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January/February 2020
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Sierra Sacramento Valley
MEDICINE 4
18
Our Future as Physicians Depends on a United Voice
Photos by Lindsay Coate
PRESIDENT’S MESSAGE
John Wiesenfarth, MD
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OPINION
The Art of Becoming Nobody Caroline Giroux, MD
12
Homeless, Cannabis Hot Topics At CMA House of Delegates
James Schlund, MD and Sean Deane, MD
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PROFILE
April Ramelli, MD: Ain’t That A Kick in the Head? Ken Smith, Managing Editor
2019 CMA House of Delegates
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Da Boise on East 8 Faith T. Fitzgerald, MD
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Community College an Option for Pre-Med Students Bob LaPerriere, MD
24
Groundbreaking Fellowship Targets Provider Well-Being Peter Yellowlees, MD
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27
New at the Museum Bob LaPerriere, MD
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2019 Holiday Social
Photos by Lindsay Coate
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POETRY
Flow
We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to SSVMedicine@ssvms. org. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the Sierra Sacramento Valley Medical Society for permission to reprint.
Andrew Hudnut, MD
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Board Briefs
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New SSVMS Members
Learning About Life And Death in the ICU Mara Ta Cao, MS III
Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 p.m. M–F, except holidays.
VOLUME 71/NUMBER 1 Official publication of the Sierra Sacramento Valley Medical Society
Cover photo: Half Dome, Yosemite National Park, in winter.
Photo by David Evans, MD
5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org
SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx
January/February 2020
1
Sierra Sacramento Valley The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.
2020 Officers & Board of Directors
John Wiesenfarth, MD, President Carol Kimball, MD, President-Elect Christian Serdahl, MD, Immediate Past President District 1 Ashutosh Raina, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, MD District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD
District 5 Sean Deane, MD Fazam Gorouhi, MD Paul Reynolds, MD Roderick Vitangcol, MD Angie Yu, MD District 6 Marcia Gollober, MD
2020 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD At-Large R. Adams Jacobs, MD Barbara Arnold, MD Helen Biren, MD Adam Dougherty, MD Katherine Gillogley, MD Marcia Gollober, MD Richard Gray, MD Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Sen. Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD John Wiesenfarth, MD Don Wreden, MD Lydia Wytrzes, MD
District 1 Alternate Megan Babb, DO District 2 Alternate Ann Gerhardt, MD District 3 Alternate Thomas Valdez, MD District 4 Alternate Anand Mehta, MD District 5 Alternate Ernesto Rivera, MD District 6 Alternate Christopher Swales, MD At-Large Alternates Brian Bernhardt, MD Natasha Bir, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Lucy Douglass, MD Mark Drabkin, MD Rachael Ekraib, MD Gordon Garcia, MD Karen Hopp, MD Brian Jones, MD Mohammad Khan, MD Jocelyn Kim, MD Derek Marsee, MD Leena Mehta, MD Neill Parikh, MD J. Bianca Roberts, MD Romero Santiago, MD Vacant
CMA Trustees, District XI Douglas Brosnan, MD
Margaret Parsons, MD
CMA President-Elect Lee Snook, MD
AMA Delegation Barbara Arnold, MD
Editorial Committee
Sandra Mendez, MD
Mustafa Bahramand, MS III Joshua Bloomstein, MS I Sean Deane, MD Caroline Giroux, MD Nate Hitzeman, MD Robert LaPerriere, MD
George Meyer, MD John Ostrich, MD Eric Ovruchesky, MS II Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD
Executive Director Managing Editor Webmaster
Aileen Wetzel Ken Smith Melissa Darling
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HOSTED BY LOCAL PHYSICIANS
Listen and subscribe to Joy of Medicine - On Call on your favorite Podcast App or visit joyofmedicine.org
Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Š2020 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bimonthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.
| FE ATURED CONTRIBUTORS |
John Wiesenfarth, MD, drjohn@winfirst.com
James Schlund, MD
schlundjames@gmail.com
Sean Deane, MD
sean.g.deane@kp.org
John Wiesenfarth, MD is an emergency medicine physician, father of a large brood and even starred on a TV show. Now he’s also the 2020 SSVMS president. In his first message, he writes about the year ahead.
Dr. Schlund is the newly elected chair of the District XI Delegation to the CMA House of Delegates. He is a radiologist serving Chico and Truckee, and a board member of the Butte-Glenn Medical Society.
Dr. Deane is the newly elected vice chair of the District XI Delegation to the CMA House of Delegates and an SSVMS board member. With Dr. Schlund, in this issue he reports from CMA’s 2019 House of Delegates.
Mara Ta Cao, MS III
Bob LaPerriere, MD
Faith T. Fitzgerald, MD
Mara Ta Cao is a third-year medical student at UC Davis. Her essay recalls her experiences and emotions from a night in the ICU as she watched the treatment of a gravely ill cardiac patient.
A frequent contributor to SSV Medicine, Dr. LaPerriere explains how American River College is helping to prepare students for health care careers and that it’s also a surprising place to find a gourmet lunch.
Dr. Fitzgerald recalls the memorable visit in the early 1980s by the Chicken Soup Group to “da boise” in East 8, the newly opened AIDS ward at UC Davis, and what medical students can still learn from it.
trochetg@gmail.com
ssvmsmus@gmail.com
ftfitzgerald@ucdavis.edu
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ssvms.org.
Peter Yellowlees, MD
pmyellowlees@ucdavis.edu
Dr. Yellowlees is a professor of psychiatry at UC Davis and leads the Train New Trainers Clinician Health and Well-Being Felllowship, which he writes about in this issue.
Ken Smith
ken@kdscommunications.com
This month, Ken catches up with Dr. April Ramelli, who will—literally—knock you off your feet. She’s an emergency room physician and also a devotee of Muay Thai, the “Art of Eight Limbs.”
January/February 2020
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| PRESIDENT’S MESSAGE |
Our Future as Physicians Depends on a United Voice By John Wiesenfarth, MD drjohn@winfirst.com
T
he mission of the Sierra Sacramento Valley Medical Society has been constant since it was founded in 1868. For over 150 years it has been there to support us, physicians from all specialties and modes of practice in our region. I am both honored and delighted to take us into 2020 as the new SSVMS president and, in that role, to promote the well-being of our honored profession. We are physicians from Sacramento, El Dorado, and Yolo Counties. We are some 6,000 in number, which makes SSVMS one of the largest medical societies in California. Our membership also includes hundreds of residents and medical students in our area who are the next generation in medicine. What we do and achieve, therefore, has far-reaching consequences both now and in the future. The most important thing that this or any medical society must do well is ensure our ability to care for our patients, which we can best accomplish by speaking with a concerted and powerful voice that represents your voice as a physician. Fighting for you is a more complicated and intense process than it may often seem. Every day, we see that physicians in this state and around the country are at risk from some non-medical entity wanting to shape our jobs and our reimbursement. That is why it is so essential for SSVMS, in conjunction with CMA, to be a strong voice for its members and their patients. SSVMS and CMA have forged close relationships with elected officials and health care leaders to support our membership in efforts to affect important decisions made by lawmakers and regulators. Consequently, I am pleased to report that we have had significant victories recently. There is now increased reimbursement for physicians treating Medi-Cal patients, as well as funding for Graduate Medical Education and telemedicine. Our advocacy also helped pass Proposition 56, the Tobacco Tax, which has resulted in the availability of millions of dollars in medical school loan repayments for physi4
Sierra Sacramento Valley Medicine
cians committed to caring for the underserved. Early in my career, I did not have full appreciation of how necessary a united voice for physicians was in the practice of medicine. I was preoccupied with learning medicine and doing no harm to my patients. Then my wife, Kathy, and I went on to have a family of four boys, two dogs, and two cats! I also took on the job of coaching on Little League and soccer fields. And, of course, there were the unavoidable home improvement projects that come with a growing family. In addition—and most surprisingly—I had a starring role in an episode of a TV show for NBC (Google “Meet Mr. Mom” sometime if you’re curious), all while practicing emergency medicine. Unfortunately, that left me little time to worry about the value of my voice in medicine.
What we do and achieve has far-reaching consequences both now and in the future. Things are now different. My youngest son is at UC Davis, where I may add, he is not studying medicine. So my wife and I are now empty nesters and I have more time to look around and see how the practice of medicine is changing, often in alarming and challenging ways. That has made one thing perfectly clear to me: We as physicians must take the lead in controlling our future, something that can only be done with the support that the unified voice of a medical society can provide. The cost of medical care will hit 19% of the GDP in the next decade. In today’s changing landscape, we have Google, Amazon and other tech giants with billions of dollars in the bank wanting a piece of what we do. If we are not careful and determined, the next generation of physicians will be employees or shift-workers for larger entities that will make decisions for us on how we treat our patients. It is clear that these companies and others believe
Photo courtesy of John Wiesenfarth, MD
The Wiesenfarth clan that led to an episode of “Meet Mr. Mom.” From left, Mike, Ryan, Matt and Andrew. standardization decreases costs. That leads to the frightening possibility that we as physicians could be placed in a position in which we can no longer think for ourselves and have to follow algorithms set forth by others. However, I don’t think we’re quite at the point of having technol-
ogy and computers replacing us yet. After all, how can an algorithm deal with cultural biases and backgrounds? Chest pain to one person means something different than chest pain to another patient from a different social or cultural background. Of course, we also know about “history alternans,” a phenom-
enon in which patients change their stories from one provider to the next. How do you program a computer to treat a woman with abdominal pain who denies any possibility of pregnancy, even as her child is crowning and actively delivering in the emergency room? There may be some truth to the adage that you can’t get a room full of physicians to agree that the sky is blue even when it is undeniably just that! But one thing we can all agree upon is the need to protect our profession and preserve our abilities to follow our Hippocratic oath and care for all our patients just as we would for our family members. Together with one voice, we are a strong and powerful force that can shape the future of medicine and ensure quality, compassionate care for our patients. I look forward to serving you to the best of my ability this year.
SSVMS Upcoming Events JAN 23
Gratitude and Money Workshop Sponsored by SAFE Credit Union
FEB Ameriprise Tax Seminar, Crumley & Associates Davis, CA 13
FEB 29
SSVMS Honors Medicine Elks Tower - Sacramento, CA
MAR Medical Marijuana CME Dinner Presentation Sacramento, CA 18
APR 18
Presented by SSVMS Alliance: Art of Medicine - Del Paso Country Club, Sacramento, CA To RSVP contact Sam Mello at rsvp@ssvms.org or (916) 452-2671
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$340 Million Available for Loan Repayments! About the CalHealthCares Program Proposition 56 provides $340 million for a loan repayment program to increase access to care for MediCal beneficiaries. The Department of Health Care Services (DHCS) contracted with Physicians for a Healthy California (PHC) to administer the loan repayment program, CalHealthCares. Eligible physicians and dentists may apply for a loan repayment up to $300,000 in exchange for a five-year service obligation. All medical and dental specialties are eligible.
Who May Apply? Applicants must:
Have an unrestricted license and currently be in good standing with their licensing board. (Medical Board of California, Osteopathic Medical Board of California or the Dental Board of California) Currently be an active enrolled Medi-Cal provider without existing suspensions, disbarments or revocations or have submitted an application to DHCS to become a Medi-Cal provider. Have graduated from an ACGME-approved residency program, dental school and/or completed a fellowship within the last five years. Not currently participating in another loan repayment program If awarded, maintain a patient caseload of 30% or more Medi-Cal beneficiaries Practice in California Be employed, self-employed or have a validated offer of employment.
Grant Cycle Summary The 2018-2019 grant cycle had awardees in 38 counties, representing 40 specialty areas of medicine in all practice settings.
BREAKDOWN BY PHYSICIAN SPECIALTY Discipline Type
# Awarded
Amount Awarded
Family Medicine
44
$11,523,732
Emergency Medicine
18
$4,316,900
Pediatrics
48
$10,654,356
General internal medicine
19
$4,894,610
Psychiatry
40
$9,286,338
71
$16,661,856
240
$57,337,792
Other Specialties
Totals
2019-2020 Grant Cycle Application Opens: Jan 13, 2020
Deadline: Feb. 07, 2020
Awardee Notifications: May 01, 2020
Page 1 of 1
Rev. 08/20/2019
DHCS has contracted with Physicians for a Healthy California to administer CalHealthCares.
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Sierra Sacramento Valley Medicine
(916) 551-2579 CalHealthCares.org CalHealthCares@phcdocs.org
Catch Your Breath
One Year of Headspace Available for SSVMS Members Download your personal medita�on guide to your phone now
January/February 2020
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| OPINION |
The Art of Becoming Nobody
Being “Somebody” Just Isn’t All That Appealing
T
he fundamental task of life is the continuous, arduous work of liberation. At birth, we are already forced into circumstances we haven’t chosen and might not ever accept: a gender, birth order, siblings, social class, upbringing, a birth country, a mother tongue, and sometimes a religion. For some, the most challenging of all is the set of expectations the external world maintains towards us, beginning with our own parents’ projected dreams of what our lives should look like. Carl Jung nailed it when he said that one of the most potent forces upon the psyche of the individual is the unlived life of one’s parents. That is quite a burden to bear for someone only a few seconds old! Just thinking about work right now, there are too many things we are supposed to do “just because” someone else who has no insight into the medical field whatsoever has decided so. From documenting a certain way to refilling controlled substances for a patient who was put on them (by a former colleague who retired) but now refuses to go off them, to managing a torrent of emails on a daily basis, not to mention countless meetings and other types of repetitive, counterproductive tasks like obtaining prior authorizations… the list goes on. 8
Sierra Sacramento Valley Medicine
In his awesome and inspiring book The Art of Non-Conformity, Chris Guillebeau (with a mild and appropriate dose of sarcasm) opens readers’ eyes about how to lead a satisfying life by distinguishing “busywork” from great or meaningful work, i.e., work that helps us create a legacy. As you know, many hours of our workdays (even for doctors) go wasted on useless tasks (busywork) that have nothing to do with what our mission should be:
By Caroline Giroux, MD cgiroux@ucdavis.edu
and a form of a mild torture, plus I thought it was a weird and pathetic cookie-cutter way of living that I wanted nothing to do with. Furthermore, eyebrows play a huge role in facial expression! And I felt that way even before Frida Kahlo became one of my heroes. Other enslaving activities I refuse: daily or compulsive use of make-up, dyeing my hair, having a perm, and off-season leg-shaving. That is not to say that there is something wrong
Eyebrows play a huge role in facial expression! And I felt that way even before Frida Kahlo became one of my heroes. improving the population’s health and quality of life. On the dial of your legacy, where would you situate yourself at this time? At times, because deep down I am an anti-conformist, I simply refused to do what didn’t make sense to me, starting with saying no (or even better: never!) for instance to stilettos, which for some might be viewed as the epitome of femininity. But for me it is, at worst, the epitome of female gender slavery, and at best, a biomechanical improbability. After clumsy attempts to weed whack my eyebrows (because this is what women do, right?), I quit; this seemed like a waste of time
with dying one’s hair. For some people it is a meaningful, loving gesture to affirm their personhood. But we should examine the intent and motivations to make sure they come from within, rather than from blind obedience to the current fad. Over the past several months, I have been blessed with epiphanies that make me even more resolute and assertive in my quest for freedom. Amidst a plethora of alienating duties, my work environment constantly confronts me with other ways of thinking and living. With great admiration, I have viewed feminine colleagues not shaving their legs or arm pits at all. And guess what: they look abso-
lutely beautiful and harmonious. I have deep admiration for being so countercurrent, and for questioning a practice (shaving specific areas of body hair rather than embracing them) at the risk of being judged. I also had a revelation when I reluctantly participated in a KCRA 3 interview in the context of the Camp Fire anniversary. Identified as a trauma expert within my institution over the past couple of years, I was a bit surprised by my own initial avoidance of the opportunity to be interviewed for television. Even my introverted self doesn’t mind recognition once in a while… or so I thought. The person from Public Affairs had emailed a colleague and me asking for our phone numbers so we could be reached last minute to coordinate this. I decided to ignore this email at first. Then the email came from my manager the next day, and my colleague couldn’t do it, so out of guilt or compassion, I sighed and provided my (limited) availability. It was mid-morning already and within minutes it was decided that the videographer would come to me at 4:30 that afternoon. Before that, I was booked with clinical duties, supervision and a lunch meeting, leaving very little time to prepare. There was too little time to review questions, come up with decent answers, rehearse and become desensitized to the distraction component derived from my accent (which might even sound more prominent due to stage fright). Then I changed my attitude. I began thinking that my make-up-less face, my dull hair, my 10-year-old dress (which I am not embarrassed
to say I wore while pregnant, even though I am not currently bearing any child or abdominal fat in excess) would constitute an unprecedented flooding experience, a de-selfing type of moment, so to speak. So much for de-selfing. After seeing the footage, I basically determined that I hated 75% of my responses. I felt mortified. I disliked feeling constrained by this examination atmosphere, answering those robotically-read questions (some
only if I have the freedom to be who I am without fearing that they will manipulate the content through the editing process. Basically, I want to no longer feel at the mercy of events or the media’s need for sensationalism. Only a few years ago, such opportunities to appear on a screen and be viewed by thousands of people would have been an insurance policy against egoic annihilation. But as I accumulate years and broaden
On the dial of your legacy, where would you situate yourself at this time? redundant), as if I were passing a test and that only specific answers were acceptable, the ones that the media wanted me to say. Shortly in the aftermath of this, I decided that I would refuse to do this ever again unless I agree with the relevance of the questions or I am especially passionate about the topics, and
my perspective, this is no longer appealing to me. I am so relieved to have reached this stage of my ego life cycle! According to Ram Dass, after being somebody, the next step is to become nobody, to transcend the idea of a self. Being somebody is constraining and forces the person
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to conform to the external role or expectations, but being nobody also means one can be anything and that it is OK to not meet the criteria for celebrity status in one’s work environment. It means that I can jump off the conveyer belt of academia at any time, without anyone noticing, to explore and find the important questions rather than wait for slow promotion as I move closer to the only response and outcome we all know and share: the grave. Embracing my nobody means freedom. I want my path to be extra ordinary, not in a glamorous way but from acting wholly, based on my out-of-the-box thinking. I want to have an impact on one person (who then can have an impact on others) rather than influence a passive
crowd that practices life avoidance. I prefer to write one decent essay that would be accessible and speak to a broad readership rather than produce a myriad of so-called scientific publications that would appear in some obscure journal that no one really cares about. There are so many other prisons I have escaped a while ago even though it meant abandoning some of my relatives or friends still stuck in such unhealthy patterns (including the compulsory shaving or eyebrow-plucking, haha!). But I cannot be effective in helping others if I am not a free spirit, if I don’t commit to what makes the most sense to me and my core values. I am thankful to not be enslaved by materialism, hegemony of brands, or seeing my car as an extension of
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myself. When you stop wanting “just because” at some point someone told you that having this possession or that title would make you somebody, you stop letting life happen to you from the outside and you become the author of your own journey as the transformation occurs from within. The uniqueness of your potential makes the concept of envy, which is sustained by junk metrics like admiration and prestige, suddenly non-relevant and non-existent. Envy is a form of pseudo-yearning wrapped in bitterness that is like this moving sand you can waste your life in. Letting go of it makes room for freedom to design your life and even rejoice in others’ own bliss at the same time. “To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment,” Ralph Waldo Emerson said, and I agree. Being yourself is basically being a presence, an essence stripped of imposed identities. I resisted the imposed identity in front of the camera. I was busy celebrating with the in-laws the evening I was supposed to appear on TV and missed the news. Maybe I was too much myself or not enough somebody in KCRA’s eyes, because the next day a friend who was watching it said she didn’t see me. Well, that sounds like good news. My words, my footage: deleted. It takes some work to strive to become a non-envious nobody, and free. But what a life upgrade!
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| REPORT FROM ANAHEIM |
Homeless, Cannabis Hot Topics At CMA House of Delegates
T
he CMA House of Delegates held its annual meeting in Anaheim October 26-27, 2019. District XI, our District, represents the physicians of the North Valley, Butte-Glenn, Placer-Nevada, Yuba-Sutter-Colusa, and Sierra Sacramento Valley medical societies. Representing each of our component societies, District XI joined other district delegations at the House of Delegates to debate key issues, introduce policy from the distinct and offer our unique perspective of medical practice in our diverse region. In keeping with recent governance reforms, the House focused its efforts on selected major topics to streamline the policymaking process. Expert speakers from across the state joined the House to present on the topics that included cannabis, homelessness, and the liability and privacy concerns surrounding the use of augmented and artificial intelligence in health care. An educational session was also held on the topic of current initiatives to address adverse childhood events, which can have a strong and lifelong correlation to numerous health, social and behavioral problems. Jeffrey Chen, MD, MBA presented information on cannabis-related issues from the perspective of the UCLA Cannabis Research Initiative. Lori Ajax, California State Bureau Chief for Cannabis Control, discussed the state of government oversight of the cannabis industry in California. Following these presentations and debate, the House adopted policy that included support for rescheduling cannabis with strict regulatory controls, encouraging cannabis-related research, and addressing current needs with respect to research and education about the adverse effects of cannabis use. Recognizing the urgency of the homeless problem, which in California now surpasses that of any other state, the House of Delegates allocated a significant amount of time in discussion and policymaking on
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Sierra Sacramento Valley Medicine
By James Schlund, MD By Sean Deane, MD schlundjames@gmail.com sean.g.deane@kp.org
the subject. UC Davis Medical Center CEO Dr. David Lubarsky, Sacramento Mayor Darrell Steinberg, and Los Angeles County Supervisor Mark Ridley-Thomas presented to the House on their experiences and ideas with respect to approaches to address the ongoing social impact of homelessness. The delegates declared that stable and affordable housing is an essential community priority and is an important social determinant of health. Policy was adopted on the subject, including endorsements of the importance of evidence-based approaches and efficacy outcomes measures with respect to interventions targeting homelessness. The dangers inherent in medical applications of augmented intelligence was the third major topic on which the House deliberated. Edward Lee, MD, Executive Vice President of Information Technology at The Permanente Federation, presented on the promise and perils of current trends in technology. The House adopted policy addressing the importance of limits on financial, administrative, and liability burdens on physicians that could be associated with the use of augmented intelligence systems in medicine.
Changing of The Guard Peter N. Bretan Jr., MD, was installed as the 152nd president of CMA. Dr. Bretan is a urologist and kidney transplant surgeon who gave up his Bay Area practice to serve patients in a safety net hospital in Watsonville. He is also the first Filipino-American to serve as CMA president. “The most important goal, not just in this year of my presidency, but always, is to take back our profession by enabling physicians to lead the struggle to protect, expand and make universal access to health care for all of our patients in California,� Dr. Bretan said in his inau-
Lee Snook, MD, is the new CMA President-Elect gural address. “If we are successful in this state, it will lead the way for sustainable universal health care for all of America.”
SSVMS Physician Named CMA President-Elect SSVMS’s own Lee T. Snook, Jr., MD was named President-Elect. He
will be installed as CMA President at the 2020 House of Delegates. Dr. Snook has served as Speaker and Vice-Speaker of the CMA House of Delegates over the past six years and has been a member of the CMA Board of Trustees for 10 years. Dr. Snook is a Sacramento pain management specialist who is certified in anesthesiology, internal medicine, addiction medicine and pain medicine. He is also a strong advocate for physician wellness. Finally, District XI celebrated and thanked our own Dr. Richard Gray for his decade of leadership in the delegation, including five years as Vice-Chair and then the next five as Chair. The authors are honored to have been chosen to serve the District in our new positions as Chair and Vice Chair, and we look forward to the guidance and input
of our colleagues in District XI as we discharge our duties over the coming year. We will endeavor to capture the collective wisdom and will of the District, and to carry that voice forward, by engaging the members and delegates at strategic times to shape opinion on issues and resolutions before the CMA. We will also be working to identify up-and-coming, talented members in the District XI delegation to take active roles in councils and committees, keeping our storied District’s voice in CMA policy strong and clear. James Schlund, MD, is chair of the District XI delegation and a member of the Butte-Glenn Medical Society board of directors. Sean Deane is vice-chair of District XI and is a member of the Sierra Sacramento Valley Medical Society board of directors.
Together, transforming lives The beginning of the year beckons with invitations for increased wellness activities and new routines. Make 2020 the year to encourage a regular habit of blood donation that can change the world for many. Thank you for your support of a safe and plentiful blood supply. For the giver, the recipient and the professionals who make blood components available to treat your patients, blood donation transforms lives every day, every season. Join the Vitalant community! Visit vitalant.org or call 877.258.4825 (877.25VITAL)
January/February 2020
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| PROFILE |
Ain’t That
A Kick in the Head?
April Ramelli, MD Gives Her All in the ER and in the Ring
T
he last thing you would expect April Ramelli, MD, an emergency room doctor at Kaiser South, to talk about is the satisfaction and grace behind landing a well-placed kick to someone’s head. But she does, and it all started with a Christmas gift. Five years ago, Dr. Ramelli was a resident who was completing medical school at UCLA and dissatisfied with her workout routine at her Southern California gym. She told her husband that all she wanted for Christmas that year was for him to find a new and exciting work-
April Ramelli, MD
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Sierra Sacramento Valley Medicine
By Ken Smith ken@kdscommunications.com
out for her. He took it as a challenge and it led to a gym in Long Beach that specialized in Muay Thai, or Thai boxing, a martial art dating back to the 13th century that is often called “The Art of Eight Limbs” because it turns the entire body into a weapon. She started with cardio classes, learned how to throw punches and kicks, and then how to catch those coming her way with pads. “My first week of basic training, I hurt everywhere. I didn’t know I could be that sore, and that made me want to know more about what I had been missing out on,” she said. “I saw those people in the ring while I was still down on the carpet doing cardio, and I’m like, I want to be you, I want to beat you. I found a goal and said, let’s just keep going.” She finds both physical and mental rewards from her training sessions, which she says have elevated her cardio and physical strength to unprecedented levels, and from her experience in the ring. “What I’ve taken away from being inside the ring is that you can do anything for a set amount of time,” she said of the three-minute rounds in the bouts. “You can take a couple hard hits for three minutes, you can feel exhausted and like you’re about to collapse. Whatever you have for 30 seconds, give it up now for 30 seconds because it’ll be done.” That philosophy has translated to the ER, especially on days that feature multiple patients or complex cases. She has learned to treat her shifts, which can run between eight and 10 hours, just like a three-minute round: a finite amount of time that she can commit to fully and then walk away from when it ends. Muay Thai is a combat sport, which means someone else is just as eager to land a punch, kick, elbow or knee on you as you are on them. Dr. Ramelli’s bouts have been at the gym level, so participants wear headgear and pads while sparring. Still, she has taken a few blows
Photos courtesy April Ramelli, MD
Cycling is a passion, whether it’s on the American River Bike Trail or at home on the Peloton.
Dr. Ramelli spars with a coach at Legacy Muay Thai in Sacramento. She says her training sessions have dramatically improved her fitness and have made her mentally stronger in ways that are beneficial when she faces long shifts. and vividly remembers her first “liver shot” during her debut sparring session. “I walked out of the ring, I put my hands up in my hair and I tried to catch my breath,” she recalled. “I watched a CSI episode at home that night and the victim bled out from a liver injury. So I was sitting there all night thinking, I’m going to die.” In her second bout, she suffered a ruptured eardrum. She also got hit in the eye, which caused some temporary disruption of her vision. “That was more of a gut check,” she said of the eye injury, and it gave her some pause to consider whether the sport she had come to love was really in her best interest. “I have a family to provide for, I have a mortgage. What am I doing? Do I need to take a step back
from this?” But as she says, you take some punches and then you rebound. At her level, developing expertise is the primary goal and is why she finds it more rewarding to accomplish the right hit using the best technique rather than sending an opponent to the deck—although she admits that’s sort of satisfying, too. “The technique is the most frustrating part and addictive part at the same time,” Dr. Ramelli said. “When you perform something well, when you sweep somebody and they go flying—you don’t want to hurt anybody, though—it’s a good move and you feel great. To execute that move it takes hours of practice, it takes hours of failure.” Not unlike, some would say, medical school. January/February 2020
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Dr. Ramelli lands a punch during a bout. She would like to advance to a higher level and more competitions, but she has temporarily adopted a non-contact training regimen because she’s pregnant with her second daughter. The irony of an emergency room doctor potentially turning an opponent into a patient is not lost on her. Many of her colleagues don’t know know about her hobby and are surprised when they find out. “It is a little ironic, but I think ER docs in general have some higher-risk physical activities they like to do,” she said. “We have a world class rock climber, a person who’s pretty high up in MMA (mixed martial arts), and a world-class water skier who also just got her black belt in karate. ER docs are kind of adrenaline junkies.” But the rush from Muay Thai is different than what she experiences in the ER. She no longer gets the uptick in her heart rate or little tremor she did from treating emergency cases during her residency, because she has seen a wide variety of illnesses and trauma and has a sense of the outcome. But when she enters the ring, especially against an opponent she doesn’t know, each match is different and the outcome is far less certain. Dr. Ramelli trains and competes in a competitive class known as “Smokers,” who are in a middle ground between beginners and the amateurs who fight without pads or headgear in rounds monitored by judges. There isn’t any official scoring at the Smokers level, she said, “but you know if you won or not.”
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She would like to advance to the point that she can experience more bouts at a higher level. At the moment, however, her training has hit what might be referred to as a pregnant pause. She is a little more than five months along toward having her second girl with her husband, who had been a reporter but just completed his master’s in December and recently landed a teaching position at Sacramento State. Her pregnancy also makes it a natural time to reassess her goals. She’s continuing to train with modified sparring in which she can hit her coach at Legacy Muay Thai in Sacramento but he can’t hit her. It was harder to find the energy after the first baby, she said, but she wants to keep going after this pregnancy. “I’m hungry for it, I want more,” Dr. Ramelli said. “But when I was training for the bouts, it’s two to three hours of exercise a day. Everyone had to get on the same page because you had to make weight, you need to dedicate the time. My husband would boil chicken and veggies for two weeks in a row. “If I could do it again and it isn’t a huge inconvenience to my family, I most definitely want to keep going. I still want to compete, I still want to get up there and see how far I’ve come.”
WE’VE MOVED! Our J Street clinic and business office have relocated to 3 Parkcenter Drive
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January/February 2020
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2019 CMA House of Delegates
2 1) 2019 SSVMS President Chris Serdahl, MD and incoming president John Wiesenfarth, MD enjoy a moment together. 2) Margaret Parsons, MD, Lee Snook, MD, Cindy Snook, Mary Jo Reynolds and Paul Reynolds, MD enjoy the CMA Broadway Gala. 3) District XI members celebrate a night on Broadway at the 1 CMA Annual Gala. 4) Anand Metha, MD and Russell Jacoby, MD on the floor of the House of Delegates. 5) Newly elected Vice Chair of District XI, Sean Deane, MD (left) and Chair James Schlund, MD (right), thank outgoing chair Richard Gray, MD (middle) for his 10 years of leadership of the District XI Delegation. 6) Senator Richard Pan, MD addresses his fellow District XI delegates. 7) Delegates Richard Jones, MD, Lydia Wytrzes, MD and Charles McDonnell, MD. 8) Delegate Rachel Ekaireb, MD debates on the House floor. 9) Vice Speaker of the House Tanya Spirtos, MD and Speaker of the House Lee Snook, MD get in the Disney spirit.
Photos by Lindsay Coate
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Da Boise on East 8
Lessons From the Chicken Soup Group Are as Valuable Today as They Were Over 30 Years Ago
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came to the University of California, Davis Medical School in Sacramento in the early 1980s, a time when cases of AIDS were multiplying rapidly, largely in gay men. Most of our infectious disease faculty wanted nothing to do with them, fearing that care demands would escalate, distracting them from their current research and swamping their clinics. There were only two internists in all of Sacramento who accepted AIDS patients into their private practices. The number of men presenting to our ER with life-threatening pneumocystis pneumonia, Kaposi’s sarcoma, and “slim disease”—profound weight loss— steadily rose. One member of our infectious disease group, Dr. Neil Flynn, went into action. He ceaselessly begged, then demanded, that an AIDS ward be created. He made such a fuss that it actually happened. It was a small victory: four two-bed rooms at the far end of a corridor in the oldest part of the “old hospital,” a ward called East 8. The patients in these beds were in isolation; all their nurses, residents, students, and attendings had to be volunteers. I noticed early on that almost none of our patients’ families or friends came to see them. They’d been abandoned, it seemed, perhaps due to fear... or shame. One day I was standing in a corridor of East 8, talking with my team, when I heard a gravelly voice behind me say “Where’s da boise?” I turned to face a woman who looked to be in her late 60s, with gray hair, a bulky purse hanging from her left elbow, and a very large styrofoam cup with a lid on it in her right hand. Behind her were three other women, all with purses and styrofoam cups, and all about the same age as the speaker. “I’m sorry, ma’am,” I said. “I don’t think we have anyone here named Daboise.” She shook her head.
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Sierra Sacramento Valley Medicine
By Faith T. Fizgerald, MD ftfitzgerald@ucdavis.edu
“We want to see da boise. You know… da ones with da terrible sickness.” These women had heard that our AIDS patients on East 8 had few visitors. So, as members of the local synagogue’s “Chicken Soup Group” they had made and brought soup (as a medicinal) along with purses stuffed with books, puzzles, games, and decks of cards as gifts for “the boys” who agreed to see them. They came regularly, always with chicken soup in hand and purses akimbo, and brought with them yet one more precious gift: They spent time with these men, told them stories, held their hands, fed them soup, listened to them, and mourned them when they died. It was, from these women, all holocaust survivors, the gift of empathy.
“We want to see da boise. You know… da ones with da terrible sickness.” In 1978 NBC produced a TV miniseries on the holocaust, and I am told that TV magazine reporters went to Germany during the filming to ask the still living percipient witnesses of the Nazi period why they did not protest. The majority of interviewees said, “We did not know.” Of those who admitted that they did know about the slaughter of Jews, gypsies, homosexuals, the mentally ill, and the “unfit” (all of whom the Nazis called “untermenschen,” or “subhumans”) most of those interviewed answered: “You don’t understand. The Gestapo and SS were everywhere. They had the guns. “They were killing people. They could have killed me and my family. What could I do?” Then the reporters interviewed some of the remaining rescuers (now called the righteous) who, at great
risk, hid or led out of danger these targets of Nazi “cleansing,” and they said: “You don’t understand. The Gestapo and SS were everywhere. They had the guns. They were killing people. They could have killed
standing. It is, rather, knowing of someone’s suffering, an inescapable awareness that “it could be me.” Because of that shared humanness, the rescuers were compelled to help. Medical school admissions
Empathy is not the same thing as kindness, sympathy, pity, or understanding. It is an inescapable awareness that “it could be me.” me and my family. What could I do?” Exactly the same answer, but a totally different moral imperative. These righteous were men and women who simply could not deny that the “others” were fully human, like them. Empathy is not the same thing as kindness, sympathy, pity, or under-
committees assay applicants for grades, test scores, and activities. We must—and many do—add evidence of empathy as a prerequisite for those chosen to be selected, just as the Chicken Soup Group showed “da boise.” It is one of the most valuable gifts any physician can give to patients.
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January/February 2020
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Community College an Option for Pre-Med Students
American River College Offers Health Career Training
C
Photo courtesy American River College
ommunity colleges are not usually the first thought for students who want to progress to fields in medicine, but they can provide some unique benefits and support for these students seeking a career in health care. American River College (ARC), in particular. has special support for pre-medical students. ARC and other colleges in the Los Rios Community College District, which also includes Sacramento City, Folsom Lake and Cosumnes River Community Colleges, offer a number of attractions for the pre-medical student. These include a more reasonable tuition, smaller classes taught by highly-regarded professors rather than teaching assistants, improved interaction with staff, and access to tutoring centers. In addition, students who meet certain criteria are guaranteed admission to the UC college system.
The suture lab at American River College provides hands-on experience for EMTs, nurses and other health professionals. 22
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By Bob LaPerriere, MD ssvmsmus@gmail.com
ARC offers options for education in a variety of healthrelated fields, including biology and biotechnology, gerontology, health education, health care interpreting, human lactation, nutrition, and respiratory care. ARC’s two-year nursing program consists of a combination of general education and nursing courses with related laboratory experience in local health agencies, and can qualify the student to become registered as a nurse. This program is extremely popular and more students apply than can be accepted. ARC’s EMT program prepares individuals to render pre-hospital advanced life support within an organized EMS system. In addition to the certification program, students have the option of taking courses to earn the Associate in Science degree. Required for admission is certification as an EMT-Basic and approximately one year of verified recent or appropriate EMS experience. The support for pre-med students is excellent, especially through the American Medical Student Association (AMSA) chapter that was chartered in 2003. It is one of only a few pre-medical chapters in community colleges that is recognized by National AMSA. AMSA ARC provides guidance for students interested in pursuing a career in medicine. It also promotes awareness about medicine, opportunities in community service, research, and coordinates visits to medical schools. Its local members also mentor elementary students in reading, math and science and are involved in projects with Habitat for Humanity. The AMSA chapter at ARC has included as many as 100 student members since its founding. Every Friday morning there is a program or lecture on a relevant topic of interest. Recent presenters have included an associate dean for research, a pediatrician, an orthopedist, and a representative of the Trauma Prevention Program. ARC is the only Los Rios school currently with this student organization. Recent pre-med students who were AMSA ARC officers
A major fundraising program is now underway to raise $3.5 million for a new, 38,000 square foot STEM (Science, Technology, Engineering and Mathematics) center that will provide flexible and movable space for interdisciplinary labs, including state-of-the-art wet labs for biology and chemistry. Community colleges can provide talented students a lower-cost
alternative that still offers a great education to those interested in the field of medicine, whether it is as a pre-med or a related field such as nursing or EMT services. If you are interested in help supporting these programs, please consider making a tax-deductible donation to the Los Rios Colleges Foundation. You can make a contribution online at foundation.losrios.edu.
ARC’s Oak Café a Hidden (and Inexpensive) Dining Treasure
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ne of the region’s best-kept dining secrets is The Oak Café, a very attractive, bright and modern student-run dining room operated by ARC’s culinary program. My wife and I have had lunches there that would have cost $50 or more at any other upscale restaurant, but at a third of the cost. The teaching staff includes several professional chefs with many years of experience in the Sacramento region. The Oak Café is designed to give students real-world experience in the running of a fine dining restaurant. The two-year program yields an associate degree in Culinary Arts and Hospitality Management, but a short course can provide training yielding a baking certificate. Three years ago, an entire new site was built for this program with up-to-date equipment and several large kitchens, including one just for baking and a temperature-controlled kitchen for making candy. The Oak Café serves exceptional three-course lunches Wednesday
Photo: Bob LaPerriere, MD
or members are currently attending, or have graduated from, the University of the Pacific School of Dentistry, UCSF School of Medicine, UC Irvine school of Medicine, and the Military Medical School in Bethesda, MD. Five are currently attending UC Davis Medical School. Pre-med students are normally at ARC for three to four years, though some students may spend up to six years if they prefer a lighter load to maintain a high grade point average or if their science courses with labs conflict with other required courses. Also, older students may work outside school. To help students apply and make the transition to further schooling, UC Davis holds an annual Pre-Health Conference that provides students and advisors with the information and skills needed to complete the admission process. The conference, which started at ARC but moved to UCD as it grew and is now the largest of its kind in Northern California, also offers students the chance to meet in person with staff and others involved in admissions. Undergraduate tuition and fees at ARC are currently $46 per unit, although financial help is available (about 50% of students receive grant or scholarship aid). First-time students who attend full time may qualify for a year of free tuition through the district’s Los Rios Promise program. ARC also offers some unique opportunities outside of its pre-med programs. It has one of California’s two funeral services programs—I have the honor of serving on its advisory committee—and a superb culinary program.
The Bavette steak at Oak Café through Friday during both semesters (reservations are highly recommended) for $17, including a beverage. Recent featured menu items have included ceviche of yellow fin tuna, grilled Bavette steak and seared scallops. The adjoining Oak Café Bakery also offers some delectable treats, and the proceeds help support the culinary program. The menu varies but typically includes coffee and tea, breakfast pastries, cookies/desserts, and lunch choices such as stuffed potatoes, single-serving pizzas, and quiche. Reservations can be made by calling (916) 484-8526. — Bob La Perriere, MD January/February 2020
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| PHYSICIAN WELLNESS |
Groundbreaking Fellowship Targets Provider Well-Being “Train the Trainer” Class Explores Causes, Solutions to Clinician Burnout
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he first class of 17 Fellows has just completed the six-month UC Davis/UC Irvine Train New Trainers Clinician Health and Well-Being Fellowship, the first such program in the world. We encourage colleagues to sign up to join the next cohort of Fellows, who will commence their studies in April 2020. The Fellowship is open to physicians in all medical specialties, especially internal medicine, family medicine, pediatrics, psychiatry, emergency medicine and the surgical specialties. It is also open to nurse practitioners, physician assistants, veterinarians and others who are either health providers or who are working in roles where knowledge of clinician health is important. The physician health program aims to examine the culture of medicine as it relates to clinician health and well-being, and in particular to study how to minimize burnout and strengthen resilience. The Fellows learn solutions and treatments for problems that commonly affect physicians and other providers, how to implement preventive health approaches to ensure positive personal health and continued fitness to practice, and how to engage, treat, and monitor impaired clinicians. This is a “train the trainer” program so multiple teaching techniques and approaches are used, both in-person and online, to help train new trainers who can spread these principles to colleagues. These include an in-person introductory weekend conference and a wrap-up project presentation session, biweekly lectures via video conference, a comprehensive online interactive course, regular individual mentoring, and supervision with individual projects. All students are given copies of all course resources so that they can take the course and teach components of it to their colleagues. Program fellows will dive deep into alcohol and substance abuse, cognitive disorders, suicide and the professional culture of medicine, colleague interactions, 24
Sierra Sacramento Valley Medicine
By Peter Yellowlees, MD pmyellowlees@ucdavis.edu
resilience and more. The fellowship will conclude with a certificate of completion from the UC Davis Department of Psychiatry and Behavioral Sciences. The goal of the fellowship is to rapidly build up a core group of experts in clinician health who will broadly spread their knowledge and skills. This will ultimately create change in the health systems in which they work to enhance the well-being of clinicians—which also leads to better outcomes for patients. The first class of 17 Fellows was very broad and consisted of 14 physicians, one nurse and two veterinarians. The physicians included practitioners in surgery, psychiatry, family medicine, pediatrics and OB/GYN. Three of the physician Fellows were residents, two were in private practice and the others came from UCD Health, Sutter, Kaiser, the VA and county health systems. The two veterinarians were faculty from the UCD Vet School and the nurse was a senior educator from UCD Health.
Dealing With Substance Abuse, Disruptive Doctors “The Fellowship was a really positive experience for me,” said P.T. Koenig, MD, a Sutter family medicine practitioner. “I’ve been the lead well-being champion for Sutter Medical Group for about two years now, and felt that I had a basic understanding of well-being issues but needed more. The Fellowship gave me more of an organizational viewpoint, rather than solely a focus on individual well-being, and emphasized that 80% of wellbeing is related to organizational and systemic factors.” Dr. Koenig said he also gained a fuller picture of substance abuse issues and challenges related to disruptive clinicians. He added that learning from what others are doing also helps to avoid re-inventing the wheel when it comes to implementing effective programs,
Faculty and members of the first class of fellows who completed program on clinician well-being. This year’s fellowship begins on April 18. which saves time and leads to a more effective use of resources. Keisuke Nakagawa, MD, who graduated from medical school in 2018, said he appreciated the wide perspective on the various physician well-being issues that can arise
burnout from an academic and practice-oriented lens.” Ruth Haskins, MD, the former president of the California Medical Association, cited “the interruption of laying on of hands and the erosion of one-on-one contact between
“Even during medical school, I now realize I had experienced episodes of burnout, but I didn’t have the self-awareness or the knowledge to realize it.” — Keisuke Nakagawa, MD as a medical career progresses. “It is so rare to have the opportunity to openly discuss physician burnout, personal struggles, and well-being issues on a weekly basis, especially with a faculty expert guiding the dialogue each session,” he said. “Even during medical school, I now realize that I had experienced episodes of burnout— but I didn’t have the self-awareness or the knowledge to realize it. I just tried to push my way through it. During this fellowship, I learned from experts, and read books and papers that helped me build a solid foundation for evaluating physician
doctor and patient” as the source of an increasing lack of career satisfaction among providers. “The Fellowship offered through UCD/UCI was exactly what I was looking for, both as an opportunity to dive deeper into the causes and solutions of physician burnout and as an enjoyable and valuable opportunity to learn how to teach my newfound skills and knowledge to others,” she said. Haskins chairs the Physician Wellness Committee at Mercy Hospital in Folsom and said her goal is to enable her colleagues and administrators to better support
each other by providing resources for help where needed. Engaging physicians in the decision-making processes, she explained, is a big step in bridging the disconnect causing discontent. Teaching, and learning from, such an able group of highly motivated Fellows was a wonderful experience for our team. We discovered that problems affecting clinicians were similar everywhere; the striking exception were the veterinarians, who have the constant trauma of having to euthanize their patients, many of whom they have known for years. This was a group of clinicians who really helped each other, interacted well, and rapidly jelled to become not just 17 strong individuals, but a collaborative group with plans to continue working on clinician health in the future and to teach their colleagues what they learned. Several of them have already volunteered to be faculty on the next course and the next group of students will undoubtedly benefit from their expertise. The second Train New Trainers Fellowship will start in April 2020. Tuition is $7,500 per fellow, and the curriculum includes 26 hours of CME credits. It begins with a weekend conference at UC Davis on April 18-19 and finishes September 30, 2020. The class includes one weekend teaching session, one hour per month mentoring sessions, and twice per month live, teleconferenced, case-based discussions. If you are interested in participating, visit https://health.ucdavis.edu/ psychiatry/education/fellowships/ phwb/fellowship.html or contact Jen Bannister, the program specialist, at clinicianhealth@ucdavis.edu. January/February 2020
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| ESSAY |
Learning About Life And Death in the ICU H
e lies before us, the heart monitor beeping, the ventilator inflating his lungs up and down. His eyes flutter behind the closed eyelids. Suddenly, he jerks, his eyes open and roll back, and his body shakes. His heart accelerates like a race car to 170 bpm. The virtual lungs on the monitor move like butterfly wings. As we watch, he becomes still again. The episode has lasted less than a minute. Standing against a corner table, I looked around, overwhelmed by the beeping bed alarms and the traffic of nurses moving back and forth. In a room across the hall, a large sedated man was being tucked into the bed while a nurse hooked him up to IV lines and a ventilator. My senior resident told us this new patient had a cardiac arrest while being transported and they had to do CPR. She had just examined him and the prognosis was bad. Just hours earlier, this man had gone to sleep after having ribs for dinner. He woke up in the middle of the night short of breath. He called his wife to get him his medications. She could not find them. He told her to call 911. When the EMTs arrived, he was fighting to breathe. They wheeled him onto the ambulance. Then his heart stopped. The EMTs started CPR and it took 10 minutes before they could get a pulse again. The door slides open and an old woman comes in. She wears a fitted denim jacket, jeans, and a cap. I ask her how she is and she responds, “I’m good! God is good. God is good. He will carry my boy.” Her boy is the 50-year-old man, Lenny, who lies sedated before us. I introduced myself. “I’m Mara. I’m a third-year medical student on the ICU team that is caring for your son.” She nodded, her face stoic as she looked at her son intubated and hooked up to beeping monitors. I assured her that the medical team was doing all we could do for Lenny. I could feel the somber heaviness as the winter sun diffused through the frosted glass doors, softening 26
Sierra Sacramento Valley Medicine
By Mara Ta Cao, MS III mtacao@ucdavis.edu
Lenny’s features. As I stood with Lenny’s mom, I wanted to know more about the man in front of me. I asked, “Where did Lenny grow up?” “Lenny grew up in Oakland,” she said. I told her I was from nearby Berkeley and I had spent much of my childhood in Oakland. As I listened to her talk about Lenny, I imagined him as a young man roaming up Broadway Avenue and crossing the vine covered gates of the California College of Arts, where he studied graphic design. I asked her what she did in Oakland. “I teach cosmetology, you know, make-up, at night at Laney College.” I once took painting classes at that same college. I told her my mom used to own a nail salon down by Alcatraz and Telegraph. She knew the exact corner I was talking about. My mom learned to do manicure while in a refugee camp in Sacramento long before I was born. She dreamed of one day owning her own shop and worked and saved her money until she was able to do so. My mom had to close her salon after the man who managed the snack store next door was shot and killed in a robbery, and after she and my aunt, who worked with her in the shop, were robbed by two men who entered pointing a gun at them. We talked about how Oakland had changed so rapidly in recent years, from a once run-down town with whole blocks of shuttered abandoned store fronts, to a city crowded with high rises and new apartment buildings, with more construction underway everywhere. I was in the ICU for two weeks. I checked on Lenny every morning during my rounds and talked to his mom, wife, and brother, who took turns standing vigil. I thought of my uncle, my mom’s brother, a heroin addict, who had died alone and abandoned in an alley way in Vietnam. I remember my mom receiving a letter about her brother’s death and saw her cry. Many people die alone with no one to hold their hands or close their eyes or whisper words of comfort
into their ears. I am not a religious person, nor do I know if there is anything that comes after we die, but I believe the last moments of a person on Earth should be accorded a measure of respect and dignity. A week later, I learned that a code blue had been called on Lenny overnight. He had lost all brainstem reflexes and his pupils were blown and nonreactive. The attending physician told us we would have to move toward declaring Lenny brain dead. To declare someone brain dead means the medical institution is no longer obligated to continue providing life support even if the family wants it. It means the person is legally dead. To make this determination, a brain death exam must be completed by two physicians, one of whom must be a neurologist or neurosurgeon. The neurologist must confirm that the patient has complete and irreversible cessation of brain function. The second confirmatory test, the apnea test, is done when ventilator support is removed; a positive test is defined by total absence of respiratory effort. Lenny never regained consciousness. The tests were administered. He did not pass either of them. His family made the decision to donate his organs. On my last day in the ICU, everyone lined up silently on both sides of the corridor for the Honor Walk as Lenny’s body was wheeled away to the operating room for organ removal, with his family marching behind.
New at the Museum By Bob LaPerriere, MD
The Medical Museum recently received a large donation from Dr. Rodger Shepherd of Oakland. It included numerous bronze medallions commemorating famous physicians, including this one for Santiago Ramón Y Cajal.
Santiago Ramón Y Cajal (1852-1934) A Spaniard and the father of modern neuroscience, Santiago Ramón Y Cajal specialized in neuropathology, neuroanatomy and histology. His artistic illustrations of the nervous system are elaborate and famous. Dr. Cajal shared the Nobel prize for Medicine and Physiology with Camillo Golgi in 1906 “in recognition of their work on the structure of the nervous system.”
Photos: Bob LaPerriere, MD
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Celebrate the Season Social On December 11, 2019 over 75 physicians and guests gathered at the El Macero Country Club in Davis to celebrate another great year for SSVMS and for the local physician community. Photos by Lindsay Coate
From left: Caroline Giroux, MD; George Meyer, MD; Amber Chatwin, MD; John Chuck, MD; Denali Tice, MD.
Medical students Andrew Escobar, Anna Acosta, Neel Brahme and Eric Jones.
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Joseph Jacobs and Ruenell Adams Jacobs, MD enjoy a cool yule.
Mark Drabkin, MD and Rick Vitancol, MD.
2019 SSVMS President Chris Serdahl, MD, Andrew Factor, MD and Adriana Factor.
Dale Smith, MD and Denise Satterfield, MD get in the holiday spirit.
Medical students (top, from left) Leah Uto, Anna Acosta, Neel Brahme, Melanie Hew, Eric Jones, Aasim Naqui with Brenden Tu, MD. Bottom: Medical students Jasen Tang, Derek Yip, and Andrew Escobar.
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Flow The next patient rooms as I leave the prior patient.
Flow The orders, diagnosis and note emerging from an MA scribe as the visit unfolds.
Flow Connecting the dots to esophageal spasm in a frustrated vegan woman with a negative Hida scan, cardiac eval, ER visit, labs and CT.
Flow The spontaneous “Yes” to the scheduled 5 p.m. wife of the 11 a.m. husband to be added in at the end of the morning.
Flow
Needed for excellence Needed for joy Needed for a sustainable career Needed for work life balance Elusive Transient Beautiful. — Andrew Hudnut, MD
Join the SSVMS Poetry Group! The Joy of Medicine creative writing and poetry group brings fellow physician-writers together to share poetry and short stories, and to provide literary feedback in a supportive environment. Group members meet periodically at a home or coffee shop. There are no submission restrictions and group members are encouraged to share writings from any genre. This group meets monthly and hopes to bring some balance to the very hectic lives of physicians and increase overall wellness as an individual. For more information or to join this group, email poetry_ joyofmedicine@ssvms.org.
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The first poetry group meeting drew Drs. Andrew Factor, Andrew Hudnut, Gerald Rogan, John Loofborouw and Caroline Giroux.
Dinner & Auction An evening to benefit the Sierra Sacramento Valley Medical Society Alliance Community Endowment Fund Live and Silent Auction
Hosted Bar Saturday, April 18, 2020 5:30 PM Del Paso Country Club
Join our growing list of sponsors! Patron Sponsor $5000 Mercy Medical Group Sutter Medical Group Peju Napa Valley Winery Sorelle Gallery Fine Art SSVMS Alliance
For more information and to purchase tickets, visit ssvmsa.org/events or call 916-718-2568
Masters Sponsor $2500 Dr. Pei-Hsiu & Mrs. Alice Huang Dr. Fred & Mrs. Linda Meyers Dr. Allen & Glenda Morris Drs. Gustavo & Mary Sosa Gore Technologies SSVMS
SSVMSA is a 501 (c) (3) not for profit organization
| BOARD BRIEFS |
Board Briefs December 9, 2019 THE BOARD: Received a report from Enid Gallegos, Account Executive for Cooperative of American Physicians (CAP). Approved the 2020 budgets for SSVMS, the Building Fund and the Community, Service, Education and Research Fund (CSERF). Approved the following recommendations for 2019 awards from the Scholarship and Awards Committee: David Kissinger, MD, Golden Stethoscope Award; Andrew Hudnut, MD, Medical Honor Award and the Sacramento Crisis Nursery for the Medical Community Service Award. Approved the 3rd Quarter Financial Statements, Investment Reports and Recommendations. Approved Jamie Baker & Company, an accounting firm, as a vetted vendor.
APPROVED THE FOLLOWING MEMBERSHIP REPORT December 2019 For Active Membership — Rawaa Almukhtar, MD; Ugochukwu Amadi, MD; Dennis Bechini, DO; Christopher Beyer, MD; John Bias, MD; Daniel Brink, MD; Alexander Chang, DO; Alex Chen, MD; Stephen Coppel, MD; Justin Curole, MD; Sarah Divittorio, MD; Tareq El-Qousy, MD; Rachelle Halasa, MD; Olivia Hoang-Kelada, MD; Hans Huang, MD; Abdulhalim Khan, MD; Jeffrey J. Lee, DO; Jason Lam, MD; Nathalie Lara, MD; Jonathan Laroya, MD; Mark Levine, MD; Stephanie Li, MD; Gil Magpantay, MD; Shirish Mahajan, MD; Theresa B. Manaloto, MD; Donna Mariano, MD; Zachary Marks, MD; Katherine Martineau, MD; R K McAfee, MD;Aklecia Mcvoy, MD; Nida Miniano, MD; Vicky Moy, MD; Daryl Munzer, MD; Scott Needle, MD; Jasmeen Randhawa, MD; Ben Rasmussen, DO; Valerie Renosto, MD; Renata Segal, DO; Lindsay Smith, DO; Kevin Smothers, MD; Denali Tice, MD; Kara Toles, MD; Alan Truong, MD; Dorotheea Warmerdam, MD; Ellen Yang, MD; Behnam Vahdati Nia, DO.
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For Reinstatement to Active Membership — Barbara Hull, MD; Paul Seites, MD; Jeffrey Sweat, MD; John Waring, MD. For Resident to Active Membership — Bjork OlafsdottirGardali, MD; David Roland, MD; Robert Rominski, MD; Nathan Vanden Berge, MD. For Resident Physician Active — Joshua Levy, MD For Multiple Membership — Marcy Ahrons, MD; Guadalupe Avila-Kirwan, MD; Michael Boyd, MD; Apeet Hundal, MD; Jeffrey Lee, MD; Katherine Lee, MD; Tennyson Lee, MD; Dan Merck, MD; James Nichol, MD; Karen Panek, MD; Narges Shariati Varnosfaderani, MD; John Youngblood, MD; Ethelwoldo Guerrero, MD; Andrew Oh, MD; Sanyukta Pawar, MD; Lily Chaput, MD; Afshine Ghaemi, MD; Veeraparn Kanchananakhin, MD; Karin Kordas, MD; David Mach, MD; Mohammad Malaekeh, MD; Thomas Maney, MD; Nesser Ramirez, MD; Mushfeka Sharif, MD; Alan Truong, MD; Yunli Zheng, MD. For Retired Membership — David Bayne, MD; Don Blythe, MD; Marie-Claude David, MD; David Manske, MD; Denyse Nishio, MD; Clarissa Tendero, MD; Robert Weston, MD; David Wolf, MD; Mark Ziegler, MD. For Resignation — Smita Awasthi, MD; Walter Boyd, MD; Michael Chew, MD; Lorien Dalrymple, MD; David Dawson, MD; Ghaneh Fananapazir, MD; Linda Farkas, MD; John Hunter, MD; Keith Jones, MD; Nicholas Lange, MD; Thaddeus Laird, MD; Surinder Mann, MD; Emanual Maverakis, MD; Javier Rodriguez, MD; Chandrasekar Santhanakrishnan, MD; Armine Sarchisian, MD; Jason Zhao, MD. For Transfer of Membership — Stephen Banks, MD (to Napa); Shelley Choi, MD (to Los Angeles); Salvador Guevara, MD Alameda-Contra Costa); Crystal May, MD (Alamenda-Contra Costa); Ramanjyot Muhar, MD; Katherine Katharine Ostedgaard, MD; Parminder Sidhu, MD; Patricia Tenold, MD; Wei Yang, MD; Michael Yen, MD. Deceased — Julian Fisher, MD; Roy Stanford, MD October 2019 For Active Membership — Marianne Abouyared, MD; Grace Amadi, MD; Edris Aman, MD; Maria Pia Anderson, MD; Mustafa Ansari, MD; Simon Ascher, MD; Reza Assadsangabi, MD; Katherine E. Barton, MD; Gagan Badhwar, DO; Norkamari Shakira Bandolin, MD; Alana
Beres, MD; Andrew Birkeland, MD; Orin Bloch, MD; Joey Boiser, MD; Allison Brashear, MD; Rebecca Brooks, MD; Colin Brown, MD; Olivia Campa, MD; Catherine Cansino, MD; John Du Cha, MD; Rinita Chakrapani, MD; Ling-Xin Chen, MD; Kayla A Cort, MD; Maneesh Dave, MD;Danielle Alexander D’Cruz, MD; Jeremy DeMartini, MD; Lee Donohue, MD; Imo Ebong, MD; Joshua Edwards, MD; Elizabeth Ekpo, MD; Bashir El-Khoury, MD; Bruce Espenshade, MD; Jennifer Fan, MD; Marcia Faustin, MD; Liliana Garcia-Vargas, MD; Michael Gibson, MD; Ammara Gill, MD; Regina Godbout, MD; Lindsey Goetz, MD; Brian W. Goldner, MD; Susan Gorman, MD; Brian Goudy, MD; Reshma Gupta, MD; Michael Han, MD; Harliv Hans, MD; AnneMarie Hargadon, MD; Marwah Helmy, MD; Melissa Hopkins, MD; Yihung Huang, MD; Vladimir Ivanovic, MD; Tiffani Johnson, MD; Helen Kales, MD; Lisa H. Kang, MD; Kiran Kanth, MD; Kevin Keenan, MD; Laura Kenkel, MD; Manoj Kesarwani, MD; Sky Lee, MD; Andrew Li, MD; John Lim, MD Allison Liu, MD; Nancy Luo, MD; Victoria Lyo, MD; Kirti Malhorta, MD; Joseph Marsano, MD; Kristy Mathes, MD; Steven Maximus, MD; Mina Momenin, MD; Christabel Moy, DO; Stanley Naguwa, MD; Kathryn Newell, MD; Adam Oesterle, MD; Sushma Pant, MD; Sapna Patel, DO; Bennett Penn, MD; Nisha Punatar, MD; Swati Rao, MD; Deepika Sankaran, MD; May Thu Saung, MD; Bahman Sayyar Roudsari,MD; Randall Schaefer, MD; Veronique Tache, MD; Steven W. Thorpe, MD; Olivia Tong, MD; Wesley Valdes, MD; Ingrid Wahjudi, MD; Hussein Warda, MD; Huixia Wei, MD; Susan Wilson, MD; Yan Zhao, MD.
For Reinstatement to Active Membership — Hilary Brodie, MD. For Change in Membership Status from Retired to Active — James Foerster, MD; Gibbe Parsons, MD; Michael Sim, MD. For Retired Membership — Roblee Allen, MD; James Boggan, MD; Terry Coates, MD; Kevin Coulter, MD; Jonathan Ducore, MD; David Gandara, MD; Eugenio Gerscovich, MD; Fredric Gorin, MD; Robin Hansen, MD; David T. Harrison, MD; Faith Fitzgerald, MD; Peter Franks, MD; Barbara Hays, MD; George Kaysen, MD; Joseph Leung, MD; Gary Levin, MD; Reginald Low, MD; Peter Moore, MD; Chung Yuan Mui, MD; Thomas Nesbitt, MD; Mary O’Hara, MD; Richard Pollard, MD; Pamela Prescott, MD; Carol Richman, MD; John Robbins, MD; Jay Solnick, MD; Arthur Swislocki, MD; Michael Tanaka, MD; Robert Weiss, MD; Richard White, MD; Jean Wiederman, MD; David Wisner, MD. Deceased — Stephen Heck, MD; David Naliboff, MD; Arthur Sugiyama, MD; Gerald Swafford, MD; Gerald Upcraft, MD.
Seeking Physician Mentors for Medical/PA Students Are you a physician willing to donate a few hours of your time to mentor medical, PA, and NP students? The Joan Viteri Memorial Clinic, a UC Davis School of Medicine student-run clinic, is searching for physicians to serve as mentors and preceptors to teach students from 10:30 a.m to 2 p.m. Scheduling is flexible, volunteer physicans are welcome to come as often as they desire. For more information, please contact jvmclinic@gmail.com.
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| NEW MEMBERS |
New SSVMS Members
The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Carol Kimball, MD, PresidentElect.
New Active Members
*Physician specialty abbreviated following name.
Rawaa Almukhtar, MD, D, The Permanente Medical Group Ugochukwu Amadi, MD, HOS, The Permanente Medical Group Dennis Bechini, DO, FP, UC Davis Medical Group Christopher Beyer, MD, OBG, The Permanente Medical Group John Bias, MD, FP, UC Davis Medical Group Daniel Brink, MD, FP, UC Davis Medical Group Alexander Chang, DO, EM, The Permanente Medical Group Alex Chen, MD, EM, The Permanente Medical Group Stephen Coppel, MD, HOS, The Permanente Medical Group Justin Curole, MD, FP, UC Davis Medical Group Sarah Divittorio, MD, OBG, The Permanente Medical Group Tareq El-Qousy, MD, IM, UC Davis Medical Group Rachelle Halasa, MD, EM, The Permanente Medical Group Olivia Hoang-Kelada, MD, PD, UC Davis Medical Group Hans Huang, MD, IM, The Permanente Medical Group Abdulhalim Khan, MD, FP, The Permanente Medical Group Jason Lam, MD, IM, The Permanente Medical Group Nathalie Lara, MD, P, The Permanente Medical Group Jeffrey J. Lee, DO, FP, UC Davis Medical Group Jonathan Laroya, MD, EM, The Permanente Medical Group Stephanie Li, MD, OM, The Permanente Medical Group Gil Magpantay, MD, AI, Sutter Medical Group Shirish Mahajan, MD, ON, Sierra Hematology and Oncology Theresa Manaloto, MD, FP, Mercy Medical Group Donna Mariano, MD, FP, The Permanente Medical Group Zachary Marks, MD, IM, UC Davis Medical Group Katherine Martineau, MD, FP, The Permanente Medical Group
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R.K. McAfee, MD, FP, UC Davis Medical Group Aklecia Mcvoy, MD, FP, The Permanente Medical Group Nida Miniano, MD, FP, UC Davis Medical Group Vicky Moy, MD, OBG, The Permanente Medical Group Daryl Munzer, MD, FP, UC Davis Medical Group Scott Needle, MD, PD, Elica Health Centers Andrew Oh, MD, IM, UC Davis Medical Group Bjork Olafsdottir-Gardali, MD, EM, The Permanente Medical Group Jasmeen Randhawa, MD, Internal Medicine, UC Davis Medical Group Ben Rasmussen, DO, IM, UC Davis Medical Group Valerie Renosto, MD, HOS, The Permanente Medical Group David Roldan, MD, FP, The Permanente Medical Group Robert Rominski, MD, EM, The Permanente Medical Group Renata Segal, DO, IM, UC Davis Medical Group Paul Seites, MD, FP, UC Davis Medical Group Lindsay Smith, DO, FP, UC Davis Medical Group Kevin Smothers, MD, IM, Sutter Health Jeffrey Sweat, MD, PS, J. Sweat Plastic Surgery Denali Tice, MD, P, Private Practice Kara Toles, MD, EM, UC Davis Medical Group Alan Truong, MD, IM, UC Davis Medical Group Nathan Vanden Berge, MD, EM, The Permanente Medical Group Behnam Vahdati Nia, DO, FP, Woodland Clinic Medical Group Dorotheea Warmerdam, MD, OPH, Med Vision Technology Medical Group Ellen Yang, MD, FP, UC Davis Medical Group New Resident Physician Active Member Joshua Levy, MD, FP, UCD
Joy of Medicine Daniel Rockers, PhD (916) 273-1740 daniel.rockers@gmail.com
Amy Ahlfeld, PsyD (916) 799-3866 drahlfeld@gmail.com
Patricia L. Bach, PsyD, RN (916) 662-0767 pbachpsd@gmail.com
Kathy James, ThD (916) 549-9363 mamaesther@me.com
P syc h o lo g i sts
Lori Roberto, PhD (916) 206-1741 drlori@drloriroberto.com
Marcella Kreysa, PsyD (916) 672-0870 drkreysa@gmail.com
Resiliency Consultations Recognizing the crushing stress and workload that physicians face, SSVMS sponsors up to six (6) wellness sessions with vetted psychologists and /or life coaches for physicians in Sacramento, El Dorado, Yolo, and Placer Counties. To schedule an appointment, contact a Vetted Provider directly and mention that you are accessing the SSVMS Joy of medicine Program.
Poetry and Creative Writing Group
Monthly Physician Peer Groups
Share your poetry and short stories with other physician writers! Submit a poem or short story to poetry_joyofmedicine@ssvms.org.
Joy of Medicine is providing physicians with the opportunity to meet with a group of colleagues.
There are no submission restrictions and group members are encouraged to share writings from any genre.
Angela Trapp (305) 962-1936 3coaching.cc@gmail.com
L if e Co a c h e s
Physician Meetups
Michael Parr, MD (916)761-1838 msparr@msn.com
Group sessions are facilitated by a Joy of Medicine coach and they meet monthly in a local physician's home. To join a group, contact Sam Mello at smello@ssvms.org or call 916-452-2671
JoyofMedicine.org
Steve Seay (916) 715-9252 stevendseay@gmail.com
Confidential Convenient Competent Cost-Free
Davis Peer Group 1st Thursday El Dorado Hills Peer Group 2nd Tuesday Newcastle Peer Group 2nd Wednesday Rocklin Peer Group Last Tuesday Elk Grove - Host Needed!
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Contact SSVMS to Access Your
M e m b e r O n ly B e n e f i t s
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
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TH
FEBRUARY
ELKS TOWER
SACRAMENTO