Dr. Giroux said. “For some, it’s a denial of death. It’s frightening to be vulnerable.”

Black and Wary, for Good Reason

Despite being among the hardest hit communities, there is still a lot of convincing to do within the Black community. The skepticism is understandable, given the infamous Tuskegee “experiment” conducted by the U.S. Public Health Service in which 600 Black men who were supposed to be receiving treatment for syphilis received only placebos, aspirin or mineral compounds rather than an antibiotic, and the “Mississippi Appendectomies” that resulted in the involuntary sterilization of Black women. “I had hesitation,” Stanford emergency physician and Sacramento native Italo Brown, MD said of the vaccine during a recent on-stage Barbershop Health Talk with UC Davis neurosurgery resident Edwin Kulubya at Oak Park’s Guild Theater. The two are members of the leadership team at TRAPMedicine—TRAP stands for trust, research, access and prevention—an initiative with the mission to create a new model for addressing the physical and emotional health of Black men and boys. Dr. Brown described his father as a Black man from the 1960s who “was so pro-Black he wouldn’t pick cotton from an aspirin bottle.” “He said Tuskegee was real. He has always preached

to me about mistrusting the medical system and I had that lingering in the back of my head,” Dr. Brown said. “But when you see the devastation up close, your perspective changes.” Despite their demographic differences, Randy and Dr. Kulubya both expressed similar sentiments about how to approach someone who is wavering or reluctant to get the vaccine: recognize that it is an individual decision and provide credible information from messengers who can be trusted by the people they are addressing. “The things we worried about overall was the equitable distribution of vaccines, making sure our communities weren't the last ones to receive the vaccine," Dr. Kulubya said. “We’ve obviously got to increase the education, the trust. We give the information, we’re not trying to push an agenda, we’re not trying to push vaccines, We want to hear your concerns.” TRAPMedicine uses what they call “the cultural capital of barbershops” to reach the Black community because they are a center for discussion and exchange of opinions. “We talk about who’s the greatest basketball player, LeBron, Kobe, we talk about family members who are acting crazy… we have all these conversations,” Dr. Brown said. “So just like that, there are opinions about the vaccine. Our goal has never been to push an agenda, it’s really to be a source of reliable information, to break down some of the these myths and misconceptions and also to get people to accept they can control their health knowledge.”

Let’s Make a Meatloaf

Making that often complex information digestible can be a challenge, but Dr. Erin Deane has found a way to do that—and it involves meatloaf. July/August 2021

“Most people don’t want something they don’t understand,” said Dr. Deane, a family practitioner in Roseville. So she uses an explanation that compares how the vaccine works to something everyone can relate to: making dinner. She describes DNA as “a book of how to throw a fancy dinner party, and our cells read the recipes and make proteins” just like you would your mother’s recipe for meatloaf. Those proteins—the “meatloaf” from the recipe—have traditionally been made in eggs and egg cells and then are injected to create a reaction. “The body gets mad and makes matching antibodies,” she tells patients. “We make little ‘meatloaf-attacking’ molecules called antibodies.” She goes on to explain to them that the messenger RNA (mRNA) vaccines such as Moderna and Pfizer work differently. Instead of injecting little meatloafs, the vaccine injects the recipe for the meatloaf—in this case, instructions for making the spike protein found on the virus and not found in our bodies—and the cells do the cooking, creating little meatloafs (the proteins) that teach the immune system to protect you from a disease that has killed millions of people worldwide. “Is it new to have our cells make proteins from strange RNA from outside your body? Not at all,” she says, especially to patients concerned about mRNA being a new type of vaccine. “It’s been happening for millions of years. Every virus you’ve ever had in your entire life uses this process to replicate. We once again are cheating and copying Mother Nature. RNA vaccines might truly be the most ‘natural’ vaccines ever created.” The question invariably comes up about allergic reactions after getting the vaccine, and she notes that the risk of anaphylaxis is estimated to be five to 10 cases per million people, while about one in 100 people in the U.S. have peanut allergies. That translates to having a 1,000-times higher chance of an allergic reaction from eating a cookie with peanuts than having an allergic reaction to a COVID-19 shot. “Do you run away from the church cookie table after the service?” she asks patients. “If not, then you should be comfortable with the COVID shot.” Even though there have been several reports of patients apparently dying after receiving the vaccine, none have shown a true correlation after investigation. Two different events aren’t necessarily related, she said, even if they happen in proximity to each other. “We are giving shots right now to older and high risk people, people who may die from their chronic health 18

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conditions at anytime,” she explains and then poses a question to patients: “Thinking about every person you know in your life who has died, they probably talked to someone, or ate a meal, or watched a TV show before their death. Did the conversation with their nephew, their slice of orange, their Perry Mason episode kill them? No, their metastatic cancer, their heart disease or stroke, liver disease, or car accident killed them. Something that occurs before something is clearly not always the direct cause of a person’s death.”

Hard to Reach, Easy to Lose

It’s a difficult endeavor to get patients and members of communities that are under-vaccinated to listen and learn. Unfortunately, it’s far easier to have them quickly tune out. “When anyone takes a posture that zeroes in on religion, politics, race, whatever… if you do that, you’re going to offend people and they’re basically going to take a hike,” Randy says, adding that he and others immediately shut down if they interpret what they’re told as “that I was a culprit, that I was part of the problem. You’re part of the problem because you’re a white, Christian conservative… and if it wasn’t for people like you, we wouldn’t have to do all this. That is extremely offensive.” Despite their differences, Randy and Drs. Brown and Kulubya agree that getting the vaccine comes down to a matter of individual choice and the comfort level of that person with the development process, their confidence in the medical system and what is right for them. It’s up to doctors and those in community leadership positions to show each person they try to educate that their first priority is that person’s health, and that it’s best to start by asking questions instead of telling them what to do. “Try to see from their perspective,” Dr. Giroux suggests. “Ask them to tell you more, and find out where you agree and expand on that instead of antagonizing their beliefs.” Randy prefers not to disclose the reasons behind why he decided to get that first shot. He says that while the statistics may show that white, conservative evangelicals are less likely to get the shot as a whole, he knows several people at churches he’s attended who have been vaccinated and some that haven’t. He made his choice based on what he thought was best for him and for his wife, who is now fully vaccinated. “It’s an individual thing for me,” he says. “You do what you need to do.”

FITNESS

CHALLENGE September 1, 2021 - September 30, 2021

Celebrate Wellness Month with a month long fitness challenge for all fitness levels. Join fellow physicians to reach the top of the leaderboard. Compete as an individual, or sign up as part of a team. Set personal goals, get active with friends, and win great prizes!

Get moving with MoveSpring! MoveSpring is a fun, easy-to-use step and activity challenge platform. Connect a wearable device or smartphone to track your activity, which syncs in real time to our native iOS, Android and web apps.

Win great prizes! Join as an individual or help get your team to the top of the leaderboard. Your hard work will pay off with great prizes and giveaways.

tinyurl.com/fitnesschallenge2021 Questions? Contact Sam Mello at smello@ssvms.org.

| RESOURCES |

Want to Be Top of Your Class? Let YouTube Show You How Content Creators Offer Tips, Tricks for Studying and Matching

n the end, lectures, textbooks, supplementary reading and YouTube all do the same thing: put content into your brain. But the increased diversity of choices means that there are not only more options for individual study styles and strategies, but new options that weren't available to medical students not all that long ago. I genuinely believe that watching certain YouTubers can make a profound difference in your study habits. I’ve learned from my time in undergrad and now medical school the importance of an improvement mindset, and moving forward takes discovering your own study style and incorporating better, more advanced study strategies into your routine. That’s where YouTube comes in. It’d be very difficult to try and read up on every single study strategy or Anki add-on individually. By subscribing to a variety of YouTubers, you can construct a network which prunes the best study tips and tricks to help you curate something that will work for you. The increasing selection and quality of YouTube content means that, over time, students will have even more resources available to supplement learning and improve study skills.

One of the videos on Med School Insiders' YouTube channel. MSI also offers tutoring and medical school admissions guidance. 20

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By James Zhou, MS II james.zhou7143@cnsu.edu

Podcasts, as Michelle Ann Wan wrote in the May/ June issue, allow medical content creators to elaborate on their thoughts in free-form conversations on a wide variety of topics. However, other content platforms such as YouTube offer the ability to provide additional outlets for creative individuals to share experiences with their audiences. The resulting combination has produced some of the most effective study resources on the internet and, in the process, has created some very popular personalities. Some of these channels have hundreds of thousands, or millions, of subscribers and are among the most-watched channels on YouTube. Here are some of my favorite channels that I’ve found to be among the most helpful YouTube resources for medical students and pre-meds.

Ali Abdaal

One of the most popular study-YouTubers is Ali Abdaal, whose channel has nearly 2 million subscribers. Ali’s videos stem from his experiences studying medicine and working as a junior doctor in the U.K. Admittedly, their medical education system is a bit different from ours here in the U.S., but his videos do a great job at covering most of the important bits. More importantly, the videos are very concise, entertaining and he articulates his subjects extremely well. His videos include “How I Ranked First at Cambridge University—The Essay Memorization Framework,” which focuses on his study strategy for memorizing vast amounts of information for exams. It is what indeed earned Abdaal the honor of being the highest ranking medical student at Cambridge University and is a technique any medical student can benefit from. In addition to memory tips and tricks, Ali also produces extremely informative videos about general productivity techniques that help him get ahead and stay on top of his work. His second most popular video,

Prerak Juthani

When studying in medical school seems like you’re trying to drink from a firehose, having qualified and effective medical YouTubers like Prerak Juthani to lend you a hand is worth its weight in gold. Juthani, a dual MD/MBA student at Yale University School of Medicine, provides students with informative videos pertaining to medicine, medical school and studying. Some of his most effective and educational videos are on the use of Anki, the flash-card study aide that uses spaced repetition to help students retain important concepts for question bank practice sessions, final exams and ultimately, licensing exams. A lot more goes into creating the perfect flash-card deck than most people might expect and Prerak goes into great detail, over many videos, on various strategies to maximize your Anki efficiency. In addition to his wealth of knowledge about the mechanisms of effective studying, Prerak creates videos based on his own experiences in medical school relating to topics such as the MCAT, the USMLE, research, extracurriculars and more. As he progresses further into his journey with medicine, I envision him covering an even wider range of topics. Ali Abdaal, MD graduated from Cambridge medical school in the U.K. two years ago. He has more than a million subscribers to his YouTube channel.

“How I Ttake Notes on my iPad Pro in Medical School,” is exactly that: it offers a step-by-step instruction guide on how to take digital notes effectively, boosting the amount of information you can retain to ultimately make your after-class studying that much more effective. Videos like these are crucial for medical students who have, or will, attend classes remotely. During the pandemic, every medical school became Zoom University and the transition back to in-person learning is still in flux. With many of us spending the majority of our time online, both productively and recreationally, creators like Ali Abdaal are leading the way by showcasing powerful techniques that can ease the burden of the modern medical student. As a bonus, he offers additional tools to improve studying and even guidance on how to start your own YouTube channel at aliabdaal.com.

Med School Insiders

Med School Insiders is a popular YouTube channel run by Dr. Kevin Jubbal, a former plastic surgeon and now a medical entrepreneur. Dr. Jubbal’s videos span a large range of subjects, but most are focused on productivity and conveying information about the field of medicine from the perspective of someone who has been part of it. His most popular video, “How to Wake Up Early— and Not Be Miserable,” is about general productivity and details how he was able to not only incorporate becoming an early riser into his journey of becoming a high-achieving medical student, but how he eventually came to like it. Other videos detail different parts of the road to becoming a physician, from acing the MCAT to preparing for the USMLE and matching. All of his videos break down broad topics into easy-to-understand information and tips, complete with neat graphics and animation. For pre-med students, Dr. Jubbal’s channel offers a plethora of videos dedicated to improving productivity

July/August 2021

Prerak Juthani is a medical student at Yale University who is also earning an MBA. Prior to attending Yale, he majored in molecular biology and public health at UC Berkeley. Among the secrets to his success he shares on his YouTube channel are tips for using Anki, the flash-card study aide. in your general classes as well as helping you improve your MCAT score. The playlist about the MCAT is especially helpful given the weight that the exam holds in the medical school admissions process. Dr. Jubbal gives a comprehensive breakdown of the exam and the studying strategies he employed in videos such as, “How I Scored 99.9th Percentile on the MCAT” and “Your Problem with MCAT Studying (and How to Fix it).” For medical students, Med School Insiders also has an excellent video about the NRMP Match Algorithm that provides a fascinating look into how and why doctors are seemingly thrown all over the country after their four years of medical school. The algorithm, which won the 2012 Nobel Prize in economic sciences, matches the hospitals you select on your application with the preferences generated by the selection committee at each of those hospitals. Every year, thousands of graduating physicians have their residency matches determined by these parameters, so saying it's important is a huge understatement.

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One highlight from Med School Insiders is the “So You Want to Be…” series that offers insights on how to match and what personalities will excel in different specialties. It was these sorts of videos that showed me that Dr. Jubbal is thinking about physicians not only as their professional profiles, but also as normal people outside of the medical profession with individual personalities and humor. As a hopeful future neurosurgeon, his video about neurosurgery was also a great sneak peek into the lifestyle and responsibilities that could await me. Social media such as YouTube is becoming a much more prevalent presence in the daily life of students everywhere, medical and otherwise. The increasing amount of content available and growing number of quality creators means today’s pre-med and medical students have a unique opportunity with just a few clicks—and algorithms working to direct them to an even greater trove of videos—to delve deeper into subjects they’re interested in and to learn how to study more effectively.

| MUSEUM UPDATE |

SSVMS Medical Museum Begins to Reopen New Online Features Added

ur Medical Society’s Museum of Medical History spans almost two hundred years of history, but one of the most remarkable events in that period of time was also responsible for its temporary closure for the past 15 months. Now that COVID is settling down we will be opening on a gradual schedule, starting one day a week and only by appointment, limited to ten attendees each hour. This limitation is initially necessary due to the limited space within the museum. The goal is to gradually reopen. Our museum is part of a coalition of Sacramento area museums that will continue to require masks. Though the museum was closed, it was not ignored. Numerous donations came in over the past year including some diplomas, one from the nursing program at Mater Misericordiae Hospital, the precursor of Mercy Hospital, started by the Sisters of Mercy in 1897. “The Sisters in charge are well known to be not deficient in experience or in devotion and tenderness in their methods of waiting upon those committed to their care,” The Sacramento Bee said on May 15, 1897. We have also added a variety of other nursing-related

The museum includes a collection of patent medicine adversting cards featuring beautiful—and often dramatic— artwork.

By Bob LaPerriere, MD ssvmsmus@gmail.com

artifacts to our Nursing History Room. Several of our retired physician volunteers have completed the inventory of our resource and reference books, numbering well over 800, in addition to our collection of approximately 1,000 medical textbooks. They have also started photographing our collection of ephemera, and their efforts are greatly appreciated. These projects will help increase the audience that can benefit from these wonderful resources. As the curator, I took advantage of “pandemic time” to markedly increase the offerings on the museum website at ssvms.org/museum. Upgrades include our hub, where photos and descriptions of over 400 items in our collection can be easily accessed and viewed. More are being added to make our museum contents available not just locally, but to anyone online. Recent additions include Plagues and Pandemics by Dr. Kent Perryman, a digital flip book that is an excellent resource for understanding the communicable diseases that have ravaged mankind for thousands of years. Others include Vignettes of California Medicine, which looks at the history and cultural elements of practicing medicine in the state since its earliest days, and images from the glass slide collection of Dr. Junius Harris featuring historic photos of Sacramento’s health care leaders and long-gone hospitals. We also have three new virtual events on the museum website, including a narrated tour, a scavenger hunt based on the sheets students use on our museum tours, and a walking tour of Sacramento’s Historic City Cemetery that features a discussion of 19th century physicians and the area’s medical history. Reservations to visit the museum can be made on the museum website starting July 1. Check the website for updates as we gradually reopen on a limited basis, and we hope to see you back at the Museum of Medical History in the future! July/August 2021

| ESSAY |

A Kitty Catastrophe

This Cat Had More Than Tuna on His Breath By Faith Fitzgerald, MD ftfitzgerald@ucdavis.edu

any years ago, I was asked to give a “Stump the Professor” session to doctors and nurses at a small city hospital to the north of Sacramento, well within driving distance for me. I accepted with delight, as the challenge of working through to diagnosis is one I had always much enjoyed, and the colleague who called to ask me to do it was a doctor whom I admired and liked. We settled on a date and time for the event acceptable to us both. When I arrived after driving to that hospital on the day of the “Stump,” I was greeted by my friend, who was guarding a parking place for me as I entered the parking lot (which was almost filled up). He told me the audience was large, which I found very flattering! He guided me to a room, full of chairs and tables of food, packed with doctors and nurses. He introduced me, then presented the case as follows: “A middle-aged unmarried woman, a beloved school teacher in our small town, was brought by ambulance in a coma to this hospital on a Monday morning,” he said. “Her schoolroom that day had been full of elementary school children when the teacher suddenly collapsed on the floor and did not speak, move, or get up. One of the students immediately ran out of the classroom door to call for help. Several other students began to cry, and a few tried to awaken her by shaking her shoulders and hands… but to no avail.” “There are many reasons for collapse,” I responded. “Had she been ill?” As Sherlock Holmes said long ago, it is a capital error to speculate without data. “On the Friday before her collapse on Monday,” he said, “the teacher had told her students—who had asked her why she seemed so unusually unhappy—that her beloved old cat had been sick for several days and that she found him lying dead next to her in her bed (where he usually slept) very early that Friday morning.” She greatly mourned his loss, he said, and with copious tears had buried him that dark day in her garden 24

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before coming to work at the school on Friday. She had stayed there until the school bell rang to go home, which both she and the students did. “What was her condition when she arrived in our emergency room on Monday morning?” I asked. “She was in a coma and could not be aroused.” “Had she mentioned the symptoms and signs of the cat’s sickness to anyone? Might it have been transferred to her by the cat? “We had no evidence when she arrived here in our hospital that she had discussed her sick cat with any of the local neighbors,” my friend said, “but she did tell the students on Friday, with tears, that her old cat had gone to heaven. “On our exam she had a fever, tachycardia, and rales in her lungs, but no palpable findings on her body. Labs were drawn, but she died before the results came back.” “Was an autopsy done?” I asked. “Only when the test returned from the lab late in the day was a diagnosis confirmed,” he said. “She was not autopsied.” He then said that a group of men, after being told what was happening, had gone out to the teacher’s home in the woods to dig up the cat. They called with the news that a dead squirrel was also seen under a bush a short distance away from where the cat had been buried. The presumption was that the cat had killed the squirrel by tearing it apart using teeth and claws and then grew increasingly ill over the next few days until he died on Friday. “Oh!” I said. He added that the teacher’s body was cremated, as were those of the cat and the squirrel. “So it is possible that something went from squirrel to cat to school teacher! Were the children, other teachers, staff and ambulance drivers—as well as those who cared for her in the hospital—all treated, as were also the men who dug up the cat from his grave and put both

the squirrel and the cat together in a tight plastic bag?” “Yes, they all were,” my friend said, “and I think you’ve got it.” “Oh! Was the diagnoses septicemic plague?” “Right!” my friend said. As news of the Gold Rush spread, ships started to come to California in 1848 and 1849 and the ships had rats on board with them. Rats and their fleas began to leave the ship at the wharves, and they went on to infect people and rodents. The bacteria, Yersinia pestis—a Gram-negative rod—is maintained in nature by wild rodents such as prairie dogs, chipmunks, wood rats, ground squirrels, deer mice and voles. Public health officers in San Francisco tried to quarantine people and kill the rats, but the then-governor of California, Henry Gage, fearing loss of state money by frightened entrepreneurs, declared in 1900 that no plague existed in California and forbade public health officials from saying it did. Three years later, a new governor was elected: George Pardee,

MD, Ph.D. and a regent of the University of California. He was told right away of the plague and took immediate steps to end it. But it was a bit too late, as the squirrels and other rodents had taken it to the woods and some (especially in the southwest) to the deserts. Plague still presents a hazard, particularly in national parks where squirrels can pass it on to other squirrels and some other rodents, and then on to wild and domestic animals—and humans—to this very day. Cats can easily get plague, as can other species including rabbits, coyotes, bobcats, goats, camels and sheep. Cats with primary septicemia plague have no obvious disease of the lymph nodes (so not bubonic) but may have fever, lethargy and poor appetite. Septic signs may also include diarrhea, vomiting, excessively rapid heart rate, weak pulse and breathing distress. The teacher was at great risk from having her cat near her face in her bed, breathing on her as she slept. To quote Shakespeare, albeit a bit backwards: “To sleep, to die… ay, there’s the rub!” July/August 2021

| BOARD BRIEFS |

Board Briefs May 10, 2021 THE BOARD: Received an update from J. Bianca Roberts, MD, Board Secretary and Chair of the SSVMS Health Equity Committee. The committee addresses racism and bias in medicine by developing best practices for medical groups, providing resources and education for physicians, and advocating for legislative policies that affect health outcomes for marginalized communities. Received an SSVMS Membership Overview for 2020 from Aileen Wetzel, CEO. Approved the resignation of Ranjit Bajwa, MD from the Board of Directors representing District 4, Office 4, El Dorado County. Approved the appointment of Shideh Chinichian, MD to the Board of Directors representing District 4, Office 4, El Dorado County. Approved the establishment of the 2021 Nominating Committee which is charged with nominating active members to vacancies on the Board of Directors and SSVMS Delegation to the California Medical Association. Approved a proposal to revise Board policy 100-03, increasing the check signature limit. Approved a request from the Public and Environmental Health Committee to join the Capital Region Climate Readiness Collaborative. Approved Derek Marsee, MD to the SSVMS Delegation representing Alternate-Delegate District 2, Office 2. Approved the 1st Quarter 2021 Financial Statements. Approved the following Membership Reports: April 26, 2021 For Active Membership — Peter R. Callaham, MD; Timothy V. Clark, MD; Raja Dutta, MD; Arish Eduljee, MD; Allison S. Glass, MD; Kossuth F. Hollingshead, Jr., MD; Anthony Y. Kelada, MD; Baroon Rai, MD; Shagun Sharma, MD; Nasratullah Wahidi, MD; Eric Wong, MD.

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For Reinstatement to Active Membership — Frank A. Apgar, MD; William R. Auch, MD; Andrea Bates, MD; Chandan Cheema, MD; Henry Chen, MD; Daniel McCrimmons, MD; Derek Marsee, MD; Anh Nguyen, MD; Margaret Portwood, MD. For Resident Active to Regular Active Membership — Michael Cardenas, MD; Louise Glaser, MD; Alexander Schmalz, MD. For Resident Physician Active Membership — Vincent R. Kennedy, DO. For Retired for Retired to Active Membership — Roger Gilbert, MD. For Retired Membership — Daniel Fisher, MD. For Resignation — Jacob Bair, DO; Lawrence Bercutt, MD; Joseph Bistrain, MD; Renee Brown, DO; Connie Chang, MD; Shravan Cheruku, MD; Wongae Choi, MD; Xi Damrell, MD; Michael Gillowgley, MD; James Goldberg, MD; Bruce Gordon, MD; Steven Harris Jr., MD; Michael Heiby, MD; Trevor Heneveld, MD; Matthew Herrick, MD; Aditee Jodhani, MD; Robert Kozel, MD; Katie Lukasek, MD; Jan Okimoto, MD; Julie Phan, MD; Keith Rosing, MD; Anurdha Shanmugham, MD; Natasha Smith, MD; Kerilee Wenker, MD; Earl Weyers, MD; David Whalen, MD. For Termination of Membership for Surrender of License — David Kosh, MD; Gilbert Simon, MD. For Transfer of Membership — Alicia Kurtz, MD (to Santa Barbara); Vanita Mistry, MD (to Santa Clara). May 10, 2021 For Regular Active Membership — Anita E. Cherian, MD; Audrey Y. Kim, MD; Judith Mikacich, MD; Tanuja R. Raju, MD. For Resignation — Peter Callaham, MD; Sunil Perera, MD.

| NEW MEMBERS |

New SSVMS Members

The following applications have been approved by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — J. Bianca Roberts, MD, Secretary.

New Active Members

*Physician specialty abbreviated following name.

Anita E. Cherian, MD, IM, The Permanente Medical Group Timothy V. Clark, DO, CCM, Sutter Medical Center, Sacramento Raja Dutta, MD, P , Woodland Memorial Hospital Arish Y. Eduljee, MD, N, Woodland Clinic Medical Group Allison S. Glass, MD, U, Woodland Clinic Medical Group Kossuth F. Hollingshead, Jr., MD, EM, Sutter Davis Hospital

Anthony Y. Kelada, MD, P , Mercy General Hospital Audrey Y. Kim, MD, FP, The Permanente Medical Group Derek K. Marsee, MD,PhD, PTH, Diagnostic Pathology Med Grp Judith A. Mikacich, MD, OBG, Sacramento Women's Health Baroon Rai, MD, CCM, Sutter Medical Center, Sacramento Tanuja R. Raju, MD, OBG, Mercy Medical Group

Alexander D. Schmalz, MD, EM, Sutter Medical Center, Sacramento Davina W. Schulman, MD, D, Pacific Skin Institute Shagun Sharma, MD, FP, The Permanente Medical Group Nasratullah Wahidi, MD, P , Mercy San Juan Medical Center Eric Wong, MD, AN, The Permanente Medical Group

July/August 2021

| THE LAST WORD |

Laminate? That's So Early 2021 I

Here’s How to Digitize Your Vax Card Instead

f there’s another item to add to the uncertainty of the end of COVID-19 pandemic restrictions, it’s this: Do I need my vaccine card for anything, and what should I do to protect it? The answer to the first question is a solid “maybe.” Guidelines in California say it’s OK for fully vaccinated people to drop their masks, but that the unvaccinated should keep them on. But compliance is largely based on the honor system and we know how well that works, especially among people who resisted wearing masks in the first place. But there will be times a vaccination card will be handy at the least or even required. Some businesses or large venues such as indoor arenas may require proof of vaccination for entry or for specialized vaccination sections. Travel, especially to foreign countries that see vaccination “passports” as a matter of public health rather than as an infringement on personal freedom, may also require documentation that you got the shots (or shot, as is the case with J&J). A vaccination card, however, is little more than flimsy card stock with ink that can be easily smudged. It’s just waiting to be lost, crinkled or tossed out with junk mail following a good kitchen counter cleaning. That’s where the second question comes in about the best way to protect this potentially valuable piece of paper. Some businesses such as Staples want to help you by laminating your card for free, while others in the medical community adamantly urge against it. There’s an even better way to keep your card safe and at your fingertips for whenever you might need it: put it on your phone. A picture of your card is nice to have, but its value is questionable. A much better approach is to use one of the services that will verify your vaccination, determine that you are who you say you are, and then provide you with a digital card that can easily be stored and readily accessed in your phone’s wallet. 28

Sierra Sacramento Valley Medicine

One such service I used is VaxYes from gogetvax (gogetvax.com/VaxYes). The company uses a secure, HIPAA-compliant process using four levels of validation that is easy to do on your phone or computer. You’ll send them pictures of your government-issued ID and of your vaccination card; they’ll verify your identity, that the vaccine dates and lot numbers make sense and don’t include fraud markers, and then use artificial intelligence and trained medical professionals to ensure the validity of the information you provide. They also match your information with state records to complete validation. The process was easy, involved sending a couple pictures and then answering a series of about a half-dozen text messages to complete a secure verification of the information. If there’s a glitch, customer service will respond fairly quickly. I know because on my initial “Level 1” card that they send out as a temporary version before going through the full validation process, gogetvax dated my first shot as February 4 (2/4) rather the actual date of April 2 (4/2). I alerted them by email and got a response within a day or two that it had been changed and that my verified card was available. It’s now in my Apple Wallet. California is also rolling out its own digital vaccination card system at myvaccinerecord.cdph.ca.gov. Initial reviews were mixed, and the link and QR code produced are reportedly only good for 24 hours. The state also recommends keeping a screenshot as opposed to how gogetvax integrates with your digital wallet. Just as printed tickets to major events are quickly becoming a thing of the past, the life span of a paper vaccination card may be as short as the time a 17-year cicada spends above ground. A proper e-vax card is simple, will likely pass muster with TSA at the airport or at your next concert, and, I’m willing to bet, will always be within reach in your pocket or purse. — Ken Smith

Closer to home + enhanced referrals = easier access to world-class care Pediatric neurosurgeon Marike Zwienenberg, M.D., FAANS, is an endoscopy expert and part of our fetal surgery team.

UC Davis Health offers nationally ranked medical specialties and prominent innovators — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley.

Our liaisons can also help to:

Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care.

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Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals, obtain information, resolve process questions, and more.

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Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, lunch-and-learns and symposiums

We welcome you to reach out to your local UC Davis Health Physician Referral Liaison today: Robert Musso | 916-878-7310 | rpmusso@ucdavis.edu

referrals.ucdavis.edu