2016-Sep/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2016

Success. It’s what Sierra Sacramento Valley’s finest physicians strive for...and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice these days, and are committed to supporting you with a range of programs and services that no other professional liability company offers. These include a 24-hour early intervention program, HR support, EHR consultation, and a robust group purchasing program, to name a few.

Free Risk Management Dinner Presentations! CAP is proud to join the Sierra Sacramento Valley Medical

To reserve your spot, please call 800-361-5569

Society (SSVMS) and Placer-Nevada County Medical

or email RSVP@CAPphysicians.com. Space is limited and

Society (PNCMS) in hosting a series of free, no-obligation

reservations are required.

risk management presentations designed to help physicians run safer, more successful medical practices.

September 22 - 6:00 p.m. The Firehouse Restaurant, Sacramento CyberRisk: Is Your Practice at Risk? Presented by Deidri Hoppe Vice President, CAP Physicians Insurance Agency November 9 - 6:00 p.m. Sienna Restaurant, El Dorado Hills Every Chart Tells a Story:

For Your Protection. For Your Success.

Reducing Risk with Appropriate Documentation Presented by Susan Jones, CPHRM Senior Risk Management & Patient Safety Specialist,

800-252-7706 | www.CAPphysicians.com

Cooperative of American Physicians

Sierra Sacramento Valley

MEDICINE 2 3

2016 Education Series PRESIDENT’S MESSAGE 2016 Opioid Prescribing Guidelines

Thomas W. Ormiston, MD

EXECUTIVE DIRECTOR’S MESSAGE Making Sense of MACRA

Aileen Wetzel, Executive Director

EDITOR’S MESSAGE Quelling Our Inflammasomes

Nathan Hitzeman, MD

Symbols of Medicine – Stop Using the Wrong One

John Paul Aboubechara, MS II, GS II

Stem Cell Program at UC Davis

F. James Rybka, MD

Call for Awards Nominations

BOOK REVIEW When Breath Becomes Air

Reviewed by George Meyer, MD, and John Loofbourow, MD

BOOK REVIEW An Unquiet Mind — Memoir of Moods and Madness

Reviewed by Lee Welter, MD, and Caroline Giroux, MD

Beta Has Our Attention

Kent Perryman, Ph.D. Reflections on Doctors as Patients

Drug Costs – The Cup Runneth Over

Jack Ostrich, MD

TRAVELOGUE Edinburgh’s Medical History Museums

Building Bridges: Science to Medicine

Farrah Nasrollahi, MS II

Interested in Shaping Health Policy?

Welcome New Members

Ann Gerhardt, MD

17 Tangles

John Loofbourow, MD

A Dog in the Hospital?

Judy Maben, Paws On-Call Volunteer

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

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx On June 1 of this year, family doctor Nate Hitzeman shot this image on his Samsung S7 with soon-to-be second year medical students from UC Davis School of Medicine while volunteering in Leon, Nicaragua. “Leon, a colonial town rich in history and the arts, has many murals pertaining to politics and the Sandinista-Contra war in the 1980s,” says Dr. Hitzeman. “This mural caught our eyes as it spoke to our growing symbiosis with our computers and smart phones. One may argue commensalism or even parasitism. The students were asked to pose as if they could not break away from their phones. They did so, and without much difficulty. Apart from the moment of this picture (and a few respites at a fruit smoothie café), the students worked hard to engage the community in a public health project and volunteered in the clinics and hospital.”

Volume 67/Number 5 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

– hitzemn@sutterhealth.org

September/October 2016

Sierra Sacramento Valley

MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2016 Officers & Board of Directors Thomas Ormiston, MD, President Ruenell Adams Jacobs, MD, President-Elect Jason Bynum, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Vijay Khatri, MD Darin Latimore, MD Christian Serdahl, MD District 3 Thomas Valdez, MD District 4 Alexis Lieser, MD

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

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

District 1 Anissa Slifer, MD District 2 Don Wreden, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Ann Gerhardt, MD Sandra Mendez, MD Robert Rabody, MD Armine Sarchisian, MD John Tiedeken, MD Eric Williams, MD Vacant Vacant Vacant Vacant Vacant Vacant Vacant Vacant

Free Risk Management Dinner Presentations

The following Risk Management Dinner Presentations are presented by the Cooperative of American Physicians (CAP) and sponsored by the Sierra Sacramento Valley Medical Society and the Placer-Nevada Medical Society. These are free, no-obligation risk management presentations designed to help physicians run safer, more successful medical practices.

▪To Make a Reservation▪ Call 800-361-5569 or email: RSVP@CAPphysicians.com

● CyberRisk: Is Your Practice at Risk? Thursday, September 22, 2016, 6:00 pm, The Firehouse Restaurant, Sacramento. Presented by Deidri Hoppe, Vice President, CAP Physician Insurance Agency. ● Every Chart Tells a Story: Reducing Risk with Appropriate Documentation. Wednesday, November 9, 2016, 6:00 pm., Sienna Restaurant, El Dorado Hills. Presented by Susan Jones, CPHRM, Senior Risk Management & Patient Safety Specialist, Cooperative of American Physicians. ……………………………..………………………………………….. The following webinar is available on-demand at: CMA Resource Library http://www.cmanet.org/resource-library It is free for SSVMS/CMA members and their staff. Nonmember price is $99. For more information call (800) 786-4262. •On Demand: MACRA: What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now? This webinar provides a brief overview of the new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) payment changes, with an emphasis on the California Medical Association’s (CMA) advocacy with the Centers for Medicare and Medicaid Services (CMS) to significantly improve the MACRA regulations for physicians. This webinar also discusses what steps to take now to be ready.

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President-Elect Ruth Haskins, MD

CMA Vice Speaker Lee Snook, MD

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising.

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

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2016 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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PRESIDENT’S MESSAGE

2016 Opioid Prescribing Guidelines By Thomas W. Ormiston, MD MY MESSAGE IN THE last issue discussed the dilemma I face as a primary care physician prescribing opioid pain medications for chronic pain. I planned to include the new CDC Opioid prescribing guidelines, until I read them and realized they required more explanation than space allowed. Here I discuss my reservations. To recap briefly, it is difficult for me to know in prescribing opioids for chronic pain whether I am prescribing for a person whose actual diagnosis should be chronic pain or opioid use disorder, given our extremely limited understanding of both conditions, and the lack of objective diagnostic criteria. The Centers for Disease Control assembled a distinguished panel of experts from around the country to review the evidence for opioid prescribing and recommend guidelines. The experts reviewed the evidence available. They rated the applicable studies almost uniformly as having serious methodologic flaws, based on the CDC rating system. The CDC system rates only the quality of the studies reviewed, not the likelihood that the recommendations based on those studies are accurate. I would have preferred the use of the Agency for Healthcare Research and Quality (AHRQ) rating system. The AHRQ system performs a similar analysis of the quality of the research but takes the process one step further by scoring the recommendations generated on how likely they are to be true. In my mind, recommendations based on low-quality evidence are essentially expert opinion. And as we know, expert opinion in medicine in the past has been shown, when tested, to be correct a little more than half the

time. We just don’t know which half. My other disappointment is that the authors did not emphasize how little we know about both chronic pain and opioid use disorder. In my opinion, our patients and our profession would be better served if we admitted how little we know in this arena and called for more highquality research to help us find the truth. So here then, with the above caveats, are the 2016 CDC opioid prescribing guidelines. For those curious, only the last recommendation rises above level 3 or 4 evidence up to level 2 (RCT with important limitations or exceptionally strong observational studies).

Determining When to Initiate or Continue Opioids for Chronic Pain 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. 3. Before starting and periodically during

September/October 2016

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

opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

When opioids are started, clinicians should prescribe the lowest effective dosage.

4. When starting opioid therapy for chronic pain, clinicians should prescribe immediaterelease opioids instead of extended-release/ long-acting (ER/LA) opioids. 5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to >50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to >90 MME/day or carefully justify a decision to titrate dosage to >90 MME/ day. 6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. 7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use 8. Before starting and periodically during

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continuation of opioid therapy, clinicians should evaluate risk factors for opioidrelated harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (>50 MME/day), or concurrent benzodiazepine use, are present. 9. Clinicians should review the patientâ&#x20AC;&#x2122;s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. 10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. 12. Clinicians should offer or arrange evidencebased treatment (usually medicationassisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder. NOTE: All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care), except recommendation 10 (designated category B, with individual decision making required). See full guideline for evidence ratings. tom.ormistonmd@dignityhealth.org

EXECUTIVE DIRECTOR’S MESSAGE

Making Sense of MACRA By Aileen Wetzel, Executive Director ON APRIL 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), reforming the way physicians will be reimbursed in the future. The California Medical Association (CMA), American Medical Association (AMA), and nearly every other physician organization supported MACRA because it was intended to provide stable payment updates, significantly reduce the quality reporting program burdens, reinstate bonus payments, and allow innovative, physician-led alternative payment models. MACRA repealed the flawed sustainable growth rate (SGR) payment system, which governed how physicians and other clinicians were paid under Part B of the Medicare program. It replaced the SGR, and its fee-forservice (FFS) reimbursement model, with two paths: The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). The Centers for Medicare and Medicaid Services (CMS) will begin measuring performance for eligible clinicians in 2017, with payments based on those results beginning in 2019. The proposed rule to implement MACRA was issued by CMS on April 27, 2016, and the final rule is expected later this year.

Two Payment Pathways: MIPS, APM What is MIPS? The Merit-Based Incentive Payment System combines the requirements of the Physician Quality Reporting System (PQRS), the Value-Based Modifier Program (VBMP), and the Medicare Electronic Health Record Incentive Program into a single, improved reporting program. It adds a fourth component to promote ongoing improvement and innovation to clinical activities. MIPS will assess individual physician

performance in four categories to generate a composite score on a 0-100-point scale that could positively or negatively affect a provider’s Medicare reimbursement, starting at 4 percent in 2019 and gradually increasing to 9 percent by 2022. The categories are: • Quality – based on PQRS. • Resource use – based on VBPM. • Advancing care information – based on meaningful use. • Clinical practice improvement activities – new program. The MIPS final rule, expected later this year, will determine how points are earned within each component and provide other details. Initially, most physicians are expected to be participants in MIPS. Are there any exemptions from MIPS? Yes. Exemptions from MIPS include: • Providers in their first year billing Medicare Part B. • Providers that meet the low volume threshold, which is defined in the proposed rule as Medicare billing charges less than or equal to $10,000 and 100 or fewer Medicare patients in a year. • Providers who qualify for payment under APMs with the associated bonuses exempt from MIPS. Additionally, it is anticipated that providers practicing in rural health clinics or Federally Qualified Health Clinics (FQHC) are also exempt from MIPS. What is an APM? Clinicians who participate to a sufficient extent in advanced Alternative Payment Models would be exempt from MIPS payment adjustments and would qualify to receive a 5 percent lump-sum bonus on Medicare payments for 2019 through 2024. This bonus will be in addition to the incentive paid

September/October 2016

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

through existing contracts with the qualified APM (e.g., Medicare Shared Savings Program), demonstration program, etc. Beginning in 2026, participants will qualify for a 0.75 percent increase in payments each year. Examples of APMs, so far, from the Center for Medicare and Medicaid Innovation (CMMI) include accountable care organizations (ACO), patient-centered medical homes, bundled payment models and other initiatives yet to be finalized. In order for a provider to receive enhanced payment through a qualified APM, the APM must also meet the following eligibility requirements: • Use of quality measures comparable to measures under MIPS. • Use of a certified electronic health record technology (CEHRT). • Assumes more than a “nominal financial risk” for monetary losses OR is a medical home expanded under the CMMI. • A physician receiving the designated percentage of Medicare payments or patients through a qualified, eligible APM based on the above requirements is considered a “qualifying participant” (QP). How does this affect me? All physicians will need to know which payment track they will be participating in — MIPS or Advanced APMs — and how quality and performance

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measurement will affect their Medicare payments. Physicians must also review and understand the preliminary lists of proposed measures to determine which are most aligned with improving their patients’ outcomes, and therefore most appropriate for their practices. Initially, most physicians are expected to be participants in MIPS. Physician practices will need to evaluate and address any gaps between current tracking and reporting capabilities and these new measures for 2017. Practices that aren’t currently utilizing certified EHR technology will also want to consider doing so. Successful reporting on many of the performance measures for both APMs and MIPs will require increasing the use of CEHRT over time. Penalties and bonuses: MIPS penalties and bonuses (for scores below or above the annual performance threshold) are on a sliding scale, with maximum MIPS bonuses/penalties of: • 2019: +/- 4 percent • 2020: +/- 5 percent • 2021: +/- 7 percent • 2022: +/- 9 percent MIPS bonuses can go even higher (up to three times these levels). However, total MIPS bonuses and penalties must balance each other. An extra “exceptional performance” bonus of up to 10 percent is available from 2019 through 2024, up to $500 million each year. Physicians and other eligible professionals with substantial revenue from qualifying APMs receive a 5 percent bonus payment in 2019 through 2024. What kind of support is available for small practices? The U.S. Department of Health and Human Services (HHS) has announced that it will allocate $20 million annually for the next five years to fund “on-the-ground” training and education for clinicians in individual or small practices. Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under-resourced areas including rural areas, health professional shortage areas (HPSA) and medically-underserved areas (MUA). CMS is also developing convenient, easily accessible continued on page 14

EDITOR’S MESSAGE

Quelling Our Inflammasomes This multiprotein oligomer can activate an inflammatory cascade

By Nathan Hitzeman, MD I RECENTLY CAME ACROSS an article in the New England Journal of Medicine (NEJM) on pseudogout. A diagram detailed the inflammatory pathways, and − lo and behold − a novel term caught my eye: an “inflammasome.” Finally, a visualization of that elusive molecular tumbleweed that has been terrorizing my patients with chronic pain without clear organic cause! Can you say “game changer”? I can already imagine future late night infomercials peddling products to control our inflammasomes and even later night lawyer group messages recruiting those whose inflammasomes have been neglected. WALL-E was an animated movie ahead of its time. Released almost a decade ago, it predicted humankind would be reduced to out of shape, overconsuming, chair-bound beings as automation and computers took care of all those pesky activities of daily living. I suspect you, like me, have an increasing number of patients in your practice who have taken on a disabled role for reasons that escape medical explanation. The requests for disability placards, utility discounts, and electric wheelchairs wash into my inbox like a diurnal tide, leaving me to decide which to address and which to throw back to sea. In the future, an inflammasomeometer might help me triage these requests. I have much respect for our armed forces personnel and veterans, but an entitlement factor and disability culture has infiltrated that population as well. I recall one resident several years ago proudly stating that her husband

had gotten 10 percent disability benefits from the military. She and he now do endurance competitions together. An interesting history of medicine article in the May 19, 2016 NEJM describes how the specialties of “curative” rehabilitative medicine and orthopedics grew out of the World War I “War Risk Insurance Act” of 1917. A guarantee was made that all disabled soldiers would

September/October 2016

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

receive rehabilitation and reeducation, and that this would obviate the need for pensions and other welfare benefits. This arose from a strain on the Treasury from the disability payments to Civil War veterans, an expense that exceeded the cost of the war! (So expect our forays into Iraq and Afghanistan to keep on giving, or taking?) These noble medical specialties and ideals have changed some since WWI. I have a hard time getting my joint-replaced patients off of opioids, but it was a nice try. Currently, in my inbox, there is a wheelchair request form for a lady in her mid 50s who frequently comes to our clinic strategically seeing a different doctor each time, complaining of a chronic cough that only responds to codeine, and going into fits and hysterics about chronic abdominal pain. She walks in and out without an assistive device. The near $10,000 price tag gives me pause, although the medical supply company who stands to have some of its bread buttered has provided a document with the

appropriate terminology to justify this expense. Electric wheelchairs have street value. Another patient of mine years back finally convinced me to authorize one for him for his post-gunshot wound chronic pain, even though he walked into the office on his own two legs. The wheelchair was subsequently lost. Another patient of mine who knew the patient said he had been renting it out to others. A Seinfeld episode with George in a motorized wheelchair also touched on this subculture of electric wheelchair status. I’m not sure what it will take to cure this epidemic of inflammasomes. We may just have to wait until we’ve spent so much of our resources and sacrificed so much of our infrastructure that a collapsed levee, a runaway train or tractor trailer, or a nearby gunshot will be the only true test on just how disabled we are and how fast our legs can move. hitzemn@sutterhealth.org

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Share with your colleagues. Pre-register for this free course at: http://www.imq.org/education/caprrc.aspx

Symbols of Medicine – Stop Using the Wrong One By John Paul Aboubechara, MS II, GS II

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

MY COLLEAGUES AND I recently founded the UC Davis Health Student Review, a studentrun medical journal. Along with developing the team and the resources needed to run the organization, we also needed to create a logo to establish our brand. I did several Google image searches to browse through logos that other health organizations used. I found that most logos were variants of two symbols. One symbol is the staff of Asclepius, which includes a single serpent wrapped around a staff (Figure 1). The other is the Caduceus, which has two serpents and a pair of wings (Figure 2). Intrigued, I spent several hours tracing the origins of these symbols, which led me to an unexpected odyssey into Greek mythology. Modern medicine demands that physicians are compassionate, honorable, and willing to place the interests of their patients above their own. This expectation has its origins rooted in the traditions of ancient Greece. This may not be a surprise for many, as Hippocrates is often regarded as the Father of Western Medicine. Interestingly, if you were to read the first sentence of the original Hippocratic Oath, you would find that Hippocrates begins by hailing the healer gods Apollo, Asclepius, Hygieia, and Panacea.1 For the sake of this article, we are interested in the story of Asclepius, who specifically represented the medical arts. In Greek mythology, Asclepius was once examining a man, Glaukos, who was smitten by a thunderbolt from Zeus.2 Suddenly, a snake appeared in the room, and Asclepius reacted by striking it dead with his staff. A second snake later entered and placed herbs in the mouth of

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the former snake, reviving it. Asclepius observed this, and made use of the same herbs to revive Glaukos. Asclepius subsequently adopted the serpent wrapped around his staff as his symbol. From as far back as 1200 B.C., the staff of Asclepius became a popular symbol for the healing arts, and was represented on many coins, statues, and physician’s rings. The use of this symbol was suppressed beginning in the 6th century A.D., as Christianity sought to eliminate the traditions and rituals of the Greco-Romans, and did not return until after the Protestant Reformation. Today, the staff of Asclepius persists as the established symbol of medicine. Beginning in the late 19th century, the Caduceus began to be occasionally adopted in place of the staff of Asclepius by medical publishers.3 However, it did not gain much traction until 1902, when Captain Frederick Reynolds — who fancied its design — adopted the Caduceus as the official emblem of the U.S. Army Medical Corps (USAMC). At first, his request was declined by Surgeon General G.W. Sternberg, but upon repeated request, was approved by Sternberg’s successor. The adoption of the Caduceus by the USAMC paved the way for other organizations, including the U.S. Public Health Service, to also use this symbol. On initial examination, the two symbols may seem quite similar; however, the Caduceus has a significantly different origin, which is both irrelevant to, and incongruous with, the principles of medicine. Greek myth attributes the Caduceus to Hermes, the messenger of Zeus, who among other things, had a role in peacemaking. Legend

describes a story in which Hermes separated two fighting serpents by striking his staff into the ground between them. The snakes then both wrapped around the staff and embraced one another in friendship.1 Hermes’ Caduceus, thus, began as two serpents coiling twice around the staff, but with time morphed to have up to seven coils and to include wings. Ironically, Hermes, in addition to carrying messages and peacemaking, was the patron god of thieves, merchants, and travelers. He was also regarded as the god of games, whose shrewd and cunning speech made him a masterful deceiver.3 Needless to say, my colleagues and I refrained from using the Caduceus, and we suggest you do the same! Yes, if your goal is to have an eye-catching logo, the Caduceus certainly has more flare than the staff of Asclepius. But as any art historian would agree, symbolism is important, and can have significant influence, even if not

FIGURE 1: Staff of Asclepius. FIGURE 2: Caduceus. *Figures courtesy of Tanya Rodman.

obvious. For a discipline that we all regard as noble, medicine deserves to be appropriately symbolized. jjaboube@gmail.com References 1 Pinch, Geraldine. Handbook of Egyptian Mythology. Santa Barbara, CA: ABC-CLIO, 2002. Print. 2 Homer. The Iliad. Fagles R, tr. London: Penguin Books; 1991. 3 Wilcox et al. The Symbol of Modern Medicine: Why One Snake Is More Than Two. Annals of Internal Medicine. April 2003.

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September/October 2016

Drug Costs − The Cup Runneth Over The ABC’s (and D’s) of Four Famous Drugs

By Jack Ostrich, MD

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

SOVALDI and HARVONI are not surnames of Italian composers. In 1988, a pharmaceutical company called Gilead Sciences was founded by Michael Riordan, then 29, a graduate of Johns Hopkins Medical School and Harvard Business School. He dedicated his company primarily to developing and marketing treatments for viral illnesses. Riordan surrounded himself with a coterie of smart people, including two Nobel Prize winners. The company now employs over 7,000 people in several countries. In 2013, Gilead received FDA approval to market Sovaldi as a convenient and effective treatment for Hepatitis C, and in 2014, Harvoni was introduced by Gilead as an even more effective, well-tolerated, once-a-day pill for Hepatitis C. A full three-month course of either of the Gilead products costs over $80,000, about $1,000 per pill. And so, like mattresses and prescription sunglasses, most newly-developed pharmaceuticals are becoming quite expensive. But what about the old standards? Has the cost of aspirin skyrocketed in the last few decades? What about the cost of some other drugs that were, like aspirin, originally derived from trees, shrubs and flowers and which have been used safely and successfully often for centuries? Including aspirin, here are four interesting examples: A is for aspirin. B is for belladonna. C is for colchicine and D is for digitalis.

Aspirin Many centuries ago, for reasons lost in the Sierra Sacramento Valley Medicine

mists of time, someone chewed on some willow bark and then noticed an hour or two later that the back pain he or she had endured for many years was a great deal better. That person tried it again and it worked again. Soon, everyone in that person’s village was chewing on willow bark for relief of all sorts of aches and pains, and even fevers. It did not taste very good, but by golly, it worked. Around 1763, Edward Stone, a British cleric and academic at Oxford University, ingested some powdered willow bark to help cure his “ague.” So impressed was he with the improvement in his symptoms that he strove to isolate the bitter and astringent principle in the bark which, he was sure, was responsible for the curative effect. He succeeded in doing so, and named it salicylic acid, after “Salix,” the Linnaean genus for willows. In 1897, chemists at Bayer Pharmaceuticals in Germany synthesized acetylsalicylic acid (ASA) which preserved the analgesic and antipyretic properties of the willow extract while making it more stable and easier to ingest. The name “aspirin” was originally trademarked by Bayer, but has become, in most of the world, a generic term. In this country, over 15 tons of aspirin are consumed each year. The cost has remained stable and low. In 1980, the average price for 100 tablets of brand-name Bayer Aspirin 325 mg strength was $4.09, and in 2012, it was $5.81. One can buy chopped-up willow bark to make your own potion or powder. One pound

of Salix alba bark costs about $12. Or you can buy 100 powdered willow bark capsules, 400 mg strength, for $5 to $10 online or in stores. At the Whole Foods market near my home, the “Nature’s Way” 100 count, 400 mg strength, white willow bark capsules were selling at $7.39 on July 13, 2016. Some believe that willow bark extract is a more effective product than ASA because it also contains some flavonoids that augment and prolong the effect of the salicylic acid.

Belladonna B is for belladonna. In Italian, “bella” means pretty or beautiful, and “donna” means lady or woman. Extracts from the diminutive plant called belladonna, known in England rather more ominously as “deadly nightshade,” were known in centuries past to contain substances that could cause a large variety of physiological and psychoactive effects. Nightshade is a member of a family of plants known as the Solanaceae. That family also includes tobacco, tomatoes, potatoes, peppers, eggplant and petunias. All contain various amounts of alkaloids, including atropine and scopolamine. Eye drops made from the juice of the berries and leaves were used by certain ladies to dilate their eyes and, thus, make them appear more alluring. They could convert themselves − Presto! − from “una donna come tante” (freely translated as “an ordinary looking woman”) to “una bella donna” simply by the discreet application of a couple of drops of the stuff into their already, presumably, heavily-mascared eyes. In 1934, the now defunct pharmaceutical company called A.H. Robins introduced a pill called “Donnatal” that contained very small amounts of atropine, scopolamine, hyoscyamine and 16.2 mg of phenobarbital. It was marketed as a treatment for peptic ulcer disease, enteritis, and a panoply of gastrointestinal symptoms that we now call Irritable Bowel Syndrome, and it fast became a best seller for Robins. In the year 2000, the pill was still being made under the same patented name by a small company in

Virginia, and 100 pills cost $25-$30. In 2014, a venture capital firm, PBM Capital Group, bought the Donnatal manufacturing rights and soon thereafter, sold those rights to a Canadian company called Concordia International Corporation. Concordia’s website states: “Concordia acquires legacy pharmaceutical products and acquires and develops orphan drugs.” Besides Donnatal, Concordia’s acquisitions include Dyrenium, Lanoxin, Fortaz, Kayexalate, Parnate and Plaquenil. But Donnatal is their best seller, as it had been for Robins. At Walgreens, the cost for 90 Donnatal tablets is $807.95 and at Walmart $811.12.

Colchicine C is for colchicine. Extracts of the crocus bulb, or corm, were known to have a salutary effect on gout and “rheumatisms” for over 3,000 years. The active agent, colchicine, was isolated by French chemists in 1820. It works in a unique way to suppress acute gout, and it can help suppress gouty attacks. Until 2009, it cost about 10 cents a pill in the 0.5 mg or 0.6 mg strength. In the USA, most of it was made by URL Pharma in Philadelphia. In 2006, the FDA undertook reviews of dozens of drugs and drug combinations that had been on the market for a long time, but had never been formally studied or officially “FDA approved,” and colchicine was one of them. So URL Pharma undertook and completed what was, in essence, a new drug application (NDA) for colchicine. The NDA passed muster and gained FDA approval. All other generic cochicine was banished from our shores, and URL now had exclusive rights to produce and market the drug in the United States. They named their new product Colcrys, and the price per pill shot up to about $5 in 2009. The present price per pill at Walgreens with an online discount coupon is about $2.50. Takeda Pharmaceutical Company of Japan recently bought URL Pharma for $800 million and soon afterwards sold URL Pharma, except for the Colcrys patent which it kept for itself, to Sun Pharmaceuticals Ltd., which is

September/October 2016

…like mattresses and prescription sunglasses, most newlydeveloped pharmaceuticals are becoming quite expensive.

India’s biggest drug manufacturer. The price that Sun paid to buy URL was not revealed as of this writing.

Digitalis and Digoxin

Digitalis plant

D is for digitalis, and digoxin. The latter is the most popular of the so-called cardiac glycosides derived from the foxglove plant. Digoxin is still made from the leaves of Digitalis lanata and was first released for use in the USA in 1922. Digitalis extracts were first studied and extensively used by British botanist and physician, William Withering, in the late 18th century. He had observed that victims of “dropsy,” or edema often due to congestive heart failure, seemed to improve if they ingested teas that contained digitalis (foxglove) leaf. In 1785, he published a pamphlet entitled, “An Account of the Foxglove and Some of Its Medical Uses.” 230 years later, there are only two pharmaceutical firms making digoxin in this country. One, Lannett Company, located near Philadelphia, was named by Fortune Magazine as the “Number One Fastest Growing Company” for the year 2015. Lannett makes only generic medications. The other is Jerome Stevens Pharmaceuticals, located in Bohemia, NY, on Long Island. Jerome Stevens recently created a newly-branded version of levothyroxine which they named “Unithroid.” It is a privately-held company. A few years ago, digoxin cost 15 to 30

cents per pill. At Walgreens, thirty 0.125 mg pills cost $43, but a coupon is available that knocks the price down to about $15. One website called “Allivet,” that concerns itself with veterinary medications, sells 100 of the Lannett Company’s digoxin pills, 0.25 mg strength, for $129. Another online drug purveyor, called “International Drug Mart,” states that there are 11 makers of digoxin in the world, and it seems that they have a line on where the best buy is, because they advertise that 100 of the 0.25 mg tablets can be sent to you for only $34.32. I clicked my way through the International Drug Mart website and found great deals for 100 of the 0.5 mg colchicine pills for $63.25, and “Dragon Liquid Pain Balm (Pudina Ka Phool-Karpoor-Gandhapura)” a steal at six bottles for $18.15. The indications for the latter are “Headache, Pain, Sprain, and Nasal Congestion.” But I was suddenly interrupted by a screen-filling McAfee warning that announced in huge letters − “WHOA! Are you sure you want to go there?” So, I decided not to go wherever it was that I was going. After all, I pay Mr. McAfee: to warn me when I am going somewhere less than legitimate. And I trust him. So, no Dragon Liquid Pain Balm or colchicine tablets for me. But you can sign on to International Drug Mart if you wish or dare. jmost119@aol.com

Making Sense of MACRA continued from page 6 educational materials that will focus on helping clinicians understand the programs and how to participate in them successfully. To help physicians understand the MACRA payment reforms, and what they can do now to start preparing for the transition, CMA has published a MACRA resource center. Member physicians can view the resource center at

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www.cmanet.org/macra. There you will find an overview of MACRA, and a comprehensive list of tools, resources and information from CMA, the American Medical Association and the Centers for Medicare and Medicaid Services. awetzel@ssvms.org

TRAVELOGUE

Edinburgh’s Medical History Museums Stories not taught in medical school

By Ann Gerhardt, MD AFTER ENDURING THE mandatory tourist throng at Scotland’s Edinburgh Castle, wander on over to the quiet, but fascinating, Surgeons’ Hall Museums at the University of Edinburgh. The one building houses the History of Surgery Museum, the Dental Collection and the Wohl Pathology Museum. The Surgeon’s History Museum describes the evolution of surgery from the time of the Barber-Surgeons of Edinburgh, which was incorporated as a craft guild in 1505. Barber-Surgeons must have wielded significant influence, since they could cut people, were

exempt from the military AND had the exclusive right to make whiskey. In 1722, surgeons and barbers went their separate ways and during the 18th century, dental, ophthalmologic, psychiatric and midwifery specialties appeared. The English/Scots contributed quite a lot to the field of anesthesia. Though Raymond Lullus first put chickens to sleep in 1275 with his “sweet vitriol” (ether), it wasn’t used in dental surgery until 1842 and in major surgeries until 1847. Joseph Priestley discovered nitrous oxide in 1772 and, in 1799, chemist Humphry Davy devised a way for it to be inhaled by humans. These discoveries paved the way for laughing gas parties and ether frolics in the early 1800s, decades before its widespread use by doctors. Hippocrates said that, “war is the only proper school for surgery,” and a significant section of the museum provides the evidence. Scottish obstetrician James Simpson was the first to use chloroform as general anesthesia in 1847, but it was not used extensively until the Crimean War. Louis Pasteur demonstrated that microbes cause disease, and Joseph Lister proved that carbolic acid could prevent infection in 1867, leading to anti-sepsis procedures used by surgeons during the Boer War (1899-1902). A back corner of the museum is devoted to the history of acquiring corpses for dissection. Two notorious Irishmen, William Burke and William Hare, sold the body of an old man who owed them money to Robert Knox’s anatomy school to cover the debt. They then committed 15 murders, “earning” 6 to 8 pounds per body. When they were caught, Hare squealed September/October 2016

At left is the Wohl Pathology Museum gallery.

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

Top row L-R: Nasal sinus polyps, a renal carcinoma, and severe lumbar scoliosis. Middle row L-R: Severe varicosities, optic nerve glioma, and tuberculous abscess of psoas muscle. Bottom row L-R: Skeleton with osteomalacia and an umbilical cord knot.

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and got off free, but Burke hanged. The judge ordered that he be dissected (at a different school). Thousands rioted for the right to see the body, which was displayed in the Edinburgh University Museum for viewing by the public. However the bodies were obtained, dissection led to significant advances in medicine. Sitting in a mini-amphitheater with benches surrounding “the cadaver,” we watched a video of a doctor describing its dissection. The deceased is David Myles, a man hanged for “incest and debauchery.” Each body part lights up as it is described, showing the inner organs, bones and vasculature. The doctor makes the point that actually seeing anatomy and disease broke with, and improved upon, the common reliance on blind beliefs taught by elders. In another corner, the women-in-medicine section describes Sophia Jex-Blake, who had to fight to study medicine at the University of Edinburgh, but was denied a degree. After finishing her degree in Switzerland, she became Scotland’s first practicing female physician and fostered medical education for women for the rest of her life. Other sections of the museum are devoted to plant-derived medicinals discovered throughout the world, and to Arthur Conan Doyle, MD, who fashioned his fictional private detective Sherlock Holmes after his teacher Joseph Bell MD’s “eerie trick of spotting details.” I avoided the Dental Collection, fearing it would bring back memories of my anestheticfree childhood. The Wohl Pathology Museum, on the other hand, was phenomenal. It contains thousands of specimens, ranging from an entire pretzel of an osteomalacic skeleton to an umbilical cord knot. Each alcove contains specimens related to a different organ system or medical discipline, along with a computer terminal that describes normal anatomy and function of that system. A medical novice could spend hours there, learning much about medicine and wondering if anyone is really normal. algerhardt@sbcglobal.net

Tangles By John Loofbourow, MD She goes most any where she used to go, with help and planning, going slow, and can do most things she used to do but very little that’s really new. She always watches TV “breaking news,” where talking heads spew tired words and views; still walks with help at one hundred three, lone and lonely as old age can be that loses loved ones most every day, one whose foes have even gone away to that mausoleum in the mind, invisible, unknown and undefined. The history she lived – redacted – gone, her universal truths now considered wrong, she’s wantonly outlived her long life; no one else recalls its joy or strife. She searches neuronal tangled time for some meaning in the paradigm that she must live on here, on and on after shared memories are long gone. Vainly queries her own past to find “Why loved ones leave, but leave me behind; “Why do I so cling to life, my dears? “Why do I live so far beyond my years?” But her old cat curls and purrs, and then that oral history student comes again about an Occam’s Razor essay; Or the Gordian Knot? – she cannot say. He loads up her iPhone with new apps And records her words on times long past, because he believes light’s speed so fast it untangles future from the past. john@loofbourow.com

September/October 2016

A Dog in the Hospital? By Judy Maben, Paws On-Call Volunteer

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

CLIFFORD THE DOG HAD a rough start in life. I found him in a shelter in Grants Pass, Oregon; he was frightened and overweight and due to be euthanized in two days. Clifford (as they had named him) was 110 pounds of trembling labradoodle with matted red-gold hair and soulful eyes; it was love at first sight. The staff told me he was very good with other dogs, especially little ones, which he treated with unfailing gentleness. I chalk this up to his amazing sense of empathy. That same empathy has made Clifford a successful therapy dog, as a Sutter Health’s Paws On-Call Visiting Team member. Paws On-Call is a pet therapy program that’s been in existence for close to 15 years. The program originated at Sutter Medical Center Sacramento, then rolled out to Sutter Roseville Medical Center, and recently to Sutter Davis Hospital and Sutter Medical Center, Solano. It is soon to be at Sutter Auburn Faith Hospital. A neighbor of mine who had experience with the Sutter Sacramento pet therapy program suggested that Clifford was a good candidate. I was recently retired and comfortable being in a hospital setting, having spent lots of time in hospitals with my sister and mother when they were ill. I inquired about the program with the Sutter Sacramento Volunteer Services office and they directed me to the Paws On-Call program coordinator, Kathy Montgomery. Kathy held an introductory meeting for people who are sure their adorable dogs would be just wonderful in any setting, including a hospital room. This is not always the case, in spite of the owners’ enthusiasm. Therapy dogs need to be friendly, calm and well trained. Kathy does a preliminary screening of dogs and handlers to see if both have potential, for it is a team, not just a pet, who will be visiting patients

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and hospital staff. Pets other than dogs can be candidates; Sutter’s program has included cats and miniature horses. Having passed the first hurdle, Clifford and I worked our way through the handler training course offered by Pet Partners, a national pet therapy registry organization. The commands for basic dog obedience were pretty easy for Cliff to master: “Calmly walk on a leash, sit, down, stay,” and to be in control while in close proximity to other dogs. Then came hospital protocol: “Leave it” (includes everything from dropped food to other interesting items), “Easy” (there are many loud noises and startling events that occur in hospitals and dogs need to stay calm), “Come say hello” (easy for Clifford… he’s a super friendly guy…to approach anyone, including wheelchair patients, patients with walkers and patients in bed). Next, we needed to be evaluated by Kathy’s team of experienced handlers and evaluators. Clifford and I needed to perform under staged, realistic hospital settings including experiences he would be likely to encounter. That included remaining “neutral” when casually walking by another therapy dog. This is a challenge for most of the dogs that are by nature friendly, or they wouldn’t be there in the first place. Wagging tails are ok, but no nose-to-nose or nose-to-butt sniffing. We passed! And so began our visits to the patients and staff at the Sutter Medical Center, Sacramento. The program has been championed by Dr. Lisa Guirguis, Surgical Oncologist – Breast Cancer, our enthusiastic cheerleader. “The human-animal connection is powerful,” said Dr. Guirguis. “Pet therapy teams provide significant measured benefits to our patients, such as reduction in anxiety and pain. The therapy these animals provide crosses

the barriers of language and race. They are an important prescription complementing the medical care our patients receive.” The pet therapy teams strive to bring a little “normal” life to patients, many of whom miss not only their family members, but their pets. Petting an animal takes patients’ minds off their immediate troubles and often brings a sense of calm. As a team visits, the handler tries to engage patients in friendly conversation and help make the animal as accessible as possible. Of course, there are strict requirements for dogs entering a health care facility. All must be on parasite control and no raw meat diets; health certificates are required annually. They must have a bath within 24 hours of hospital visits, have their nails trimmed, teeth cleaned and be brushed to well-groomed silkiness. So the day before a visit is sort of a doggy spa day for them. And it isn’t just patients who are happy to see the dogs and the two miniature horses who are also part of our program. Staff members often welcome a break from their high pressure responsibilities to take a few minutes to fuss over a fuzzy muzzle. Because my mom was in the ICU so often, I have enormous respect for the care that is given patients there, and I always try to swing by the ICU desk to say hello and let Clifford receive affection from his admiring public. One of the most poignant encounters we have had was in the ICU. One patient could not relax, even with mild sedation, so the nursing staff asked if Clifford and I would visit for a few minutes. I took the patient’s hand and put it on Cliff’s soft ear. Almost reflexively the patient began to stroke it. I talked quietly about Clifford’s sad beginnings and how much he now liked to visit people who had their own struggles. The patient calmed down, and in a few minutes relaxed into sleep. Many of our visits include waiting rooms and family members who are ticking off the hours waiting to hear how their loved ones have survived a surgery or procedure. The dogs distract and entertain them, and we hear lots of wonderful stories about family pets, past and

present. Children, in particular, are delighted by the dogs. Because Clifford is so big, I usually have him lie down in front of a small person to make it easier for them to pet him. We do visit children who are hospitalized, especially over the winter holidays when we bring small, stuffed animals to the patients. One evening in the pediatric care unit, we were asked to have three of the dogs, all “doodles,” pose with their reindeer handlers in the corridor for a photo. Just then, a dad went into the adjacent room with a hot pizza. You can guess where the dogs’ attention went. But most of our visits are to folks who are in the hospital for an extended time. It could be in Oncology, High Risk Pregnancy, Neurology, Med Surg, ICU or Orthopedics. We check with the Charge Nurse first to see who might benefit from a doggy visit. We do not visit patients who have contact precautions. We ask at the door of each room if the patients and families inside would like a visit from the dogs. Not everyone is a dog lover and some folks are just too uncomfortable to visit. We use sanitizing foam before entering and after leaving each room, and give each person who petted the animals a blob of hand sanitizing gel. It is amazing to me how grateful people are for a little dose of animal comfort. Clifford, like all the dogs in the program, seems to have a way of looking into your eyes and saying, “I hope you are feeling better soon.” Since the dogs ultimately age and retire, the most difficult part is finding volunteers with calm, well-trained dogs who have some time to volunteer...we are always searching. If anyone has interest, or knows of someone who might, please contact Kathy Montgomery at MontgoK2@sutterhealth.org.

Christmas reindeer dogs and their handlers cheer up hospital patients during the holidays.

judymaben@surewest.net

September/October 2016

TOP

REASONS

To Join SSVMS and CMA

COMMITMENT TO THE PROFESSION: By joining SSVMS and CMA, physicians affirm their commitment to the profession of medicine and to preserving its honored place in modern society.

LEGISLATIVE ADVOCACY: Ensure physicians have a voice and remain in control of medicine this year and in years to come. By speaking as a united voice, SSVMS/CMA exert a powerful influence on health policy and public health issues at the local, state, and national levels.

IMPROVING COMMUNITY HEALTH: SSVMS is a leader in our local communities in providing care for the medically indigent and uninsured through our SPIRIT program and addressing local public health issues such as mental health, vaccines, and safe prescribing.

PROTECTING MICRA: SSVMS and CMA continue to work diligently to protect the Medical Injury Compensation Reform Act (MICRA). Prop 46 was soundly defeated, saving physicians practicing in the Sacramento region an average of $93,000 per year in liability insurance premiums.

PRACTICE MANAGEMENT ASSISTANCE Resolve contracting, billing, and payment problems with one-on-one assistance from CMA’s team of practice management experts.

“Working together, the Sierra Sacramento Valley Medical Society and the California Medical Association are strong advocates for physicians from all modes of practice and for the profession of medicine.”

PRESERVING MEDICARE: SSVMS/CMA successfully eliminated Medicare’s SGR and GPCI inequities. Beginning in 2017, physicians in the Sacramento region will see Medicare increases between 1.6 – 6.6%.

OPPORTUNITIES TO GET INVOLVED: Participate on a committee or council, volunteer through SPIRIT, serve on the Board or Delegation to the CMA House of Delegates.

FOSTERING COLLEGIALITY: SSVMS and CMA bring doctors from all parts of the medical community together – through leadership, cooperation, social gatherings, and service.

FOCUSING ON WHAT’S REALLY IMPORTANT TO YOU: SSVMS and CMA provide access to a powerful staff of experts to help protect the viability of your practice so you can focus on what’s really important: your patients.

COMMITMENT TO THE PROFESSION Your support of SSVMS and CMA through membership affirms your commitment to the medical profession and ensures physicians remain in control of medicine this year and in years to come.

PLEASE JOIN OR RENEW YOUR MEMBERSHIP TODAY JOIN ONLINE: www.ssvms.org/membership/join-now.aspx RENEW YOUR MEMBERSHIP ONLINE www.ssvms.org/Membership/RenewandPayDues.aspx

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Stem Cell Program at UC Davis By F. James Rybka, MD IN THE SEPTEMBER-OCTOBER 2012 issue of SSV Medicine, Dr. Francisco Prieto, a member of the California Institute for Regenerative Medicine (CIRM), outlined the story behind how the passage of Proposition 71 in 2004 led to California funding some 15 stem cell laboratories in the State, including UC Davis. Today, the UC Davis Stem Cell Program is one of the largest in the nation with over 150 investigators on the Sacramento and Davis campuses. The hub of the program is in Sacramento at the Institute for Regenerative Cures (IRC) located on the campus of the Sacramento Medical Center. It is housed in a spacious 109,000-square-foot building that was a former State Fair warehouse. Last October, Dr. John Osborn, who is an IRC donor, arranged for me and some plastic surgery colleagues to have a tour of the Institute. We met the director of the IRC, Jan Nolta, PhD. She is a friendly, energetic lady who is in charge of some 150 scientists who work on 18 different disease-specific teams. Dr. Nolta has devoted her professional life to the study of stem cells, and is currently a highly-regarded national leader, having served on over 200 NIH review panels. She is the author of over 150 manuscripts and 30 book chapters, and is the editor of the prestigious journal, “Stem Cell.”

Some stem cell fraud Considering the labyrinthine process in securing FDA approvals, along with the potential jackpot of money that could be extracted from desperate patients, it comes as no surprise that hucksters have emerged who by-pass the rules. Recently, The Sacramento Bee ran a series

of full-page colored ads for stem cell clinics announcing seminars at a hotel for people with chronic bone and joint pain and neuropathies. We do not know where they obtain their stem cells, but they do not come from UC Davis. Dr. Nolta says that the FDA has a number of illegal stem cell clinics in its crosshairs, and it is sending out increasing numbers of “cease and desist” letters to put them out of business. Many in our tour group were retirees, and we found ourselves addressed by a corps of young IRC scientists, a few of whom seemed about the ages of our grandchildren. We watched somewhat awed as they described their line of work. Their faces would light up and they became animated, using their hands as they spoke. In fact, if there was one emotion that seemed to permeate this lab, it was the enthusiasm they had to be working on the cutting edge of research that would offer hope to so many.

Adult stem cells Forty years ago, when stem cells from bone marrow were used for cancer patients, one problem was that they did not survive very long after they were isolated. When she was working on her thesis (PhD in Molecular Biology at USC), Dr. Nolta became interested in stromal stem cells from the bone marrow, also called mesenchymal stem cells (MSC). They were shown to provide a growth factor to nurture the blood stem cells and to prolong their life. “I ended up doing my thesis on them because they were so fascinating. They were clearly nurturing other cells and feeding them,” she says. The MSC have been called the “paramedics of the body.”

September/October 2016

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Microscope image showing muscle cells in green and mesenchymal stem cells in red.

Following intravenous injection, they recognize where it is, that a limb is ischemic, and then stimulate arterioles around it to revascularize and nurture the area. One of our first surprises was finding out that the controversial embryonic stem cells were hardly ever used anymore. About a decade ago, the field of “induced pluripotent stem cells (iPSC)” was discovered that was awarded in a Nobel Prize to Dr. Shinya Yamanaka. This process starts with adult dermal fibroblasts from skin. Scientists treat them to open their DNA back up so that they are programmed to become iPSC. These return to their earlier program, and can regenerate any tissue − hepatic, neural, cardiac, etc. The iPSC can do everything that embryonic stem cells can do, but they come from adult skin, not embryos, so there is no controversy. In fact, embryonic stem cells are hardly used anymore at the IRC.

Watching “magic” happening On the tour, we were amazed how the IRC scientists can visualize cell-to-cell interactions in vitro as two types of stem cells, each colored differently with phosphorescent dyes. They can be visualized using a fluorescent microscope. As they actively move around, they seemed magnetized to find one another, and to interdigitate. One can actually watch them pass

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cellular material (mitochondria) from one cell line to the other. These white, fluorescent, time-lapse microscopes are equipped so that the tissues in the in-vitro dish are kept at 37 C, with a supply of oxygen and carbon dioxide. (See a photo of this microscope on the opening page of the website, www.ucdmc.ucdavis.edu/ stemcellresearch.) On a major part of the tour, we gathered in a conference room where several scientists described their research, and fielded questions from us. We found out that the 150 or so faculty members conduct stem cell research on more than a dozen different disease teams. These are composed of clinicians and research scientists, as well as graduate students from CSU Sacramento who are working on a Master’s Degree program in stem cell research. Their areas of research include Huntington’s disease, Parkinson’s, Alzheimer’s, autism spectrum disorders, osteoporosis, critical limb ischemia, heart disease, spina bifida, chronic diabetic wounds, HIV, swallowing and airway disorders, traumatic brain injury, debilitating cartilage conditions, disc degeneration and macular degeneration. Each of these teams has both a chief clinician and a research scientist as co-directors. Mention any disease and Dr. Nolta can name these directors and proudly tell about their current work. The cultivation of cell lines for all of this research is an exacting and time-consuming process. And these cells have to be fed with various factors on a strict time frame, roughly every six hours. Usually the younger, grad student investigators are seen coming into the building at all hours, day and night, to do these chores. Dr. Nolta recalled how, when she was a grad student, she had an air mattress beneath her desk where she could sleep a few hours at night while caring for the stem cells.

Disease in a dish The IRC scientists are excited about induced pluripotent stem cells (iPSC) because they can study a patient, say, with a rare genetic heart disease, by obtaining a small skin biopsy from him or her, and then growing out a line that has

this person’s genetic information. Then they can study in a dish how various factors influence the mutant gene products in the patient’s cardiac cells, all without having to biopsy his heart muscle. To illustrate the tedious steps in trying to conquer just one disease, Dr. Nolta described her work on Huntington’s Disease (HD). This rare congenital disorder (7 per 100,000) is caused by an autosomal dominant mutation wherein the cysteine-adenine-guanine (CAG) triplet is uncontrollably repeated so the gene becomes overly-long, producing a different type of protein that damages and kills brain nerve cells. Symptoms, like uncoordinated, jerky motions (chorea,) commence in adults, and gradually worsen into dementia and paralysis, with death invariably occurring about 20 years after the first symptoms appear. Working with the Huntington’s gene in a dish, her team is able to use crispr, the novel gene-editing technique, to repeatedly cut the long gene at both ends until it is normal in size. Dr. Nolta reports, “This works great in the dish.” Not stopping with this, her team then got FDA approval to work on mice with a juvenile form of HD, and injected adult mesenchymal cells into the mouse brains that delivered a growth factor that kept the damaged, dormant neurons alive, and caused new neurons to form. This mouse data has just been published.1,2 They are hoping to translate the growth factor therapy to patients in the future. The process is indeed slow, but we can envision how well-directed they are to commence a human clinical trial. UCD has one of the largest HD clinics in the nation (350 families with HD). The clinic is under the charge of the neurologist, Dr. Vicki Wheelock, while Dr. Nolta directs the HD laboratory research. She showed us a Christmas card she had received from one family with three small children, all of who have the juvenile form of HD. Our tour group became fascinated to learn about new research the IRC is doing with iPSC cells. They are on the cusp of being able to grow new organoids for patients with an organ failure – e.g., hepatic, renal or cardiac.

They can now grow little human liver buds in immune-deficient mice that have been created from human hepatocytes and blood vessels grown from the iPSCs. These buds make human hepatic enzymes, and last for three months. They are currently networking the buds together to make a larger organ.

Clinical trials One group you are not likely to find around the IRC lab is that of patients. They cluster in clinics run by the trial team clinicians in the area. Currently, UC Davis has about a dozen ongoing, or recently completed, stem cell and regenerative medicine clinical trials, and others pending. (If a physician has a patient who might be a candidate for a clinical trial, he or she should check clincialtrials.gov or the UC Davis Stem Cell Program website (ucdavisstemcell.org) to find if there is a trial going on, and to which clinic this patient might be referred.) The IRC scientists may hold academic

September/October 2016

Dr. Jan Nolta and Dr. John Osborn

appointments to UC Davis but they are all on what is called, “soft money,” meaning that their salaries come entirely from grants. A smaller source of income for the lab comes from partnerships with industry. There also is a small percentage of their budget that comes from donations. This last money is particularly valued because it can be awarded without the red tape inherent with grant money. It is used as seed money to help junior investigators, some with a brilliant idea for research, but who, because of their short bibliography, cannot compete with more established scientists for grant money.

A nidus for biotechnical development Already, the UC Davis IRC lab has developed partnerships with a number of start-up companies in the area, and this will be growing. As part of a med zone initiative, the university is planning a new building at the Med Center where the research scientists and corporate leaders can meet to develop new ideas. Without question the IRC lab will become a wellspring

for biotechnical development in the Sacramento Valley. At the end of the tour, we older physicians knew that most of these inventive, new therapies are still being worked out, and will unlikely arrive to benefit those in our generation. Nevertheless, we felt very comforted to envision the potential benefits and cures for so many of the debilitating and heartrending problems that our patients face today. jimrybka@hotmail.com References 1 Pollock K, Dahlenburg H, Nelson H, Fink KD, Cary W, Hendrix K, Annett G, Torrest A, Deng P, Gutierrez J, Nacey C, Pepper K, Kalomoiris S, Anderson JD, McGee JL, Gruenloh W, Fury B, Bauer G, Duffy A, Tempkin T, Wheelock V and Nolta JA. Human Mesenchymal Stem Cells Genetically Engineered to Overexpress Brain-derived Neurotrophic Factor Improve Outcomes in Huntington’s disease Mouse Models. In Press Molecular Therapy 2 Fink KD, Deng P, Gutierrez J, Anderson JS, Torrest A, Komarla A, Kalomoiris S, Cary W, Anderson JD, Gruenloh W, Duffy A, Tempkin T, Wheelock V, Segal DJ, and Nolta, JA. Allele-specific reduction of the mutant huntingtin allele using transcription activator-like effectors in human Huntington’s disease fibroblasts. In press Cell Transplantation

Call for Awards Nominations NOMINATIONS ARE BEING sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting in January 2017. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El

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Dorado-Sacramento-Yolo region. The candidate must be an SSVMS member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El DoradoSacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship and Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, cstincelli@ssvms.org. Deadline: November 1, 2016.

BOOK REVIEW

When Breath Becomes Air By Paul Kalanithi, Forward by Abraham Verghese; Random House Publisher; ISBN-13 978-0812988406

Reviewed By George Meyer, MD, and John Loofbourow, MD THIS AUTHOR TAKES THE reader with him through the terrible transition between his very ambitious and successful early life to his death as a 36-year-old man − who gets lung cancer in the last years of his neurosurgery residency at Stanford University. He had originally wanted to be a writer, but chose medicine instead. Yet he is still also a writer. As physician readers and reviewers, we walked his walk not wanting to put the book down until the last word. Though Paul was unable to actually finish his book, he takes the reader to the point where he loses the ability to go on. His wife, Lucy, an internist whom he first met in medical school, provides closure in a touching epilogue. The story begins at the ending...in the prologue. The author, previously treated for cancer, has recovered enough to nearly complete his 6th and last year of neurosurgery residency, when he develops extreme exhaustion and ominous symptoms. He pulls up and views his own CT scan with “lungs matted, spine deformed, a lobe of the liver obliterated.” Part I, 100 pages, could be of most interest to the non-medically-savvy reader. It tells of Paul’s life, from childhood through his years in medical school. Most interesting is that, even while young, he is concerned about life and death. That interest is sharpened later by patient care and by the death of his best friend. His writing is filled with pithy literary quotes, reflecting his extensive reading as a child and young man and, perhaps, great proficiency with his Internet browser. His portrayal of medical school and his experiences with patient care will be familiar

territory to most physicians, and informative to others. He nicely portrays many of the challenges and contradictions medical students deal with as they progress through their training. Paul talks about the difficulty most of us had with our cadavers and of the depersonalization we may develop so we are not too emotionally involved with the bodies we dissect. He describes the struggle of first-year residents who are fighting just to keep their heads above water. He worries that he is on “the way to becoming Tolstoy’s stereotype of a doctor,” and reminds us of the demands of residency, then practice, filled with the taste and smell of life and death constrained by the demands of the hospital and insurance industries. It seems, though, that Paul develops a sense of who he is and what he stands for sooner than many of us do. He professes great sensitivity to patients and their families in the most trying of circumstances. He gets involved with patients − personally and actively − despite the cold algorithms of 21st century medicine; he stays with them − and with their friends or families until the outcome is settled.

Learn to Die Part II, titled Cease Not Til Death, will likely be most meaningful to physicians, our friends, families, and other medical professionals. It is headed by this quote from Montaigne: “...to study philosophy is to Learn to Die.” Paul, the physician, becomes the patient. He describes his years-long struggle, both mentally and physically, fighting his malignancy. During a tenuous remission, he is able to complete all of the demanding requirements of his

September/October 2016

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neurosurgery residency. He writes of the experience during diagnosis, chemo, recovery, mental rigors, and recurrence. Both he and his wife are high powered, high pressure professionals, and the marriage is stressful and long distance; yet the cancer changes that, bringing them more together. Paul’s long, drawnout dying also intimately involves his oncologist, who helps him consider and make crucial decisions. All their intertwined lives are changed. This book − short by comparison with so many that are far less informative − is well worth reading, both by medical professionals and by the general public. The former often look into the eyes of death, and the latter will too, at some point. It seems likely that neither will escape life without that encounter. geowmeyer@icloud.com john@loofbourow.com

Expertise you can rely on. “Medicine isn’t As a trusted partner to businesses and families across generations since 1919, Baird has seen investors through many market cycles. And the insight we’ve gained from this experience informs all we do today as we strive to create great outcomes for our clients throughout their financial lives. Put Baird’s time-tested expertise to work toward your long-term goals.

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a job. It’s a life. You’re always on call.” – Donald Pinkel, MD First Director and former CEO of St. Jude Children’s Research Hospital

BOOK REVIEW

An Unquiet Mind − Memoir of Moods and Madness By Kay Medford Jamison, PhD; Vintage Publisher; ISBN-13: 978-0679763307

Reviewed By Lee Welter, MD, and Caroline Giroux, MD KAY REFIELD JAMISON, PhD, is a professor of psychiatry at the Johns Hopkins University School of Medicine, and author of the national best sellers, An Unquiet Mind − A Memoir of Moods and Madness, Night Falls Fast − Understanding Suicide, and Touched with Fire − Manic-Depressive Illness and the Artistic Temperament. This brilliant author offers a premonitory glimpse of a stormy life — an emotional whirlwind — before digressing into the sunshine and apparent sanity of a young girl in her nurturing family. Her initial account of this girl as a young woman, running all night in the UCLA hospital parking lot with her male friend, includes wry humor. A policeman questioning them about their strange behavior chuckles upon hearing their explanation, “We’re both on the faculty in the psychiatry department.” Captivated by her tale, the reader senses this woman’s vivid life and nearness to death as she gradually ﬁnds help for her mental illness. Conquering (or at least learning to control) the mood swings of manic-depressive illness permitted her to not just share her own experience as a skilled author, but to teach others how to appreciate an often unmet need and hope for mental health care. Dr. Redfield Jamison is author or co-author of more than 100 scientiﬁc papers about mood disorders, creativity, and psychopharmacology. Though we could write more about this book, it might waste time that you could better spend actually reading it. It gives insights into the nature of mental illness and

offers hope for better treatment of its sufferers. Here are Jamison’s “Rules for the Gracious Acceptance of Lithium into Your Life”: 1) Clear out the medicine cabinet before guests arrive for dinner or new lovers stay the night. 2) Remember to put the Lithium back into the cabinet the next day. 3) Don’t be too embarrassed by your lack of coordination or your inability to do well in the sports you once did with ease. 4) Learn to laugh about spilling coffee, having the palsied signature of an 80-yearold, and being unable to put on cuff links in less than 10 minutes. 5) Smile when people joke about how they think they “need to be on Lithium.” 6) Nod intelligently, and with conviction, when your physician explains to you the many advantages of Lithium in leveling out the chaos in your life. 7) Be patient when waiting for this leveling off. Very patient. Reread the Book of Job. Continue being patient. Contemplate the similarity between the phrases “being patient” and “being a patient.” 8) Try not to let the fact that you can’t read without effort annoy you. Be philosophical. Even if you could read, you probably wouldn’t remember most of it anyway. 9) Accommodate to a certain lack of enthusiasm and bounce that you once had. Try not to think about all the wild nights you once had. Probably best not to have had those nights anyway. continued on Page 30 September/October 2016

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

Beta Has Our Attention The early history of electroencephalography

By Kent Perryman, Ph.D. PRIOR TO THE DEVELOPMENT and recognition of electroencephalography (EEG), lumbar puncture, pneumoencephalography and ventriculography were the only diagnostic tools to detect and localize scar and tumor sites in the brain. The currents of nervous tissue were not recognized until 1791 when the Italian physician, Luigi Galvani, published Commentary on his theory of “animal electricity”: This was the dawn of neurophysiology that eventually led to an appreciation of the brain’s neuroelectrical properties that gradually evolved into electroencephalography.

Richard Caton (1842-1926)

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Du Bois-Reymond, a German physician and physiologist, has been credited for the discovery of the nerve action potential responsible for communication between neurons in the peripheral and central nervous system. Later in 1875, Richard Caton, a scientist and lecturer in physiology at the Royal Infirmary School of Medicine in Liverpool, England, continued Du Bois-Reymonds’s experiments measuring nerve-muscle currents in animal preparations using an optical reflecting galvanometer. This was a time prior to vacuum tube amplifiers that relied more on electromechanical instruments to measure electrical currents. This was also a period when there was increased interest in localization of the brain’s functions. Investigations into the functions of various motor regions of the frontal lobes were just beginning to be explored with ablation and stimulation techniques in animals. By the 1870s, it was widely accepted by some in the scientific community that regions of the motor cortex were electrically excitable and that

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localized, peripheral muscle groups could be activated. However, the sensory regions of the cortical surface were more reluctant to reveal their secrets at this time. Caton believed the cerebral cortex, like peripheral nerves, was also capable of generating electrical currents. Using an optical galvanometer at a meeting of the British Medical Association in Edinburgh in 1875, he demonstrated the existence of electric currents on the surface of a dog’s exposed cerebral cortex. The dog’s occipital bioelectrical rhythms could be influenced by retinal stimulation. Caton theorized that these cortical currents could possibly provide a means of understanding the functions of the hemispheres. He was also the first neuroscientist to report on EEG variations associated with waking and sleep. Some 15 years later, Adolf Beck, a distinguished Polish physiologist, demonstrated the EEG “blocking effect” recorded from a dog’s exposed cortex, whereby external stimulation disrupts the normal resting rhythm. Beck went on to also demonstrate slowing effects of chloroform anesthesia on cortical EEG activity.

Hans Berger (1873-1941) It wasn’t until 1924 that Hans Berger, a neuropsychiatrist at the University of Jene in Germany, used the term elektrenkephalogramm to describe the graphical representation of electric currents from the exposed brain of a 17-yearold boy during a neurosurgical procedure. Berger began his research career by recording changes in cerebral blood flow in patients with cranial defects using a plethysmograph. He was initially interested in measuring the energy converted into heat and electricity by

the brain during various mental tasks. Dr. Berger was the first neuroscientist to categorize rhythmic brain wave activity by frequency and amplitude into Alpha and Beta nomenclature that he considered at the time mere artifacts. Later, Berger also validated Caton’s observations of Alpha Blocking with external stimulation. He continued to focus his research on braininjured patients that eventually contributed to the foundations of clinical neurology. Most of his research findings were published in less respected psychiatric journals that some believe may have contributed to his deepening depression that eventually led to him taking his own life. His findings were not widely accepted by the neuroscience and medical community until 1934 when Lord Adrian in England and Hallowell Davis at Harvard replicated his work. Eventually, in1946, the medical science branch of clinical neurophysiology was recognized as well as the Clinical Neurophysiology Society in Berger’s honor.

Berger’s Legacy Berger’s recording electrodes were too large to make precise topographical EEG studies to pinpoint epileptic lesion and tumor sites. These early electrodes made of lead, and later silver, were placed over the forehead and occipital region of the scalp with dampened saline cotton to improve conductivity. Currently, German silver alloy composed of copper, nickel and zinc is used in EEG recordings with occasional stainless steel ceramic electrodes sewn into a nylon skull cap, according to the international 10-20 array. Later in 1936, British scientist and engineer, W. Gray Walter, was able to narrow down the loci of abnormal EEG activity from a tumor using a number of smaller diameter electrodes pasted on the scalp. Walter went on to develop the toposcope in 1957 whereby he could reconstruct bidimensional maps of EEG activity over the brain’s surface. The toposcope was comprised of 22 cathode ray tubes (CRT), each connected to a pair of electrodes. This array of CRTs was photographed to display the electrical wave patterns in the various lobes simultaneously.

Hans Berger, who first recorded the electrical activity of the brain in man in 1925.

Walter, like Berger, had his subjects perform various mental tasks resulting in increased Beta activity. Walter further refined his recording technique using more sensitive amplifiers to locate epileptic foci without much commercial success. During the 1930s, Franklyn Offner, a professor of biophysics at Northwestern University, developed one of the first commercially-successful EEG machines for clinical practice that incorporated a piezoelectric ink writer called a Crystograph (also known as an Offner Dynagraph). Eventually, many other EEG, tube-type instruments such as the Grass were introduced for clinical and research purposes. From 1929 to the late 1960s, EEG was mainly evaluated visually until digital computers, and sophisticated software algorithms made it possible to apply Fourier analysis to extract the spectral content. Ross Adey, a neurologist at the UCLA Brain Research Institute, was one of the first neuroscientists to digitize this procedure, referred to as quantitative EEG (QEEG) or neurometrics. This technology has rapidly advanced into the development of Brain Electrical Activity Mapping (BEAM).

September/October 2016

Early 20th century galvanometers for recording neuroelectrical activity.

QEEG brain mapping provided clinicians with the ability to view dynamic electrical changes throughout the brain during processing tasks in order to determine which regions are fully engaged. Dr. Adey was also responsible for developing the Normative Library of Brain Wave Maps using QEEG recordings from several populations of neurologically-impaired and healthy individuals. These maps have become available to many clinicians and clinics as aids in the differential diagnoses of many neurological disorders. BEAM has also been employed as a diagnostic neurological tool to localize abnormal EEG slowing to evaluate cognitive dysfunction associated with various dementias. Footnote: For those readers unfamiliar with EEG nomenclature and possibly puzzled as to the meaning of this article’s title, the

human wave patterns in the resting state are normally Alpha waves (8-12 Hz) while the alert, vigilant mental status is associated with Beta rhythms (13-30 Hz). kperryman@suddenlink.net References Tudor, M, Tudor, L, and Tudor, KL. Hans Berger (1873-1941) The History of Electroencephalography, Acta Med Croatica., 2005; Vol 59(4): 307-313. Brazier, MAB. A History of the Electrical Activity of the Brain: The First Half Century. 1961; McMillian Co. Sabbatini, RME, The History of the Electroencephalogram. https:// www.cerebromente.org.br./no3/tecnologia/historia.htm

An Unquiet Mind continued from page 27 10) Always keep in perspective how much better you are. Everyone else certainly points it out often enough, and, annoyingly enough, it’s probably true. 11) Be appreciative. Don’t even consider stopping your Lithium. 12) When you do stop, get manic, get depressed, expect to hear two basic themes

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from your family, friends, and healers: “But you were doing so much better, I just don’t understand it. I told you this would happen.” 13) Restock your medicine cabinet. welter@computer.org cgiroux@ucdavis.edu

Reflections on Doctors as Patients Background: After all, doctors have to have their own doctors, right? Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows: I acquired a bad cough after cleaning out a dirty, rat-infested garage. A week later, coughing and wheezing, my boss said I should see a doctor, so I did. Steroids and inhalers seemed to help for awhile, but then escalating doses (sort of on my own) failed to quell the cough, forcing me to sleep in a chair for 10 days or so. Taking a walk in San Francisco, the homeless steered away from my hacking personage. I asked for antibiotics online, and this was declined by my PCP without a CXR. So, X-ray I did, LLL pneumonia, and after one day of the Pak, the cough all but disappeared. Physicians as patients must be reliant on the advice around them. Personal bias can cause problems in self-diagnosis and treatment. Physicians treating patients should take no short cuts, a full history, a complete informed consent, and a strong relationship is required. Making assumptions about what the biased physician patient may or may not understand, or that their opinion is the best one, is fraught with hazard for both physicians. Do no harm, to others or to yourself. −Thom Atkins, MD About 25 years ago, a bout of tennis elbow led to taking an anti-inflammatory − Tolectin, from the office drug cabinet. Symptoms were improved, but a recurrence of pain required more drug, and shortly after, I became quite ill with fever, rash, fatigue, failing kidneys. Multiple consultants were unable to make a diagnosis. With persistent deterioration, highdose steroids reversed the condition and resulted

in a full recovery. I did not think to mention my drug usage. Recurrence of tennis elbow symptoms led to another dose of Tolectin. Previous symptoms started to recur and steroids resolved them quickly. A subsequent diagnosis of drug sensitivity with Stevens-Johnson syndrome was made by my many specialists. My anti-inflammatory drug usage was sharply curtailed. Steroid injection resolved the tennis elbow, but did not improve my mediocre play. I don’t recommend physicians self-medicating. −John Young, MD I am a retired physician (8 years), 48 years as an FP. Two years ago, I awoke at 4:00 am with sub-diaphragmatic pain. No history of any abdominal problem. No abdominal tenderness to palpating. Old adage, “ A physician who treats himself has a fool for a patient.” To ER by 8:00 am. History and physical, a scan (either an MRI or CT) and lab. “Everything negative, you can go home now.” I replied that I needed a surgical consult and appendicitis was the probable dx. Met my hospitalist about noon, relayed the whole story including the wisdom of obtaining a surgical consult. My surgical consult came at 8:00 am the next day, 28 hours after the pain started. Two hours before the consult, when standing in the bathroom, a very loud noise occurred in my abdomen followed by intense pain. I fell to the floor, yelled for morphine and passed out. I received the morphine, no more pain. The surgical consult came at 8:10 am, 24 hours after I had arrived at the E.R. She insisted on OR imaging of the gallbladder in spite of my insistence that my appendix had ruptured. I went to surgery at 10 PM with pre-op dx of cholecystitis. Yes, it was immediately changed to appendectomy and general abdominal cleaning. Aftermath: 17 days in ICU, 7 units of blood,

September/October 2016

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I cannot think of a more powerful experience that helps a doctor better relate to his patient’s care and concerns than themselves going through the medical system as a patient…

employment of 5 sub-specialists and a super nursing staff followed by 3 weeks in a nursing home to regain sufficient strength to stand and walk, with help, and then 6 weeks of PT at home before I could go upstairs and start driving again. Problem: The ER doctor did not ask the radiologist if he even saw the appendix, but said I could go home. The film had been read by another radiologist stating that the appendix showed inflammation. The hospitalist displayed a passive nonchalance, no hurry, and consultation for possible appendicitis is OK for tomorrow. The surgeon, even though I did have 48 years in practice, refused to believe me. The hospitalist, as the primary care physician, but here today and gone tomorrow, cannot possibly fulfill the position in which he or she has been thrust! −Wayne Matthews, MD As their doctor, I assume that a physician should receive the same complete history, physical exam and education that I give all my patients − I can’t assume what knowledge they have. As a patient, my experience is mixed. There are the good doctors who, perhaps because I’m a physician, do decent histories and exams, believe that my subtle, atypical symptoms really mean something, don’t blow me off and give me good care. I’ve had more than my share of bad experiences, though. I wrote in great detail in this magazine about the retinal specialist who fell in love with his wrong diagnosis, and the exceptional doctors who subsequently diagnosed and zapped the Baylisascaris worm before my vision was totally destroyed. There was the ER doc who didn’t believe I was having an asthma attack because he didn’t hear wheezes (I couldn’t move air fast enough to create a wheeze). I gave up having a primary care doctor after my Internist ignored my complaints of deep ear pain and gurgling noises, thought my ear canal osteoma was a normal tympanic membrane and told me I had TMJ syndrome − I self-referred to an ENT who repaired my tympanic membrane, excised the debris and osteoma and reconstructed the canal. Worst of all, I’ve been made very uncomfortable by a male doctor

who abused his special privilege of examination by doing a rectal during a pre-participation evaluation for high school basketball. For now, I’ll see doctors who can peer into orifices (and do it respectfully), and/or do surgeries that I can’t. −Ann Gerhardt, MD As a retired MD, who has progressed from provider to user, I truly appreciate the good patient care I have received. I note two trends. Advances in the science of medicine. The improving understanding of our micro biome and the practical application of genetics. The negative effect of digital medical records on patient time and understanding. Hospitalists who prescribe discharge meds on the basis of orders, even though the meds were not given during the hospitalization. The marked decline of the physical examination, even in the emergency room with a complaint of abdominal pain. In essence, doctor patients are very appreciative and also very discerning. −Richard Park, MD FACS I am a surgical sub-specialist who has been popular amongst my peers for the last 30 years. I have also been a patient who required surgery on a couple occasions. When hospitalized, I did not make any attempt to let it be known that I was a physician. I believe that systems of treatment exist because those involved with creating those systems have the interest of patients at their core. Perhaps I just believe in people having their “best intentions” at work. Nonetheless, I could discern there were some nurses/MD’s/ancillary staff who had insight to my medical condition and a minority who were clueless. In addition, when treating medical staff, I try not to bend the rules. Better to treat colleagues/medical staff through the usual channels. −Steve Workman, MD I cannot think of a more powerful experience that helps a doctor better relate to his patient’s care and concerns than themselves going through the medical system as a patient and dealing with a disease process or having a surgical procedure. I have found that my patients have had a more immediate connection with me, and are put more at ease, when I share those experiences. −Russell Unger, MD continued on page 34

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Building Bridges: Science to Medicine By Farrah Nasrollahi, MS II WHY DOES THE PREMED science curriculum have to be an “If it doesn’t kill you, it makes you stronger” experience? As a kid in chemistry class, when I first began to understand what “matter” is, a common train of thought went something like this: “So there are these atoms that exist... they make these molecules… somehow these molecules ‘talk’... wait now, there are acids and bases? Ugh… but I don’t want to work with acids and bases... so wait... why am I learning this?” I’m pretty sure I’m not alone on this. A lack of understanding of curricular relevance contributes to the American brain drain – and indeed, on international tests, other countries often outperform American students in the sciences. Many parents, educators and employers are concerned about this phenomenon and are demanding that schools go “back to the drawing board.” This is where Next Generation Science Standards (NGSS) come in. The cornerstone of the NGSS program is to train students for the professions they want to enter from an earlier age, much like education systems abroad. The intention is that young students will be more successful in the future if we show them how their science curriculum is applicable to the HERE and NOW. For example, wouldn’t biology be more interesting if you could use your own body as a model and make discoveries as you go? Science was only “cool” to my younger self when I could relate it to and apply it to my own life and interests. As a medical student at California Northstate University College of Medicine, I have worked to put my educational philosophy into action. My peers and I visited a

middle school for two hours every week to assist students in the nationally renowned “Science Olympiad” team competition. This year’s Science Olympiad topic was the Musculoskeletal system. Our goal was to introduce relevant material to students in a new way, to connect the dots between basic science knowledge and the practical application thereof, specifically in the context of the human body. We showed students how biological sciences, the same biological sciences they were learning in class, directly relate to the practice of medicine. We worked with limited items. We used pen and paper for assisted drawings, a human skeleton, and our own bodies. Our efforts proved fruitful when our middle school students clearly outshined their peers in the topics on which we coached them, which included anatomy and physiology, as well as the physics of muscle movement. Their understanding was apparent when we questioned them about how confident they felt after our instruction. One student replied, “I feel like now I know why we were learning what we were learning. Before I just felt like I had to memorize everything.” As a standardized test instructor for Kaplan for the past three years, I know when a student is just regurgitating facts back versus when he or she is explaining a concept. The latter shows a true understanding of information. I enjoyed seeing the light bulbs go on. “Oh that’s why muscles come in pairs and move the way they do! You’re saying hormones work the same? So they balance?” We accomplished tying science and its abstractness to the concrete, relevant, medical applicability.

September/October 2016

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Instead of learning about pressure and force through mechanics, why can’t students talk about these concepts in the context of major

Classroom instruction on the human skeleton.

blood vessels or air flow through the lungs? Instead of learning about acids and bases using the periodic table, why don’t we talk about acidosis and alkalosis resulting from hypo- and hyperventilation? Instead of discussing things out of a physical context and in the abstract, why don’t we teach in the concrete, in the here and now so that students may then extrapolate to the abstract? Through this method, students will better develop critical thinking skills. We can only hope that the NGSS is able to bring the same kind of success that our instruction team saw. As a future physician, I believe that medicine can serve the community in a broader function than just behind closed hospital doors. We need to inspire those who will follow, and make science, and medicine, cool for our kids. farrah.nasrollahi@gmail.com

Reflections on Doctors as Patients continued from page 27

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Providing your patients a safe and enriching place to spend the day, while giving family caregivers respite.

www.TripleR.org (916) 808-1591

Locations in Midtown, North Sacramento, and Greenhaven

Licensed by the State of California, Dept. of Social Services

Sierra Sacramento Valley Medicine

In physicians being patients, we are reminded first that we are humans and of the fears and difficulties our patients face. Rather than our illness being occasions where we expect the rules to be bent for us and expectations to set new heights, we can learn insights of how to improve the process for all and set examples of cooperation and courtesy. −Mohammad Kabbesh,MD I recently had a new patient appointment with a FP at the VA for a new back problem. I asked, when she started to examine me, if I should remove my shirt; she said that was not necessary and proceeded to listen to my heart and chest through my shirt. She also did not even look at my back or do a back exam. I am worried that we are screwing up our health care system with too much reliance on technology and not enough attention to the patient (e.g. open door rounds). −George Meyer, MD

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

of Delegates by attending and actively participating in Delegation caucus meetings and all sessions of the House of Delegates. In 2016, the House of Delegates will meet in Sacramento October 15-16, 2016 at the Sacramento Convention Center. SSVMS reimburses all of its Delegation members for transportation and hotel accommodations. A daily meal allowance is also provided. Delegation members must stay for the entire meeting (Saturday-Sunday) in order to be eligible for reimbursement. For more information contact: Chris Stincelli, Associate Director, (916) 452-2671 or cstincelli@ssvms. org.

Welcome New Members The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Chris Serdahl, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP: Brian Bellucci, MD, Internal Medicine/Pulmonary Disease, LSU School of Medicine – 2010, Pulmonary Medicine Associates, 1300 Ethan Way #600, Sacramento, CA 95825 Jennifer Cahn, MD, Family Practice, Georgetown University – 2005, TPMG, 2345 Fair Oaks Blvd., Sacramento, CA 95825 John Canio, MD, Gastroenterology, Howard University College of Medicine – 1994, Capitol Gastroenterology Consultants, 6555 Coyle Avenue #330, Carmichael, CA 95608 Karen DeAquino, MD, Internal Medicine, University of Santo Tomas Faculty of Medicine – 2003, TPMG, 1650 Response Road, Sacramento, CA 95815 Nathaniel Gordon, MD, Internal Medicine, LSU School of Medicine – 2010, Pulmonary Medicine Associates, 1300 Ethan Way #600, Sacramento, CA 95825

Susan M. Joy, MD, Sports Medicine, University of Connecticut School of Medicine – 1996, 2025 Morse Avenue, Sacramento, CA 95825 Handel Robinson, MD, Vascular Surgery, Emory University School of Medicine – 2004, 3000 Q Street, Sacramento, CA 95816 Kathleen Rooney, MD, OB GYN, University of California, Davis School of Medicine – 2011, 2277 Fair Oaks Blvd #355, Sacramento, CA 95825 Efrain Talamantes, MD, Internal Medicine, University of California, Los Angeles School of Medicine – 2008, 2921 Stockton Blvd., Ste 1408, Sacramento, CA 95817 Jaspreet Tiwana, MD, Internal Medicine, Baba Farid University of Health Sciences – 2007, 8191 Timberlake Way #200, Sacramento, CA 95823

APPLICANTS FOR RESIDENT/FELLOWSHIP MEMBERSHIP: Cassy Friedrich, MD, Family Medicine/Psychiatry Residency Program – 2019, 2315 Stockton Blvd, Sacramento, CA 95817 Theodore Geissler, MD, Anesthesia Residency Program – 2019, 2315 Stockton Blvd, Sacramento, CA 95817 Jessica Brazil Gould, MD, Family Medicine Residency Program – 2018, 2315 Stockton Blvd, Sacramento, CA 95817 Robert Harper, MD, Orthopedic Surgery Residency Program – 2020, 2315 Stockton Blvd, Sacramento, CA 95817 David L. Penner, MD, Cardiothoracic Surgery Fellowship – 2017, 2315 Stockton Blvd, Sacramento, CA 95817 Erin Schwab, MD, Hematology Oncology Fellowship – 2019, 2315 Stockton Blvd, Sacramento, CA 95817 Susana Torres, MD, Family Medicine Residency Program – 2018, 2315 Stockton Blvd, Sacramento, CA 95817

September/October 2016

Contact SSVMS TODAY to Access These

M EMBER O NLY B ENEFITS (916) 452-2671 BENEFIT

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement

CMA’s Center for Economic Services (CES) www.cmanet.org/ces | 800.401.5911 | economicservices@cmanet.org

Legal Services CMA On-Call, California Physician’s Legal Handbook (CPLH) and more...

CMA’s Center for Legal Affairs www.cmanet.org/resources/legal-assistance legalinfo@cmanet.org

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

Prudential Travel Accident Policy & AXA Travel Assistance Program http://tinyurl.com/SSVMS-travel-policy

ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD10 Code Set Boot Camps

AAPC www.cmanet.org/aapc

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 www.cmanet.org/groupdiscounts

CME Certification Services Discounted CME Certification for members

CMA’s Institute for Medical Quality (IMQ)

Health Information Technology Free secure messaging application

DocBookMD www.docbookmd.com/physicians/

HIPAA Compliance Toolkit Various discounts; see website for details

PrivaPlan Associates, Inc www.privaplan.com

Magazine Subscriptions 50% off all subscriptions

Subscription Services, Inc

Medical ID’s 24-hour emergency identification and family notification services

MedicAlert www.cmanet.org/groupdiscounts

Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services

EnviroMerica www.cmanet.org/groupdiscounts www.enviromerica.com

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

StaplesAdvantage www.cmanet.org/groupdiscounts

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

COLA www.cmanet.org/groupdiscounts

Security Prescription Products 15% off tamper-resistant security subscription pads

RxSecurity www.rxsecurity.com/cma-order

PUBLICATIONS CMA Publications

www.cmanet.org/news-and-events/ publications CMA Alert e-newsletter CMA Practice Resources CMA Resource Library & Store www.cmanet.org/resource-library/list? category=publications

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

SSVMS Publications

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

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

Sierra Sacramento Valley Medical Societyâ&#x20AC;&#x2122;s Fall Social Event California State Railroad Museum Saturday, September 10, 2016 6:00 pm - 8:30 pm This is a Free Family-Friendly Event All Physicians & Their Families Are Welcome to Attend You and your guest(s) are invited to join the SSVMS Board of Directors for a private gathering at the California State Railroad Museum. This is a great opportunity to bring your family and visit with colleagues while touring the museum. Hors d'oeuvres and beverages will be served.

RSVP to: (916) 452-2671 or mholland@ssvms.org RSVP Deadline: Tuesday, September 6, 2016 Special Appreciation to Our Sponsors Cooperative of American Physicians, BloodSource and NORCAL Mutual Insurance Company

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