2018-Sept/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2018

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MEDICINE 3

PRESIDENT’S MESSAGE Finding Joy in Medicine

16 Typhoid

Rajiv Misquitta, MD

EXECUTIVE DIRECTOR’S MESSAGE Are You Ready for CURES?

Aileen Wetzel, Executive Director

Letters to the Editor

Naloxone Availability at Community Pharmacies

Zachary Nicholas, MS III

Matthew Huh

Fight, Flight or Freeze

Caroline Giroux, MD

So You Want to be an Undertaker?

Bob LaPerriere, MD

Reflections on Women in Medicine Experience

Madhouses and Lunatic Asylums

Kent Perryman, Ph.D.

Dead Diet Dogma

Ann Gerhardt, MD

Physician Suicides

Using California as a Model for Maternity Care

Peter Yellowlees, MD

Welcome New Members

Makenna Marty, MS II

Board Briefs

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

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 Our cover image by Sacramento otolaryngologist Dr. David Evans captures an old house slowly being reclaimed by nature. The look of the image is a result of the fact that it is an infrared image and foliage strongly reflects infrared light, similar to the way snow reflects visible light. Digital camera sensors are inherently sensitive to infrared light but normally have a filter placed in front of the sensor to block these wavelengths. This camera is converted for infrared use by removing this filter and replacing it with one that selectively transmits “near” infrared and blocks most of the visible light. −devans@sacent.com

September/October 2018

Volume 69/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

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MEDICINE

SACRAMENTO OPIOID MISUSE PREVENTION SUMMIT

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.

Join health care professionals, treatment and prevention experts, educators, students, and law enforcement leadership for an in-depth discussion of the prevention, treatment, and enforcement efforts being undertaken to combat this growing public health crisis.

2018 Officers & Board of Directors Rajiv Misquitta, MD, President Chris Serdahl, MD, President-Elect Ruenell Adams Jacobs, MD, Immed. Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

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

Wednesday, September 12, 2018 7:30 AM - 5:00 PM

2018 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD At-Large Ruenell Adams Jacobs, MD Barbara Arnold, MD Natasha Bir, MD Richard Gray, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Chris Serdahl, MD Ajay Singh, MD Don Wreden, MD

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

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA Immed. Past President Ruth Haskins, MD CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD

Sandra Mendez, MD

Editorial Committee Sean Deane, MD Maria Garnica, MS II Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD

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

Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

California State University, Sacramento The University Union Ballroom 6000 J Street, Sacramento, CA 95819 Pre-registration required. Breakfast and lunch provided. For questions or concerns, please contact us at: info@sacopioidcoalition.org RSVP at: https://conta.cc/2LI7t2W

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2018 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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PRESIDENT’S MESSAGE

Finding Joy in Medicine By Rajiv Misquitta, MD “THE ART IS LONG, life is short and opportunity is fleeting.” Hippocrates was credited with these words, which accurately depict the life of a physician. Add to that the modern stresses of the unprecedented changes of the health care delivery, and you have the current demanding situation. As physicians, we strive to do what is best for our patients, and we often put our needs last. This can, sometimes, take its toll on us. Among the general population, physicians are nearly twice as likely to commit suicide, and this is an underestimate. Patients also feel the ripple effect since the average physician cares for 2,300 patients. This hit home to me when I recently learned of a medical school colleague and friend from the East Coast who succumbed to suicide. He seemed happy, and his social media posts regularly depicted the amazing activities in his life, so it was a shock when I learned of his death. Physicians suffer from depression, much like the general population, but many doctors don’t reach out for help because of privacy issues and high expectations for performance. Dr. Peter Yellowlees, one of our fellow SSVMS members who is a psychiatrist at UC Davis and an expert in this area, recently published a book on the topic. He points out that there are 400 physician suicides that occur each year in the U.S., and many of them can be prevented.1 There is a lack of formal curricula or training on wellness and resilience in physician education. There are many complex issues surrounding physician suicide; however, burnout can be a contributing factor. As physicians, we have problems just like everyone else, but no time to sort it out, as we work long, stress-filled hours. As part of the solution, Dr. Yellowlees talks about the organizational need to simplify workflows and design systems that promote wellness and resilience. An important cornerstone of well-being

is also attaining balance in our lives, which is easier said than done. Other protective behaviors include seeking out meaning and joy in one’s work, taking time out for family and friends, and cultivating meaningful relationships. In support of our physicians, SSVMS has developed a robust program to help enhance physician resilience and bring the joy back to medicine. Our Joy of Medicine program offers resiliency consultations with licensed psychologists and life coaches, as well as physician socials and shared-interest groups. Physician and professor William Osler said, “Live neither in the past nor in the future, but let each day’s work absorb your entire energies, and satisfy your widest ambition.” The opposite of burnout is engagement and Osler understood the power of mindfulness and engagement. The Joy of Medicine program provides Sacramento area physicians with the opportunity to meet in peer groups with colleagues who understand and identify with what it means to be a physician. I recommend that you visit our website at joyofmedicine.org. Wellness also encompasses healthy nutrition, as it plays a pivotal role in the development of modern illness. I wrote about my own health challenges in a previous editorial, and the difference plantbased nutrition has made for me. As part of the Joy of Medicine, we will be launching a 21-day plant-based physician challenge. I look forward to seeing you at our annual Joy of Medicine Summit in September, where you will learn to enhance your personal wellness, join other physicians for fellowship, and reclaim that Joy in Medicine. Thank you again for all you do to improve the health of the Sacramento area, and please take care of your own personal wellness. rajiv.misquitta@gmail.com September/October 2018

REFERENCES 1 Yellowlees, Peter. Physician Suicide, cases and commentaries. Amer Psychiatric Pub Inc; (June 20, 2018)

EXECUTIVE DIRECTOR’S MESSAGE

Are You Ready for CURES? Starting October 2, all physicians must consult database before prescribing controlled substances.

By Aileen Wetzel, Executive Director EFFECTIVE OCTOBER 2, 2018, physicians must consult California’s prescription drug monitoring database (The Controlled Substance Utilization Review and Evaluation System, or CURES) – prior to prescribing Schedule II, III or IV controlled substances. All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate must be registered to use CURES. Because of the critical importance of adequate technical support for physicians who will have to rely on CURES as a part of their prescribing workflow, the California Medical Association (CMA) negotiated into the final legislation a requirement that the mandate could not take effect until the California Department of Justice (DOJ) certified that the database was ready for statewide use and that the department had adequate staff to handle the related technical and administrative workload. On April 2, 2018 – two years after the law was enacted – DOJ finally certified that CURES was ready for statewide use. The certification began a six-month transition period, with the duty-to-consult taking full effect on October 2, 2018.

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

What Physicians Need to Know Under the new mandate, physicians must consult the database prior to prescribing controlled substances to a patient for the first time, and at least once every four months thereafter if that substance remains part of the patient’s treatment. Physicians must consult

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CURES no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient. The law provides, however, that the requirement to consult CURES would not apply if doing so would result in the patient’s inability to obtain a prescription in a timely manner and would adversely impact the patient’s conditions, so long as the quantity of the controlled substance does not exceed a five-day supply. Physicians are also not held to this duty to consult when prescribing controlled substances to patients who are: • Admitted to a facility for use while on the premises, • In the emergency department of a general acute care hospital, so long as the quantity of the controlled substance does not exceed a seven-day supply, • As part of a surgical procedure in a clinic, outpatient setting, health facility or dental office, so long as the quantity of the controlled substance does not exceed a fiveday supply, or • Receiving hospice care. In addition, there are exceptions to the duty to consult when access to CURES is not reasonably possible, CURES is not operational, or the database cannot be accessed because of technological limitations that are beyond the control of the physician.

CMA Fights for CURES Protections CMA worked closely with the bill’s author and other stakeholders to reach mutually-agreeable language, which was reflected in the final

version of the bill (SB 481, Lara). Among the negotiated amendments are liability protections related to the duty to consult the database and changes to ensure that health care providers can meet the requirements under state and federal law to provide patients with their own medical information without penalty. The bill also clarifies that health care providers sharing the information within the parameters of HIPAA and the Confidential Medical Information Act, including adding the CURES report to the patient’s medical record, are not out of compliance with the CURES statute. CMA co-hosted a CURES webinar with DOJ August 22, 2018. The webinars are free to all interested parties and can be accessed at cmanet.org/events. Physicians who experience problems with the CURES database should contact the DOJ CURES Help Desk at (916) 227-3843 or cures@doj.ca.gov.

CMA Publishes Safe Prescribing Resources for Physicians The CMA has published a members-only resource page to provide physicians with the most current information and resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose. The page includes two CMA white papers on opioid prescribing, links to CMA’s health law library resources on the topic, the Medical Board of California’s “Guidelines on Prescribing Controlled Substances for Pain,” a listing of continuing medical education courses and webinars on pain management and safe prescribing, as well as the latest information on the state’s prescription drug monitoring database. Members can find the page at cmanet.org/safe-prescribing. awetzel@ssvms.org

CALL FOR 2018 AWARDS NOMINATIONS The SSVMS Awards Committee is seeking nominations for the 2018 Annual Awards, which recognize physicians whose achievements have contributed greatly to the medical community. Anyone may nominate a physician-member. The Awards will be presented on February 28, 2019 from 6:00pm-8:30pm at the Tsakopoulos Library Galleria.

Medical Honor Award Candidate’s achievements have significantly contributed to local, statewide, national or international healthcare. Candidate has been a member of SSVMS for at least 5 continuous years.

Golden Stethoscope Award

Candidate has demonstrated unselfishness, compassion and empathy to his/her practice and patients. Candidate has been a member of SSVMS for at least 15 continuous years. Please email letters of nomination to Chris Stincelli at cstincelli@ssvms.org or send to: SSVMS c/o Margaret Parsons, MD, Chair, Scholarship & Awards Committee 5380 Elvas Ave., Suite 101, Sacramento, CA 95819

September/October 2018

LETTER TO THE EDITOR

Letters to the Editor Dear Editor, I read with interest Dr. Caroline Giroux’s article on the hassles she and her patients experience with prior authorizations. One remedy could be to apply to a health insurance company a process like Trip Advisor uses to rate restaurants and hotels. Call it “Health Insurance Advisor.” Patients and physicians would enter into an online database their evaluation of an insurance company. When a person seeks to enroll or re-enroll, the Advisor would be queried. If this idea is picked up, someone could set up the system. Sacramento could become a beta test site. In knowledge there is power. Gerald N. Rogan, MD

Dear Editor, To argue about when life begins misses the big picture about abortion. Most “pro-choice” advocates agree that abortion is not a good birth control method. Many “pro-life” advocates, who developed their beliefs from their religious backgrounds, would not even allow abortions related to a mother’s health or in cases of rape or incest. I went to medical school before Roe v Wade. I have seen the results of back alley abortions, often with coat hangers. One paper estimates that before Roe v Wade in the 1950s and 1960s, between 200,000 and 1.2 million illegal abortions were performed annually in the U.S. In 1965 an estimated 17 percent of all reported pregnancy deaths were due to illegal abortions, 200 in that year alone. In 2012, four deaths were reported after 1 million legal abortions were performed. (Gold and Donovan, Guttmacher Institute, Sept 2017). Let me relate a personal experience in which circumstances changed attitudes about abor-

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

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tion. When I was stationed in Germany as the commander of a large Air Force clinic, two members of our organization, married to each other, had strong religious convictions against abortion. They were extremely excited to have their first child until the ultrasound showed that the baby was anencephalic (no brain was developing). They struggled with the decision to allow this pregnancy to go to term or to intervene. After extensive prayer and soul-searching, they elected to have an abortion. Because there is a U.S. law preventing ANY federal funds to pay for any abortion, no matter the circumstances, these active duty Air Force personnel were forced to seek their treatment in a German facility at their own expense. Their attitude about all abortions changed after that! Can we at least agree that there are circumstances in which abortion can be acceptable for medical reasons? In 2004, while being interviewed by Bill Moyers, Sister Joan Chittister said, “I do not believe that just because you’re opposed to abortion that that makes you pro-life. In fact, I think in many cases your morality is deeply lacking if all you want is a child born, but not a child fed, not a child educated, not a child housed. And why would I think that you don’t? Because you don’t want any tax money to go there. That’s not pro-life. That’s pro birth. We need a much broader conversation on what the morality of pro-life is.” Access to affordable and effective contraception is one of the hallmark achievements of the Affordable Care Act (ACA), which increased women’s access to a wide range of contraceptives with no out-of-pocket costs. Research suggests that family planning and poverty are inextricably linked. At the most basic level, when governments limit access to birth control, it’s poorer women who bear the brunt. That’s what experts fear will now happen in the U.S. “More affluent women will be able to pay

out of pocket,” Martha J. Bailey explains. As a professor of economics, she has spent years studying the socio-economic impact of access to contraception. (World Economic Forum, 17 Oct 2017). And for those who can’t afford the added cost? “Research suggests that unintended pregnancies will increase,” Bailey points out. “It’s hard to say by how much, but we know what happens as a result. In 2011, 42 percent of unintended pregnancies ended in abortion.” (World Economic Forum, 17 Oct 2017). The Affordable Care Act – also known as Obamacare – changed that, requiring insurance companies to cover all FDA-approved contraception. There were a few exceptions – churches and some religious groups, for example – but the impact was still enormous. Within two years, the share of women paying for oral contraception fell from almost 21 percent to 3.6 percent (World Economic Forum, 17 Oct 2017). Recently those exceptions became much broader. In keeping with a campaign pledge, the Trump administration announced that any company with “sincerely held religious beliefs or moral convictions” can refuse to cover contraception. This means that 55 million American women who currently have access to free birth control risk losing their coverage. (World Economic Forum, 17 Oct 2017) The best solution to the abortion question is to prevent pregnancy in the first place. While abstinence works quite well, most of us realize that most hormone-charged young people will not remain abstinent. So the best solution is to invest in pregnancy prevention. In November 2017 an article reviewed the State of Colorado’s attempt to decrease unwanted pregnancies. In 2009, Colorado offered free, low cost access to intrauterine contraceptive devices and, eight years later, Colorado’s teen birth rate fell by 54 percent and the teen abortion rate declined by 64 percent! A grant from Warren Buffet’s family allowed Colorado to spend $28 million over an eight-year period, and a study estimated the state avoided $70 million in costs for labor and delivery, health care, food stamps and child care assistance due to the decreased birth rate.

The current budget issues have led our President to ask to cut the Children’s Health Insurance Program (CHIP] by $7 billion (CNN Politics, 9 May 2018). The current budget proposal for 2019 includes a request to reduce the Supplemental Nutrition Assistance Program (SNAP) by $213 billion over the next 10 years, almost a 30 percent cut (NPR, 12 February 2018). The administration is proposing to cap federal Medicaid payments to states and to cut federal Medicaid spending by $1.439 trillion – that is trillion with a T – over the 10-year period from 2019 to 2028. That is about 26 percent of what the administration projects federal Medicaid spending would otherwise be, and close to the $1.455 trillion cost of the tax cuts enacted in December 2017 (Georgetown University Health Policy Institute Center for Children and Families Health, 12 February 2018). My biggest concern is that if we are unable to provide food, shelter, education, and health care for these children (many of whom are from unplanned pregnancies), then they end up having limited options which often results in engaging in illegal and violent activity later in life. We then end up putting them in prison where they cost us more money. And many “pro-life” advocates seem to lose their interest in preserving life in the case of possible capital punishment for crimes such as murder. Can we agree that capital punishment does not meet the definition of pro-life? The teenage pregnancy rate has been declining steadily since it peaked in about 1990 (Gutmacher Institute), as have the number of live births and abortions. Strong evidence suggests that the steep drop in abortion was related to improved access to contraception. Our government should stop denying funding to programs that include abortions in their options. We should spend more money to support programs such as the one in Colorado which has been shown to save money in the long run. If we support these programs, and unwanted pregnancies continue to decrease, then the argument about when life begins will be moot.

The best solution to the abortion question is to prevent pregnancy in the first place.

George Meyer, MD

September/October 2018

Naloxone Availability at Community Pharmacies By Zachary Nicholas, MS III RECENTLY, THE PRESIDENT declared the opioid epidemic a public health emergency, publicly recognizing a familiar problem for health care professionals. As the awareness of the opioid epidemic has increased, so has the search for effective solutions to combat the rising death toll. One such solution has been to improve the community availability of naloxone, an opioid receptor antagonist and life-saving medication. Naloxone is not a newly discovered compound; it has been used for decades by first responders and emergency departments. In response to the rise in opioid overdose deaths, public health and harm reduction advocates have sought to increase the availability of naloxone within the community for use by the general public. For example, the U.S. Surgeon General has voiced support for layperson use of naloxone like that of an EpiPenÂŠ for anaphylactic reactions; even this seemingly innocuous comparison mischaracterizes the safety profile of naloxone administration. Normalization of naloxone and improving lay-person ability to administer dosages may improve availability and utilization rates in community settings. Multiple methods have been employed to increase the amount of naloxone in at-risk communities. These tactics include co-prescription with opioid medications, community programs and harm reduction organizations that distribute naloxone, public education programs to reduce social stigma around opioid treatment, and facilitating naloxone distribution at community pharmacies. To achieve this last method, many states, including California, permit pharmacists to furnish naloxone to customers without a physician prescription on

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

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a voluntary basis. Even with such regulatory efforts in place, little is known about pharmacy participation and adherence to prescribing guidelines or pharmacist knowledge of naloxone as a harm reduction strategy. Existing research has indicated that there are multiple lapses in communication between public health experts, harm reduction advocates, pharmacists, and physicians. No resources exist which describe how Sacramento area pharmacies have reacted to the new responsibilities thrust upon them in combating opioid-related public health issues. To investigate this issue, the Sierra Sacramento Valley Medical Society (SSVMS) obtained a grant from the California Department of Public Health to survey community pharmacies in the Sacramento area to gain insight into the awareness of furnishing guidelines and quantify naloxone availability. Students were recruited to create and administer a survey to pharmacies that provided Sacramento area physicians and the community with information to conduct targeted interventions which aim to empower pharmacists to participate in these life-saving strategies. Over the past year, surveys were administered to pharmacies in Sacramento County to answer these questions. This report details the results of short surveys that were successfully administered to pharmacists or pharmacy technicians in March and April of 2018 at 48 registered independent and corporate chain pharmacies in 24 Sacramento County ZIP codes. Less than half of pharmacies surveyed indicated stocking naloxone at the time of contact. Most pharmacies were willing and able to order naloxone for next-day availability; however, different populations may

benefit from different naloxone administration methods which may be limited by transportation or practical barriers. NarcanÂŠ nasal spray was the most commonly available formulation due to multiple factors including ease of administration, efforts to encourage bulk purchasing methods, and usage in slang vocabulary among at-risk populations and health care providers. The variation in formulations, i.e. intramuscular injection, is relevant to serving different customer populations; individuals who are unfamiliar or uncomfortable with syringes may be reticent to administer the medication when necessary, while pre-loaded (e.g. NarcanÂŠ) and automated (e.g. EvzioÂŠ) options may be more user-friendly for the average person. Slightly less than half of the pharmacies indicated adherence to current guidelines allowing pharmacists to furnish naloxone without a physician prescription. Responses to this question included pharmacies that have a history of furnishing naloxone and those that have never encountered patient requests for naloxone, but would follow guidelines if given the opportunity. Interestingly, a higher percentage of pharmacies that stock naloxone would also furnish without a physician prescription as compared to non-stocking pharmacies. This discrepancy is possibly due to multiple variables including pharmacist education on naloxone, knowledge of current guidelines, socioeconomic, etc., but may also suggest that pharmacies which stock naloxone may be more willing to furnish regardless of underlying causes. Additional comments elicited during the survey process indicated that many pharmacists and pharmacy technicians do not regularly encounter patients seeking naloxone, which results in a lack of confidence on the topic. Other comments suggested a lack of access or time for the additional required education and general hesitation regarding all opioid-related issues. Existing research points to the delicate nature of patient-pharmacist interaction around pain management and opioids: Patients fear the appearance of drug-seeking behavior and

pharmacists fear alienating patients who may react negatively to similar perceived accusations when offered naloxone. This environment results in an apprehensive atmosphere, which may have contributed to pharmacies opting-out of the survey due to pharmacy awareness of the regulatory and community scrutiny surrounding opioids. Though pharmacy distribution is only one component of naloxone distribution, it may provide access for specific populations in combination with other strategies. Numerous Sacramento-based organizations, such as Harm Reduction Services in Oak Park, provide extensive outreach opportunities for at-risk populations, including naloxone distribution and administration training, referral for housing and treatment services, and needle exchange programs. Similarly, SSVMS continues to partner with Sacramento area law enforcement agencies to train and equip non-medical personnel with naloxone to provide an initial dose for suspected opioid overdoses. Additional efforts by medical organizations, including SSVMS, are aimed at educating medical providers on the value of naloxone co-prescription as a tool to prevent overdose deaths associated with prescription medication, while simultaneously working with relevant parties to address practical concerns such as affordability. Overall, our study suggests that additional research is needed to further elucidate barriers in the pharmacy environment from both the provider and patient perspective. Such data may be used to develop tailored approaches to increase pharmacy confidence with naloxone distribution and patient awareness of naloxone availability at local pharmacies in Sacramento County. Additional analysis may identify spatial barriers to naloxone availability which may negatively impact naloxone distribution in local communities. Our research team seeks to continue investigating naloxone and other harm reduction strategies in the pharmacy environment and medical student education. zrnicholas@gmail.com

Slightly less than half of the pharmacies indicated adherence to current guidelines allowing pharmacists to furnish naloxone without a physician prescription.

Dead Diet Dogma Why Can’t We Shed the “3,500 Calorie Deficit Equals a Pound” Fallacy?

By Ann Gerhardt, MD FOR YEARS WE WERE taught that eating 3,500 fewer calories-worth of food carved a pound off your body. Over a day, week or month, as long as the cumulative caloric reduction was 3,500 calories, a pound would be gone. Then science caught up to reality and that relationship had to be modified. We learned that people lose much more weight than predicted in the first two dieting weeks because of losing water weight. We learned that the body really doesn’t want to starve to death, so it slows metabolism to conserve calories: Any effect on weight of a modest daily calorie deficit is swallowed up by reduced caloric requirement. We learned that sleep deprivation changes insulin resistance, and cortisol and catecholamine hormones, all of which affect metabolism and weight. We learned that it gets harder to fight hunger over time, as the brain releases appetitestimulating hormones in another effort to prevent starvation. We learned all these things many years ago. We also know that a smaller body needs fewer calories, which is why it is important to exercise to keep weight off. If the new, reduced body needs just the number of calories that were consumed getting to that size, no new weight will be lost unless there is an additional calorie cut. These contrary data didn’t suddenly appear last year – It’s been accumulating for decades. Why then, in 2018, when doctors should know better, does the Journal of the American Medical Association (JAMA) publish an opinion article1 by an author who regurgitates the old meme that a 3,500 calorie deficit=1 pound lost? The author’s point is that weight loss

requires calorie-cutting. Of course it does – Do we need a viewpoint article to tell us that? One doesn’t lose weight while eating excess calories, unless one has cancer or some other major inflammatory disease. Calorie reduction is necessary, but scientists have proven time and again that weight loss is not linear or directly proportional to 3,500 calorie increments. The few people who successfully lose weight and keep it off lose some weight, plateau, adapt with more dietary change, lose, plateau, adapt and so on. Their initial calorie decrement of, for example, 3,500 calories per week stops working. Much more often, dieters lose, plateau, increase, adapt with more dietary change, lose, plateau, give up and regain all the lost weight.

In my experience, these dieters think they haven’t sabotaged their weight loss, but they have. Plateaus often occur while the dieter continues to make an effort and believes that he/she hasn’t deviated from the diet. In my experience, these dieters think they haven’t sabotaged their weight loss, but they have. Previously forbidden foods sneak back in “occasionally.” Birthday parties happen. Going out to eat becomes an excuse to overeat, as a special occasion. Weight loss makes them think a little dietary laxity won’t make a difference. But I’ve also seen people continue to follow their plan and stop losing weight. In a letter to the JAMA editor, a group of

September/October 2018

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

scientists, including an old colleague of mine, refute the “slow, steady” 3,500 calories per pound notion with facts.2 These facts include accurate measurement of calories consumed and burned, using the doubly-labeled water technique. (This technique has also demonstrated that almost everyone way underreports their food intake, invalidating most conclusions from dietary recall and food record studies like the Nurses’ Health Study.) Objective measurements show that, over time, a dieter burns fewer calories and increases food intake, leading to a plateau or weight increase after a year, if not before. Their numbers prove that it takes a larger initial or increasing calorie deficit over time to successfully lose more than a small percentage of body weight. This is true even with anorexigenic medication. Most drug studies demonstrate no more than a 10 percent weight loss, totally frustrating Americans who just want to take a pill to

compensate for their indulgent lifestyle. Achieving a calorie deficit and sustained weight loss takes vigilance, honesty with oneself about what is being consumed, and exercise. Overweight and yo-yo dieting are not healthy – Finding a way to approach a healthy weight and stay there is. For some, it takes a special diet that kills appetite, like the low-carb diet that works well for some but not others. For others, it takes swearing off individual foods, like soda, sweets or fast food. In any case, counting 3,500 calorie deficits and expecting proportional weight loss is delusional. Perpetuating that myth/dogma/delusion is irresponsible and doesn’t belong in a respectable journal like JAMA. algerhardt@sbcglobal.net REFERENCES 1 Guth E. JAMA 2018;319(3):225-226. 2 Hall K, Schoeller DA, Brown A. JAMA 2018;319(22):2336-7.

Donate blood. Give hope.

Amira survived acute lymphoblastic leukemia (ALL) as a young child with the help of blood donors. Now 12 years old, Amira looks forward to a healthy and exciting future.

There are more ways than ever to help patients in need celebrate the healthy futures they imagine. Blood donors deliver hope in very specific ways by donating the blood components needed by patients each and every day: red blood cells, platelets, transfusable plasma or source plasma. Schedule an appointment at a BloodSource Donor Center or mobile blood drive soon. Learn more by visiting bloodsource.org or calling 866.822.5663. Together, we do save lives.

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Using California as a Model for Maternity Care By Makenna Marty, MS II

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

“YOU WANT TO BE AN OB/GYN? Oh, you must love babies.” I frequently receive this response when I answer the age-old medical student question: which specialty I intend on one day entering. I typically politely point out that while I do indeed love babies, if I intended to focus on infant care, I’d be planning on pediatrics. My passion, rather, is women’s health. This is not to undermine the importance of infant health, infant mortality rates, or the role OB/GYNs play in contributing toward infant health; these are, of course, important matters in their own right. But I believe this statement I often encounter reflects a societal emphasis on the infant aspect of pregnancy, rather than on mothers. This idea is not new. National Public Radio (NPR) published an attention-grabbing story regarding this matter in May 2017, and if you Google “U.S. maternal mortality rate,” you will find a slew of articles with charged headlines about the inadequacy of American maternal care. A long-touted statistic that seems to be common knowledge, often to our embarrassment, is that, “America has the worst maternal mortality rate of any developed country.” For 2015, the World Health Organization reported 14 maternal deaths up to 42 days postpartum per 100,000 live births in the U.S., compared to seven deaths per 100,000 births right next-door in Canada.1 In my experience, it often seems that maternal mortality is discussed in the context of being a futile problem; the challenges are discussed, but rarely have I had conversation centered around solutions. Perhaps this is because the

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contributions to maternal mortality are multifactorial and highly complicated, leading to a sense that addressing the problem is simply too overwhelming. But, the key to addressing such a complex issue may lie in finding systemic approaches to the various causative factors. Maternal mortality review committees (MMRCs) are helping to do so, and California has been leading the way for many years. The idea behind an MMRC is to address maternal mortality head-on, first by identifying direct contributing factors; what exactly is causing new mothers to die, immediately following a birth or up to one year after? (Note, though, that “up to one year” is a U.S. definition of maternal mortality. The World Health Organization defines a maternal death as one that occurs during or up to only 42 days after pregnancy – a discrepancy that has an impact on statistical analysis on rates in the U.S. versus other developed countries, yet does not fully explain discrepancies in mortality rates.) After identifying causes, committees then produce programs that equip hospitals to appropriately handle conditions which can rarely but quickly spiral into fatal birth complications. At a national level, HR 1318 (The Preventing Maternal Deaths Act) was introduced in 2017 to “establish a program under which the Department of Health and Human Services may make grants to states” to support the establishment of MMRCs.2 But there has yet to be any action on this legislation beyond its introduction to the House of Representatives. Meanwhile, California established its own MMRC over a decade ago, before the rest of the country thought to do so.

In 2006, Stanford University School of Medicine, with the California Department of Public Health, began the California Maternal Quality Care Collaborative (CMQCC), an organization “committed to ending preventable morbidity, mortality, and racial disparities in California maternity care.”3 Within the CMQCC is an established MMRC, which utilizes data to identify the common causes of maternal mortality. In response to collected data, the CMQCC creates various quality improvement projects, mainly by developing what they call “toolkits.” Toolkits are intended to equip hospitals with the knowledge and resources necessary to respond swiftly to the leading causes of preventable maternal death. All toolkits are available for download on the CMQCC website, for free. Looking through the obstetric hemorrhage toolkit, for example, one finds 180 pages of extremely thorough and user-friendly algorithms for treatment, checklists of resources, and recommendations for complete toolkit implementation. Just one of many preparation methods is an OB hemorrhage cart; similar to a crash-cart, it stocks a variety of frequently necessary tools and medications to treat obstetric hemorrhage, to be placed within easy access in labor and delivery units. Through this and other measures, the toolkit’s preparation directly impacts the number of mothers with a postpartum hemorrhage who have access to prompt, life-saving care. It is initiatives like this that have helped California’s maternal mortality rate decline by an impressive 55 percent from 2006-2013, down to 7.3 deaths up to one year postpartum per 100,000 live births. During this same time period, the U.S. maternal mortality rate continued to climb higher, up to 22 deaths per 100,000 live births.4 The widespread participation in CMQCC initiatives at 241 California birth centers is an inspiring example of how diligence in toolkit implementation helped to transform the idea of decreasing maternal mortality into a reality. What has made California so successful with implementing programs that work?

I posed this question to Dr. John Wachtel, a Stanford OB/GYN and a member of the CMQCC Executive Committee with experience implementing toolkits in California. He boils it down to three crucial components: visionary leadership, data, and a wealth of volunteers. The leader spearheading the CMQCC efforts, Dr. Elliot Main, was and continues to be integral in making progress. Excellent quality data that can be accepted as valid by health care workers is also required to support the claim that intervention is necessary; California has access to such data due to diligent efforts from the CMQCC to ensure high-quality collection and analysis. And finally, it takes an extreme amount of manpower to undertake such an expensive and time-consuming project as implementing the toolkits, particularly in such a large and heterogenous state as California. Dr. Wachtel states that these initiatives would not have had such a great effect on reducing the California maternal mortality rate if not for the dedicated volunteers willing to contribute. In moving forward with implementation in other states, Dr. Wachtel believes all three items will be integral to work toward the same successes that California has had. Maternal deaths are often preventable, and always tragic. MMRCs are the health care providers’ way of taking responsibility in saying, we can do better. We will continue to strive to do so, with California medical organizations continuing to pave the way. As HR 1318 directly cites California as a model MMRC, other states will likely begin to utilize its groundwork as a way to combat maternal deaths across the country, especially as attention and funding for this health care problem will, hopefully, continue to rise. Perhaps the most significant point here is that as current and future health care providers, we are in a unique and powerful place to be what the CMQCC calls Champions, by continuing to advocate for programs to be implemented. Despite the progress already made, overcoming maternal mortality is a long and arduous task, one that needs dedicated advocates to continue. continued on page 22

September/October 2018

Maternal deaths are often preventable, and always tragic.

Typhoid Fever By Matthew Huh Editor’s/SSVMS Museum Curator’s note: This is the fifth article in a series by Mira Loma High School student Matthew Huh, featuring diseases that were common and often fatal at the time of the inception of our Medical Society in 1868.

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

TYPHOID FEVER, dubbed the “Great Killer of the 19th century,” is caused by the bacterium Salmonella typhi. It is thought to have caused the deaths of Wilbur Wright, Prince Albert (Queen Victoria’s consort) and Alexander the Great. Humans are its only reservoir. S. typhi multiplies in the gallbladder, bile ducts, and liver and then is carried in the gastrointestinal tract. The bacteria are spread via contaminated food and water. The incidence of typhoid fever has drastically dropped in developed countries due to improved sanitation, but still remains a relevant issue in other parts of the world. Symptoms begin one to two weeks after exposure. For the first week, symptoms will include abdominal pain and tenderness as well as a fever which rises in temperature during the day and drops overnight. By the end of the first week, the fever will become stable and flat, and red spots known as rose spots may appear over the body. In the second week, these symptoms may progress and the abdomen becomes bloated. The third week involves rapid weight loss with some individuals experiencing “pea-soup” diarrhea. They then may undergo a “typhoid state” when the patient becomes apathetic, confused, and possibly psychotic. Bowel perforation and intestinal hemorrhage may also occur during the third week, which may lead to death. Survivors may be left with complications and, in addition, there is a possibility that the bacteria will continue to live in the body, without symptoms, and be transmitted to others indefinitely. These people, known as healthy carriers,

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continue to shed S. typhi in their stool and thus are contagious. A notorious example of a healthy carrier was Mary Mallon, an Irish immigrant living in New York in 1884. She contracted typhoid at an early age and recovered from it, but her immune system never killed off the typhoid bacteria. In the early 1900s, she worked as a cook for eight wealthy families and spread typhoid to 22 people, some of whom died. Her specialty was her peach ice cream, which is believed to be the culprit in spreading the disease to her clients. It is said that she was ultimately responsible for more than 3,000 typhoid cases in New York. A sanitary engineer named George Sober was hired by one of these wealthy families to find the source of these reoccurring typhoid cases and this led him to find Mallon. She was dubbed “Typhoid Mary” and the New York Health Department isolated her on an island which served as a hospital for TB patients. The department gave her the option to undergo gallbladder removal surgery, which she declined. Mallon, not understanding the concept of a healthy carrier, sued the health department but lost the case. In the end, after many repeals, she was offered release from isolation so long as she stopped cooking. She agreed at first, but eventually changed her name and continued to cook. She proceeded to cause additional typhoid cases and two more deaths. The same sanitary engineer investigated these new typhoid cases only to find Mallon once again. She was promptly isolated once more until her eventual death in 1938. At the time, this case raised several ethical questions regarding the importance of public health over civil rights. One of the first physicians to do significant research on the emergence of typhoid fever was Dr. William Jenner, a physician appointed

to the royal family of England during the mid to late 19th century. Prince Albert was one of Jenner’s patients when the Queen’s Consort died in 1861. Jenner had observed more than 1,000 patients at the London Fever Hospital in 1847 and found that the cause of typhus, a similar disease, was completely different than typhoid fever, contrary to previous belief. These diseases have many similar symptoms like abdominal pain, rash, fever, and confusion, but have different vectors. Typhus is the name for a group of diseases caused by rickettsiae. Typhoid is spread via contaminated food and water while typhus is spread by infected lice, fleas, mites or ticks. In 1850, Jenner published a report, The Identity or Non-Identity of Typhoid and Typhus Fevers, which delineated the distinction between the two. In 1880, Karl J. Eberth, a German bacteriologist, first visualized the bacillus responsible for typhoid fever and, in 1884, Robert Koch’s lab group confirmed that the bacterium Salmonella typhi is the cause of typhoid fever. This discovery led to an immunization being created in 1887, but this was met with controversy as it was far from perfect, and thus its use was limited. In 1896, German bacteriologist, Richard Pfeiffer, and British bacteriologist and immunologist, Sir Almroth Edward Wright, discovered similar techniques for inoculation involving introducing dead typhoid bacteria to the body. Wright published it first in 1897, but literature from the late 1800s and early 1900s show that the credit for this vaccine was shared between the two. The first time this vaccine demonstrated its effectiveness was during World War I. Scientists knew that during the Boer War (1899–1902), the British army lost more than 13,000 men to typhoid fever. This accounted for almost double the number of casualties compared to battle injuries. Learning from this, British troops were vaccinated during WWI and, as a result, morbidity and mortality from typhoid fever was drastically lower, a stark contrast to the events of the Boer War. The typhoid vaccine, however, was not

always effective and there arose several techniques to treat typhoid patients in the 19th century. The most prevalent form of treatment was simply limiting the diet in order to prevent a perforation in the bowel. Others, like Dr. George Wood, an American physician who practiced in the mid 1800s, outlined a method of treatment in his Treatise on the Practice of Medicine. To address abdominal pains, laxatives like magnesium sulphate (Epsom salt) or Seidlitz powders (tartaric acid, potassium sodium tartrate and sodium bicarbonate) were used to evacuate the bowels to avoid perforation. To avoid irritation to the bowels, he prescribed 20 drops of laudanum (tincture of opium). If inflammation of the brain was present and life threatening, evident by the presence of a severe headache, leeches were used to draw up blood to “stop inflammation.” Treatment also consisted of sponging temples, arms, and legs with cold water and opium administered as a painkiller when necessary. The current treatment is antibiotics. Fortunately, the incidence of typhoid, especially in developed countries, is much lower due to modern plumbing, sanitation, and vaccinations. According to the CDC, there are 5,700 cases in the U.S. every year, but more than 75 percent of these are acquired by traveling internationally. Globally, however, it remains a serious problem. There are 21.5 million cases worldwide and 200,000 deaths per year. It is clear that sanitation and hygiene are crucial in prevention of this disease. In Harare, Zimbabwe in late 2016, a drought occurred which led citizens to drink water from boreholes and shallow wells. Combined with over 100 sewer lines breaking, this led to over 800 typhoid cases and four deaths. Outbreaks like this demonstrate that clean water and sanitation remain a vital aspect of public health. matthewdhuh@yahoo.com

September/October 2018

Dr. J.E Woodbridge’s late 19th century treatment was based on ingesting antiseptics to “absorb” toxins, using small doses of podophyllum resin and calomel with antiseptics such as guaiacol carbonate, enthol, eucalyptol and thymol...up to 70 doses within 24 hours.

REFERENCES The list of sources used in this article is available upon request from the author.

Fight, Flight or Freeze By Caroline Giroux, MD

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

ON JUNE 15TH, MY colleague, a group of psychiatry residents from a trauma sub-committee and I gave a talk and led a role play for the staff at the Food Bank and Family Services. The atmosphere was lively as we walked in the middle of their Friday celebration, at the Sierra 2 Center, a beautiful architecture with the indoor smell bringing me back to my elementary school days. The Curtis Hall was very inviting, with wide windows, people chatting happily, eating, while three staff members were serving ice cream. A woman was knitting a colorful piece at a round table. It was a diverse, energetic, engaged audience. My colleague opened the talk with a solid foundation on the neurobiology of trauma, the “fight, flight or freeze response,” the Adverse Childhood Experiences study and the importance of secure attachment. Then I focused on certain elements of the trauma story and our universal need for storytelling as a source of resilience and a pillar of meaning, and a resident ended that first section with an overview of trauma-informed care. The first question at the end was about what we could do, as a medical field, about the horrific situation at the border that consisted of dislocating Central American families (whose only crime was trying to find a better, safer world) and detaining their children in cages. My heart sank as it had been an issue causing a crescendo of sadness, incomprehension and anger in me. One of our residents took the microphone and re-emphasized the consequences from such a human rights violation for the survivors throughout their lives, and the damage created from ignoring attachment theory. Because I see on a daily basis the long-term impact from childhood trauma, and because it

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keeps happening in various forms despite the fact that it is preventable, for the past several months, I have bounced back and forth between the fantasy of fleeing this country, and urges to protest. I have oscillated between flight and fight. The next day I had to shift gears pretty abruptly as I was still very overwhelmed by our presentation experience. By noon, I was trying to recover from the sensory overload of three hours spent at my boys’ swim meet and where I was in a severe state of depersonalization... So many short events (races) to keep track of, heats, lanes, etc. And for each of my three kids! It seemed worse than flying alone with them when they were all under the age of 6. The swimming event was just like multiple checkins, different gates, and different flights, all at irregular intervals. Suddenly, Bruce Springsteen’s blasting “Born in the USA” seemed incredibly offensive. I felt on the verge of mental collapse, refusing to care about swimming statistics or “how many seconds did he shave off since last time,” trying to reconcile this obscene luxury of the American competitiveness and the crime against humanity happening at the border, on our soil, where 700 Mexican (and other nationalities: El Salvadorian, Guatemalan) families had been separated since October. I was in total freeze mode. Four days later, the current administration finally halted that cruel measure as a response to the public outrage. But as predicted, the damage had already been done. Once this article is published, we will have passed the deadline ordered after the American Civil Liberties Union lawsuit. As I am writing these lines less than two weeks before July 26th, the government said around 2,551 migrant children still needed reunification with parents. Some parents may

have already been deported without them. The logistical nightmare of a reunification process seems as random and disorganized as the new “zero tolerance” policy. Records were not kept during the separation. Some DNA tests might be needed. Each minute away from their parents counts for each one of these children. The separation and fear from uncertainty have activated their stress response systems; the high levels of cortisol have toxic effects on the body, especially the developing frontal lobes and the limbic system. Apparently, some children do not recognize their parents during the slow reunification process. Or they might have felt so deeply abandoned that they are developing an avoidant form of attachment. This is very alarming.

Apparently, some children do not recognize their parents during the slow reunification process. I just read in the August 2018 issue of the National Geographic that in Sweden, hundreds of immigrant children whose families face deportation have developed resignation syndrome, a disorder in which the child withdraws from the world, won’t react to painful stimuli (in psychiatry, we would call this phenomenon dissociation), and must be nourished with a feeding tube (is this some form of failure to thrive from societal/political neglect?). The pendulum of oppression hurts those who are kept in the dark and those who witness, powerless. What do you make of the re-enactment of such colonialism? I can’t help but think about the Canadian and Australian native children sent to boarding schools in the 1950-60s away from their villages, cultures, and the irreparable damage to the subsequent generations also. We cannot ignore history, and this is no longer a question of politics at this point (Rep. versus Dem.), it is a question of morality. Are we all responding in a different way to this vicarious traumatization? Some of us dissociate, remaining frozen in a sanity-saving denial.

Others flight because they prefer to actively avoid. And others feel like warriors against injustice. Resisting, complaining, making noise, voicing our outrage. How to be effective in the change we want to see happening? Protesting this, resisting or fighting is not about control at all. It is about pragmatic interventions to protect children’s emotional and physical safety because they can’t do it for themselves. It is not a power struggle (honestly, I have no time for this); it weighs on our conscience because it is unacceptable and will have long-term, irreversible consequences. Referring to WWII, so many still wonder why did not more people speak up? There is no excuse to let this happen again. The human mind should know better. I treat people who were once children, who were abandoned, neglected, abused, or who lost a parent. Decades later, they are still deeply wounded. Secure attachment is the foundation for everything: mood regulation, self-esteem, general health, ability to explore and maintain harmonious, stable relationships throughout life. Patients I evaluate and who have a history of trauma are deeply affected and triggered. We have a duty to protect our children. They are the tomorrow. And all the children of the world are our children; our own will share their same tomorrow. After their liberation and reunion with their loved ones (for the lucky ones who can find each other), let us open our arms wide to these children, let us be prepared to listen to their stories, as horrible as they may sound. Both children and those who care for them will need an attentive presence. Such wounds never completely go away. We can’t turn back the clock of those formative years. But we still have a duty as healers. We must give them a voice or be that voice for them. We must also let them all educate the whole of humanity, and if there is still such a thing in us, our most significant role is to believe them, bear witness to their suffering and be present to their painful, incomprehensible past, so we don’t repeat it and so the future is all theirs. cgiroux@ucdavis.edu

September/October 2018

So You Want to be an Undertaker? By Bob LaPerriere, MD

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

UNDERTAKER, MORTICIAN and funeral director all generally apply to a professional who prepares for the burial or other disposition of dead human bodies, supervises such burial or disposition, maintains a funeral establishment for such purposes, and counsels with survivors. If you have thoughts about taking care of the dead instead of the living, my first recommendation is to read “Smoke Gets in Your Eyes: And Other Lessons from the Crematory by Caitlin Doughty.” This book is a fascinating New York Times bestseller about a young woman and her experience in the funeral business. And if you want to go beyond that, you need not go farther than American River College (ARC), part of the Los Rios Community College District. California ranks in the top tier for employment of morticians and in the uppermid range for mortician salaries. There are only two programs in California (and 59 in the United States) that train students in a funerary occupation. One is in Southern California, the Cypress College Mortuary Science Department. The other is the American River College Funeral Service Education Program. Both are accredited by the American Board of Funeral Service Education and offer an Associate Degree in Mortuary Science. ARC “imported” their program from the San Francisco College of Mortuary Science (SFCMS) in 2002 when it closed after over 70 years. Jeff Stephenson, Ph.D., served as the first program director at American River College. Valarie Rose, M.A., the current program director, took over when Damon de la Cruz, Ph.D. left to move back to Cypress College. Another key person at the start of the program was Lucille Rybka, Ed.D, RN, wife of SSVMS member Dr.

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Jim Rybka. In a community college setting, the program reaps the many benefits of access to related disciplines such as science, anatomy, art and business. Even Theater Arts supplies students who perform as grieving family members. There are several prerequisites before entering the program, including certain biology and math courses. Current enrollment in the first year of the program is 14 students, with a recent graduating class of 27, and total enrollment currently of 51 with a capacity for 60. There are both one-year and two-year programs. In the one-year program, students attend four days a week plus summer courses, and they complete the A.S. degree in two semesters. Students in the two-year program attend classes two days a week for four semesters, while also completing their G.E. requirements. They also receive an A.S. degree upon completion. One of the favorite courses is restorative art, where the students work on a wax head. The program prepares students for a career as a funeral director or an embalmer. A funeral director is primarily involved in communicating with the family, making sure the process runs smoothly, and conducting the funeral service. The embalmer prepares the body to make it presentable and peaceful looking, which assists with the closure for the family. They are also responsible for any “sanitation” aspects and the cremation, if that is chosen by the family. Students in the program have varied backgrounds and different reasons for choosing this career. Some may have a fascination with death, grief, funerals, or anatomy and science. However, they will realize that their primary purpose will be to help the living process

the death of a loved one. As one student noted, “Honoring a life lived through ceremony, interment and memorializing is about allowing space for people to confront their own mortality and sometimes be changed by the process and mystery of the cycles of life and death. I think it sometimes can make us all better people when we live with the knowledge that our time is not forever… It can be an important lesson to learn, and maybe one we don’t learn soon enough.” A significant number of graduates eventually leave the funeral industry due, in part, to the stress and irregular hours. But those remaining find it rewarding, as they help families with closure and healing. Students are encouraged to work during their early semesters to gain more experience, though their whole fourth semester is spent working in a funeral home. Students are required to do 10 embalmings, 10 funeral services, and 10 arrangements, and take five first calls and do five transfers. As opportunities in the community are limited, and classrooms are often shared, they are in the early planning stage to develop and run a funeral chapel. ARC recently received approval to work in conjunction with the Sacramento Coroners office, East Lawn Cemetery, and NorCal Crematory to do embalmings, viewings, services, and cremation for indigent families in the Sacramento region.

Historical Perspective There has been tremendous evolution in mortuary science, with the rate of cremation increasing dramatically, and green burials becoming more popular. A variety of requirements based on religion also need to be considered. Embalming probably dates to the Egyptians and was a two-month process requiring many pounds of spices and other agents. Later embalmers were often physicians and anatomists. In 18th century England, Dr. William Hunter was generally credited as the first to adopt arterial injection. Early embalming in the U.S. and Europe was initially done to preserve anatomical material. In the 19th century, embalming was not

This embalming pump was used in the early 1900s. It is currently in our Museum of Medical History, on loan from Placer County Museums.

generally used until the Civil War, when soldiers had to be transported home for burial. Arsenic was a common ingredient in embalming fluid and, today, still presents a potential hazard in old gravesites. Phenol was another common ingredient used through the early 1900s, and embalming after the Civil War was uncommon until later when it became more of a business with a trend for viewing the body before burial. Coffins were initially made by carpenters and cabinet makers, and later could be found for sale in furniture stores. The care and preparation of the body was generally handled by the family, and the viewing, or “wake,” was in the parlor of their home (hence the later development of the term “funeral parlor”). Much of the work on preservation was done by medical men, as newer methods were required to make the body more presentable for viewing. The 1888 formula from one of the physician ledgers in our museum can be seen in the accompanying illustration. It reads in part: “I have embalmed 12 bodies with satisfactory results. Have never removed any of the viscera but have injected into the abdomen ...One body was interred two weeks before shipment, hauled 100 miles in lumber wagon to the RR depot after being disinterred and arrived at its

September/October 2018

destination in the east in good condition.” Today, with the cremation rate in California at about 60 percent, more choices are evolving: Do you want your loved one’s cremains in a locket, in multiple urns for different family members, compressed into a diamond, shot into space, or incorporated in a reef for fish? However, a method more friendly to the environment, alkaline hydrolysis or water cremation, could replace “fire” cremation. Governor Jerry Brown signed AB 967 which legalizes this method in California. It results in a liquid residual that, when dry, resembles powdered sugar and the bones. Funeral directing has evolved into a big business. Today, much like wineries, numerous funeral homes still carry their historic family name, but are actually owned by conglomerates such as Service Corporation International (SCI), Carriage Services Inc. (CSV), and Stewart Enterprises Inc. (STEI) that own well over 2,000 funeral homes and cemeteries. And don’t forget Walmart and Amazon both sell caskets.

Early embalming recipe.

ssvmsedcom@gmail.com REFERENCES www.arc.losrios.edu/ARC_Majors/Health_And_Education/Funeral_Service/Program_ Information_.htm

Using California as a Model for Maternity Care continued from page 15 Maternal mortality review committees and the improvements they initiate are an effort to change the culture of maternity care, a way of saying that we value mothers’ lives equally as infants.’ Remembering this, and aligning ourselves as allies, is essential, until preventable maternal mortality is no longer proclaimed as the “shame of American health care.”5 makenna.marty7901@cnsu.edu

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REFERENCES 1 World Health Organization, “Maternal Health: Maternal mortality ratio per 100,000 live births” (2015). 2 H.R. 1318 – Preventing Maternal Deaths Act. March 2017. https://www.congress.gov/bill/115th-congress/house-bill/1318/ text. 3,4 California Maternal Quality Care Collaborative, “Who We Are.” https://www.cmqcc.org/who-we-are. 5 Turlington, C.B., “Maternal Mortality is the Shame of American Healthcare,” CNN (2017).

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Reflections on Women in Medicine Experience

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

Background: The Editorial Committee recently sent out a call for articles regarding how women in medicine make their career choices. Female physicians were invited to share their thoughts and experiences that determined their medical career choice, and what changes in medical schools and practice systems might have altered their course. Male/Female disparity in medicine persists in spite of women now comprising more than half of medical students and residents. No one denies the male/female physician pay gap. Recent data estimates average male primary care physicians’ compensation as $239,000 versus $203,000 for women. Males in specialties earned an average $358,000 versus $263,000 for women. In 2016, only 21 percent of medical school full professors were women, in spite of a similar number having families with children. Within the Harvard patriarchy, that number was only 17 percent. Ashley C. Wietsma, MD, in the Journal of Community Hospital Internal Medicine Perspectives (2014; 4(3): 10.3402), opined that “Women are challenging themselves to live up to the expectations of their professional peers, society, and their patients in order to ‘have it all.’ These pressures are leading to professional and personal dissatisfaction. Is this a problem that will resolve itself as the younger generations of female physicians graduate into faculty positions, or does it require more attention from both male and female medical professionals?” Comments/replies follow below: There were many who thought my own trajectory would lead me to a full professorship at a prominent medical school and to being a major force in the national Clinical Nutrition community. Having completed an Internal

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Medicine residency and three years of researchbased Clinical Nutrition fellowships in two universities, I was on the tenure track faculty at UC Davis. Then, after 3.75 years of tolerating an abusive division chief and enduring a road-blocking administration, I decided to go out on my own. I might have made a different decision if my Division Chief hadn’t been abusive. I probably would have learned to live with a University administration. If I hadn’t successfully gained research funding, I might have had to leave later anyway.

My private practice style helped to reduce the average female physician income figure, rather than boost it. I didn’t contribute to the percentage of females in medical leadership roles. My private practice style helped to reduce the average female physician income figure, rather than boost it. But I got to decide how I would care for my patients and still have an extremely active family and personal life. Personal decisions caused me to change my practice every seven years or so, adapting to medicine’s changing landscape. Former SSVMS Executive Director Bill Sandberg once told me that I was the only physician he knew who practiced the way I wanted. Even now that I’m older, I choose to continue to practice because I still like it (except, of course, the EHR). My personal decisions didn’t help statistics about women in medicine, but I believe they helped my family, my patients and me. –Ann Gerhardt, MD

I might be out of the norm, but I chose pulmonary and critical care because I loved it. I had no idea that being a mother would become so profoundly important to me. Honestly, had I known then what I know now, I probably would have chosen a more female-friendly field (i.e., less call and work hours). When I was going through college, and medical school and residency, I thought being a mother would just be something that I would do. I never understood that it would fundamentally change who I am and what my priorities are. I wish I could spend more time with my kids. I wish I could stay home with them and watch them grow. But I can’t. My husband sacrificed his career for mine and is now a stay-at-home Dad so that I can continue to pursue my career. I feel like I have to succeed and make enough money for the both of us, so I don’t see my kids as much as I want. These were things I never considered as a student and resident. I don’t know that changing the system would help me. I wish I could change my biology. I set myself up to be this strong and successful career woman without even realizing that being a strong mother would bring me just as much joy as all the successes in my career and education. I’m still so happy with my life. I just wish I had known how much I would love being a mother. I always try to impart this information to female medical students whenever I can. Sometimes it feels like I’m being anti-feminist when I talk about this, but I really think the true definition and spirit of feminism is giving women choices and not judging them for doing what they are called to do, whether that is to have a career, a family, or both. Hearing all sides of the story, and not just the constant portrayal of women who can “do it all,” is probably in a female student’s best interest. –Vanessa Walker, DO Again and again I heard that I’d hate my medical school surgery clerkship, mostly because of the long hours, the hard work, and the rude attendings. On day one, when the chief surgical resident took us around to ensure that every patient who had an NG tube had a functional tube, and showed us how to ensure that, I was

sold. He was a kind, warm, and gentle young man who obviously loved our patients. I realized that surgical practice allowed great emotional intimacy and on-going relationships with the patients, and that the problem solving was both mental and physical; I loved it throughout my career. –Scarlet La Rue, MD I never thought of pursuing medicine, until my mother had a right-sided occipital lobe stroke. I was deeply impacted by her and the hustle in the ambulance and moving towards the hospital within a “golden hour” timeframe. During her recovery, I changed. I wanted to do so much more than being an observer. I decided to attend both Cal and Davis, studying neuroscience. I am empowered to help by using my hands to effect change in individual’s lives. As an Afghani-American woman, pursuing medicine is a fascinating journey. This I say because, one, I am from an immigrant background, and most importantly, I like to call myself a self-made, wonder woman. As an Afghani-American, learning English proficiently was a challenge, especially the medical jargon. However, with the help of mentors and my own internal drive, I was able to quickly learn medical vocabulary. In the past, women were underestimated in medicine, and till this day, there is still bias within institutions, that which includes the unequal pay between the two genders. However, I strongly am empowered by the positions women are taking in medicine as leaders for the both the present and future physicians. To see the positive outcomes made from past to present – gives me both hope and strength that medicine is flourishing. –Sehra Rahmany, MD I really liked my Urology rotation and considered going into that specialty, but there were no female urologists that I knew of in 1972, and I just did not have the energy to fight the system there. So I did an Internal Medicine residency. There were precious few female surgeons of any type, and women were not encouraged to enter surgical specialties. Offered a job in the Emergency Department in the days when there were no Emergency Medicine residents, I found that I really enjoyed the work

September/October 2018

My husband sacrificed his career for mine and is now a stayat-home Dad so that I can continue to pursue my career.

and I grandfathered (grandmothered?) into Emergency Medicine as I have always enjoyed using my hands in procedures as well as my brain in diagnosis. –Joanne Berkowitz, MD

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medicine… In 1972 when I was accepted into medical school, the career choice initially was more about nursing vs. medicine, since women in medical school still comprised less than 20 percent, but my folks were very supportive. I chose the specialty that fit my interests and temperament (family medicine, notoriously low on the totem pole for compensation compared to other choices). I had minimal debt to worry about. I have no complaints about what I am paid, but certainly chafe at the disparity between specialties and documented gender differences. However my spouse, a family physician, is not paid differently than me, and for a short period of our careers, I out-earned him! He didn’t take that too well, either. I came into academia through the back door so to speak. One should not forget that a significant amount of good academic work occurs not at the ivory tower but in community settings. This is also often overlooked and undervalued which is a pity. –Marion Leff, MD

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Madhouses and Lunatic Asylums History of Mental Illness and its Treatments.

By Kent Perryman, Ph.D. BEFORE THE ADVENT of modern psychiatry in the 20th century, mental illness was not categorized behaviorally into the numerous diagnostic symptoms associated with thought and mood disorders. Aberrant behavior was not recognized as a mental illness with any medically accepted concepts until well up into the 18th century. Most ancient mental disorders were lumped into some form of “madness” or possession that resulted from a spiritual cause. This article will not delve into the numerous psychiatric classifications, but rather, expose the evolution of popular and medical attitudes towards abnormal behavior and its treatments. There is archaeological evidence for nearly 7,000 years of treatments of aberrant behavior. Stone-age tools discovered in Mesoamerica, preColumbian civilizations, were theorized to bore holes in the skull to release evil spirits associated with demonic possession. In the ancient city of Babylon in Mesopotamia, what has been referred to as “madness” was attributed to supernatural events and beings. Spirits from deceased individuals were thought to influence the behavior of the living. Many early religions promoted beliefs that disease and misfortune could be punishment for disobedience of a god’s commandments. One Greek proverb exemplifies this as “those whom the gods wish to destroy they first make mad.” “Madness” as a mental illness was first addressed in the 5th century B.C. by Hippocrates (460-370 B.C.) Both physical and mental health was believed to depend on a balance of four

bodily humours: black bile (melan chole), yellow bile (chole), phlegm (phlegma) and blood (haima). Any imbalance between these four fluids resulted in some form of illness. For example, an excess of black bile was believed to cause melancholy, while mania resulted from an excess of either phlegm or yellow bile. The ancient Greek approach to treatment was to rebalance these humours through methods such as bloodletting, emetics, and purges to expel surplus humours. Herbal treatments, as well as changes in diet and hot-cold baths, were also employed as supplemental treatments. This ancient form of humoral balance was carried over through and up to the 19th century for various physical maladies. Another Greek physician, Claudius Galen (129-200 B.C.) who practiced in Rome, refined the humoral treatment for mental disorders by creating a classification of human temperaments based on the four elements of hot, cold, dry and wet. The balance between these elements determined one’s temperament. For instance, a “sanguine” temperament was composed primarily of hot and wet while a “choleric” temperament was dominated by hot and dry. Mental traits and bodily features were also assigned to these personality traits. Choleric individuals had energetic, passionate and aggressive temperaments. These temperaments were believed to predispose one to specific mental disorders such as mania and melancholia. Galen’s classification dominated medical thought for 15 centuries and influenced

September/October 2018

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

western medicine up until the 20th century and may have been a predecessor to the contemporary classification of personality disorders. There was also another more harsh approach to treating aberrant behavior during this time. Aulus Cornelius Celsus (14 B.C-50 A.D.), a Roman medical encyclopedist, was the first documented physician to recommend the use of chains, whippings and starving as a treatment for madness. Celsus was also the first to describe paranoia. During the Greek and Roman era, mania and melancholia or depression were the only two forms of mental illness recognized. Following the fall of the Roman Empire in 476 A.D., Christianity in the form of the Catholic Church dominated the perception of mental illness during the Middle Ages (5001500 A.D.). The Christian view of mental illness at this time attributed aberrant behavior as a madness due to repeated intercourse with either an incubus or succubus (sexual demons) that could lead to death. Individuals with behavioral disorders were ostracized from the community, chained, and sometimes locked in caves. In northern Europe, toward the latter Middle Ages (1200 A.D.), religious orders established shelters called “hospices” for these individuals. The basic premise of curing mental afflictions was to save the sinful souls of inmates. In Catholic countries (Spain and France), mentally deranged souls would be escorted on pilgrimages to shrines, healing springs, temples, monasteries, and churches. Curing mental illness during these times involved praying, seeking consola-

A painting of Philippe Pinel removing the chains from mentally disturbed patients at Hospice de La Salpetriere at Paris in in 1796.

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tion, and hoping to find a miraculous cure. In the Middle East during the Middle Ages within the Islamic regions of Syria, Persia, and Iraq, the Hippocratic tradition toward the care and treatment of mentally ill citizens was maintained. In Bagdad, Iraq and Aleppo, Syria, hospitals were constructed to house the insane in a humane manner where patients were housed, fed and treated with herbal remedies. In many of the Islamic hospitals supported by personal charities, music was played for the patients and flowers provided alongside outdoor bathing facilities. These facilities were under an imperative to care for both the wealthy as well as the poor, regardless of sex, age or religious affiliation. Muslim societies and Islamic medicine viewed oddly behaving individuals as madmen or possessed and referred to them as “majnun.” During the period between 1690 and 1800 known as the “enlightenment,” Europe also experienced an “Age of Melancholy,” as well as an age of confinement. During this time, devils and demons were still, to some extent, implicated in insanity. In 1621, the English scholar Robert Burton (1577-1640) published the “Anatomy of Melancholy,” a 1,000-page detailed treatise describing the demonstrative form of depression. All of his numerous classifications were without scientific validation and based on religious definitions of melancholy. Europe was witness to a boom in the construction of workhouses and penitentiaries to house the insane, paupers, beggars, vagabonds and criminals from the mid-seventeenth century to the end of the 1800s. French historian and philosopher Michael Foucault (1926-1984) described this era as the “great confinement.” Vagrants, beggars, and rogues were thought of as lunatics at the time by the authorities. These individuals were viewed as setting a bad example for the rest of society and should be chained, flogged and placed in confinement. The English Vagrancy Act of 1714 linked lunatics with beggars and rogues, permitting justices of the peace to confine these individuals. Later in 1764, the French created the “Workhouse” institution (Depots de Mendicite)

in Paris to help bare the financial burden of maintaining these individuals where they had to perform labor. The harshest example of confinement for its poor hygiene was the Bethlem Royal Hospital in England that was built in 1377 and rebuilt in 1677 as a facility for the mentally ill. This asylum continued to be a mental hospital until 1948 when it was closed due to public scandal for allowing visitors to view the patient’s suffering. It became known as “Bedlam” for madness. The harsh treatment of mentally ill patients was not the norm for most of Europe during this time. In most instances, these individuals remained with their families until they were too difficult to manage, at which time there were accommodations made at a church or monastery. If patients were chained, it was usually to prevent them from injuring themselves. Later in the 18th and 19th centuries, English mental health care was provided by both private asylums and government-run “madhouses.” Most of the private facilities provided little or no records of patient histories due to an absence of any legal requirements. There was very little medical oversight of these private and public facilities for the mentally ill. Physicians and nurses rarely attended to the patients until 1828. Moral treatment of mentally ill patients eventually became available in Great Britain in 1796 with the establishment of the Quaker York Retreat by William Tuke (1793-1822). Tuke’s therapeutic approach to restoring mental health was to strengthen the power of self-control in order for the patient to adjust to the demands of everyday life and return to their community. Earlier in 1793, the French pioneer psychiatrist Philippe Pinel (1745-1826) removed the chains of mentally disturbed patients at the Bicetre Mental Hospital in Paris, and three years later at the Hospice de La Salpetriere. The Salpetriere, originally a gunpowder factory, was converted over to a hospice in 1656 under the direction of Louis XIV for housing prostitutes, the mentally ill, women with learning disabilities, epileptics and the poor. At one time in 1864, it had a population of 10,000 patients and 300 prisoners from the streets of Paris.

Pinel became the chief physician in 1794 in charge of a small 200-bed infirmary within the huge hospice. Most of the day-to-day patient care at the infirmary was carried out by a Catholic nursing order. Pinel’s “Moral Therapy” or moral treatment focused on removing the earlier asylum tortuous treatments of chaining, whipping, starvation and isolation. He had the nursing staff disinfect infirmaries, eliminate vermin and improve nourishment and hygiene. His intense interest in the study of mental illness eventually resulted in an early classification of psychiatric disorders that included melancholia, mania, idiots, and dementia praecox which became known as schizophrenia. The Salpetriere would later be headed by Jean-Martin Charcot (1825-1893), a French neurologist and professor of anatomical pathology. Charcot’s research and lectures on hysteria were believed instrumental for forming the foundations of psychoanalysis. The first private hospital in the United States for the mentally insane was established in Pennsylvania in 1752 under the influence of Benjamin Franklin (1706-1790). Upon being admitted, patients had their heads shaved followed by blistering and the administering of purgatives and chaining. Benjamin Rush (17461813), the founding father of psychiatry, was a physician at the Pennsylvania Hospital between 1783 and 1813. As was the case for the Bethlem Hospital in London, the Pennsylvania Hospital also permitted visitors to view the antics of inmates. This was more or less a human zoo until 1830 when the Philadelphia city statues forbade the public gawking. During this time, many of the mentally disturbed, including paupers, orphans, the disabled, the feebleminded and insane, were sold at public auctions to join the purchaser’s household as “talking animals.” For many townships on the East coast, this was a cost-effective method of avoiding confinement expenses. The Eastern Lunatic Asylum of Virginia in Williamsburg was the first private hospital dedicated to confining only the insane in 1773. Later, asylums for the insane were also established at the New York Hospital in 1791

September/October 2018

If patients were chained, it was usually to prevent them from injuring themselves.

The first California institution for the mentally disabled was established in 1852 at Stockton with a population of 124.

and the Maryland Hospital in 1798. By 1844, under the auspices of the American Psychiatric Association, more than 20 mental hospitals were established. In 1855, the first federallyfunded mental hospital was the Government Hospital for the Insane in Washington D.C. (also called St. Elizabeth’s Hospital). The first state mental institution was established at the Massachusetts State Lunatic Hospital in 1874 at Danvers. Mental Hospitals in the United States were witness to an evolution of more humane and moral treatment regime long before their European counterparts. Much of the reformation was due to the efforts of Dorothea Dix (1802-1887) in promoting a lunacy reform movement. Dix pressured state legislatures throughout the East to eliminate the horrors the mentally disturbed faced in confinement, and transform treatments to more compassionate care. The first California institution for the mentally disabled was established in 1852 at Stockton with a population of 124. Eleven additional hospitals were subsequently built throughout the state including those at Atascadero, Camarillo, Coalinga, and Napa. Before the establishment of the Stockton facility, mentally disturbed inmates were usually confined with criminals in crowded penal institutions or county jails. Early treatment regimes at this time in California included sterilization of the feebleminded that was lawfully authorized. Beginning in 1941, the Langley Porter Clinic in San Francisco maintained a 100-bed neuropsychiatric hospital that functioned as a teaching, treatment, and research center for mental illness. Later, in 1961, the University of California Los Angeles Neuropsychiatric Institute (NPI) opened and was placed in charge of the departments of psychiatry, neurology, and neurosurgery. It was later renamed the Jane and Terry Semel Institute for Neuroscience and Human Behavior in 2004. The NPI, as well as the UCLA Brain Research Institute, has been at the cutting edge of brain mapping, neuroscience research devoted to brain diseases, and mental disorders. Beginning in the 1930s, mental hospitals,

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not only in California but also in other regions of the United States and Europe, witnessed the advent of “psychosurgery” treatments for mental illness. The number of institutionalized mentally ill patients in the United States exceeded 400,000 and occupied more than half of all hospital beds by the mid 20th century. During this time, there were no effective pharmacological treatments available for mood and thought disorders. Egas Moniz (1874-1955), a Portuguese neurologist, performed one of the first “leucotomys” in 1935 on a patient with severe depression that helped lessen her symptoms. Moniz utilized ethanol injections into the frontal lobe through burr holes to destroy brain cells. Later, he refined his technique by fashioning a metal rod he referred to as a “leucotome” to sever white matter connections between the prefrontal cortex and the cingulate-thalamic regions of the brain. Moniz, later in 1949, received the Nobel Prize in medicine for this radical surgical treatment of the mentally ill. This treatment was later modified by Walter Freeman (1895-1972), an American neurologist and neuropathologist, renaming the procedure “lobotomy.” Freeman’s procedure severed fibers between the prefrontal cortex and the thalamus claiming the successful improvement of mood disorders in over 200 patients. In 1952, Freeman developed a procedure he called the “transorbital lobotomy,” also known as the “icepick lobotomy,” which was performed by inserting a metal pick into the corner of each eye socket then using a mallet to puncture the skull and rotating the instrument laterally to severe the connective fibers. This procedure was performed without the benefit of anesthesia by employing electroconvulsive therapy (ECT) to induce a seizure. Freeman later traveled the United States in his “lobotomobile” performing his lobotomy on recognized individuals such as President John F. Kennedy’s sister, Rosemary, to treat her severe mental disabilities. All-in-all, over 4,000 of these psychosurgical procedures were performed up until 1967 for as little as $25.

The ECT procedure is currently still being used to induce seizures in a few remaining facilities for the treatment of severe depression. Insulin shock, another form of convulsive therapy employing cardiazol and metrazol, was introduced briefly in the 1940s and 1950s by American psychiatrist Manford Sakel (19001957) to treat schizophrenia. Insulin shock therapy fell out of favor with the introduction of psychotropics to treat mental disorders later in the 1960s. The introduction of psychotropic medications in the 1960s with the antipsychotic chlorpromazine (Thorazine) eliminated the need for psychosurgery as well as the need for long-term hospitalization, thus effectively reducing the cost of mental health care. During the last half of the 19th century, there had been an attempt to employ psychopharmacotherapy using morphine, potassium bromide, chloral hydrate and hyoscine. With the development of neuropsychopharmacology beginning in the second half of the 20th century, numerous psychiatric medications were introduced for mood and thought disorders, as well as anxiolytics, and hypnotics. Much of the progress in developing psychotropics can be attributed to the research discoveries of an American biochemist Julius Axelrod’s understanding of the interactions among neurotransmitters. Axelrod received the Nobel Prize in Medicine in 1970 for his contributions to neuroscience. As a result of the progress made in psychopharmacology in the 1960s, many California state mental hospitals began transferring patients to nursing homes and board-and-care facilities also known as “group homes,” “boarding homes,” and “assisted living facilities.” By 1967, Governor Ronald Reagan completed deinstitutionalization of most California state mental institutions. California eventually passed the LanternPetris-Short (LPS) Act in 1972 which abolished involuntary hospitalization except in extreme cases. The LPS Act prevented mentally ill patients suffering a relapse from being re-admitted to a state hospital. Generally, these individuals had to be taken care of by private board-and-care

Sacramento State Hospital The Sacramento State Hospital, established in 1851, was a general hospital operated by the state with a separate ward for mental patients. The authorizing legislation was approved on April 15, 1851. It provided that the care of indigent ill and mentally ill was a state responsibility. The hospital was in operation for two years and was located on M street (now Capitol Mall) between 2nd and 3rd streets. The legislation authorizing the hospital also established the first pre-paid health insurance in California; individuals could purchase all of the hospital care they needed for the year if they prepaid the $10 annual premium.

facilities such as the Beverly Enterprises with their 38 homes. Section 5150 of the LPS allows a 72-hour hold in a psychiatric facility for a mental status evaluation if a peace officer, registered nurse or a physician deems it necessary. A section 5250 provides confinement of up to 14 days and a section 5270 an additional 30-day involuntary psychiatric hold for evaluation and treatments. During the 14-day hold, a patient may be placed on a “T-Con” with is a temporary conservatorship pending an actual hearing. T-Cons can be extended for up to one year. Over the course of history, society has witnessed a more tolerant appreciation and ethical treatment of abnormal behavior due to advances in medicine and a better understanding of the brain’s neurochemistry. We no longer have to tolerate the harsh treatments of mentally ill patients that were once prevalent in the past due to the developments of psychotropic medications. Today’s care for the mentally ill is carefully titrated by a number of medical professionals trained in neuropsychiatry in numerous regions of the world. kperryman@suddenlink.net REFERENCES Pietikainen, P. Madness: A History, 2015, Routledge. Scull, A Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from Madhouse to Modern Medicine. 2016, Prince University Press.

September/October 2018

BOOK REVIEW

Physician Suicides Education on self-care and culture change is needed to reduce the prevalence of physician suicides.

By Peter Yellowlees, MD Reference book: “Physician Suicide: Cases and Commentaries” by Peter Yellowlees MD, 2018. Publisher American Psychiatric Publishing Inc. ISBN-13: 978-1615371693.

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

FEW QUESTIONS IN medicine are more important than how can we reduce the annual loss in the U.S. of 300-400 physicians to suicide, the equivalent of two large medical school classes per year? There are many possible interventions to reduce this tragedy, although most have not been well researched or examined, as this area of investigation has not, until recently, attracted much interest. Such is the professional denial of the problem. Such interventions range from organizational and personal changes to aid our resilience, including basic self-care and learning how to better recognize at-risk colleagues at one end of the spectrum, to the more controversial proposals such as the mandated implementation of universal randomized drug testing at work, or the implementation of required competency assessments at specified ages for all physicians in the retirement phase of their lives. The topic of physician suicide, and the need to promote physician health and well-being and to find joy in medicine, are finally being seen as crucially important. Some even say that the Triple Aim should become the Quadruple Aim, with the fourth aim being improving the work life of health providers. Burnout research is becoming more common, with many health systems starting to measure burnout in physicians and other providers, although fewer of them are sure of what to do when they find the almost universal rates of 30-50 percent for at least some burnout

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symptoms in their tested groups. The literature is moving in the direction of concluding that levels of burnout are primarily a symptom or marker of workplace or institutional dysfunction, and some groups, notably at the Mayo Clinic and Stanford, have implemented organizational change interventions to reduce burnout. Certainly, it is to be hoped that the days of blaming physicians for having burnout are over. The current message from the research literature is clear that it is not possible to “resilience yourself” out of burnout, although training physicians in the knowledge and skills to increase their personal resiliency is, without doubt, a good way of improving individual health and well-being. Physician wellness is an area of significant focus for the Sierra Sacramento Valley Medical Society (SSVMS), and I would encourage all readers to access the resources and tools available through the Medical Society’s Joy of Medicine program by visiting www.joyofmedicine.org. The vision of SSVMS’ program is to relieve physician pain and help to reclaim the joy of practicing medicine through education, advocacy and program services designed to nurture the individual well-being and collegiality and to promote systems-wide changes. The National Academy of Medicine is a very active player in this field, and has set up an impressively well-organized and resourced Action Collaborative on Clinician Well-Being and Resilience (See https://nam.edu/initiatives/ clinician-resilience-and-well-being) which is comprised of working groups, committees, events, publications and resources, as well as an art show, all focused on clinician well-

being. This is an excellent website to visit for all interested in this topic. The collaborative focus is described as “a set of activities that are promoting sustained attention at organizational, state and national levels, as well as investment in research and information-sharing to advance evidence based solutions.” The American Medical Association, like several other colleges and professional associations, is also committed to this issue and has created five excellent modules in their online “steps forward” program on physician health and well-being that are replete with good practical examples of how to reduce levels of burnout and improve organizational and individual responses to stress. The AMA has a particular focus on residents in some of these modules, which should be required viewing for all physicians in training. The American Psychiatric Association has also set up an excellent interactive website, again replete with resources of particular interest to psychiatrists, as has the American Society for Addiction Medicine, and the American Family Medicine Association. The thread that runs through all of these endeavors is the realization that the medical profession, in its entirety, is under significant stress, and that it is no longer appropriate to deny or ignore these pressures, as has happened in the past because they are now so well linked to impaired patient care outcomes. The health of physicians has finally become a patient safety issue, and the loss of hundreds of physicians per year to suicide can no longer be tolerated or ignored, but has to be examined and the underlying causes identified and, hopefully, reduced. What needs to happen next is the gradual spread, expansion and dissemination of all of these activities much more widely and deeply with the aim of eventually changing the culture of medical practice. There is still an almost complete lack of formal educational curricula or courses on physician health and resilience training in medical schools. The Association of American Medical Colleges (AAMC) has acknowledged the need for self-care competencies to be integrated into

the medical school curricula nationally and is working on these. It is hoped that such skills will eventually be taken up by all physicians at the graduate level. Given the increasing level of interest in physician health and well-being, it is worth asking what topics might comprise a comprehensive curriculum on physician health, were such a curriculum to be developed. Several authors have suggested components of what could become a core curriculum for medical students and residents that might act as a selfcare toolkit for use throughout their careers. A more comprehensive curriculum on physician health and well-being, which includes some of these suggestions and ideas, has recently been published (Yellowlees PM, 2018) and includes the following: • Regular participation in process-oriented reflective small groups; • Mentoring and mentee supervision opportunities; • Ways of creating opportunities to strengthen professional and social relationships and how to network widely and appropriately; • Decision making and clinical reasoning that takes into account future changes in medicine such as the need for physicians to be expert in large data analysis and pattern matching, as well as being excellent diagnosticians who can take into account massively increasing and disparate datasets; • Content on the various specific psychiatric, substance abuse and personality disorders that affect physicians, and how to recognize and treat them in any physician, including the individual themselves; • Content and discussion of personal identity development and transformation, the interaction between burnout and physician health (including suicide), empathy, compassion, resiliency and how to become reflective practitioners; • Active participation and learning about resilience, mindfulness, exercise, nutrition and relationships; • Learning about organizational systems and continued on page 34

September/October 2018

Welcome New Members The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Carol Kimball, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP: Brian Bernhardt, MD, Anesthesiology/Pain Management, Drexel University College of Medicine – 2008, IPM Medical Group, 333 University Ave. Ste 140, Sacramento, CA 95825 George Bolton, MD, Radiology, George Washington University- 1989, Sutter Medical Imaging, 2801 K St #501, Sacramento, CA 95816 Harpreet Dhatt, MD, Radiology, Stanford University School of Medicine – 2007, Sutter Medical Group, 1500 Expo Pkwy, Sacramento, CA 95815 Jason Guardino, DO, Gastroenterology, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Mark Levine, MD, Psychiatry, University Vermont- 1976, Community Psychiatry, 3835 N. Freeway Blvd. Ste 100, Sacramento, CA 95834 Ashutosh Raina, MD, Pediatric Neurology, Pune University/NDMVP Samaj Medical School – 1997, CEPN, 5800 Stanford Ranch Rd, Building 800, Rocklin, CA 95765 Tyler Smith, MD, Orthopedic Spine, University of Nevada School of Medicine – 2004, Sierra Spine Institute, 5 Medical Plaza Drive, Suite 120, Roseville, CA 95661

Peter Conner, UCD Rosemary Cotter, UCD Jorge Cuza, UCD Tarin Dhaliwal, UCD Manveer Dilts-Garacha, UCD Katherine Donaldson, UCD Kevin Durgun, UCD Dylan Ely, UCD Zoe Feld, UCD Joseph Firriolo, UCD Jake Fisher, UCD Kathryn Fitzwater, UCD Nasim Forontan, UCD S. Bridger Frampton, UCD Clayton Gerndt, UCD Sophia Giang, UCD Samantha Goggin, UCD Travis Hart, UCD Robert Haughton, UCD Elise Hill, UCD Rebecca Howe, UCD Pamela Imperiale, UCD Jingran Ji, UCD Alexandra Johns, UCD Elizabeth Johnson, UCD Ryan Jones, UCD Andrew Jones, UCD Nimar Pal Kahlon, UCD Shaina Kaye, UCD Samantha Kerns, UCD Hammad Khan, UCD Daniel Khokhorin, UCD Phillip Kim, UCD Kara Kleber, UCD Harsha Koneru, UCD

Meghan Krowicki, UCD Andrew Kyle, UCD Sean Lam, UCD Lue Lao, UCD Jin Sol Lee, UCD Marcia Leung, UCD Claudia Lopez, UCD Karyn Mallya, UCD Leonard Marinis, UCD Charles McElyea, UCD Kelsey McLean, UCD Justin McLees, UCD Juanita Melau, UCD Angel Mendoza, UCD Jamie Metcalfe, UCD Keyon Mitchell, UCD Hope Moore, UCD Kelly Moquin, UCD Natalie Morgan, Mercy Family Med Residency Program Hana Moua, UCD Meilen Munoz, UCD Scott Myers, UCD Jasmine Neeno, UCD Vasyl Nesteryuk, UCD Trinh Nguyen, UCD Son Nguyen, UCD Chase Nicholson, UCD Kristin Nosova, UCD Ngabo Nzigira, Mercy Family Med Residency Program Michelle Odette, UCD Obinna Oko, UCD Cameron Oldham, UCD Christina O’Neal, UCD

Haeli Park, UCD Hemali Patel, UCD Pooja Patel, UCD David Patrick, UCD Kranti Peddada, UCD Julianne Pilla, UCD Nicholas Placone, UCD Taylaur Placone, UCD Zola Quas, UCD Samy Ramadan, UCD Renuka Reddy, UCD Marie Rossi, UCD Leonardo Rozal, UCD Steven Russo, UCD Kazuliro Sabet, UCD Zakir Safdar, UCD Nancy Saied, UCD Jorge Salazar, UCD Nandini Sarma, UCD Ory Schuman, UCD Fiona Scott, MD, UCD Maziar Shakeri, UCD Selina Singh, UCD Baljit Singh Dhesi, UCD Leah Sitler, UCD Lucy Sung, UCD Rebecca Surrey, UCD Ricky Thoms, UCD David Tindle, UCD Daniel Trevizo, UCD Jeff Usui, UCD Kenny Vo, UCD Meghan Webber, UCD Jacquelyn Yu, UCD Billy Zhang, UCD

Physician Suicide continued from page 33

APPLICANTS FOR RESIDENT/ FELLOW PHYSICIAN ACTIVE MEMBERSHIP: Ajjya Acharya, UCD Beatrice Akers, UCD Leonardo Aliaga, UCD Ebaa Al-Obeidi, UCD Felipe Arredondo, UCD Sheila Attaie, UCD Nataliya Bahatyrevich, UCD Poornima Bajwa, UCD Cameron Barr, UCD Courtney Beaver, UCD Andrew Biedlingmaier, UCD Philip Biggs, UCD Elise Boykin, UCD Nathan Butler, UCD Christopher Campos, UCD Bodhi Canfield, UCD Rita Chang, UCD Juliann Cho, UCD

the interactions that occur within them and an understanding of institutional awareness and resources that can be used to change institutions; • Specific skills development in interpersonal professional relationships; • Modules and discussion groups on leadership, financial and business skills; • Media training, combined with experiential training using multiple communications technologies with patients and colleagues. This draft set of components is not an inclusive curriculum on physician health and well-being, but it is a reasonable start and, if implemented, could begin to transform the lives and work practices of many of us, and hopefully start reducing the suicides and burnout levels currently being experienced. pmyellowlees@ucdavis.edu

Sierra Sacramento Valley Medicine

Board Briefs July 9, 2018 The Board: Received an update regarding the 11th District Delegation from delegation chair, Richard Gray, MD. Approved the 2017 Annual Audit Review. Approved SSVMS endorsement of the resolution proposed by the Humboldt-Del Norte Medical Society, Delegates and Alternates Participation in CMA Year-Round Governance, which calls for a revision in CMA Bylaws to allow delegates and alternates to begin participation in the year-round governance process upon election. Approved the Financial Statements ending May 31, 2018. Approved including The Mortgage Company in the SSVMS Vetted Vendor Program. Approved the following appointments to the SSVMS Delegation to the CMA: Adam Dougherty, MD, Delegate, At-Large, Office 16; Ajay Singh, MD, Delegate, At-Large, Office 23; Anand Mehta, MD, Alternate-Delegate, At-Large, Office 16; Leena Mehta, MD, Alternate-Delegate At-Large, Office 13. Approved the Membership Reports: July 9, 2018 and June 25, 2018 For Active Membership – Harpreet Dhatt, MD; Jason Guardino, MD; Tyler Smith, MD. For Reinstatement to Active Membership – Lakshmi Avala, MD; Wonjae Choi, MD. For Retired Membership – Janahn Scalapino, MD, Marian Te Selle, MD. For Transfer of Membership to Placer-Nevada – Nelson Tun, MD. For Termination of Membership for Nonpayment of Dues – Andrew Parker, MD. For Resident/Fellow Physician Active Member-

ship – Drs. Ajjya Acharya; Beatrice Akers; Leonardo Aliaga; Ebaa Al-Obeidi; Felipe Arredondo; Sheila Attaie; Nataliya Bahatyrevich; Poornima Bajwa; Cameron Barr; Courtney Beaver; Andrew Biedlingmaier; Philip Biggs; Elise Boykin; Nathan Butler; Christopher Campos; Bodhi Canfield; Juliann Cho; Heather Chou; Peter Conner; Rosemary Cotter; Jorge Cuza; Balijit Singh Dhesi; Tarin Dhaliwal; Manveer Dilts-Garacha; Katherine Donaldson; Kevin Durgun; Dylan Ely; Zoe Feld; Joseph Firriolo; Jake Fisher; Kathryn Fitzwater; Nasim Forontan; S. Bridger Frampton; Clayton Gerndt; Sophia Gian; Samantha Goffin; Travis Hart; Elise Hill; Rebecca Howe; Pamela Imperiale; Jingra Ji; Alexandra Johns; Elizabeth Johnson; Ryan Jones; Andrew Jones; Nimar Pal Kahlon; Shaina Kaye; Samantha Kerns; Hammad Khan; Daniel Khokhorin; Phillip Kim; Kara Kleber; Harsha Koneru; Meghan Krowicki; Andrew Kyle; Sean Lam; Lue Lao; Jin Sol Lee; Marcia Leung; Claudia Lopez; Karyn Mallya; Leonard Marinis; Charles McElyea; Kelsey McLean; Justin McLees; Juanita Melau; Angel Mendoza; Jamie Metcalfe; Hope Moore; Kelly Moquin; Hana Moua; Meilen Munoz; Scott Myers; Jasmine Neeno; Vasyl Nesteryuk; Trinh Nguyen; Son Nguyen; Chase Nicholson; Kristin Nosova; Michelle Odette; Obinna Oko; Cameron Oldham; Christina O’Neal; Haeli Park; Pooja Patel; Hemali Patel; David Patrick; Kranti Peddada; Julianne Pilla; Nicholas Placone; Taylaur Placone; Zola Quas; Samy Ramadan; Renuka Reddy; Marie Rossi; Lena Rothstein; Leonardo Rozal; Steven Russo; Kazuliro Sabet; Zakir Safdar; Nancy Saied; Jorge Salazar; Nandini Sarma; Ory Schuman; Maziar Shakeri; Selina Singh; Leah Sitler; Lucy Sung; Rebecca Surrey; Ricky Thoms; David Tindle; Daniel Trevizo; Jeff Usui; Kenny Vo; Meghan Webber; Jacquelyn Yu; Billy Zhang.

September/October 2018

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

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