2019-Jan/Feb - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2019

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MEDICINE 3

PRESIDENT’S MESSAGE MIA: Our Sense of Humor

Christian Serdahl, MD

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EXECUTIVE DIRECTOR’S MESSAGE No Longer Business as Usual

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The Embarrassing Patient History

David Gunn, MD

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Patients Don’t Know How Much They Don’t Know

Ann Gerhardt, MD

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A Story About Shared Decision Making

Gerald Rogan, MD

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GUEST EDITORIAL Combating Government-Caused Poverty, Disease

Steven Nemcek, MS IV

Aileen Wetzel, Executive Director

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From “Curio Shop” to Medical Museum

Bob LaPerriere, MD

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GUEST EDITORIAL Shame and Misogyny

Caroline Giroux, MD

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Railroad Hospitals

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2018 HOD: Four Major Issues

Kent Perryman, PhD

Lee T. Snook, Jr, MD

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Collateral Damage

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Welcome New Members

Russell De Jong, MS III

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Election Results

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Celebrate the Season Social

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 The cover image represents the Southern Pacific Hospital at the corner of 8th and F Street in Sacramento. It was one of three railroad hospitals in Sacramento in the 19th and 20th centuries and was one of the first hospitals in California that also served as a trauma center with a pre-paid medical plan. SSVMS’ Museum Archives has a postcard mailed in 1910 with the same image. See page 11 for the article, “Railroad Hospitals,” by Kent Perryman, PhD. Image provided by CA State Railroad Museum Library and Archives.

January/February 2019

Volume 70/Number 1 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 The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.

2019 Officers & Board of Directors Christian Serdahl, MD, President John Wiesenfarth, MD, President-Elect Rajiv Misquitta, MD, Immediate Past President District 1 Ashutosh Raina, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD Roderick Vitangcol, MD District 6 Carol Kimball, MD

2018 CMA Delegation District 1 District 1 Reinhardt Hilzinger, MD Harmeet Bhullar, MD District 2 District 2 Lydia Wytrzes, MD Ann Gerhardt, MD District 3 District 3 Katherine Gillogley, MD Thomas Valdez, MD District 4 District 4 Richard Bermudes, MD Russell Jacoby, MD District 5 District 5 Armine Sarchisian, MD Sean Deane, MD District 6 District 6 Christopher Swales, MD Marcia Gollober, MD At-Large At-Large Megan Anzar Babb, DO Ruenell Adams Arlene Burton, MD Jacobs, MD Ronald Chambers, MD Barbara Arnold, MD Amber Chatwin, MD Natasha Bir, MD Harprett Dhatt, MD Helen Biren, MD Adam Dougherty, MD Richard Gray, MD Reinhardt Hilzinger, MD Mark Drabkin, MD Karen Hopp, MD Kevin Jones, DO Carol Kimball, MD Richard Jones, MD Charles McDonnell, MD Derek Marsee, MD Anand Mehta, MD Sandra Mendez, MD Richard Pan, MD, Senator Leena Mehta, MD Rajiv Misquitta, MD Kuldip Sandhu, MD Paul Reynolds, MD James Sehr, MD Ernesto Rivera, MD Christian Serdahl, MD J. Bianca Roberts, MD Ajay Singh, MD John Wiesenfarth, MD Naomi Ross, MD Don Wreden, MD CMA Trustees District XI Douglas Brosnan, MD

AMA Delegation Barbara Arnold, MD

Sandra Mendez, MD

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

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

Executive Director Webmaster Graphic Design

Aileen Wetzel Melissa Darling Planet Kelly

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Listen and Subscribe to Joy of Medicine-on Call on your favorite Podcast App or visit http://joyofmedicine.org

Margaret Parsons, MD

CMA Speaker Lee Snook, MD

HOSTED BY DR. RAJIV MISQUITTA

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. Š2018 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

MIA: Our Sense of Humor

By Christian Serdahl, MD FIRST, I WRITE THIS with feelings of humility and joy, and I also feel very lucky.

I am reminded of something the character Crash Davis said in the movie “Bull Durham.”

When he was told that his job was to nurse a young pitching prospect, he asked, “What’s in it for me?” And the manager said, “You get to keep coming to the ball park, and you are getting paid to do it.”

I get to meet and treat my patients and get paid for it, and now I get to be president of our medical society. For all of that, I am deeply grateful.

Now, let me make an observation about most physicians: We have no sense of humor.

It’s gotten so bad that many folks don’t like spending time with us. Of course, some will still invite one or two of us to a backyard BBQ just to get some free medical advice. Truthfully, even I don’t like spending my free time with doctors, but please don’t tell my wife, Dr. Clarissa Tendero, I said this.

How did we get to be such a humorless bunch? Is it our new electronic medical records system that was foisted on our offices with about 10 minutes of explanation from a young tech support person? Was it the patient you cured with a brilliant diagnosis and surgery, who is upset because his insurance made him pay $10,000? Or was it the realization that the hospital got $9,995, and you got $5? Or, maybe it was the uncomfortable furniture and bad food in the doctor’s lounge.

SSVMS has focused on physician wellbeing, tackling the subject of physician burnout. The Joy of Medicine Program has been a success.

Let’s build on the foundation of meditation and psychiatric counseling (in my case) to some

other areas that I believe are important for our happiness.

Some suggested topics: How the Internet made me a better doctor; The spiritual aspect of medical care in a secular society; And my favorite, is humor better medicine than homeopathy?

It is possible, and important, to regain our innate sense of humor. Try an exercise my late Dad taught me. Look at yourself in the mirror in the morning when you wake up and say, “Chris, you are no bargain!” But please substitute your name for mine, as I had to remind several of my friends who tried this. Next, get your coffee and grab your newspaper. Open it to the comic section and force yourself to laugh at Charlie Brown (who is now my psychiatrist).

Or perhaps a better option is to read Jason Gay’s sports column in the Wall Street Journal, which will really make you laugh.

I promise that if you learn two jokes, you will get invited to more parties, assuming you can tell the jokes without forgetting the punch line.

Yes, telling a humorous story can be challenging in our overly sensitive and humorless society, but that makes it even more important to try. So here is the deal: Send me your funniest patient encounter or joke, and your submission just might be published in this magazine.

I am Norwegian; so don’t worry about offending me. If you send me something really funny, you will receive a bottle of wine from my wife’s prized collection. Just don’t tell her!

Meanwhile, let’s all try harder to find that missing sense of humor. ccneye@sbcglobal.net

January/February 2019

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

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EXECUTIVE DIRECTOR’S MESSAGE

No Longer Business as Usual

By Aileen Wetzel, Executive Director 2018 WAS A MOMENTOUS YEAR for the Sierra Sacramento Valley Medical Society (SSVMS). In addition to celebrating our 150th anniversary, SSVMS’ membership grew to an all-time high of nearly 4,000 physicians. We also successfully expanded our community programs, including Joy of Medicine, RX Safe Physicians, Future of Medicine, and our Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) Program. We even physically doubled the footprint of our Museum of Medical History, which welcomes thousands of visitors each year.

Your Medical Society has plans to continue blowing up business as usual in 2019. Someone once said that breaking routine changes perspectives, and we’re all in. For starters, our annual dinner has been reimagined to better reflect our objectives of increasing access to healthcare, improving health outcomes, providing mental health advocacy, supporting physician wellness and building the future of healthcare.

We hope you will join us for the inaugural SSVMS Honors Medicine event on Thursday, February 28, 2019 at the Tsakopoulos Library Galleria. The event will be an evening of food, wine and entertainment as SSVMS honors the recipients of the Golden Stethoscope, Medical

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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Honor, and Medical Community Service Awards.

Proceeds from the event will benefit SSVMS’ Community Programs, including our nationally recognized SPIRIT Program which provided treatment to nearly 800 patients in 2018 alone.

Since the SPIRIT Program’s inception, physician volunteers have provided over $11 million in free care to the uninsured, treated over 53,000 patients and performed over 1,000 surgeries. In addition to a live auction, a unique raffle will be held to benefit the SSVMS Medical Student Scholarship Fund, which provides scholarships to deserving medical students.

“How did we get to be such a humorless bunch?” asks 2019 SSVMS President, ophthalmologist Chris Serdahl in this issue’s Presidents’ message. Indeed, laughter is sometimes the best medicine. Our SSVMS Honors Medicine event will feature comedian Jack Gallagher as he explores laughter in medicine. I look forward to seeing everyone at the event. We promise you’ll leave smiling.

To RSVP, email mjackson@ssvms.org, call 916-452-2671 or visit https://tinyurl.com/ SSVMSHonors. awetzel@ssvms.org

Proudly serving the San Joaquin Valley and Greater Sacramento

From “Curio Shop” to Medical Museum

By Bob LaPerriere, MD, Curator, SSVMS Museum of Medical History FOUNDED IN 2001, the Sierra Sacramento Valley Medical Society (SSVMS) Museum of Medical History has lingered in a 900 square foot space and looked in areas more like a congested curio shop. However, thanks to a generous donation from Mrs. Mildred (Millie) Kahane, RN, widow of the late Al Kahane, MD, a long-time member of SSVMS, the Medical Society recently doubled the size of the museum.

The remodeled area and the new addition include six new exhibit cases, a room devoted to Nursing History and another room featuring a diorama of a physician’s office from the early 1900s. The new addition is dedicated to the memory of Dr. Kahane for his many contributions to organized medicine and the medical community.

During the six weeks of remodeling, members of the Society’s Historical Committee, searched through numerous boxes that were in storage, dramatically improved our prior museum space, cleared out old, unused journals and shelving, and developed the new exhibit area. The result is a spacious, organized museum that is more welcoming to visitors. However, the job is never done. New and revised labels are

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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a continuous project as are thoughts for new exhibits. We are always open to suggestions.

The SSVMS Museum of Medical History is one of only four medical museums in California, and only one of two open on a regular basis with no admission charge, we are unique. And, our collections are unique ranging from a working iron lung to a variety of Civil War amputation kits.

Although our museum is off the “beaten path,” people from across the region and the United States still find us. In addition, we offer docent-led school tours, especially for 4th grade students and older.

Please tell your colleagues, friends and family to visit our newly renovated museum.

The museum is located in the Medical Society’s building at 5380 Elvas Avenue, Sacramento. We are open free to the public Monday-Friday from 9:00 am to 4:00 pm, except holidays. To schedule a docent-led tour, or for more information, please contact SSVMS at (916) 452-2671 or mjackson@ssvms.org. Or, visit our website at: www.ssvms.org/museum.aspx. ssvmsedcom@gmail.com

January/February 2019

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GUEST EDITORIAL

Shame and Misogyny A Long Overdue Conversation

By Caroline Giroux, MD IN HIGH SCHOOL, I REMEMBER a gloomy morning in December when our teacher, visibly shaken, announced that a man had erupted at an engineering school in Montreal and shot female students. Marc Lépine, age 25, began his attack by entering a classroom where he separated the male and female students. After claiming that he was “fighting feminism,” he shot all nine women in the room, killing six.

He then moved through the university building, specifically targeting women. In just under 20 minutes, he murdered 14 women and injured 10 other women and four men before turning the gun on himself. His suicide note blamed feminists for ruining his life and included a list of 19 women whom he apparently wished to kill.

The École Polytechnique massacre is the deadliest mass shooting in Canadian history, and it took place at the building next to the medical school I would attend. Some suicides were reported the following years, and at least two students cited the distress from the massacre as the reason in their suicide note.

Years before, I had watched a TV program narrating the unresolved murder of a woman who was an engineering student in Quebec.

She was shot after getting groceries from a convenience store in the neighborhood where I would live for three years to study on the campus she attended. The image of her inert body haunted me often. I could have been any of these victims. The main suspect was a man but he was found not guilty. Of course, the murderer could have been a woman, but more men than women commit violent crimes against women.

Even though I couldn’t fully articulate the reality of misogyny growing up, my direct expe-

rience of it was perplexing and toxic. I thought, naively of course, that this would inevitably die out with the generation committing those incomprehensible and barbaric attacks on femininity. For some time, I believed that what I was going through (hearing locker room talk from adult males or classmates, hearing others criticizing women in the political scene), would be just unpleasant memories once I reached adulthood. I had expected to tell my children the tale of getting a humiliating nosebleed from being unexplainably punched at age 11 by a boy (while I was quietly waiting for my turn to play a video game) to illustrate the proof of progress, or evolution of our consciousness. Instead, over the past weeks, memories ranging from microaggressions to severe threats of violence continue to flood my awareness.

In clinical practice, I have observed many survivors’ re-experiencing symptoms with more and more women courageously coming forward with sexual assault allegations since the #MeToo movement. Is what needs to be addressed a profoundly ingrained hostility, passed on from generation to generation? I believe the problem of misogyny is only one tentacle of this monster called Intolerance from Gooey Shame.

Shame can be at the root of such hostility.

But something perceived as unspeakably defective or ugly in perpetrators triggers envy. For narcissistically fragile people, thinking someone else has something you don’t have and which you think you deserve is unbearable, so rage develops. Then, projection (paranoia), grandiosity and omnipotence take place in a succession of very convoluted set of defenses to hide rage. Hence, we witness vehement denials and externalization of blame (for instance, outrage

January/February 2019

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

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REFERENCE https://montrealgazette.com/news/ local-news/25-yearsafter-polytechniquegun-control-movementhas-lost-steam

at accusations “ruining” a man’s life).

Victim-blaming can be a convenient way for the wounded ego to divert attention, but the poorly processed rage may ultimately result in acting out behavior like rape, murder and mass shootings. Rage and grandiosity constitute an explosive mixture. (Lépine had attempted to join the Canadian Army but, according to his suicide letter, he was rejected because he was “anti-social.”)

How does that relate to medicine and health policies? First, I believe that gun violence can be prevented by more stringent gun laws.

According to the Coalition for Gun Control in Canada, gun control is a factor in many domestic-abuse cases, causing some women to stay in abusive situations out of fear of being shot by their partner.1 Second, a for-profit health care system maintains social inequalities, and its fragmented structure and denial of services are often re-traumatizing. This expression of patriarchy is unacceptable because it contributes to keeping women in a state of vulnerability.

Some women stay in abusive marriages because they are financially dependent, or have medical conditions and can’t afford to be without health coverage; other women stay employed despite a sexually harassing boss because they are single mothers who need health coverage for themselves or their family.

We need universal health care to support and empower all people, including women. Our field (and our society, for that matter) has looked the other way for too long.

The first step toward a viable solution seems to be a gender-equal and inclusive dialogue.

We must promote safety at work, on school campuses and in all institutions, challenge greed and advocate for a better allocation of resources. We must reiterate the need to preserve parent-child attachment during formative years and reinforce positive role models (Lépine was raised by a single mother after his father, apparently not considering women being equal to men, had been violent toward both).

Moreover, the essential ingredient is mindfulness.

Cultivating self-awareness through meditation is an entitlement-suppressing machine. The ego

is a scaffolding during personality development and not something to cling onto or overly identify with, like the chrysalis of a higher being just waiting to transcend itself.

We should also make sure we challenge the gender stereotypes and stop teaching aggressiveness in boys and compliance in girls. We should laser beam taboos and rape myths, and glorify respect and compassion. We should tell all our children that wanting something or someone doesn’t entitle them to take, and conversely, just for being who they are they deserve nothing less than respect and should treat others with compassion.

We have to unite our effort and prevent adverse childhood experiences. The impact of childhood trauma can be destructive for both the person and for society. We should scrutinize perpetrators to prevent violence against women and in general because there is something severely dysregulated in them, not the victims. Unmasking shame will make concepts such as misogyny, feminism and anti-feminism preposterous.

For those who have committed mindless acts toward other beings, the decent and moral thing at this point would be to admit it and apologize.

Shifting the responsibility from victims (“What was she doing there late at night?”) to perpetrators by enforcing legal consequences is essential.

Society’s attempts to repair can give a victim some of his/her dignity. Society must condemn leaders who dare to ridicule victims in front of laughing crowds, re-enacting a larger-scale version of the original trauma. This form of rape warfare from male-dominated institutions toward women should end.

Denial or suppression of the trauma stories maintains the oppressive social order when unaddressed microaggressions can culminate in rape and mass shootings. Ignoring an issue that concerns all of us will make the chrysalis become like cement, entrapping a primitive creature, and the future generations will never complete their transformation and elevation of consciousness for a fairer, more peaceful, humane world. cgiroux@ucdavis.edu

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Railroad Hospitals America’s Early Managed Health Care

By Kent Perryman, Ph.D. 2019 HERALDS THE 150th anniversary of the completion of the Transcontinental Railroad. linking the Eastern and Western borders of the United States for rapid transportation of travelers and their goods. With the advent of steam transportation in the 1830s, the latter part of the 19th century and the first half of the 20th century witnessed a considerable history of rail injuries and illness associated with construction and operation of this industry. As a result, the U.S. railroad industries were instrumental in stepping up and instituting the earliest form of managed health care for their employees by establishing hospitals throughout the country.

Early Railroad Development It was during the first Industrial Revolution that Scottish mechanical engineer James Watt (1736-1819) introduced his improved steam engine and adapted it to produce rotary motion, which led to the steam locomotive. Many of the early locomotives were imported into the United States from Great Britain. In 1812, Colonel John Stevens III conceived of, and was responsible for, constructing the first U.S. steam-powered locomotive on his estate in Hoboken, New Jersey.

Prior to the railroad industry, commercial transport relied principally upon access to waterways. Some foresighted entrepreneurs saw the potential and cost effectiveness that rail transport could provide. On February 28, 1827, the Baltimore and Ohio Railroad introduced the first U.S.-built locomotive to transport goods, called the “Tom Thumb.” Three years later, with the successful completion of track between Baltimore, Maryland, and Ellicott City, Maryland, the B&O Railroad commenced

commercial rail transport.

The first commercially operated passenger train was introduced in 1830 by the South Carolina Canal and Railroad Company heralding the birth of a modern railroad industry in America. Numerous additional railroad networks followed in 1835 that went no further than a few miles, but by 1850, there were over 9,000 miles of track laid, and by 1860, most of the northeastern and midwestern cities were linked by rail lines to transport grain and livestock east. In the Corn Belt, over 80 percent of farms were within five miles of a railhead.

The economic depression of 1873 witnessed the bankruptcy of many railroads, followed by the Great Railroad Strikes of 1877 and 1886, due to massive layoffs and large wage reductions.

Thanks to a developing Wall Street financial system and state subsidies, by 1890 the majority of rails were consolidated into 20 trunk lines.

Standardization of track gauge, equipment and standards of service were instituted.

The Transcontinental Railroad In 1832, Dr. Hartwell Carver, a wealthy physician and businessman, was one of the first to advocate a coast-to-coast rail line. In 1847, he wrote a congressional proposal to build a rail line from Lake Michigan to the Pacific, and between 1853 and 1855 the Department of War authorized the Pacific Railroad Surveys.

Numerous routes were proposed by the northern and southern states. Theodore Judah (1826-1863), an engineer for the Sacramento Valley Railroad who became an effective lobbyist in Washington, promoted a route through the Sierra Nevada Mountains in Northern California with a terminus in Council Bluffs,

January/February 2019

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

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mile westward route was constructed by Union Pacific, which employed mostly Irish immigrants and Civil War veterans, while the Central Pacific hired Chinese laborers and some freed African-American slaves.

Explosions, freezing temperatures and avalanches in the Sierras killed hundreds of Chinese. Many of the laborers resorted to sleeping in tunnels. Crushed and fractured limbs and frostbite were only some of the hazards they faced as they blasted through solid granite. The Union Pacific workers endured their own hardships with resistance from the Sioux, Cheyenne, and Arapahoe tribes that resented the railroad’s intrusion. Raiding parties killed employees and livestock and also destroyed track and equipment.

On May 10, 1869, California’s Governor (and president of the Central Pacific Railroad), Leland Stanford, drove the Golden Spike at Promontory, Utah completing the construction of the first Transcontinental Railroad. It was also referred to as the “Pacific Railroad” and the “Overland Route.”

Railroad Accidents and Safety

Central Pacific Engine # 2201 accident that took place on June 4, 1902; CA State Railroad Museum Library and Archives

Iowa. President Abraham Lincoln eventually agreed with Congress and Thomas C. Durant, a physician and American financier, on the selection of Omaha, Nebraska and Council Bluffs, Iowa (well north of the Mason-Dixon Line) as the eastern terminus link. It was also the shortest route through the south pass of the Rockies in Wyoming.

Construction by the Western Pacific Railroad Company began in 1862 with 132 miles of track laid between Oakland and Sacramento, and the remaining 690 miles of rail installed by the Central Pacific Railroad Company eastward to Promontory Summit, Utah. The 1,085

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There was little or no government regulation, and accident and casualty rates for employees and passengers were high. European travelers were astonished at the steep grades and sharp curves. Attempts to show a profit for the railroad’s share-holders may have influenced the construction. Bridges were thrown together in haste without guardrails, crossing signals were misplaced, and flimsy wooden trestles, rails and wheels were substituted for metal. The rails could not bear the weight of heavy locomotives and overloaded passenger and freight cars.

1853 witnessed the beginnings of trainrelated fatalities on the Erie Railroad with the Norwalk rail accident, where 48 passengers and employees were killed when a train traveling 50 mph derailed on a sharp turn. Numerous derailments, collisions and steam-related accidents followed. Humanitarian concerns started to outweigh economic gains, and states formed railroad commissions to legislate regulations.

By the 1860s, many of these safety concerns

had been addressed and, with technological improvements, there was a reduction in accidents and causality rates. However, the health and welfare of the railroad industry employees still needed to be addressed.

Railroad Hospitals and Railway Surgeons The western railroad industries realized that they needed to offer a managed health care plan for legal and economic reasons: 1) The Federal Employers’ Liability Law, combined with a lack of federal and state worker’s compensation, was an incentive for injured parties to sue the railroad for compensation; 2) There was a need to provide medical services for employees in remote locations; and 3) Medical care would be an inducement to recruiting employees. During the 1870s and 1880s, the Southern Pacific and the Union Pacific were some of the safest railroads in the U.S. In 1867, the founders of the Central Pacific Railroad began providing a pre-paid health plan for their employees in Sacramento. Charles Crocker, one of the four founders of the Central Pacific, provided a physician and a nurse for railroad employees at a private residence that was converted to a hospital at 13th and C Streets. A newly constructed hospital, completed in 1870 at 8th and F Streets, was devoted solely to the care of railroad employees and was referred to as the “Hotel Dieu” by the local French citizens.

It cost $64,000 to build and consisted of a fourstory structure with six wards and eight private rooms, and it accommodated 125 patients. Dr. S. P. Thomas of Auburn, California was its chief surgeon.

Many of the physicians involved in providing medical care during construction of the Transcontinental Railroad were later recruited as railway surgeons by the Central Pacific. Some of the more prominent were Drs. A. B. Nixon, S. P. Thomas, H. W. Harkness, and T. W. Huntington.

Daily job-related injuries included crushed limbs needing amputation. Many of these injuries were associated with railcar couplings and switchyard traffic. The high incidence of illness was partly due to climate exposure and poor

sanitation and included typhoid fever, malaria, tuberculosis, spinal meningitis, diphtheria, and cancer. Very few of these workers had sufficient funds to cover injuries or periods of sickness, resulting in lowered morale and less productive labor.

The Central Pacific Railroad medical plan provided health care with subsidies and grants from the federal and state governments, as well as having each employee (with the exception of the Chinese) contribute 50 cents a month.

The average railroad laborer at that time earned $6 per month. When the plan was initially instituted in 1867, there was a 5,000 employee enrollment, increasing to 13,000 by 1889. This plan remained in existence with increases in employee contributions from 1867 until 1975.

During the 1920s, Southern Pacific’s prepaid comprehensive medical plan jumped to five cents per day or $1.50 per month. Additional railroad hospitals sprung up throughout the U.S. with 40 railroads operating 35 hospitals offering 3,700 beds and serving more than 550,000 patients. Not all offered pre-paid medical plans.

When the Sacramento Central Pacific hospital opened, there were more than 70 physicians in the city. Some staff doctors were also members of the newly-formed Sacramento Society for Medical Improvement, founded in March 1868. It later became the Sierra Sacramento Valley Medical Society. This association encouraged progressive education and

January/February 2019

Railroad engine collision on August 30, 1887: Central Pacific No. 165 and California Pacific No. 11, Chico, CA; California State University, Chico, Meriam Library Special Collections

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Thomas W. Huntington, MD; Dr. JB Harris Glass Slide Collection; Center for Sacramento History

study for its members, and the adoption of new medical techniques that would advance health care.

One of the more prominent railway surgeons on the staff was Dr. Thomas Huntington, who firmly believed in aseptic surgery. He was responsible for opening the first aseptic operating room on the West Coast in 1882. He also performed the first successful appendectomy in California at the Central Pacific Hospital in 1891. Dr. Huntington went on to become the Chief of Surgery at the railroad hospital and was instrumental in furthering medical education through his constant improvements in surgical procedures. He was one of the first U.S. surgeons to employ catgut rather than silk sutures to encourage proper drainage of closed wounds, and he adopted the use of sterilized normal saline solution. He went on to become a professor of Clinical Surgery at the University of California Medical School in San Francisco.

Many additional lives were saved by other surgeons following his lead on the prevention of wound infections employing Joseph Lister’s “Listerism” that focused on asepsis and antisepsis. In 1870, soon after the Central Pacific Hospital opened in Sacramento, it employed part-time physicians in many areas along the rail line for their employees. Many had their own private practice in residences and boarding houses where patients were cared for. These

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physicians also treated passengers. If the injuries were serious, the physician was authorized to recruit a nurse to accompany the patient to a local hospital by rail unless an extended stay was anticipated, in which case further transport to the Sacramento railroad hospital was required.

On April 1, 1885 the Central Pacific Railroad was leased to Southern Pacific and, in 1887, was renamed the Southern Pacific Railroad Hospital. Eventually, in June 1889 the Central Pacific formally merged with the Southern Pacific. In 1899, Southern Pacific relocated the Sacramento facility to a newly-erected railroad hospital at 14th and Mission Streets in San Francisco at a cost of $114,284. The new facility included housing for the nursing staff.

In April 1906, that hospital was destroyed by fire from the San Francisco earthquake. All of the patients were evacuated by horse carts and transported to hospital rail cars where they could be attended to. Baggage cars were converted into ward rooms for bedridden patients, and chair cars were utilized for the ambulatory.

Chief Surgeon F. K. Ainsworth commandeered Pullman sleeping and dining cars as well as a locomotive to transport the hospital train to Sacramento the following day.

In 1912, Southern Pacific had a three-story hospital built in Sacramento at 2nd and H Streets that served primarily for emergencies and as a clinic for their employees. Railroad employees could also take advantage of the health care provided by a private hospital at 29th and J Streets, operated by Drs. John and George White.

In 1909, a new four-story, 300-bed Southern Pacific Hospital was erected at the corner of Fell and Baker Streets in San Francisco. It was eventually enlarged to 450 beds with ENT, Ophthalmology and Pathology departments, as well as an early electrocardiographic and dental clinic. In addition to patient quarters, the hospital had living accommodations for all the staff and a research laboratory and auditorium.

A cutting-edge medical facility for the times, it became the second hospital in the nation to feature an intensive care ward.

The hospital also had a successful graduate training program for interns and residents that was later approved by the American Medical Association and the American College of Surgeons. The hospital’s training program attracted medical students from all over the U.S. and Europe due to the nature of unusual injuries, variety of rare illnesses, cutting-edge technology and the outstanding railway surgeons on the staff. However, following the Great Depression of 1929, the Southern Pacific began laying off many of its employees. Their hospital department allowed these individuals to continue with their medical plan by making out-of-pocket contributions. Many of the unemployed who were unable to pay were still treated by the hospital staff.

Following the outbreak of World War II, the Southern Pacific Hospital lost most of its medical staff to the military. Many of the railroad hospitals throughout the nation suffered similar economic hardships and were forced to accept private patients in order to generate enough revenue to reduce employee charges. Following the conclusion of WWII, many railroad hospitals in the U.S. were faced with heavy tax burdens that were relieved by forming foundations to own and operate their hospitals and health plans. These foundations provided employee representation in management and became known as Employee Hospital Associations (EHAs), with some becoming nonprofit and thus conferring more tax benefits.

Railroad hospitals gradually fell into disfavor during the 1960s due to employees preferring to choose their own doctors and health care facilities closer to home. They benefitted by more private insurance carriers and federal and state-managed coverage. Many of the nation’s railroad hospitals eventually closed or continued to operate as community hospitals.

Southern Pacific’s San Francisco Hospital was eventually sold in 1968 and renamed the Harkness Hospital. It closed its doors in 1974, falling into disrepair, and was purchased and refurbished in 1981. It reopened as Mercy Terrace, an assisted living facility for seniors with 158 apartments.

Conclusion Railroad companies throughout the country realized they had to address the high injury rates resulting from substandard safety precautions. The Central/Southern Pacific Railway was one of the first to institute a reliable pre-paid health care program. The Sacramento Railroad Hospital was one of the first to offer affordable, comprehensive care. It was also railroad hospital staff, encouraged by the Sacramento Society for Medical Improvement, that were responsible for many of the medical innovations in health care that saved countless lives.

Operating Room Central Pacific Railroad Hospital; Surgeon Thomas W. Huntington and staff; Dr. JB Harris Glass Slide Collection; Center for Sacramento History

kperryman@suddenlink.net REFERENCES Short, HJ. Railroad Doctors, Hospitals and Associations: Pioneers in Comprehensive Low-Cost Medical Care, 1986, Upper Lake SelfPublish.

Aldrich, M. Death Rode the Rails: American Railroad Accidents and Safety, 1828-1965, 2006, The Johns Hopkins University Press.

Rodgerson, E. Adobe, Brick & Steel: A History of Hospitals and Shelters for the Sick in Sacramento and El Dorado Counties, 1993.

Sacramento-El Dorado Medical Society.

Gillespie, RS. The Train Doctors: A Brief History of Railway Surgeons, 2006, railwaysurgery.org.

Rutkow, I. Railway surgery: Traumatology and Managed Health Care in 19th-Century United States. Archives of Surgery, 1993; 128(4): 458-463.

Jones, JR. The Old Central Pacific Hospital, 1964, Western Association of Railway Surgeons.

January/February 2019

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Collateral Damage

By Russell De Jong, MS III

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

THE THIRD YEAR OF medical school, true to its reputation, has been a whirlwind thus far: meeting new preceptors almost weekly, trying to grasp the perfect history and physical write-up format, honing patient examination and interview skills. To complicate matters, high-stakes final exams keep coming every one or two months that have major implications for residency placement. Yet, through all the noise, moments shine through. Some are overwhelmingly positive and balloon the spirits, others glaringly negative, tugging at the heartstrings and distracting the mind for days to weeks. This is one of the latter moments as I experienced it.

It was the second-to-last patient of what had been a busy Thursday morning at the neurology clinic. Though the patient population had been mostly Chinese who conversed in Mandarin, I had already gleaned a lot about the signs and symptoms a neurologist clues in on to diagnose and treat a wide variety of pathologies. This patient seemed to be more of the same: a late 70s’ man coming in with his wife and daughter for a routine post-stroke checkup.

It was an unfortunate story. Two years ago, he was undergoing a coronary artery bypass grafting (CABG) procedure when a nidus of clot began to form in his heart. As the procedure was wrapped up, a tentative success, the clot dislodged, shooting emboli into the man’s brain. The symptoms developed quickly – deficits in language, arm and facial strength, and visual fields appeared almost instantaneously as the emboli decreased the perfusion to critical areas of the left cerebral cortex. It was a known risk that the best medicine couldn’t have prevented.

Today, he still had clinically-significant deficits in vision and language. This presentation, in itself, is not uncommon, but rather it was the

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interaction I witnessed between the physician, patient, and family that is bouncing around my hippocampi as a vivid memory.

As my preceptor opened the encounter, it was obvious the family was suffering. He first addressed the patient in Mandarin and was met with a blank stare. The daughter jumped in and informed him of her father’s difficulties with language. It was mostly a conversation between them from then on. The history of the patient unfolded through the eyes of the daughter, and here’s the pivotal moment: she spent some time on his remote medical history, then came to the CABG procedure and paused, subtly but noticeably.

“We checked him into the hospital the night before his procedure. Everything was all set up, so I went home for the night. The next morning they did the pre-operative checks and brought him into surgery, and when he came out, the stroke happened. I’ve read a lot since then and I can’t keep from thinking that they missed something during the pre-op. I wasn’t there. I should’ve been. Maybe the outcome could’ve been different.”

Tears welled up in her eyes and escaped down her cheek before she could check them with her wadded-up tissue. It was a vulnerable, human moment in which the next statement by the physician could make a world of difference.

After this point, she could go on carrying the burden of her father’s maladies on her narrow shoulders, or she could move on, knowing there was nothing the best-trained of clinicians could have done to prevent this random tragedy, let alone a patient’s daughter.

My preceptor paused for a moment, then said, “Okay. So what medications is your dad taking?” The weight did not budge. The interview continued and soon we were in the next room, that much closer to lunch.

Collateral damage is a term used to describe destruction inflicted upon an unintended target.

In this circumstance, I believe this is exactly what this family became after their patriarch’s stroke. As I’ve mentioned, there’s nothing to be done about the stroke itself, but the collateral damage could surely be mitigated.

I firmly believe if she knew there was nothing she could do, it would alleviate the blame she was clearly placing on herself…

What this daughter was lacking was education. She didn’t know there are checklists upon checklists that are implemented with every CABG patient in an effort to prevent situations like this one. I firmly believe if she knew there was nothing she could do, it would alleviate the blame she was clearly placing on herself, thereby putting her on the road to healing the emotional wounds that blame has created. I can

only imagine the hours of sleep she has lost and the tears she has, and will, shed over this.

There is no medication to prescribe a procedure to be done here; this is where the art of medicine has to come into play. This example is one of long-term failure by this family’s doctors to realize that they were hurting, and that a simple conversation could change that completely. I share this experience to bring awareness to patients like these and to challenge you, the readers. We all come to this field of work to help people, and I assert we can do that for more than just our direct patients.

Awareness, being present in the moment, and reading between the lines when working with families and other loved ones can be just as potent a medicine for them as a beta blocker is for congestive heart failure, or reduction and fixation is for a broken bone. Let us push ourselves as a profession to share our knowledge with those who need it to heal. Collateral damage is something we can prevent. russell.dejong2133@cnsu.edu

Letter to the Editor RE: “Yellow Fever” by Matthew Huh, November-December 2018 SSV Medicine

Dear Matthew, I read your article, “Yellow Fever,” as published in Nov/Dec 2018 SSVMS. You should be very proud of your writing ability – clear, concise and, most importantly, compelling.

Compelling the reader to read another paragraph is the most important tool in writing and in speaking. Why should the reader continue: you are only as good as your last paragraph.

I was surprised…no that is an understatement. I was shocked that you were/are a high school student. Amazing! Your parents must

be very proud of you. I hope you will consider applying to medical school. And, for a man of your talents, there is no better field for you than general family medicine!

Don’t let the “specialists” sway you, general medicine is the most challenging of them all.

If I can be of service to you in the future, you have my contact information.

Sincerely, David Gunn, MD

January/February 2019

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Celebrate the Season Over 130 physicians, medical students and guests attended the Joy of Medicine, “Celebrate the Season�

Social where guests were invited to tour the newly expanded and renovated SSVMS Museum of Medical History. SSVMS President-Elect, Dr. Chris Serdahl, welcomed everyone and presented Mrs. Mildred Kahane with a plaque dedicating the expanded section of museum in the memory of her husband, Dr. Al Kahane. Guests also participated in a gratitude activity and took fun holiday themed photos in the photobooth. It was an evening full of laughter and great conversation. Thank you to everyone who attended!

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January/February 2019

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The Embarrassing Patient History “Do you have to write this down?”

By David Gunn, 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.

A 25-YEAR-OLD Asian American male with no medical history presented for evaluation of cough. Upon entering the room, he explains he does not actually have a cough, but wants to discuss something else. “Is that ok?”

The patient explains that two days ago, after consuming a large quantity of alcohol with his friends, he wandered off along the street and started talking with a woman standing in front of a convenience store. After a brief exchange, they went behind the corner into an alley and had intimacy. The patient, after discovering the woman was a transgendered male, asked for and attempted to receive insertive anal penetration from the presumed sex-worker. There was no penetration or ejaculation, and the encounter lasted for a brief period of time. The patient had no symptoms, other than still being hung over, tired and rather embarrassed by his behavior.

He had consumed approximately 160 grams of ethanol, or 10-12 standard drinks, and had no previous episodes of impaired judgment or impulsive behavior while drinking. He has no history of a mood disorder or any other medical conditions.

“What about post-exposure prophylaxis for HIV? I was reading that it’s still not too late for that. Oh, also I’m still on my mom’s insurance, and really want to keep this private. Can you not write any of this down? Will she be able to see what we talk about?”

It used to be that the patient and physician relationship was ultimately very private – records were the physician’s and were usually

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sparse and kept under lock and key in the physician’s office. Patients were generally not privy to what was recorded and often times they were, frankly, illegible. In an integrated health system with electronic records, consultants, billers, administrators and others could have access to the patient’s record now and in the future.

There is also risk of data breaches or other lapses of security. To tell “your doctor” something in the strictest of confidence, only to have it inadvertently disclosed to another person – whether or not part of a health system – can seriously damage the doctor-patient relationship.

No longer does what happens in the exam room stay between the patient and physician – there are chaperones, “Care Everywhere” records, emergency department records and automatic pharmacy importations to be reconciled. I have had patients with genuine surprise tell me, “Where did you get that information?” and “How did you know that?!” Even after explaining how these information-sharing systems work, I can see the patients begin to choose their words more carefully.

Ultimately, our duty is to the patient – to respect the patients’ privacy while protecting their health. At the same time, a physician cannot ethically write down a false history in a chart – if for no other reason than lying is fundamentally wrong, and at the very least because it can mislead other doctors in the future.

Nevertheless, what can a physician do in a situation like the one described above to honor

both the patient’s request for privacy and the physicians obligation to accurately record the patient history? Moreover, what compromises can be safely made to ensure that both obligations are met dutifully?

I would argue it is not necessary to include such details as the transgender identity of the sex worker – a high-risk encounter is high risk no matter what the gender. In this way, some details that were particularly embarrassing to the patient can be safely omitted while not affecting the quality of care the patient receives.

Clearly, the alcohol use must be recorded if only to the point that it shows his judgment was impaired and that he denied having had previous episodes of similar behavior.

As for the diagnosis code? I would argue for “Screening for STD” Z11.3 as a benign diagnosis, rather than the more descriptive “High risk sexual behavior” Z72.51 or the “At risk for HIV due to homosexual contact” Z91.89.

The issue of transparency in record keeping is a double-edged sword in this respect – some things are meant to be private, yet there is a push for greater transparency from patients to access their complete medical record on demand. Part of this is undoubtedly curiosity – “What is he writing down about ME?”– but there are also genuinely interested patients who forget what is said, or who want to return to their medical record, laboratory results and diagnoses to understand their symptoms, health and illness.

Physicians have mixed feelings on the issue.

According to one panel interview of residents and faculty from a well-known college in Massachussetts, there were concerns about the potential harm to the doctor-patient relationship, as well as the increased time needed to adjust or correct the medical record to the patient’s satisfaction – especially on details that were not deemed medically necessary, i.e. “I grew up in Houston, not Dallas,” or “my brother died when he was 62, not 65,” etc. While at the same time, they acknowledged that it could show the patient just how much thought went into their medical care, akin to bedside rounding.

However, it was also noted that some patients would likely be upset by copy-pasting

of previous notes. There was concern about misreading the written word, especially on sensitive topics such as weight, substance abuse, sexual history and the habit of noting potential, though remote, diagnoses to consider – i.e. cancer or Parkinson’s or Alzheimer’s. And to this end, notes could suffer by becoming more vague, or even confusing to the patient if these “black cloud” diagnoses were ultimately not proven to be the case.

Another study of patients’ experiences accessing notes cited refreshing memory, improving their understanding of the health information and confirmation of their understanding. They reported improved trust and quality. Patients reported feeling more empowered for self-care and greater sense of control. In fact, patients who not only accessed the open notes, but who did so more frequently (defined as at least eight viewings over two years) reported less confusion, fewer safety and privacy concerns and increased trust.

Female patients reported better understanding and appreciation of their doctor’s work and skills. Patients with anxiety, depression, substance abuse, psychosis or other mental illness more frequently experienced improved communication, care coordination and increased ability to self-manage when compared to patients without these diagnoses. There were comments about customizing notes and changing or adjusting details or comments on notes, and they did want the opportunity to give the doctor comments or feedback.

Surprisingly, some patients also commented about withholding information from the doctor to avoid other people seeing it. In another study, patients who reviewed previous notes sometimes inquired about postponing their upcoming check-up “because after reviewing your last note, I’m quite sure nothing has changed.”

In a review of reactions to open notes, 1-8 percent of patients reported confusion, worry or offense to the notes’ content, 26-36 percent reported concerns over privacy of the notes’ content, and 60-78 percent of patients reported increased medication adherence. However, doctors reported longer visits (0-5 percent) and

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more time addressing patients’ questions outside of visits (0-8 percent). And 3-36 percent of doctors reported changing documentation content after the patients’ review.

Despite the studies that were quite successful in enrolling patients to use open notes, the literature review reports patients’ reaction to open notes is very much population specific – some patient demographics and subpopulations will certainly use this technology more or less than others. To this end, a study attempted to merely enroll patients in an “open access medical record” of the ~15,000 patients in the practice, only 450 registered to use the service, and only 153 actually accessed their record at least twice over a 12-month period.

If these figures are any reflection of the state of medical record use in the UCLA system, there may not be much access happening at all. However, as the adage goes, it is 10 percent of the people who use 90 percent of the resources. dgunn@mednet.ucla.edu REFERENCES The list of sources used in this article is available upon request from the author.

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©2018 Robert W. Baird & Co. Incorporated. Member SIPC. MC-237590.

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Patients Don’t Know How Much They Don’t Know

By Ann Gerhardt, MD DOCTORS MOAN ABOUT patients asking for testing and medication they discovered on the Internet, complaining that such discussions waste precious visit time. Some doctors take the easy way out and accommodate requests, finish a visit quickly and satisfy the patient... at least until symptoms don’t resolve and the patient unhappily returns.

In my practice, those requests are puppy chow compared to the difficulty of extracting symptom descriptions from a sincere, intelligent patient who believes that a diagnosis acquired from friends or search engines equates with a symptom. For some bizarro reason, I’d like to play doctor and work through a history of symptoms and an exam to elaborate on them, to reach a plausible diagnosis and devise appropriate next steps. Unfortunately, it can take huge amounts of time to extract real symptoms from patients.

Ms. J consulted Doctor Internet and arrives reporting, along with a list of other complaints, that she’s exhausted and her stomach doesn’t digest food. She blamed the fatigue on the many medications she takes for a variety of chronic maladies. She was unable to describe a symptom other than “poor digestion.” It took 20 minutes to tease out the facts that her “stomach” symptom is an ache with mild cramping across her entire lower abdomen.

She has constipation and no visible undigested food in her stool, and her weight is stably excessive. She had stopped the antacid medications she had been prescribed for prior recurrent ulcer disease, because they weren’t helping this “digestion” problem. (On them she hadn’t had any epigastric symptoms, and two months later

she suffered an ulcer that caused gastric outlet obstruction and responded to an IV drip of Pantoprazole. Whatever.)

Anyway, armed with knowledge of her real symptoms, I ordered testing. Shortly thereafter she was admitted to the hospital with profound exhaustion and weakness. Treatment of hypothyroidism improved her energy and hydrocortisone for adrenal insufficiency miraculously resolved her low abdominal ache. Hours of vectoring toward real symptoms and appropriate testing had finally achieved resolution.

Mr. S says his heart transplant is failing and he needs iron. It takes a while to find out that his symptom is intermittent fatigue, and even more time to convince this person with a normal CBC and absolutely no signs or symptoms of heart failure that his fatigue is due to intermittent volume depletion over the hot summer.

Ms. L is convinced that she has all the “severe” medical problems that her online CVID (Common Variable Immune Deficiency) group friends have, panicking over minor symptoms that are easily resolved.

Scared patients feel that they are maximizing their care by doing their own research.

In response to a real Review of Symptoms, many men are unable to get past saying, “I have X, but that’s because of Y.” They can’t or won’t elaborate on symptoms when that connection makes no sense and other more likely diagnoses that would require treatment occur to me. I get

January/February 2019

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

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

the sense that they want to be strong and in control and don’t want me to give them a new problem.

People make connections. They want to avoid taking their problems to doctors. Scared patients feel that they are maximizing their care by doing their own research. I understand all that, but it would be nice if they could use their words to adequately describe symptoms and let us be diagnosticians. Supplementing with descriptions of prior illnesses with similar symptoms, thoughts about real or imagined associations with events, medications and exposures, and ideas gleaned from the Internet might help the process, but it shouldn’t be the entire process. If it were, they could have stayed home... except for the fact that they need us to order tests and prescribe medication mandated

by Google. algerhardt@sbcglobal.net

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Formerly BloodSource

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A Story About Shared Decision Making

By Gerald Rogan, MD WHAT’S IT LIKE as a patient to participate in shared decision making with my physician? Is there a benefit? Yes and No! For my first total hip arthroplasty in 2009, I discussed the choice of implant with my orthopedist. We selected a metal on metal (MOM) Birmingham hip made by Smith and Nephew. It proved to be a bad shared decision.

The FDA approval of this device was premature.

The device is not safe for some patients. Years of use were required to determine safety. The older four-part model THA prosthesis had been proven safe and should have been our choice.

When the MOM THA required replacement after nine years of chronic deterioration, I was determined not to repeat the same mistake. My orthopedist recommended a different implant that had more than 20 years’ history of safety.

I agreed.

Another shared decision was which drug to use to prevent a deep vein thrombosis (DVT) or pulmonary embolism (PE). Arixtra (fondaparinux sodium) was prescribed following my first THA. It did not work. I developed a PE on POD #10. This time we used warfarin, which has a much longer history of safety and effectiveness. Plus, its effect on my body can be measured versus relying on population-based statistics reported by drug companies that have a conflict of interest. Although the International Normalized Ratio (INR) target range is a judgment call, measuring the INR result every few days gave me some comfort, compared to relying on a population-based study. Likewise, a non-physician patient can easily be trained to

understand the INR target range goal, the INR result, compliance with the treatment plan, and how to follow any necessary adjustments to warfarin dose, other drugs, or diet.

Another shared decision was how to avoid post-op swelling. With my first THA, the swelling was substantial. This time we chose to use a continuous flow ice water machine, the bladder of which was applied in the operating room to my surgical site and left in place for four days.

The swelling was much less compared with the 2009 operation, even though the amount of bone cut and the length of the incision were three times more than with the first surgery.

With my first THA, I used narcotics for a month. A secondary effect of the ice water treatment was that the post-op pain was never greater than 3 out of 10. Pain was controlled with acetaminophen alone. Without narcotics, I moved around more which may have helped prevent a PE. Plus, there was no post-op constipation.

Another shared decision was to go on a liquid diet for three days before the surgery. As a result, I did not have a BM for four days and had no constipation, unlike the first THA. I encourage readers of my article to discuss with their patients options available to reduce the need for post-op narcotics, ways to reduce the risk of post-op constipation and swelling, and how to best prepare for the stress of surgery on the body. Our detailed pre-operative planning discussion helped improve my outcome. jerryroganmd@sbcglobal.net

January/February 2019

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

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Combating GovernmentCaused Poverty, Disease

By Steven Nemcek, MS IV

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

“YOUR INSURANCE IS HARDLY going to cover these,” the Walgreens pharmacy technician told me. “They’re going to cost $2,500.” I balked, thinking to myself, “I’d rather get HIV.” I, stupidly, or too trustingly perhaps, was walking barefoot to the laundry facilities situated a short distance away from my apartment in downtown Sacramento. Along the pathway leading up to the shed containing the washers and dryers is a grassy yard with an area for summer grilling and outdoor recreation. I naively assumed that such a space would be safe, clean, and fit for public use.

So, when I felt something sharp on the bottom of my right foot, I was a bit put-off. I glanced down and saw, glistening under the pale moonlight, a hypodermic needle sticking vertically out of the sole of my foot, with droplets of red blood pooling around it. As a 4th year medical student and soon-to-be-doctor, I knew that what lay ahead was not going to be pleasant.

Initially, after looking up my risk profile using the Risk Assessment Stratification Protocol (RASP) on the MD Calc website (https://www.mdcalc.com), I determined that my risk of seroconversion was extremely low, and debated whether to even visit an emergency department (ED). But as a newly married man, and with potentially life-altering consequences on the line, I decided it was better to be safe than sorry.

After going to an ED and being seen by a physician assistant student, I was given four days of HIV prophylaxis, and told that a month’s amount (a month is the standard length of time for prophylaxis) of medication was too

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expensive to dispense, so I would have to take my Tenofovir/Emtricitabine and Raltegravir prescriptions to a pharmacy to fill.

At my local Walgreens pharmacy, I was informed that my private insurance plan, which was the minimum qualifying plan mandated by both my school and the Affordable Care Act (at least through 2018,) had a $5,000 deductible and wouldn’t touch the cost of the prescriptions. So I would have to pay $2,500 out of pocket if I wanted to attempt to prevent myself from becoming HIV+.

At first blush, that’s a pretty remarkable amount for drugs whose wholesale cost in the rest of the world is between $6 and $7 for an entire month’s supply.1 This story does have a happy ending. But were it not for the lead pharmacist’s intervention, which I will get to later, I might have chosen to risk becoming HIV+ rather than spend so much money on prophylaxis.

As someone who had a bubble-wrapped upbringing, I never expected to experience anything like this. The situation lead to some reflection, set my classical liberal persuasions ablaze, and convinced me that I needed to tell this story to outline how public policy failed me in this situation. I see a two-fanged beast here; first is the economic problem of the cost of insurance and medications in America in the broad sense – which I firmly believe is largely caused by government interference, and second is the social problem of stepping on a discarded hypodermic needle in my backyard. I’ll only address the first of these for the purposes of this article.

A basic understanding of economics would

lead one to believe that if demand for a good is continually and artificially raised, and the supply of a good is relatively fixed, the price of said good will increase dramatically. A corollary of this is that even if the supply of the good is expandable, but demand is virtually infinite, the price will still increase. This is what the government does, all the time, in the name of helping the poor. Somewhere along the line, somebody with good intentions said, in effect, “Look at this sickly person over here, who cannot afford HIV prophylaxis. We should form a government program to pay for his medications!”

And something like Medicaid is born. What happens next is that pharmacy companies think, “Oh, if the government is going to pay for this, I’m going to charge a bit more, say $10, for these HIV drugs instead of $6 or $7 per month, because I know I can exploit their bleeding heart nature.” So the good-intentioned people say, “Ok, well, this person couldn’t afford his drugs at $6 or $7 per month, and now he DEFINITELY can’t afford his drugs at $10, so we’ll be kind and generous and all come together and pay the $10 so this sickly person can get his HIV prophylaxis.” One month later after repetitions

of this, you get a drug regimen that costs $2,500 in America instead of $6 or $7.

Another example: Health insurance deductibles on employer-sponsored plans are up 212 percent since 2008, increasing from an average of $303 to an average of $1,350 now, increasing eight times faster than wage growth and 12 times faster than inflation.2 At some point one would assume such growth will become unsustainable, and then instead of having the inequitable situation of a single or a few sickly people who can’t afford HIV prophylaxis, you have an equitable situation of an entire country being unable to afford it.

Again, this happens all the time. Check out this graph, which was taken from a SlateStarCodex.com article:3 We see that things like medical care, tuition and fees, and shelter have all increased in cost way beyond the rate of inflation. Why? Because government distorts the market and redirects, with the full backing of the U.S. economy, taxpayer dollars into these sectors. In education, there’s even a name for it. Former Education Secretary William Bennett wrote in the 1980s that for every dollar the U.S. govern-

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ment put into tuition and fees through federally subsidized loans, 35 cents went directly to increased costs.4 This became known as the Bennett hypothesis.

While it’s easy to blame morally dubious characters like Martin Shkreli for their “unethical capitalist profits,” when one is honest and admits that non-profit bastions of liberalism like our nation’s colleges and universities are even bigger culprits of this price-setting behavior, he might come to the conclusion that weeds can only be killed by pulling at their roots, and though this is more difficult and labor intensive, pruning behaviors such as price controls and regulation are only band-aid fixes.

If we’re going to go back to the days when Nobel Laureates in physics didn’t have to sell their medals for $765,000 to pay for medical bills,5 and to the days when students could pay off their student loans by working minimum wage jobs in the summer,6 we have to look seriously at this problem, and address it from the root-up. That root is government interference in the marketplace, and until we destroy the notion that interference is beneficial, we’re going to be left with $60,000 annual tuitions (rough cost of my medical school’s tuition) and medical bills in the hundreds of thousands.

These inflated costs are setting back an entire generation of individuals who in the past would be buying houses, cars, starting families, and forming businesses with the money they now carry as debt, and if unchecked, will lead to national bankruptcy.

Let me return to my story. After being told that my HIV prophylaxis drugs would cost $2,500, I asked the pharmacy technician if there were coupons or any programs for medical students who are up to their eyeballs in government-inflated debt. The main pharmacist came over and I relayed my story to her, saying that I simply couldn’t afford to pay $2,500 for these prophylaxis drugs, so if nothing could be done I’d just have to take my chances. She was aghast at my suggestion, and proclaimed, “No!

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Sierra Sacramento Valley Medicine

Let me see what I can do.”

Immediately going to work on my behalf, she enrolled me in a program with one drug company for those with private insurance that didn’t cover the cost of the drug, and found a coupon online for the second drug to bring my total cost down to $0. Yes, she literally saved me $2,500, and maybe a lifetime of HIV in the process. She also relayed to me that she and the other pharmacists were under pressure to disseminate needles to those seeking them, and that she was threatened with her job if she didn’t comply. But she said she was standing up for her employees, stating that when she dispenses needles, the drug users drop them in the trash inside and outside her store, and on the ground near the pharmacy drive-through leading to four other needle stick incidents among her staff.

In the following days, I marveled at what had happened. The only way it makes any sense that the drug companies could afford to provide the drugs to me for free was if they were making up the cost from third-party payers, either insurance companies or government entities, at margins exorbitantly above production cost, likely through the economic mechanisms described above. I also counted my blessings – that I ran into an angel with empathy who could navigate such a broken system to potentially alter the course of my life, combating the demons that are broken social policy. steven.nemcek2019@cnsu.edu REFERENCES 1 https://en.wikipedia.org/wiki/Emtricitabine/tenofovir 2 https://reason.com/blog/2018/10/08/insurance-deductibles-up212-percent?utm_medium=email 3 http://slatestarcodex.com/2017/02/09/considerations-on-costdisease/ 4 https://www.forbes.com/sites/ccap/2015/07/21/the-bennetthypothesis-confirmed-again/#77157d0c794a 5 https://www.vox.com/health-care/2018/10/4/17936626/leonlederman-nobel-prize-medical-bills 6 https://www.politifact.com/truth-o-meter/statements/2014/ aug/08/facebook-posts/1978-someone-minimum-wage-couldearn-enough-summer/

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Call 916-714-5500 to schedule an appointment.

2018 HOD: Four Major Issues

By Lee T. Snook, Jr., MD, Speaker of the House of Delegates AS SPEAKER OF THE House of Delegates for the California Medical Association (CMA), I would like to acknowledge and thank the over 500 physicians who represented their districts, medical societies, and peers at CMA’s annual House of Delegates (HOD). The HOD convened the weekend of October 13-14, 2018 in Sacramento to review, debate and approve the most comprehensive evaluation of health care costs in CMA history.

By proactively addressing the cost of health care, California’s physicians embarked on an ambitious and far-reaching endeavor. To streamline the process, the HOD focused on four major issues: 1) Utilization through improved care

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delivery and payment reforms. Improve patient access and quality of care by reforming health care delivery and utilization by making payment and delivery more efficient, as well as expand telehealth; 2) Enhancing competitiveness of the health care market. Expand patient choice and affordability by increasing competition throughout health care with market-based solutions.

3) Reducing administrative burdens on physician practices. Maximize physicians’ time spent with patients by reducing administrative burdens and eliminating duplicative tasks that add unnecessary cost with improving health outcomes.

4) Addressing increased pharmaceutical

costs. Ensure patients have access to necessary treatment and medications.

From these four major issues, a total of 37 recommendations were reviewed, both online and prior to the HOD. Those items extracted were debated, improved and approved, with very few referrals for further consideration to the CMA Board of Trustees.

To the Delegates, Alternate-Delegates and CMA members who participated, you have delivered the most comprehensive up-todate compendium of health care policy ever attempted at the CMA. You have provided your CMA with the guidelines needed to boldly move forward and advance our mission at the State Capitol of California as well as Capitol Hill in Washington, DC. Also, at the HOD, Los Angeles ophthalmologist David Aizuss, MD was installed as

the 151st President of the CMA. In his address to the Delegates, Dr. Aizuss said that physician satisfaction and practice sustainability would be among his top priorities in the upcoming year. And, elected by the House of Delegates as President-Elect was Peter N. Bretan, Jr., MD, a urologist and kidney transplant surgeon who practices in Marin, Sonoma and Santa Cruz counties.

To review a complete summary of the actions on the 2018 House of Delegates, go to: https://tinyurl.com/HOD2018CMA. lsnook@pain-mpmc.com

40 SSVMS Members of the 11th District Delegation participated in the 2018 CMA House of Delegates at the Sacramento Convention Center October 13-14.

January/February 2019

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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: Mohamed Ali, MD, General Surgery, Med Univ South Carolina – 1995, UC Davis Medical Center

Griffith Harsh MD, Neurological Surgery, Harvard Medical School – 1980, UC Davis Medical Center

Nida Ali, MD, Hospitalist, University of Karachi, Dow Medical College – 2008, Mercy Medical Group

Casuarina Hart, MD, Ob/Gyn, Stony Brook University Medical Center – 2014, The Permanente Medical Group

Mohammad Arshad, MD, General Medicine, Ross University School of Medicine – 2015, The Permanente Medical Group

Shawn Hersevoort, MD, Psychiatry, Tulane University School of Medicine – 2003, UCD Dept of Psychiatry & Behavioral Sciences

Ardavan Aslie, MD, General Surgery, New York University Medical College – 1994, The Spine Treatment Center

Donovan Huynh, MD, Hospitalist, University of Texas Medical Branch – 2015, Mercy Medical Group

Philip Avedschmidt, MD, Emergency Medicine, Loma Linda University School of Medicine – 2015, The Permanente Medical Group Angella Barr, MD, Addiction Medicine, Columbia University College of Physicians & Surg. – 2006, Chemical Dependency Treatment Associates Manjula Bobbala, MD, Internal Medicine, University of Health Sciences – 1997, Calif. Correctional Health Care Svcs.

Alison Boudreaux, MD, Dermatology, UC San Francisco – 1991, Calkin & Boudreaux Dermatology Associates Jacqueline Calkin, MD, Dermatology, UC San Francisco – 1993, Calkin & Boudreaux Dermatology Associates Celia Chang, MD, Pediatric Neurology, UC Davis – 1993, UC Davis Medical Center Andres Crowley, MD, General Surgery, University North Carolina at Chapel Hill – 2008, The Permanente Medical Group Trang Dinh, MD, Pediatrics, University of Wisconsin Medical School – 1999, The Permanente Medical Group Deborah Dossick, MD, Emergency Medicine, Pennsylvania State University College of Medicine – 2011, The Permanente Medical Group Jenny Du, DO, Urgent Care, Touro University College of Osteopathic Medicine – 2015, Mercy Medical Group Abida Faiz, DO, Family Medicine, Edward Via College of Osteopathic Medicine – 2015, The Permanente Medical Group D. Gregory Farwell, MD, Otolaryngology, Washington Univ. – 1994, UC Davis Medical Center Lin Lin Gao, MD, Plastic Surgery, Harvard Medical School - 2011, The Permanente Medical Group Mary Paz Golingho, MD, Family Medicine, Far Eastern University DR N Reyes Medical Foundation – 2011, The Permanente Medical Group Farzam Gorouhi, MD, Dermatology, Tehran University of Medical Sciences and Health Services – 2004, The Permanente Medical Group Mandeep Grewal, MD, Pulmonary Critical Care Medicine, Ross University School of Medicine – 2012, Pulmonary Medicine Associates Susan Guralnick, MD, Pediatrics/Associate Dean for GME, State University of New York at Buffalo School of Medicine – 1986, UC Davis Medical Center

Samuel Hwang, MD, Dermatology, Harvard Medical School – 1991, UC Davis Medical Center Thomas Konia, MD, Pathologist, UHS Chicago Med School – 1995, UCD Dept of Dermatology Satyan Lakshminrusimha, MD, Pediatrics, Mysore Medical College – 1988, UC Davis Children’s Hospital Francis Lam, MD, Internal Medicine, University of Arkansas for Medical Sciences - 2012, The Permanente Medical Group Lara Levin, MD, Internal Medicine, University of Colorado School of Medicine – 1998, The Permanente Medical Group Hao “Harry” Li, MD, Hospitalist, University of California School of Medicine, Davis – 2015, Mercy Medical Group Nijhu Mahbub, DO, Family Medicine, New York Institute of Technology Osteopathic School – 2015, The Permanente Medical Group

Kaela Reinert, MD, Emergency Medicine, Medical University of South Carolina College of Medicine – 2015, The Permanente Medical Group Jamal Sadik, MD, Pulmonary Critical Care, Bahria University, Shifa College of Medicine – 2009, Mercy Medical Group Kiran Sampley, MD, Hospitalist, University of Lublin – 2015, Mercy Medical Group Kiarash Shahlaie, MD, Neurological Surgery, University of California School of Medical – Davis – 2001, UC Davis Medical Center Sarah Shelton, MD, Ob/Gyn, East Tennesee State University James H Quillen College of Med – 2014, The Permanente Medical Group Tiffany Shiau, MD, Internal Medicine, Sidney Kimmel Medical College at Thomas Jefferson University – 2012, The Permanente Medical Group Gerard Somers, DO, Hospitalist, AT Still University, Osteopathic Medical School – 2015, Mercy Medical Group Eric Steinman, MD, Anesthesiology, Loma Linda University School of Medicine – 2013, The Permanente Medical Group Caleb Sunde, MD, Emergency Medicine, University of Southern California – 2014, The Permanente Medical Group Leslie Tamura, DO, Hospitalist, Arizona College of Osteopathic Medicine – 2015, Mercy Medical Group

David Mazariegos, MD, Psychiatry, University of Pittsburg – 2013, The Permanente Medical Group

Eric Tepper, MD, Family Medicine, Hahnemann Univ – 2000, 5030 J St #201, Sacramento, CA 95819

Matthew Mell, MD, Surgery, Harvard Medical School – 1987, UC Davis Medical Center

Azadeh Toofaninejad, DO, Cardiovascular Disease, Des Moines University, College of Osteopathic Medicine & Surgery – 2009, Mercy Medical Group

Marvi Montano-Ip, MD, Pediatrics, University of Santo Tomas Faculty of Medicine – 2004, Mercy Medical Group Jodi Mrosko, MD, Emergency Medicine, Wright State University School of Medicine – 2015, The Permanente Medical Group Minh-Bao Mundschenk, MD, Plastic Surgery, Southern Illinois School of Medicine – 2011, The Permanente Medical Group

Natascha Tuznik, DO, Hospitalist, NOVA Southeastern College of Osteopathic Medicine – 2006, Mercy Medical Group Mark Waheed, DO, Neurology, Touro University of Nevada College of Osteopathic Medicine – 2013, The Permanente Medical Group Charlie Wang, MD, Ob/Gyn, UC Davis School of Medicine – 2014, The Permanente Medical Group

Laura Nasatir, MD, Psychiatry, Univ. Cincinnati – 1987, 100 Howe Ave, Suite 210 South, Sacramento, CA 95825

Paterra Yang, MD, Hospitalist, University of California School of Medicine, Davis – 2015, Mercy Medical Group

Albert Nayeri, MD, Internal Medicine, State University of New York Health Science Center at Syracuse – 2004, The Permanente Medical Group

Serena Yang-Loudin, MD, Urology, Baylor College of Medicine – 2013, Mercy Medical Group

Baran Onder, MD, Family Medicine, Case Western Univ. – 2007, The Permanente Medical Group

Zoe Yu, MD, Internal Medicine, Pritzker School of Medicine of University of Chicago – 2011, The Permanente Medical Group

Mikala Pacifique, MD, Emergency Medicine, University of Queensland Medical School – 2013, The Permanente Medical Group

APPLICANTS FOR RESIDENT ACTIVE MEMBERSHIP:

Joshua Rae, MD, Physical Medicine and Rehabilitation, New York Medical College – 2014, The Permanente Medical Group R Lor Randall, MD, Orthopaedic Surgery, Yale University School of Medicine -1992, UC Davis Medical Center

Brittany Bartolome, MD, UCDMC Resident & Fellow Prog. – 2020 Leland Bourdon, MD, UCDMC Resident & Fellow Prog. – 2019 Lauren Perry, MD, UCDMC Resident & Fellow Prog.

– 2018

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Resiliency Consultations Recognizing the crushing stress and workload that physicians face, SSVMS sponsors up to six wellness sessions with vetted psychologists and life coaches for physicians in Sacramento, El Dorado, Yolo and Placer Counties. These services are confidential, convenient, competent and cost-free.

Vetted Providers:

Daniel Rockers, PhD (916) 273-1740 daniel.rockers@gmail.com

Lori Roberto, PhD (916) 206-1741 drlori@drloriroberto.com

Amy Ahlfeld, Psy.D (916) 799-3866 drahlfeld@gmail.com

Angela Trapp, MSW (305) 962-1936 3coaching.cc@gmail.com

Patricia L. Bach, Psy.D, RN (916) 662-0767 pbachpsd@gmail.com

Kathy James, ThD (916) 549-9363 mamaesther@me.com

Marcella Kreysa, Psy.D., M.A. (916) 672-0870 drmarcellakreysa.com

Steven Seay, Life Coach (916) 715- 9252 stevenseay@gmail.com

To schedule an appointment, contact a Vetted Provider directly and mention that you are accessing the SSVMS Joy of Medicine Program.

For more information visit: http://joyofmedicine.org/building-resiliency/

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Sierra Sacramento Valley Medicine

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

SSVMS Election Results 2019 Board of Directors President: Christian Serdahl, MD President-Elect: John Wiesenfarth, MD Immediate Past President: Rajiv Misquitta, MD District 1, North: Ashutosh Raina, MD District 2, Central: Adam Dougherty, MD, J. Bianca Roberts, MD; Vanessa Walker, DO District 3, South: Ravinder Khaira, MD District 4, El Dorado County: Ranjit Bajwa, MD District 5, The Permanente Medical Group: Sean Deane, MD, Cynthia Ramos, MD, Vijay Rathore, MD, Paul Reynolds, MD, Roderick Vitangcol, MD District 6, Yolo County: Carol Kimball, MD

2019 CMA Delegation District 1, North Area: Reinhardt Hilzinger, MD, Delegate; Harmeet Bhullar, MD, Alternate District 2, Central Area: Lydia Wytrzes, MD, Delegate; Ann Gerhardt, MD, Alternate District 3, South Area: Katherine Gillogley, MD, Delegate; Thomas Valdez, MD, Alternate District 4, El Dorado County: Russell Jacoby, MD, Delegate; Richard Bermudes, MD, Alternate District 5, The Permanente Medical Group: Sean Deane, MD, Delegate; Armine Sarchisian, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Christopher Swales, MD, Alternate At-Large Office 7: John Wiesenfarth, MD, Delegate; Rajiv Misquitta, MD, Alternate At-Large Office 8: Chris Serdahl, MD, Delegate; J. Bianca Roberts, MD, Alternate At-Large Office 9: Don Wreden, MD, Delegate; Carol Kimball, MD, Alternate At-Large Office 10: Ruenell Adams Jacobs, MD, Delegate; Megan Babb, MD, Alternate At-Large Office 11: Natasha Bir, MD, Delegate; Adam Dougherty, MD, Alternate At-Large Office 12: Kuldip Sandhu, MD, Delegate; Harpreet Dhatt, MD, Alternate At-Large Office 13: Charles McDonnell, MD, Delegate; Leena Mehta, MD, Alternate At-Large Office 14: Richard Jones, MD, Delegate; Naomi Ross, MD, Alternate At-Large Office 15: Richard Gray, MD, Delegate; Derek Marsee, MD, Alternate At-Large Office 16: Helen Biren, MD, Delegate; Anand Mehta, MD, Alternate At-Large Office 17: Tom Ormiston, MD, Delegate; Arlene Burton, MD, Alternate At-Large Office 18: Barbara Arnold, MD, Delegate; Ernesto Rivera, MD, Alternate At-Large Office 19: James Sehr, MD, Delegate; Alternate Mark Drabkin, MD At-Large Office 20: Senator Richard Pan, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office 21: Sandra Mendez, MD, Delegate; Amber Chatwin, MD, Alternate At-Large Office 22: Kevin Jones, DO, Delegate; Ronald Chambers, MD, Alternate At-Large Office 23: Ajay Singh, MD, Delegate; Paul Reynolds, MD, Alternate

January/February 2019

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Contact SSVMS to Access Your

Member Only Benefits

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

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement.

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

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

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

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

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

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

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

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

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

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

MAYACO Marketing & Internet www.mayaco.com/physicians

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

Mercury Insurance Group www.mercuryinsurance.com/cma

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

Avis or Hertz

CME Certification Services Discounted CME Certification for members.

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

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

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

Healthcare Messaging Free secure messaging application

DocBookMD www.docbookmd.com/physicians

HIPAA Compliance Solutions Members receive a discount on the Toolkit.

PrivaPlan Associates, Inc www.privaplan.com

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

Subscription Services, Inc www.buymags.com/cma

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

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

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

EnviroMerica www.enviromerica.com

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

StaplesAdvantage

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

COLA (800) 981-9883

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

SSVMS Vetted Vendor Partners SSVMS’ Vetted Vendors are trusted partners of the Medical Society. Each business has gone through an application process and provided multiple physician references that can attest to their satisfaction with the business. Access Vetted Vendors 916-452-2671 or msharpe@ssvms.org.

Cooperative of American Physicians (CAP) Medical professional liability protection to over 12,000 of California’s finest physicians.

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

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

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

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

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

Honors Medicine

An evening of food, wine and entertainment honoring the following Award Recipients: Golden Stethoscope, Denise Satterfield, MD Medical Honor, David A. Herbert, MD Medical Community Service, Society for the Blind

Join us for a Night of Laughter in Medicine Featuring Comedian Jack Gallagher Thursday, February 28, 2019 Tsakopoulos Library Galleria 6:30pm to 8:30pm Cost is $100 per person; Early-bird registration by Feb. 3 is $75 per person.

Members are encouraged to consider hosting a medical student or resident.

Live Auction to Benefit the SPIRIT Program

2-Night Stay Resort at Squaw Creek, Donated by Chris Serdahl, MD and Clarissa Tendero, MD Private Dinner for Four with John Chuck, MD at Buckhorn Grill Print of Archival Ink on Canvas by Barbara Arnold, MD

Date Night For a Year Raffle Benefiting SSVMS’ Medical Student Scholarship Fund Valued at $1,200 | Raffle Tickets are $100 | Only 100 Tickets Sold Reserve Raffle Tickets with mjackson@ssvms.org

RSVP with mjackson@ssvms.org or visit https://tinyurl.com/SSVMSHonors

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