Sierra Sacramento Valley
Sierra Sacramento Valley
PRESIDENT’S MESSAGE ”My Doctor Says...”
Two Related Posits
Richard Jones, MD
Juror Number One
EDITOR’S MESSAGE The 2007 Essay Contests
Marion Leff, MD
Voices of Medicine
John Loofbourow, MD
Del Meyer, MD
EXECUTIVE DIRECTOR’S MESSAGE Dr. Green’s Gift for Medical Student Scholarships
Eleanor Rodgerson, MD
PTSD in Afghanistan and Iraq War Veterans
Reflections on Electronic Medical Record Systems
Emily Keram, MD
Eduardo Bermudez, MD
New SSVMS Committees
Penicillin in the Vein
Robert LaPerriere, MD
Kent Perryman, PhD
“Taken to the Outlet”
Student Essay Announcement
Marlene M. Mirassou, MD
To Sail a Wheelchair
Gilbert Wright, MD
Special online article with this issue at www.SSVMS.org: Dr. David Gibson and Jennifer Gibson review the three major efforts to reform health care.
We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.
SSV Medicine is online at www.ssvms.org/magazine.asp
This watercolor of Chinese pots, painted three years ago, is the first in a series of covers by Barbara Arnold, MD. It is an unusual subject for her — she typically paints outdoor scenes and sees this as a study in color and texture, capturing 19 pots from among hundreds stacked on a factory floor.
Volume 58/Number 1
Dr Arnold is an ophthalmologist who uses microsurgery in her work. She feels that the arm movements for tiny surgical incisions are in much of the same rhythm as the brush strokes for larger paintings; these common movements originate from the shoulder.
5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax email@example.com
Official publication of the Sierra Sacramento Valley Medical Society
Her patients appreciate a restoration of color vision following surgery, and color values are important in her paintings. This watercolor is 18 x 30 inches on 300-pound cold press Arches cotton rag.
January/February 2007 1
Sierra Sacramento Valley
MEDICINE 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. 2007 Officers & Board of Directors Richard Jones, MD President Margaret Parsons, MD President-Elect Kuldip Sandhu, MD, Immediate Past President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Charles McDonnell, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD 2007 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Barbara Arnold, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Tom Ormiston, MD At-Large Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Margaret Parsons, MD Charles McDonnell, MD Robert Midgley, MD Janet O’Brien, MD Richard Pan, MD Earl Washburn, MD
District 4 Ulrich Hacker, MD District 5 Eduardo Bermudez, MD David Herbert, MD Elisabeth Mathew, MD Stephen Melcher, MD District 6 Marcia Gollober, MD Alternate-Delegates District 1 Robert Kahle, MD District 2 Samuel Ciricillo, MD District 3 Ken Ozawa, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Craighton Chin, MD At-Large Alicia Abels, MD Christopher Chong, MD Marcia Gollober, MD Robert Jacoby, MD Anthony Russell, MD Kuldip Sandhu, MD Jeff Suplica, MD
CMA Trustees 11th District Joanne Berkowitz, MD Dean Hadley, MD Solo/Small Group Practice Forum Lee T. Snook, MD Very Large Group Forum Paul R. Phinney, MD Council on Scientific Affairs Allan Siefkin, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor David Gibson, MD, Vice Chair William Peniston, MD Robert LaPerriere, MD Eleanor Rodgerson, MD Gordon Love, MD F. James Rybka, MD John McCarthy, MD Gilbert Wright, MD Del Meyer, MD Lydia Wytrzes, MD George Meyer, MD John Ostrich, MD Medical Students Robin Telerant
Managing Editor Webmaster Graphic Design
Ted Fourkas Melissa Darling Kelly Davis, Sol Design
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. ©2006 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 Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.
Sierra Sacramento Valley Medicine
“My Doctor Says…” By Richard Jones, MD Recently I was talking to a friend of mine. He is an accomplished, well respected, nationally known physician, self-assured and wise to the ways of the world. I asked him about his health and expected to hear a sarcastic, unabashed and not too humble self diagnosis. But what he actually said surprised me. He quietly and sincerely answered, ”Well, my doctor says...” “My doctor says…” How often is that phrase repeated, on television programs, commercials, and in the media? It can almost seem a cliché. So when I heard my strong willed physician friend declare, “My doctor says,” it triggered a realization of the respect and power physicians possess while also highlighting the vulnerability and dependency that we experience when we are the patient. So what is it that inspires millions of people daily to have the confidence in what their doctor says? How do our professional organizations, like the CMA and SSVMS, shape that philosophy and preserve the solemnity of those words, ”My doctor says…“? First and foremost, we as doctors have a personal responsibility to our patients. We have to be competent, compassionate, conscientious and communicative. A good doctor doesn’t just cure, because cures can come despite our intervention. A good doctor isn’t simply a great diagnostician, because a diagnosis without a solution is morbidity. A good doctor isn’t one who knows the most scientific details, because there is still so much not known; and a good doctor is not just caring, because sympathy and compassion alone will not fix a sick body. A good doctor is the mélange of all these and more. On a societal level, we have to advocate for the betterment of public health. We must formulate policy and legislation that achieve a
health care delivery that is advanced, affordable, and accessible to all. By piloting public health care policy, we can refute the axiom, “If you truly want to practice medicine, become a politician.” But what have CMA and SSVMS done to enhance our practices of medicine and advocate for improved healthcare? Since 1860, from the despair of a cholera epidemic in which 17 local Sacramento physicians died caring for the afflicted, our society has answered that question beginning with its incarnation as the Sacramento Society for Medical Improvement (SSMI). Statewide within the CMA, excellence in medical care is promoted in many arenas. It is ensured by the CMA Institute for Medical Quality, keeping the standards high for healthcare facilities. The CMA Foundation, the charitable arm of the CMA, reaches out to improve community based healthcare. In the CMA there are numerous public health advisory committees, over 500 members of the CMA House of Delegates and Trustees, CALPAC, specialty, and ethnic societies and, many, many other groups and staff all devoting countless hours of time and resources to improving social health. At our local level in SSVMS, health is served by the committed efforts of SPIRIT Program volunteers, participants in Adopt-a-School, members of Committees on Public and Environmental Health, Child and Adolescent Health Services, and Emergency Care. We have been active in planning for disaster relief, bioterrorism, correctional medicine and working with local governmental agencies in a non-partisan manner to facilitate a common sense public health care policy. Community healthcare outreach is also greatly assisted by the faithful efforts of the SSVMS Alliance.
We order blood tests, we get phlebotomized, we prescribe medication, we gasp at our pharmacy bill, we recommend colonoscopies; we get colonoscopies and wonder why we recommend them!
We physicians not only must minister to our patients at a personal and societal level, but attend as well to the non-economic integrity of our profession. Politically based intrusions into medicine such as scope of practice legislation, mandated non-relevant CME, Medical Board over-zealotry, and dishonesty and unscrupulousness within our own ranks; all are assaults upon the integrity of our profession that must be repelled. We have to innovate and drive the science of medicine and health care policy forward. We cannot become a “Detroit of Doctors,“ losing market share, power and influence through defensive, dated dogma. The adage innovate or die holds literal truth in medicine. All of us have a duty to learn and advance new treatments, therapies, and more cost efficient ways to proffer medical care. It is through the many legislative, judicial, and scientific efforts of the CMA and SSVMS that we preserve the integrity, ethics, art and science of medicine. Technical advisory committees, strong affiliations with specialty societies, educational outreach through sponsored CME, Judicial, and Professional Conduct committees all maintain that probity. From this environment patients can have faith in a safe product that is undergoing vigilant refinement and scrutiny which can educe that trust exhibited in their saying, “My doctor says… “ We as trusted doctors are not only responsible for our patient’s health, societal health and our profession’s health, but also our personal and financial health. We have studied hard, forfeited time and youth and struggled to the pinnacle of academic excellence. We amass tremendous debts and work formidable hours in both training and eventual practice. We have long days, have high overhead, chaotic clinics; stressful surgeries, make life and death decisions daily, and yet we still have families to support and nurture. Nationally, it is estimated that administrative costs of healthcare are almost 25 percent while doctors’ service fees are only 20 percent. We deserve and should expect adequate compensation. If medical practice cannot be economically attractive, less capable talent will be left to care for the public. Thus indirectly, our own personal
Sierra Sacramento Valley Medicine
and economic self interest is critical to the health of our nation. CMA focuses extraordinary attention to these issues like MICRA, keeping costs of liability insurance down, stopping Medicare and MediCal cuts, preventing insurance malfeasance as in the revolutionary CMA-led RICO settlements, and many other economic initiatives saving physicians tens of thousands of dollars annually. These efforts also keep small practices and community clinics viable to continue aiding the indigent and the underserved. My mother once told me she was tired of listening to organ recitals. I wasn’t sure what she was talking about until recently when my wife, colleagues and I began lamenting our growing list of minor maladies — yes, our organ recitals! Will we have a choice of competent doctors, well-equipped hospitals, and new medications for us when we need them? Will Medicare even exist after all those years of tax contributions? Thus we are not just doctors, we are patients too! We are in the unique position of being deliverer and recipient of health care. We order blood tests, we get phlebotomized, we prescribe medication, we gasp at our pharmacy bill, we recommend colonoscopies; we get colonoscopies and wonder why we recommend them! We prevent sickness, we get sick, we send patient bills, we pay bills, we buy expensive health insurance, we get limited access to care, we usher in new life in hospitals, we will lie and may die in hospitals. Accordingly, we have a compelling vested stake in improving the quality and affordability of medicine. “My doctor says.” Reflect upon that simple statement. It is a metaphor about patients’ confidence in their doctors, inculcated by the promotion of the art, science and public health care achievements of our colleagues in the national, state and local medical societies past present and future. “My doctor says…” You should follow this prescription: “Be active in organized medicine. It is good for the public’s health and good for you!” firstname.lastname@example.org
The 2007 Essay Contests The inside back cover provides additional information.
By John Loofbourow, MD The SSVMS Board of Directors recently approved and laid out procedures for a $500 essay contest proposed by the Editorial Committee. Subsequently a matching donation doubled that amount, allowing us to invite two classes of competitors: junior/senior high school students; and medical student/residents. Bill Sandberg and David Gibson met with several high school administrators, who offered suggestions. The committee bounced many email revisions of the announcement back and forth until reaching a final draft. In early December 2006, invitational letters and announcement posters were sent to high schools in our three counties. Email notices were sent to UCD medical students/resident members. In addition, all physician members whose emails are current1 were emailed the announcement for high school students, so they might alert friends, family, or others whose children might want to participate. In both cases, the important dates and details are the same: • Entries must be received by 5:00 p.m. on April 4, 2007. • The winning essay will be announced April 30, 2007. • The winning essay will be published in Sierra Sacramento Valley Medicine. • The winning author will be awarded $500. The announcements are summarized on the inside back cover. Complete announcements and guidelines are posted on the SSV Medicine web site at www.SSVMS.org. Editorial Committee members realize that the topics are not simple. Yet these questions are seminal in determining the future of medicine for those who will write the essays, and for the
rest of us as well. We are confident that there are those who will address these essay topics with determination and skill. While announcements were sent only to local students and UCD medical students/residents, competition is not limited to them. It would be unfair to exclude, for example, a member’s grandchild who lives in West Virginia. Furthermore the topic for medical students/residents is global2; it’s a big world with big problems. There is a risk that no one will write at all in a world stupefied by TV. Yet we still value the written word, even if it is sometimes only apparent in text messaging or drama.3 This essay contest is our modest effort to assist in a literary code blue, and at the same time to reach out to our members and to the world we live in. email@example.com 1 If you didn’t get an email notice, we may have an obsolete address, or one you don’t use. If that seems to be the case, contact Melissa Darling at the Medical Society or at MDarling@ ssvms.org to update your file. Email is the most economical and most efficient way we can communicate. 2 See Dr. George Meyer’s review in our last issue of the AMA publication, ”Awakening Hippocrates,” by Edward O. O’Neil. Also, Tracy Kidder’s Award winning book about Paul Farmer and Jim Kim, ”Mountains Beyond Mountains.” 3 A Dec. 1, 2006 Sacramento Bee article reported on a world wide competition for the Guinness record in text messaging. Ang Chuang Yang, 16, of Singapore nosed out Ben Cook of Provo, Utah in thumbing 162 operations within 42 seconds, about 3.9 operations per second. There could be no mistakes, including periods and capitals, and no abbreviations in the following text about piranhas: The razor toothed piranhas of the genera Serrasalmus and Pygocentrus are the most ferocious freshwater fish in the world. In reality they seldom attack a human. People’s capacity to develop new skills is simply incomprehensible and unpredictable, particularly when disguised as a teenager.
Dr. Green’s Gift for Medical Student Scholarships By Bill Sandberg Sydney H. Green, MD, a psychiatrist, joined the Medical Society in 1948 and was in private practice until his retirement in 1979. In planning his estate, Dr. Green took time to ponder what he would do with his accumulated wealth. Certainly, he wanted to provide for his wife and family. But he also decided that if there were funds left in his trust after his wife passed away that those funds should be split evenly among six local organizations. Once in an informal conversation with his friend, Richard Johnson, MD, who served as President of this Medical Society in 1978 (and was a long time editor of this magazine), he asked for advice on organizations to which he might leave the remainder of his trust. Among the organizations they discussed was the William E. Dochterman Medical Student Scholarship Program1. Dr. Green died in 1988 and his wife, Pearl OsofskyGreen, passed away in October 2006. Just three days before Christmas, SSVMS received a check for $100,000 as our share of the remainder of Dr. Green’s estate. Since 1967, our Medical Society has awarded 156 scholarships to deserving medical students who have attended or graduated from high schools in El Dorado, Sacramento and Yolo Counties (a requirement for scholarship consideration). A number of those students have returned to establish their medical practices here and have become members of our Society. In 1987, the Scholarship Fund was renamed in honor of William E. Dochterman, who served as executive director of the Society for 25 years.
Sierra Sacramento Valley Medicine
It was Bill Dochterman who helped establish the program with funds left over from the Society’s “Salk Vaccine Campaign Against Polio” when we inoculated our entire community of 250,000 people over two very busy weekends in 1962. In the 30 years since our first scholarships, we have received some memorial gifts and a few small bequests to the Scholarship Fund, but our endowment has not grown as much as we would like. Dr. Green’s gift will add a hefty amount to the fund, and we hope it will inspire other members to follow the lead of Dr. Green. firstname.lastname@example.org 1 For more information and scholarship applications visit http:// www.ssvms.org/scholar.asp. The scholarship program is one program in the Society’s Community Service, Education and Research Fund, a separate tax exempt 501 (c) (3) corporation see http://www.ssvms.org/cserf.asp.
Recipients of SSVMS Medical Education Scholarships name year awarded Algeo, Stephen 1974 Alzate, Gregg, D. 1978 Andya, Michael, D. 1987 Applegate, Kimberly, E. 1985, 86 Baker, Molly, M. H.* 1984, 85 Barber, Wayne 1974, 75, 76 Beard, Ursula 1997 Berez, Paul, B. 1977, 78, 79, 80 Brown, Jeffrey, W. 1983 Bobolis, Kristie Ann 1982 Buechel, Severon 1968 Carroll, Patrick, T. 1986 Causin, Mark, A. 2000 Chaffin, Michael Ellis 1971 Chapman, Jerolyn, R. 1983 Cheung, Winnie, W. 1997, 98 Chu, George, M. 1980 Clark, Lauren 1975, 76 Compoginis, John, M. 2003 Connelly, Lloyd, G. 2003, 04 Criswell, Garrett, R. 2002 Dalton, Marcie, M. 1986 Dennings, Robin, M. 1990, 91 Dhillon, Tina, J. 1996 Fong, Tiffany C. 2004, 05 Force, Sandra, K. 1984, 86 Fujiwara, Paula, I. 1980, 81, 82 Gardner, Lori, D. 1988, 89 Ghilarducci, Mark, J. 1982, 83, 84 Gibbons, Suzanne, I.* 1985 Gillott, Douglas, L. 1989, 91 Hachigian, Gregory 1979, 80, 81 Hammel, Elizabeth, M. 1992, 93, 94, 95 Hammel, James, F. 1998, 99, 00, 01 Harris, Elaine, C. 1984, 85 Henson, Robin, B. 1983 Hongkham, Alex S. 1998 Hubbard, Stephen, T. 1971, 72 Ichiho, Henry 1967 Jensen, David, F. 1981, 82 Jones, Davis S. 1971 Jones, Erin 2006 Keh, Benjamin* 1974, 75 Keller, Lia, C. 1986, 87, 88, 89 Krivoshto, Irina 2005 Kwong, Norra 2004 Leclaire, Maureen, A. 1982
name year awarded Lin, Vernon, Wen-Hau 1985 Lingle, Jerry 1967 Locke, Carol A. 1984 Madigan, Kevin Steven 1986, 87, 88 Madraigo, Erin, J. 2000 Mao, Amy 2002 Martin, Barry 1973 McClain, Deborah, A. 1974 McCoy, Ronald D. 1985 McGettigan, Jr., John W. 1976, 77 Meehan, Michael, C. 1972 Miller, Timothy R. 1996, 97, 98 Morris, Victor, A. 1988, 89 Morrisroe, Shelby, N. 1999, 00 Ngueyn, Kim Lien T. 2001, 02, 03, 04 Ngueyn, Tran, H. P. 1992 Noguchi, Geary* 1995, 96, 97 Nova, Victor 1973, 75 Nugent, Kevin P. 1982, 84 Okumu, Kris, A. 1997, 98, 99, 00 Ong, Elaine K. 1991, 95 Ong, Elisa 1994 Ong, Yvonne, K. 1993 Pimstone, Daniel, J. 2001 Phillips, Cheryl, L.* 1983 Pilcher, David, W. 1992, 93, 94 Reiser, Karen 1973 Ronquillo, Ricardo 1986 Sachs, Robert, L. 1972 Samuel, Peter â€œRockyâ€? 2006 Sanden, Roderick, G.S.* 1978 Sandhu, Sujan K. 2004, 05 Scanlon, Graham, C. 2003, 04 Sheffler, Lindsey 2006 Simmons, Andre, M. 1979 Skolness, Erin, M. 2003 Sloan, Robert 1986 Smith, Laura, L. 1989 Taylor, Sherry, L. 1986 Torabian, Sima Z. 1998 Tran, Quy, N.H. 1999, 00 Wing, Vivian 1976 Valle, Yolanda H.* 1977, 78 Vanderwagen, William 1976 Vang, Chor 2005 Yen, Lester, J. 1982, 83 Yu, Kin-Hung P. 1984, 86, 87 * current SSVMS Member
Reflections on Electronic Medical Record Systems Adios Dr. Osler and Bienvenido Scottie?
By Eduardo Bermudez, MD During my medical training, attendings emphasized the importance of direct observation of the patient in making a diagnosis. Paying attention to body language and nuances in eye contact were as much a part of making a diagnosis as listening to the patient’s symptoms. It was not just what the patient said, but how the patient said it that would allow you to determine what these symptoms meant. However, about two years ago our medical group invested in an electronic medical record system, called Epic, aka, Health Connect. It is a complete electronic system for medical records, billing, and laboratory tests. It is integrated into every department so that one can order labs, X-rays, or obtain results, medical records and make appointments from any terminal. It requires that we input our notes and all of our requests directly into the computer. It claims to improve the quality of health care, since patients will no longer have to carry slips back and forth, or risk losing them. In addition, there will be less risk of misinterpreting what is requested since no one has to try to decipher a doctor’s handwriting. Furthermore, doctors should no longer have to wait for a chart or struggle through the inevitable lab value that didn’t make it back on the chart or, worse yet, try to find a lost chart. Doctors are able to e-mail lab results directly to their patients, and patients benefit from scheduling their own
Sierra Sacramento Valley Medicine
appointments at the time most convenient for them. They can send e-mails directly to the doctor, who can make timely responses. However, I felt anxious about the changes that would occur in my practice style. In the past, when I walked into the exam room, I would shake the patient’s hand and sit down directly in front of the patient, giving my full attention and making direct eye contact. Now I walk into the exam room, greet the patient, and quickly divert my gaze to the computer to enter the necessary password and pull up the patient’s record. Although it only takes a few seconds to punch the keys, it feels uncomfortably long. While I am typing, the patient will invariably ask me a question or attempt to continue the conversation. However, since I am concentrating on putting in the right numbers, my attention is divided and I struggle to keep track of what the patient is saying. Often I try to ease the awkwardness by asking the patients if they like the new system. Most of the younger patients seem to empathize with my dilemma, as they are going through similar changes in their own offices. The older patients seem uneasy, but are also proud that I am keeping up to date with the new technology. Others seem annoyed as they do not have a computer and have no interest in getting one. As I try to focus on getting a history, I am simultaneously trying to type the information into the computer. After all, I cannot keep interrupting the flow of the conversation because I
have to finish typing the last sentence, pull up a lab, or an X-ray report. At the end of the visit, I have to type in orders for the pharmacy, or for any tests. Usually during this time, the patient will start a side conversation with a casual “By the way...” and then I am compelled to enter yet more data into the medical record. Before the visit is finished, I can pull up and print out a list of instructions on the patient’s disease. For instance, there are sheets on HTN, DM or cholesterol. The patients seem to be in awe of the amount of information they receive. In addition, they are impressed that they do not have to carry papers to the lab, or to X-ray, or prescriptions to the pharmacy. It is all done electronically. When the visit is finished, I go back to my office to try to type up the encounter for the medical record. However, I am usually sidetracked in the hall by some busy nurse or medical assistant with a lab or order that needs my “electronic signature” In the past, I would just quickly scrawl my signature on the paper. Now I have to go into the computer, type in my password, enter several more keystrokes to get to the right screen and sign the order. As I wait for the next patient to be roomed, I try to type my note, but find I am again interrupted by the phone or other messages. I have difficulty typing my note, and concentrating on these distractions, so it takes a long time to finish. As I walk down the hallway, I notice the medical assistants and nurses also typing on a computer. I feel guilty about interrupting them because of my own dislike for being interrupted when I am online. Everyone seems to be very busy on the computer because there are so many things waiting to be done. Labs and X-rays need to be e-mailed to patients, messages sent or routed. I receive messages from the call center that require a typed response which I will either e-mail in reply, or will call the patient and type another note to document the telephone conversation. Secure Messages is a system that allows the patient to directly e-mail the physician without having the message screened by a medical assistant or nurse. Often the patient’s request is simply
to get the results of a lab or X-ray. However, often patients request detailed explanations about their disease. or they ask about some new symptoms which require a diagnosis. For complicated e-mails, I ask the patient to schedule an appointment, but they often e-mail back and just ask me to prescribe a medication. Obviously, this is more convenient for the patient, but it is more time consuming for me, and pressures me to make a diagnosis without a full exam. Wondering how others felt about computers at work, I searched for studies regarding the issue. Interestingly, these articles show that patients have a positive response to clinician use of computers in the exam room. It allows them to feel more connected to their doctor.
As I wait for the next patient to be roomed, I try to type my note, but find I am again interrupted by the phone or other messages. I have difficulty typing my note, and concentrating on these distractions, so it takes a long time to finish. The clinician initially feels inefficient with the system.1 One study2 found that the “initial” visit took about 37.5 percent longer (10 minutes) with the computer than without, while, followup visits took about the same time. Another article3 found there were four domains affected by computer use. (1) Spatial — effect of the physical presence and location of computers on the interaction between the physician and the patient. A fixed computer in the exam room limited the physician’s mobility, but computers with mobile arms were preferred by patients and physicians. (2) Relational factors — perceptions of physician and patients about the computer and how those perceptions affected its use. If a patient presented for a brief visit such as URI or UTI, etc., the clinician would generally finish the note in the exam room. However, if the visit was complicated or emotional, the clinician would generally ignore the computer and focus on the patient.
Physicians had several styles in relation to their use of computers: (A) Information-focused physicians sat in front of the computer and used computer-guided questions to focus on the problem oriented details. (B) Physicians with an interpersonal style either sat or stood away from the computer or faced the patient using the mobility of the computer. (C) Physicians with managerial styles alternated their attention in defined intervals between the patient and the computer. (3) Educational factors — developing a physician’s proficiency with and improving patient’s understanding about the electronic medical system. Physicians may need to improve typing skills and also need to know how to navigate the Internet or learn more computer skills.
I ask myself whether that terminal in the room will improve patient-doctor interactions, or if we will spend more time trying to get data out of and into the computer than getting information out of and into the patient. Also, there is a need to educate the patient on the use of the computer to improve the interaction in the office visit. (4) Structural factors — institutional and technological forces that influence how physicians perceived their use of the electronic medical records. Monetary factors played a prominent role in deciding if a physician typed or dictated office notes. Typing was less expensive. Physicians using templates developed notes that lacked depth and intricate details, producing “cookie cutter” notes. Despite problems, electronic records are easier to read, and allow improved access to labs and X-ray reports. There is less duplication of tests because results are less likely to be lost. It lends to better tracking of diagnosis, treatment, and outcomes for visits. In addition, improved coding should lead to better reimbursement. Some physicians felt that there was improvement in communication between providers
Sierra Sacramento Valley Medicine
because they could send e-mails. In general, the overall amount of time spent by physicians may increase, but the electronic medical record seems to benefit ancillary providers. My concern is that I do not want to lose my identity and personal patient contact to the medical record. I ask myself whether that terminal in the room will improve patient-doctor interactions, or if we will spend more time trying to get data out of and into the computer than getting information out of and into the patient. We are not looking at the extra physician time required to provide these extra electronically mediated services. Our group has provided us with laptop computers so that we can bring home the work we are unable to finish in the office. We need to address the extra physician time spent in responding to e-mail, ordering tests, or signing orders electronically. Doctors need extra time to handle the added load of e-mails, which can pile up without restriction, as compared to the limited time afforded by an answering machine. What are some solutions to enhance the interaction between the patient, the doctor, and the computerized exam room? I found at least one answer: I need to LEVEL myself. According to one article1, a suggestion is to: L — Let the patient look at the computer with you. E — Eye contact with the patient. V — Value the computer as a tool. E — Explain what you are doing. L — Log off and say so when you do. Only the future will tell what these changes will bring. Obviously the technology is here to stay, but we still need to determine at what cost. I am logging off! email@example.com 1 Shaboch, Joanne, MBA, Mann Ward R., “FNP Computer in the Exam R oom. — Friend or Foe” The Permanente Journal, Fall 2004: Vol 8(4) 2 McCall Gregory, PhD Curry Raymond, MD Tang Paul, MD “The Use of Electronic Medical Records. Communication patterns in Outpatient Encounters.” JAMA Med Inform Assoc. 2001 NovDec: 8(6):610-615 3 Ventres William, MD Kooienga Sarah, FNP et al “Physicians, Patients, and the Electronic Health Record: an Ethnographic Analysis” Annals of Family Medicine 4:124-131 (2006)
Penicillin in the Vein By Robert LaPerriere, MD This article is adapted from a presentation at a recent Sacramento County Historical Society event on “A Taste of History.” Through a chance observation in 1928, Alexander Fleming discovered that colonies of Penicillium mold growing in his bacterial cultures were able to stave off infection (due to the production of an antibacterial molecule known as penicillin). The name Penicillium comes from penicillus, or brush, based on the brush-like appearance of the fruiting structures. Penicillin and other beta-lactam antibiotics (named for an unusual, highly reactive lactam ring) have few side effects apart from allergic reactions in some people, because the penicillin attacks a process unique to bacteria and not found in higher organisms. The enzymes attacked by penicillin are found on the outside of the cytoplasmic membrane surrounding the bacterial cell, so the drugs can attack directly without having to cross this strong barrier. Penicillium notatum produces penicillin. Penicillium roqueforti produces blue cheese. Penicillium glaucum produces bleu cheeses including Gorgonzola and Stilton. Penicillium candidum produces white mold cheese and a white rind in some cheeses. The spores in Penicillium often contain blue or green pigments which give the colonies in cheese their characteristic color. The three most common blues are Roquefort (from France, 1070 AD), Gorgonzola (879 AD from Italy) and Stilton (from England, 18th Century). Another blue cheese, Maytag, was developed in 1941 and is made in Iowa by members of the washing-machine family, which also produces Anchor Steam Beer in San Francisco. Another variety is Danish blue cheese.
More local blue cheeses would include Pt. Reyes Original Blue by Point Reyes Farmstead Cheese Company and a blue cheese by Cowgirl Creamery. The earliest production of blue cheese west of the Mississippi was in 1956 by Rogue Valley Creamery in Oregon. There are well over 70 varieties of blue cheese. Until quite recently, the process of introducing mold to these cheeses was left to Mother Nature. Blocks of Roquefort were actually held in ancient caves where the mold lived! Today the mold spores are usually mixed with the milk or the curd during cheese making. Enzymes in the mold that eat and digest milk fat are responsible for the unique flavor of blue cheese. Over time, the mold penetrates the cheese causing ”veins” to form and the cheese to become crumbly. Roquefort is made from sheep’s milk, although other blues around the world are made from the milk of cows and goats. Maytag is made with cow’s milk and Penicillium roqueforti. The Roquefort name can only be used legally for cheese made by the traditional method in a specific place. firstname.lastname@example.org A Penicillium mold from a bleu cheese, cultured and photographed by Editorial Committee member Dr. Gordon L. Love.
January/February 2007 11
Shocking Treatment One of the gems in the Sierra Sacramento Valley Museum of Medical History is a 1960s Electroconvulsive Treatment (ECT) device.
By Kent Perryman, PhD The author is a member of the SSVMS Historical Committee. He is a retired associate professor in the Department of Psychiatry and Biobehavioral Medicine at the UCLA School of Medicine, and a retired cognitive neurophysiologist with the Veterans Administration Psychiatry Service in Los Angeles. ECT devices were initially designed in Italy in the late 1930s to electrically induce brief brain seizures for treating severe mental disorders. Beginning in the 1940s, physicians in America and Europe focused their attention on ECT in the management of severe depression. Early practitioners would position electrodes across the patientâ€™s temples and briefly apply an alternating current to induce a psychomotor seizure. Following the seizure, the patient would lapse into a coma for 20 to 30 minutes. Patients would undergo this procedure three or four times a week for up to 15 treatments. During the 1940s and 1950s, physicians would cart their ECT from one bed to the next in a mental hospital ward, applying electroshock to as many as 30 individuals in a single morning. Some physicians during this period, accompanied by a nurse, would carry their ECT devices on house calls to private residences for severely depressed patients unable to come to their offices. Several companies including Medcraft Corporation still manufacture ECT devices for use in alleviating depressive episodes in extenuating medical circumstances when psychotherapy and medications cannot be employed. The Model B-24 pictured on page 15 was
Sierra Sacramento Valley Medicine
given to the Sierra Sacramento Valley Museum of Medical History by Donald Richard Walk, MD, a major donor of medical artifacts to the Museum. The history below accompanies the Model B-24.
History of Convulsive Treatment Ancient Greek temple priests on the island of Lefkas would throw depressed patients into the sea from a cliff 600 feet high. Patients who survived were retrieved from the sea by another group of priests waiting in boats below the cliff. This may conceivably be the first shock treatment for depression! A more controlled course of somatic treatment for mental illnesses began appearing in the early 1930s in Europe. Convulsive treatment procedures began with the realization that the symptoms associated with mental illnesses were sometimes reduced in severity following an epileptic seizure. Intramuscular camphor, and then pentylinetetrazol (Metrazol), were employed in 1934 for a brief period by Laszlo von Meduna in Budapest. Metrazol was much more effective than camphor-in-oil injections in treating depression. This form of pharmacoconvulsive therapy was not used for long in treating schizophrenia, depression and mania because of uncontrolled grand mal convulsions. Around this same time, insulin coma therapy was introduced as a treatment for schizophrenia by Manfred Sakel at the Lichterfelder sanitarium near Berlin. Sakel believed elevated levels of adrenalin were responsible for mental illness and that insulin could be used as an adrenaline antagonist. However, this procedure was cumbersome and difficult to control, sometimes resulting in continued on page 15
“Taken to the Outlet” An old ECT machine triggers memories of the way things used to be.
By Marlene M. Mirassou, MD The author, until recently a member of the SSVMS Editorial Committee, is retired from UC Davis and has relocated to Santa Cruz to be nearer her fiancé; they will marry in July. She has started working as a campus psychiatrist at UC Santa Cruz. When I visited the SSVMS museum recently, the old electroconvulsive treatment (ECT) machine on display brought to mind how I learned the treatment technique when a resident in psychiatry in Wisconsin in the 1970s. The ECT machine I first used was even older than the model in the museum. It was a small black box with latched cover, cords, electrodes and minimal controls. The power knob had low, medium and high settings and a “glissando” setting. The gradual increase in power produced with the glissando was thought to be helpful when the machine was made, though not when I learned the technique. I suspect the machine may have been 20 years-old or more. The technology was so primitive that instead of a timer for the stimulus, the physician counted “one-one thousand…” for the duration of stimulus desired. The machine hadn’t been used much in the years prior to my request to learn to treat patients with ECT, but a new psychiatry faculty member from another medical school was experienced in ECT treatment and wanted to be able to use ECT for patients in need of it and to teach residents. Treatment was carried out in a sunny corner of the recovery room with a nurse anesthetist who was willing to help us. We selected our patients carefully, based on severity of depression and lack of response to other treatments.
Fortunately, though ECT had been used little in Milwaukee in the previous decade because of the advent of antidepressants that were easier to use (desipramine, nortryptiline and the like), it had not become a political issue as it had in California at that time. As much as their illnesses allowed, we included our patients in the decision to use ECT. Some of our patients had been successfully treated with ECT in the past so they and their families were greatly relieved by the prospect of treatment again. Maintenance of oxygenation, muscle relaxation, and monitoring of the seizure duration by use of a limb isolated from the muscle relaxant were carefully practiced. We followed our patients’ improvement in mood and modified our treatments if confusion was marked. Later in my career, when at UC Davis Medical Center, I worked in an inpatient psychiatric unit and I refreshed my knowledge and skills in the use of ECT. The equipment was much more sophisticated and much had been learned about electrode placement, stimulus waveforms and other aspects of treatment. Confusion in our patients was less of an issue though memory complaints still occurred. Again, we had many good responses, though as in most of medicine, not all patients responded as well as we hoped. In both settings, the treatment teams and almost all of our patients were rewarded with the patients’ improvement in mood. Though I do recall one woman whose dysthymia didn’t get better, I also recall how much she had wanted electroconvulsive therapy because of
January/February 2007 13
her lack of much improvement from extensive previous psychotherapy and medication treatment and how well her side effects cleared after treatment. Though some patients noted persistent memory problems for the time immediately prior to their treatments and during the course of treatment, it was never clear how much was due to the ECT and how much was due to the severity of their depressions, as major depression can significantly interfere with memory. Certainly, the problems with adverse effects decreased with the improved technique. Though I am well aware of the negative
An ad for a slightly later model than the one in the museum collection.
Sierra Sacramento Valley Medicine
view of many regarding ECT, I suppose I had approached it with a more positive opinion since one of my relatives had received at least one course of ECT in her life. When her major depression was treated with ECT, it allowed her to go on to many more years of life she could enjoy; one of her sisters had died in a state mental hospital with the same disease. Later in my life, I encountered a medical student with severe non-responsive depression who returned to his prior excellent performance in medical school and graduated after a successful course of ECT, reinforcing my view of electroconvulsive therapy as a life-saving treatment in more than one way. Of course, there is that long-standing negative image of ECT. Some of that negative attitude was likely warranted in the past when ECT was applied for inappropriate reasons — such as at the request of a husband to calm an unruly wife. Its earlier years were crude and the representation of its crudeness and negative results in public media such as the images in “One Flew Over the Cuckoo’s Nest” certainly would make it seem only a punishment with no redeeming virtues. I can’t deny that there is still the potential for negative effects even with present improvement of technique and better selection of candidates for treatment, though risks are massively less than in the past. We still don’t know its mechanism of effect, either. We’ve come a long way in so many medical treatments since the beginning of my medical career and some therapies have been determined ineffective or too dangerous to warrant limited benefit. At present, electroconvulsive treatment continues to present significant benefit with relatively low adverse effects. Even with increasing responses to improved antidepressants and improved psychotherapies and their combinations, ECT continues to be a viable treatment. I know that, had I a major depression nonresponsive to reasonable trials of other treatment, I would want to be taken “to the outlet.” email@example.com
Shocking continued from page 12 prolonged and irreversible coma with a significant number of patient deaths. This was never a treatment of choice for depressive illness. Electric shock treatment rapidly replaced chemically-induced seizures because of its more controllable and safer outcome. Prior to the use of electroconvulsive treatment in the 20th century, documentation of the use of electroshock to alleviate nervous disorders was scarce. Supposedly, the Roman court physician Scribonius Largus (47 AD) treated the emperor Claudius’s headaches using an electric eel. The first recorded electroconvulsive treatment for mental illness was in 1755 by the French physician J. B. LeRoy. Static electricity was commonly use, by rubbing amber and linen or wool cloth together to produce a charge. It wasn’t until the early part of the 20th century that alternating current could be successfully applied to the scalp to induce seizures. Two Italian physicians, Ugo Cerletti and Lucino Bini, began developing a model of epilepsy in 1934 using schizophrenic patients. These two early neuroscientists had observed that Roman slaughterhouses employed an electric stimulus to stun pigs prior to dispatching them while comatose. They were confident that if the electrical stimulus did not kill the pigs, it would be safe for use with their patients. With some minor adjustments to stimulus parameters (particularly voltage), Cerletti and Bini successively demonstrated that electroconvulsive therapy could be safely applied to treat mental illness. One of their electroconvulsive devices was brought to the United States in 1940; the first treatments here were performed by Renato Almansi and Dale Impastato at Columbus Hospital in New York City. Their patient was a 29 year-old women suffering from schizophrenia who was reported to have made a sudden and remarkable recovery. Electroconvulsive treatment was then referred to as “electo-shock” and the equipment was crude. Very often, treating physicians could feel an electrical tingling sensation between their
fingers while operating the device! However, these early electroconvulsive machines were very effective in producing grand mal convulsions. Patients were positioned on a bed with their back slightly arched and a tongue depressor inserted into one side of the mouth between the upper and lower molars. Since no anesthesia and muscle relaxants were given in those days, several nurses or assistants would hold the patients’ shoulders and extremities to prevent flaying during the convulsion. The patient would subsequently lapse into a coma for 30 to 40 minutes with no memory of the treatment procedure later. We can just imagine what a frightening experience electroconvulsive treatments administered back in the 1930s and 1940s must have been for both the patients and the staff. The 1960s saw the introduction of muscle relaxants during electroconvulsive treatment to prevent fractures and dislocations. Curare was used for a brief period but was later replaced by the much safer and controllable succinylcholine to prevent skeletal complications associated with grand mal convulsions.
Supposedly, the Roman court physician Scribonius Largus (47 AD) treated the emperor Claudius’s headaches using an electric eel.
January/February 2007 15
To Sail a Wheelchair on the San Francisco Bay By Gilbert Wright, MD That’s not as difficult as you would think. The Bay Area Association of Disabled Sailors (BAADS) has a sailing team in which the skipper and jib trimmer are quadriplegic and paraplegic, respectively. With a crew of three of four, we sail a Sonar Class 23-foot keel boat. The Sonar is the official boat of Paraplegic Olympic competition that follows the regular Olympics every four years. I am the boson (team manager) and owner of our boat. We are based at the Treasure Island Sailing Club. Like the smaller and better known Laser, the Sonar was designed by Bruce Kieby. Both boats have similar flat hull designs. Many describe the Sonar as a large Laser with a keel. The keel weighs 2,000 pounds and provides stability and some lift when sailing against the wind. We have the first and only Sonar racer on the bay so we named her ”Alpha.” All disabled people are not equal, so a unique aspect of Olympic Paraplegic competition is that the crew must be evaluated as to degree of limitation, must be rated, or handicapped — as in handicapping the handicapped. My personal involvement began after a meeting at BAADS with an experienced racer, a quadriplegic sailor who was forming a team. After finding out I was an amputation surgeon, he asked, “Can you get me a one-legged amputee?” That’s because Paralympics rules require a team disability of 14 points or less. Individuals are rated by experienced examiners by their performance on specific sailing skills, such as
Sierra Sacramento Valley Medicine
speed and strength in handling sail control lines, and mobility for weight transfer to balance the boat. On a scale of 1 to 7, a quadriplegic individual will rate 1 or 2, and a paraplegic 2 or 3. A unilateral amputee can rate as high as 7. Motor and visual disabilities will rate somewhere in between these values. I located an amputee for my friend and soon became involved with the program. I subsequently bought a Sonar sailboat and formed a team. We race on San Francisco Bay and hope to qualify some day for the Paralympics. A Sonar can be sailed entirely from a seated position. The principle problem for a paraplegic after getting into the boat is shifting sides when the boat comes about (or changes directions; therefore, the wind comes from the opposite side). Proper placement of crew weight is a key element of good sailing technique. The ”driver” (who manages the tiller to steer the boat) must move from the low to the high side as the wind direction changes with respect to the boat. Some paraplegics need a mechanical assist. Others settle for a seat in the midline or even stay on the ”low” side while the rest of the crew shifts. A bench may make it easier for crew to shift while seated. Trimming the jib sheets (ropes) can require a lot of strength in some situations, so the Sonar has a compound pulley system. The spinnaker is a large parachute-like sail that can be used to pull the boat forward when sailing down (with) the wind. This can increase sail area by 150 percent but
also increases the chance of capsizing or foundering by a factor of 10 or more. Therefore, the spinnaker is not normally allowed in paraplegic racing; instead, the jib is rigged with an udder strut (a whisker pole) to allow it to function as spinnaker when sailing downwind. The host club for BAADS is the South Beach Yacht Club. We have raced in regattas there against able-bodied crews, and been competitive. To qualify for the Olympics is a remote possibility; however, we will continue to try. Paraplegic racing for Sonar class has not yet arrived on the west coast. For our trial, we had to trailer Alpha to St. Petersburg, Florida. We would like to bring some competition to the Bay. The sailing club at Treasure Island has held qualifying events for the Olympics many times. firstname.lastname@example.org
This is a draft logo for BAADS.
January/February 2007 17
Annual Meeting 1
Nearly 300 persons attended this yearâ€™s Annual Meeting and Installation Dinner of the Sierra Sacramento Valley Medical Society and Alliance, on January 12 at the Hyatt Regency Hotel. The Golden Stethoscope Award, the Societyâ€™s highest honor, was presented to William G. Bush, MD, who grew up in Sacramento and in 1963 began a practice here in internal medicine, cardiology and nephrology. He became known for his extensive involvement in community service through the Rotary Club, and was active on numerous health-related boards. John Chuck, MD, received the Medical Honor Award for his contribution to the communityâ€™s health as founder and CEO of Serotonin Surge Charities. In 1998 he and friends formed the charity as an all-volunteer public benefit 501(c)3 non-profit organization, to raise money for health care-related charities. More than $500,000 has been raised for student scholarship programs, clinics that serve the uninsured and underinsured, and for breast cancer research. The Medical Community Service Award went to medical students who volunteer at the U. C. Davis Student-Run Clinics, for their significant contributions to the health of underserved populations. The five clinics are Clinica Tepati, Imani Clinic at Oak Park, Joan Viteri Memorial Clinic, Paul Hom Asian Clinic and the Shifa Community Clinic. Marla Bommer received the Dedicated County Alliance Member Award, and Ann Parsons was presented the Dorothy Dozier Helping Hands Award Bill Sandberg was recognized for his 20th Anniversary as Executive Director of the Sierra Sacramento Valley Medical Society. 4
Sierra Sacramento Valley Medicine
1 President Richard A. Jones, MD, and his wife, Lydia Wytrzes, MD. 2 Past President Paul Phinney, MD, (left) and Medical Honor Recipient John Chuck, MD 3 Golden Stethoscope Award recipient William Bush, MD, with spouse Karolee Bush. 4 The Alliance Celebrates its 75th Anniversary dressed in clothing through the decades: From the left, Catherine Doggett, Lisa Smith, Marla Bommer, M.J. Kelly, Ann Parsons, Barbara Andras, Mariann Fisher, Susan Brownridge, Linda Meyers, Evie Palumbo 5 2007 Officers: From the left, Kuldip Sandhu, MD, Immediate Past President; Richard Jones, MD, President; Margaret Parsons, MD, President-Elect; Charles McDonnell, MD, Secretary. Not pictured is Stephen Melcher, MD, Treasurer
6 UCD Student-Run Clinics received the Medical Community Service Award. Standing from the left: Claire Pomeroy, MD, Dean of the UC Davis School of Medicine; Aime Castillo, Clinica Tepati; Amy Jouan, Coordinator, Student-Run Clinics; Alison Breen, MSII, Joan Viteri Memorial Clinic. Seated: Amerish Bera, MD, Assistant Dean, UCD Admissions and Outreach; Chul-Kyun Park, MSII, Paul Hom Asian Clinic; Omar Mohamedaly, MSII, Shifa Clinic; Sarah Fitzmaurice, MSII, Imani Clinic;
7 Catherine Doggett presents the Dedicated County Alliance Member Award to Marla Bommer. 8 Bill Sandberg receives a plaque from Dr. Kuldip Sandhu. 9 Ann Parsons received the Dorothy Dozier Helping Hands Award
January/February 2007 19
Two Related Posits: “SSVMS/CMA should support legislation to: (1) Limit transfats and carbohydrates in school lunches and vending machines; (2) Ban smoking in all public entertainment, whether live, or as portrayed on TV and in movies.”
“Frankly, as a libertarian, I find the current trend toward making physicians into church ladies repulsive.”
Within the annual tsunami of legislation are laws and regulations banning harmful behavior, or choices. Yet, how legislation can affect health is complex; and is often subject to the ”law of unintended consequences.” It is fascinating, if depressing, to observe the interaction of politics and profits. Compare, for example, the prevalence of smoking in movies and on TV with that among the general public. Is there a disparity because many special interests profit from smoking, including those of us who want to tax the addiction to benefit providers of medical care? On the other hand, is it wise to tolerate exposure of children to harmful food and behavior? Approximately 80 percent of respondents agreed with posit one on transfats and carbohydrates. An ill-defined majority disagreed with posit two on smoking — “ill–defined” because of disconnects between some opinions and the associated comment. Example: disapproval for legal reasons but approval for motives of health; or approval in general but a feeling the idea was politically impractical. More than 36 percent agreed with both posits, but only 12 libertarians, or 7 percent, disapproved of both. Commentary was prolific. Edited comments follow, while unedited commentary are viewable online at www.ssvms.org. “I certainly agree with limiting carbohydrates in school lunches/vending machines, but your wording won’t work…. The labeling laws need to be changed to the chemically and biochemically correct fact of: all carbs = sugars; and separately break down the types… sucrose, glucose, fructose, maltose, refined corn starch, wheat starches, hydroxypropylated corn starch, cyclodextrins, etc. As a scary note, hydroxypropylated corn starch Sierra Sacramento Valley Medicine
is the end result of raw corn treated with sulfur dioxide to soften it, then soaked in 1 percent hypochlorite (bleach, i.e., Clorox) at boiling temperatures, then reacted pound for pound with propylene oxide or chlorohydrin — both classic mutagens, carcinogens and alkylating agents…. Check it out at www.corn.com in the Corn Growers handbook…” — Colin Paul Spears, MD “New York City has taken the lead in eliminating transfats in all restaurant and commercially prepared foods. While seen by some as a violation of individual rights, the decision won’t adversely affect access to the same tasty and often high-fat foods to which people have become accustomed. The ACC supported this decision because it will confer substantial health benefits and likely long term health care cost reductions to taxpayers, and without adversely affecting their enjoyment of food. That’s a great trade off.” — Jack Lewin, MD “Frankly, as a libertarian, I find the current trend toward making physicians into church ladies repulsive. Nanny medicine trivializes the profession and further marginalizes physicians. We should be a resource for the entire population not just the asexual vegan prunes that make up the vocal minority that drives policy. Being a libertarian is becoming a lonely position. We are being overrun by food, cigarette, weight (you name it) police. Does anyone mind their own business anymore?” — David Gibson, MD “Transfat is not a foodstuff, rather it is an industrial invention that is cheap and convenient for those who make and sell food. It does not benefit the consumer, and is in fact harmful. Armed with this knowledge, who would want to raise their children and grandchildren on it?” — A. Czerwinski, MD
“There is far too much incursion of ’junk food’ into school settings. The schools should be supporting a healthy lifestyle and food choices for students. This is a major public health issue and should be a ’no brainer’ for schools! [However, regarding smoking, the restrictions of the posit] …would be the same as a ban on violence, sex, cursing, or any other ’artistic expression,’ and in my opinion would be unconstitutional.” — Matthew van der Veen, MD “Limiting transfats is OK. Limiting all carbohydrates is not. There are many healthy foods that contain carbohydrates, including fruit, vegetables, dairy and whole grains. Without carbs, the snacks would be fat and protein.” — Ann Gerhardt, MD “I think the corporate predators in the tobacco industry should be stopped from all advertising. The industry should be nationalized and run as a government non-profit. Each brand should be given a number, not a name. The executives of these corporations should face criminal charges and asset forfeiture for years of deadly pathological lying to the public.” — John J. McCarthy, MD “…’Limiting’ such harmful products is the least we can do. Limits are better than complete ’bans.’ We are already limited in how much alcohol consumption can be viewed in public entertainment. If one wishes a true ban, then one ought to also accept such a ban on alcohol consumption in public entertainment. It is a hypocrisy that we have such different standards for alcohol and for tobacco in our society.” — Khasimuddin Syed Ameen, MD “Responsible adults must not promote poor nutrition for children. However, responsible legislators could promote responsible behavior WITHOUT their excess of meddlesome and often counterproductive legislation.” — L. Welter, MD “…As a pediatrician I would consider it a child neglect if I make my kids eat the school lunches day after day. So, over the last 10 years I’ve been preparing my kids lunches every school day with joy, and wonder if they will have to do the same thing for their children. However, it is also difficult to have the students choose the
right food to eat from the school cafeteria when at home they don’t and they are not accustomed to it.” — Tezcan Kamer, MD “[Banning transfats] …does nothing to get at the root of the problem and wastes a bunch of money on transfat police. It also sends the message that fat is ok as long as it is not trans.” — Mark Ewens, MD “[Transfats use] is contributing to childhood obesity and diabetes. I don’t know a more harmful substance to mankind than smoking.” — Lee Vong, MD “I would love to see this, but doubt that it would pass constitutional muster.” — Francisco Prieto, MD “Too ’nanny state’ — adults can smoke if they want.” — Steve Dorfman, MD “…I think it would be great to have no smoking in public entertainment, but I do not think that is the mission of SSVMS or CMA. While such support could be…in the interest of health of the population, it smacks of culture control and limitation of freedom of expression and individual choice.” — Nancy Gilbert, MD “Nutrition education should be taught and reinforced in the school and at home. This does not mean restricting choice. School lunch should be exemplary in its constitution, and therefore there should be no question as to its healthiness...” — Jose Ma C. Leuterio, MD “…With the growing pollution around the world and increasing #s of hyper-reactive bronchial and other respiratory illnesses…it is only medically appropriate that this be done for the better health of the citizenry! In the movies and TV, I would prefer one of the characters objecting to the smoking [of] another actor…to actually request someone to stop, take it outside or do it at another time…. Wouldn’t that be splendid?” Elizabeth Mathew, MD “The real issue is educating families about proper nutrition and exercise and providing nutritional education and promoting fitness to children at a young age. Cigarette smoking is still the most frequent and serious we as physicians have to deal with.” — James Alan Margolis, MD “Bring back apple and orange machines.” — Charles Maas, MD
“I think the corporate predators in the tobacco industry should be stopped from all advertising. The industry should be nationalized and run as a government non-profit.”
Juror Number One By Marion Leff, MD Last fall I had the “opportunity” to serve society in a manner quite different than that for which I trained. Many physicians have had their deposition taken or even sat on the witness stand to give expert testimony, but I recently spent five weeks as a juror on a murder trial. In the beginning I was embarrassed because everyone I knew who had ever been summoned managed to get out, and I had not. At the time, I must confess (no pun intended) I was also curious about this whole process. From jury selection to sitting in jury seat number one in courtroom #33 of our Sacramento Courthouse, it was a cultural experience like no other I have known. Should you ever find yourself potentially spending time at the 7th and H street courthouse, let me describe the highlights that await you. Having deferred jury service several times, I found that duty to patient care was not an adequate reason to be disqualified, so I sat in the large assembly room where all potential jurors have their first taste of waiting. The current “promise” the court gives to our citizens who are called to appear is ”one day or one trial.” Unfortunately, there is no limit to the length of time to serve if selected for that one trial. The assembly room is like an airport waiting area with people dozing, reading, or talking too loud on cell phones. Everyone is ignoring the incessant educational video that plays over and over and over. Soon another film replaces this and it is replete with testimonials from jurors who have been inspired by their experience, encouraging us to think positively. After being called to a courtroom for possible selection, I receive my first juror badge. The hallway of the 5th floor is crowded at 9 a.m. with people wearing a variety of colored badges.
Sierra Sacramento Valley Medicine
White is for potential juror, to be converted to a bolder color once among the chosen. In courtroom #33, the judge presents a preview of the case. It is to be a serious case, robbery and murder with multiple defendants each represented by a defense attorney in addition to a special defense attorney who will only focus on DNA evidence. The judge informs us we may be needed for up to 6 weeks. Suddenly my curiosity about experiencing a criminal trial is not so keen as I think about the disruption of my practice and the burden on my partners. I am the first one called with the first group of 18 juror candidates who will be interviewed. Twelve regular and four alternate slots must be filled. We are each asked a sample of questions by the judge and all the attorneys have a crack at us. Some of the questions seem appropriate to the case to determine strong biases, such as asking if we had ever been a member of a pro or anti-gun organization, or a crime victim, but others are random. For example, one attorney asks if any of us had ever had a letter to a newspaper published. I shot my hand up affirmatively for that one thinking to myself, “This will get me dismissed,” but it was a meaningless question that went nowhere. In fact, the attorney remarked he always asked that question and no one had ever answered “yes” before. Over the course of the next two days, folks are dismissed and new potential jurors are seated. As those of us still remaining are faced with the possibility that we might actually be chosen, a flurry of messages are sent to the judge via the bailiff requesting consideration of hardship. I am no exception. The bailiff is the juror’s link to the inner sanctum. All communication goes through the bailiff. He advises us on proper etiquette in the courtroom. When my turn comes, I plead my case, “I
am a family doctor and this will be quite difficult, etcetera, etcetera.” The judge is polite, a good listener and merely asks me if I can be attentive, even though there might be work distractions on my mind. I am cursed with the inability to lie adeptly, and I spend too much time pondering the question. This is it. I am well aware it depends on how I respond to this question. Juror seat number one now belongs to me! My new best friends as I come to know my fellow jurors are a reasonable mix of our community: seven men, five women, ethnically diverse and all seem to have beyond a high school education. The panel includes another physician, two nurses, a couple of engineers, retired business manager, and a baker, just to name a few. We receive our yellow badges and have free parking in the designated lots for the duration of our duty. I now have a new appreciation for the expression, “the wheels of justice move slow.” The jurors’ hours are strictly limited, nine to four with mandatory morning and afternoon breaks and a 90-minute lunch. Learning to accept this is a requirement to maintaining composure. Any number of unexpected variables can cause delays, and the juror can expect to get through a couple of books, many magazines, or carry on cell phone work. There is no wi-fi for internet access, however, anywhere in the public sector. It is day number three when the opening statements begin. The prosecution opens by warning us that this will not be like “Law and Order” or ”CSI.” It was nonetheless dramatic. Sadly, there was a horrific crime committed by four youths, three of whom are defendants and one turned state witness. The fact that several different ethnic groups are involved adds to complexity of the tale. The story is laid out by the prosecution outlining how these four youths, in an effort to get money, donned ski masks and gloves along with guns and at four in the morning, broke into the house of a young pot dealer who was asleep with his girlfriend in his home inhabited by several other family members including young children. In the chaos to rob the victim, guns were fired and a 21 year-old boy dies.
Defense has its opportunity and warns us not to trust the testimony of a lying snitch. I learn that circumstantial evidence from an accomplice cannot be accepted without corroborative evidence. Defense’s job will be to plant doubt in our minds. At the close of this day and each day’s session the judge admonishes us: We may not discuss the case with anyone, not even to say if we are in a criminal or a civil case. We can’t “google” the defendants, witnesses or anyone else, nor can we drive by any scenes described. Lots of evidence and lots of testimony is to follow. As the trial really gets underway with witness testimony, a rhythm sets in. Each juror has a notepad for taking as many notes as she wishes. We become not only keen observers of the witnesses, but of all else that goes on in the courtroom: the attire of the lawyers, their unique style, the behavior of the defendants and the visitors representing the victim or the defendant and over all, our honorable presiding judge. As jurors, we hear a Powerpoint mini lecture on DNA evidence, from how it is collected to how it might be interpreted, particularly when there may be multiple DNA ”fingerprints” on evidence. We listen to wire-tapped phone conversations and see video testimony. Articles of evidence from the crime scene are brought forward repeatedly so that different expert witnesses can comment on the findings: finger prints, DNA profiles, and gun shot residue. This becomes so repetitive that we jurors are at risk of dozing off. We drink a lot of coffee. While not physically taxing, this job of giving adequate attention is exhausting. Tearful family members of the victim testify and hostile witnesses create even more drama. I learn about a variety of weapons, that a grill is a fashion statement for the teeth in some neighborhoods and you can make a blunt by packing a cigar with marijuana and a “queen for a day” agreement is a sweet deal for a defendant turned witness for the prosecution. One day, I almost got kicked off the jury because during a break in the cafeteria, the defense attorneys sat down near me and were conversing. They moved as soon as they recognized me as a juror. The bailiff called me in,
This is it. I am well aware it depends on how I respond to this question. Juror seat number one now belongs to me!
My patients were more understanding than I was, but were surprised that I was serving.
and I was asked if I had heard anything. I still wonder if I had answered yes, would I have been dismissed? The husband of one juror came to court and for days observed in the visitorâ€™s section. When the judge learned of this, he was kicked out, but his wife remained a juror. As the trial moved in to week four, we experienced cancelled days because of attorney illness that ultimately resulted in one of the three defendants being removed from the trial because his lawyer had not recovered adequately. During this time, I became very frustrated. Trying to see patients who were willing to be on a â€œwill callâ€? list, tending to messages most days during breaks and before 9 a.m. or late afternoon was trying. My patients were more understanding than I was, but were surprised that I was serving. After not one, but two more attempts to appeal to the judge that this duty had created a true hardship, I was finally dismissed, five weeks after I began. While I cannot comment on the experience of sitting in a room with 11 other citizens to decide on the fate of these defendants, I did stay in touch with the foreman and learned the
Wilke Fleury ad p/u Nov/Dec 06
Sierra Sacramento Valley Medicine
outcome of the trial. The verdict was guilty on both charges of robbery and murder. The material evidence and testimony, was from the start, overwhelming. The defendants never took the stand, or had alibis to offer, and now these young men face life sentences. The crime was terrible and terrifying as we heard it unfold, and it is upsetting to know multiple lives are also wasted. Sadder still is the environment that allows young men to view robbery as a viable path to achieving the good life. This story was made even more complicated by the fact that it involved several different ethnic communities in a chronically struggling neighborhood. With my curiosity now satisfied, I can rest assured I have at least 12 months before I can be called up again for this civic duty. My wise son who is the same age as the youngest defendant reminded me that this was only five weeks out of my life, while an entire lifetime was at stake for the defendants. A sad post script, I think. email@example.com
Voices of Medicine The impact of prayer on recovery, and deciding whether to stay with Medicare.
By Del Meyer, MD
Proof and Prayer Emily Dalton, MD, discusses “Science and Intercessory Prayer” in the November 2006 issues of The Bulletin, published monthly by the Humboldt-Del Norte County Medical Society. “‘Intercessory Prayer Ineffective!’ touted the headlines in the medical periodicals when a major study on intercessory prayer and recovery from cardiac surgery was published in the American Heart Journal. The study looked at about 1800 post-op CABG patients and assigned each to one of three groups: 1) receiving prayer after being informed that they may or may not be prayed for, 2) not receiving prayer after being informed that they may or may not be prayed for, and 3) receiving prayer after being informed they would be prayed for. The complication and mortality rates were monitored. The authors concluded that the prayer had no effect on complication-free recovery from CABG, but that the certainty of receiving intercessory prayer was associated with a higher incidence of complications. Well, that doesn’t sound good. It’s hard to imagine how knowing you are being prayed for could increase your likelihood of post-surgical complications. In fact, the authors could think of no possible explanation for the results, and postulated chance as the most likely reason. “I think this study has some major limitations. The underlying assumption, which is not stated, but clearly implied, is that prayer should work in a simple ’ask and you shall receive’ manner. This is a very immature approach to prayer, akin to a young child who asks God to grant him a new bicycle. Most people who pray do not expect instant, specific wish gratifica-
tion, yet this does not deter them from praying nor does it detract from the value and importance of prayer… “The benefits of prayer may be hard to measure — they may occur at varying times and may affect the recipient, the person doing the prayer (stress reduction, lowered blood pressure), or the world at large. Prayers come in many various forms, including supplication, praise and worship, undefined, requests for self-transformation and so forth. One can pray for acceptance of the will of God, such as when Jesus prayed, “not my will but Thine be done” prior to his crucifixion. Some people pray without understandable words, and leave it a mystery as to what their prayers may be about — even to themselves. I don’t think one can conclude much about the overall value of prayer from one study looking at one outcome from one type of prayer. “Here is the real paradox: Belief in God is supposed to require a leap of faith. If you could prove the effectiveness of prayer, then belief in God would not require faith and would thus invalidate the initial premise. So, in a sense, the results of this study confirm what we know about God, that belief in God requires faith, not proof. To reiterate, faith is about belief without proof. Science is about belief based on proof. These two are like yin/yang opposites, and this is why using science to study religion doesn’t work well…” The entire article is at www.humboldt1. com/~medsoc/images/bulletins/NOVEMBER%2020 06%20BULLETIN%20for%20web.pdf.
Opt out of Medicare?
…the usual economic principles governing trade do not apply to Medicare. The options for physicians who treat the elderly are very limited.
David Goldschmid, MD, President of the San Mateo County Medical Society, focuses on “Medicare’s Web” in the SMCMA Bulletin. “The current concern to most physicians about Medicare is that Medicare reimbursement rates are not keeping up with practice costs as costs continue to rise. This leads one to consider changing one’s Medicare status from a participating physician to another category. Are there any economic advantages to becoming a nonparticipating physician? Does it make sense to opt out of Medicare? “Recently we have heard several politicians informing us that Medicare’s current reimbursement rates are acceptable as proven by classic economic indicators. They quote statistics that show a gradual increase over the past few years of the number of physicians who participate in the Medicare system.… In this column I will outline the alternatives for physicians, and as you will see, the usual economic principles governing trade do not apply to Medicare. The options for physicians who treat the elderly are very limited. “Medicare recognizes three categories for physicians: “1. Participating “This category is the most familiar. These physicians accept Medicare’s allowed charges as payment in full for all of their Medicare patients. Medicare pays 80 percent of these charges directly to the physician and the patient (or supplemental insurance) must pay 20 percent. If the patient has supplemental insurance, Medicare automatically forwards medigap claims to the appropriate carrier for payment. Medicare pays participating physicians 5 percent more than nonparticipating physicians. Participating physicians are included in Medicare directories. Medicare carriers process claims of participating physicians more quickly and provide toll-free claims processing lines. “2. Nonparticipating “These physicians may decide on a case by case basis whether to accept assignment or to bill their patients more than the Medicare fee schedule. There are federal laws limiting what
Sierra Sacramento Valley Medicine
these physicians may charge. The effect of these laws combined with the 5 percent reduction provided in Medicare regulations have a net effect of allowing these physicians to charge 9.25 percent more than participating physicians…. The payments go to the patient and must be collected from the patient. “3. Opt-Out “These physicians do not participate in the Medicare program at all. They may treat Medicare patients using private contracts with the patients and may charge without the limits imposed by federal law. These physicians may not submit any claims to Medicare for a two-year period. Their patients may not be reimbursed by Medicare, or a supplemental insurance carrier, for any item or service furnished by the physician that would have otherwise been covered by Medicare had the physician been participating. It seems unlikely that any but the most-wealthy Medicare-aged patients would accept this. “Several other principles are worthy of mention. The first is that participating physicians may only change their status to nonparticipating during a short ’open enrollment’ period. Second, the government has shown its willingness to aggressively prosecute nonparticipating physicians for repeatedly violating the assignment agreement. Third, contracts between patients and opted-out physicians are complex and may require legal review. Finally, rules for treatment of emergencies are completely different, causing confusion. “So it seems that opting out means that you have basically decided not to treat any Medicare patients. Becoming a nonparticipating physician means you can increase your charges by a meager 9.25 percent in exchange for significant possible collection problems. The choices suggest that the only recourse we have to the dilemma of falling reimbursement is to fight the political fight to improve reimbursement or to limit access to optimize the expenses-to-cost ratio of running a practice. Once again, we need to stick together.” The complete article is at www.smcma.org/ Bulletin/BulletinIssues/Oct06issue/President.html. DelMeyer@HealthCareCom.net
Energy Control By Eleanor Rodgerson, MD Problems, problems! What to do? Did I remember to turn off those lights? Is that tap leaking? Did you turn down the heat? Was that a waste of energy? Can I do better? Do energy companies help? What is an energy company, anyway? What does it do? I turned to the computer and learned there are some 15 million energy companies in the world. Close to home, one of them hired a relative at a salary that included enough for life in a high rent city and payment for some of the past student loans. Energy must be crucial. Research revealed that an energy company may be large, or small, deal with private corporations, or work with government. It may specialize in petroleum, petrochemicals, lubricants, electricity, natural gas, nuclear operations, wind, sun, water, biomass, and so forth. It may number among the engineering consulting firms that aim to reduce the depletion of the world’s natural resources. There may be audits of buildings — perhaps as far north as Alaska and as far south as the desert. Recommendations are made for saving money and making better use of it. California is noted for its national leadership in energy efficiency.
Take a building with windows that never feel the sun. Cold seeps through. What happens to the heating system? Suppose the windows catch the sun? What happens to the cooling system? Suppose there is an indoor swimming pool? What effect does its heat have? Adjustments mean saving dollars for a company and making better use of its energy. It is up to the institution that ordered the audit in the first place to follow the suggestions an energy company makes, and improve. Who does the work in these companies? Engineers, particularly civil and environmental, and they must be mathematicians as well. Energy companies are using the world’s energy in every way they can, using and preserving, substituting where possible. Effort is made not to waste it. Private and government institutions are both involved and, as energy companies have multiplied, so have the world’s energy problems been corrected and sometimes abolished. A bright future for life on this earth ought to be assured. firstname.lastname@example.org
Kiss Me, You Fool! “Kissing, the filthiest custom of man, is the most important single method of accidental transmission of pneumonia, syphilis, leprosy and tuberculosis. Influenza, common colds, sore throats, measles diphtheria, scarlet fever, whooping cough, trench mouth, meningitis and a host of other diseases are constantly spread by it. The human mouth is a veritable cesspool of corruption, what with rotting teeth, infected tonsils, running eyes, purulent bronchi, fetid sinuses
and putrid gullet discharging pus into it day and night. With the tabus and abnormal repressions of civilized life osculation is nothing more than an aberrant form of sex expression. Avoid it like you would the plague if you would keep your teeth and remain healthy.” — from Medical Bacteriology and Clinical Parasitology, Page 38, M. Feman-Nunez, MD, F.A.C.P., 1943
PTSD in Afghanistan and Iraq War Veterans By Emily Keram, MD Reprinted from Sonoma Medicine magazine. Dr. Keram is a staff psychiatrist at the VA Outpatient Clinic in Santa Rosa. In 1996, as part of a nationwide effort to make health care more accessible to veterans, the San Francisco VA Medical Center established its first outpatient satellite, the Santa Rosa Community Based Outpatient Clinic (CBOC). Ten years later, the Santa Rosa CBOC provides primary care and mental health treatment to over 5,000 veterans. With the ongoing wars in Iraq and Afghanistan, Santa Rosa CBOC clinicians, along with counselors at the Vet Center in Rohnert Park, are currently treating veterans with very recent combat experience. The Department of Defense (DoD) refers to the wars in Afghanistan and Iraq as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively. CBOC and Vet Center patients now include OEF/OIF veterans from all branches of the armed forces, as well as Reservists and members of the California National Guard. Upon return to the United States, all OEF/ OIF veterans—whether they served in the regular armed forces, the Reserves, or the National Guard—are entitled to a two-year period of free care through the VA. The VA encourages these veterans to file a claim for service-connection for appropriate diagnoses during that two-year period, to ensure that all service-related conditions are recognized and compensated. Once a veteran’s claim is accepted, the VA provides lifelong free care for all service-connected diagnoses. As veterans of previous wars will attest, the longer a veteran waits to file a claim, the more
Sierra Sacramento Valley Medicine
likely the difficulty in locating supporting military and medical documentation, thus delaying the claim’s adjudication. These potential delays make early recognition of service-related illness especially important. Although the DoD and the VA provide OEF/OIF veterans with contact information for local VA services, these veterans may also access other providers of care. The DoD is relying on members of the National Guard and Reserves in the current conflicts, so many military returnees are older, resuming previous employment, and privately insured. They may prefer to turn to long-standing relationships with their community primary care physicians for help with postdeployment medical and mental health issues. Their mental health concerns may affect other health issues seen in the primary care setting. All veterans, including OEF/OIF veterans, are administered a postdeployment health assessment on their return from active duty. National assessments completed between May 1, 2003, and April 30, 2004, demonstrate a prevalence of reporting a mental health problem of 19.1% among Iraq veterans and 11.3% among Afghanistan veterans, compared to a prevalence of 8.5% among veterans returning from other locations.1 Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem.1 Combat exposure is the war-zone stressor most commonly associated with mental health symptoms in postdeployment veterans. However, OEF/OIF veterans may have been exposed to additional stressful or traumatizing
issues and events, including difficult living and working environment; concerns about life and family disruptions; sexual or racial harassment; perceived exposure to radiological, biological, and chemical weapons; perceived threats, insufficient preparedness, and inadequate armaments; exposure to suffering of servicemen and civilians; and exposure to death and destruction.2 OEF/OIF veterans are at risk for developing depression, substance use disorders, and PTSD. Symptoms of PTSD include re-experiencing trauma (nightmares, intrusion, flashbacks), avoidance of reminders of trauma, emotional numbing and detachment (lack of intimate relationships, sense of foreshortened future), and autonomic arousal (anxiety, insomnia, cognitive difficulties, exaggerated startle reflex, and hypervigilance).3 Depression, guilt, shame, and panic attacks may also be present. The Iraq War Physician Guide reports that over 90% of veterans indicate that their traumatic experiences and symptoms are important and relevant to their primary care.2 The relationship between trauma exposure and increased health care utilization appears to be mediated by the diagnosis of PTSD. Primary care physicians are accustomed to evaluating and treating patients for common mental health concerns, including depression, bereavement, and substance abuse. Screening for PTSD may be done in the primary care setting as well (see box). Endorsement of any three items on the Primary Care PTSD screen is associated with a diagnostic accuracy of 0.85 (sensitivity 0.78, specificity 0.87) and indicates the need for further evaluation. Primary care physicians can serve important functions for returning OEF/OIF veterans with PTSD. Physicians should acknowledge their patients’ difficulties with statements such as, “I am so sorry that you are struggling with this,” and “I can appreciate how difficult this is for you.” Patients with PTSD may be worried that their symptoms are a sign of weakness or that they are “going crazy.” They should be reassured that their symptoms are a common and expected reaction to extraordinary stress.
Some patients find it helpful to identify symptoms such as hypervigilance and insomnia as behaviors that helped them quickly identify and respond to danger while on active duty. Thus, although they are maladaptive in the civilian setting, some symptoms of PTSD are actually protective in combat. Patients should also be reassured that treatment exists for PTSD, and that both medication and therapy are available that will ameliorate its symptoms. Disability, should it occur, is likely to be temporary. In addition to providing reassurance and treatment to patients, primary care physicians can provide them with educational resources, so that they and their families can learn more about living with PTSD. Particularly useful is Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families.4 Written by clinicians in the PTSD Program at the San Francisco VA Medical Center, this book reviews common reactions to war and coping strategies, and it provides information about additional resources. The VA’s National Center for PTSD also maintains a website with educational handouts for veterans and their families; the address is http://www.ncptsd.va.gov/. Community physicians should encourage veterans to file claims with the VA for diagnoses they believe are related to their military service. Veterans should be referred to the Sonoma County Veterans Service Office (707-565-5960), where an officer will help them file claims and obtain other federal benefits to which veterans and their family members are entitled.
Primary Care PTSD Screening Test In your life, have you had any experiences that were so frightening, horrible, or upsetting that, in the past month, you: Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings?
Addressing PTSD symptoms that arise in medical settings Medical examinations or procedures may cause the patient to feel anxious or panicky. The following techniques, from The Iraq War Physician Guide, may help in addressing traumarelated symptoms that arise in the medical setting.2 Speak in a calm, matter-of-fact voice. Reassure the patient that everything is okay. Remind the patient that he or she is in a safe place and his or her care and well-being are a top priority. Explain medical procedures and check with the patient (e.g., “Are you ok?”). Ask (or remind) the patient where he or she is right now. If the patient is experiencing flashbacks, remind the patient that he or she is in a doctor’s office at a specific time in a specific place (grounding). Offer the patient a drink of water, an extra gown, or a warm or cold washcloth for the face. Call the patient later in the day to follow-up on his or her recovery.
Sierra Sacramento Valley Medicine
A diagnosis of PTSD has implications for the patient’s physical health as well. PTSD is associated with an increased risk of alcohol and drug abuse and risky sexual behavior. PTSD can also lead to neurobiological dysregulation, altering the functioning of the catecholamine, hypothalamic-pituitary-adrenocorticoid, endogenous opioid, thyroid, immune, and neurotransmitter systems. In addition, exposure to traumatic stress is associated with increased health complaints, health service utilization, morbidity, and mortality.2 Finally, appointments with primary care physicians may be anxiety-provoking and trigger symptoms of PTSD. Physicians should be ready to respond to such scenarios (see box). The VA specializes in the pharmacological and psychotherapeutic treatment of servicerelated PTSD. However, some veterans may prefer to receive treatment in the community. Although referral to the VA is recommended in almost all cases, some patients with mild symptoms may be prescribed medication in the primary care setting. Medication as a standalone approach to treatment is not recommended, however, so referral to the VA for psychotherapy should be made as well. SSRIs are generally used as the first-line medication for PTSD. In addition to diminishing the re-experiencing of symptoms and autonomic arousal, SSRIs are useful for comorbid symptoms such as depression and panic attacks. Sedative-hypnotics are usually avoided, as insomnia may become a chronic feature of the diagnosis. Patients with sleep disorders often respond well to trazodone or diphenhydramine. Recently, prazosin has been demonstrated to be effective at reducing or eliminating traumatic nightmares, with subsequent improvement in length and quality of sleep. Atypical antipsychotics may be useful as augmentation strategies for patients with treatment-resistant insomnia, severe anxiety, agitation, paranoia, hypervigilance, and dissociation. Anticonvulsants may be helpful for patients with aggression and impulsive behavior.2,5 The current conflicts in Iraq and Afghanistan may reactivate or exacerbate PTSD symptoms in
veterans of earlier armed conflicts. Exposure to news of the war, along with real or perceived similarities between the current conflicts and previous wars, may cause veterans to experience intrusive thoughts, memories, and images of their combat experiences. These symptoms, along with nightmares, emotional numbing, and autonomic arousal may cause disruption in family, social, and occupational functioning. Therefore, it may be useful for primary care and other physicians to ask their veteran patients whether the current conflicts are causing them stress and symptoms. Re-traumatized veterans should be reassured that their reactions are expected, normal, and amenable to treatment, should they so desire. To summarize, treatment of OEF/OIF veterans presents new challenges to physicians. Due to the increased role of the Reserves and National Guard in Afghanistan and Iraq, and
because many Reserve and Guard veterans have private insurance, community-based physicians will likely treat veterans with recent combat experience. Developing an increased expertise in the diagnosis and treatment of PTSD, as well as an awareness of the resources available to OEF/OIF veterans and their families, will improve medical and mental health care for these special men and women. 1.Hoge CW, et al, “Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan,” JAMA, 295;9:1023-32 (2006). 2. National Center for Post-Traumatic Stress Disorder, Iraq War Physician Guide, 2nd ed., http://www.ncptsd.va.gov/ (June 2004). 3. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Publishing (2000). 4. Armstrong K, et al, Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families, Ulysses Press (2005). 5. Friedman MJ, et al, “Pharmacotherapy for PTSD,” Psychiatric Annals, 33:57-62 (2003).
Sierra Sacramento Valley Medicine
New SSVMS Committees Below are committee appointments approved by the Board of Directors for 2007.
Child and Adolescent Health Services — Drs. Mary Jess Wilson, Chair, Charles Maas, Vice Chair, Marcia Britton—Gray, Monique Hanible, Lindalee Huston, Maynard Johnston, Robert Kahle, Samrina Marshall, Robert Meagher, Richard Pan, Patricia Samuelson, Joseph Sison Editorial — Drs. John Loofbourow, Editor/ Chair, David Gibson, Vice Chair, Robert LaPerriere, Gordon Love, John McCarthy, Delbert Meyer, George Meyer, John Ostrich, William Peniston, Eleanor Rodgerson, F. James Rybka, Gilbert Wright, Lydia Wytrzes, Ted Fourkas, Managing Editor; Medical Students: Tasha Marenbach, Robin Telerant Emergency Care — Drs. John Tucker, Chair, Felix Battistella, David Berman, Peter Hull, Loren Johnson, J. Douglas Kirk, Robert Kozel, Norman Label, Rodney Loeffler, James Martel, Kelly Nations, Kenneth Ozawa, Pankaj Patel, Harold Renollet, Steve Tharratt, Lee Welter, David Wisner, John Wood Historical — Drs. Robert LaPerriere, Chair, Francine Gallawa, Frank Glassy, Sandra Hand, Julian Holt, Roland Lippold, Joseph Masters, Margaret Masters, Otto Neubuerger, Kent Perryman, F. James Rybka, Irma West Judicial — Drs. Joanne Berkowitz, Jose Cueto, Barbara Hays, Elisabeth Mathew, Richard Pan, Paul Phinney Medical Review and Advisory — Drs. Howard Slyter, Chair, Joanne Berkowitz, Vice Chair, Denny Anspach, Jose Arevalo, Richard Axelrod, Peter Carruth, Mark Chang, Satya Chatterjee, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Michael Goodman, Robert Greene,
Kern Guppy, Okyanus Gurel, Ruth Haskins, David Haugen, Edward Hearn, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Robert Lentzner, Charles McDonnell, George Meyer, Gail Pirie, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto, Gerald Simon Membership — Drs. James Sehr, Chair, James Farley, Vice Chair, Christine Fernando, James Hamill, Barbara Hays, Steven Long, Daksha Shah Professional Conduct and Ethics — Drs. Joanne Berkowitz, Chair, Frank Apgar, Satya Chatterjee, Kevin Elliott, Jon Finkler, Bonnie Gieschen, James Hamill, John Kasch, Ralph Koldinger, Charles Kuehner, Janet O’Brien, Ivan Rarick, Ronald Rogers, Linda Schaffer, Daksha Shah, Stephen Skinner, Robert Treat, Glennah Trochet Public and Environmental Health — Drs. Donald Lyman, Chair, Richard Sun, Vice Chair, Regan Asher, Donald Brown, Clinton Collins, Anthony DeRiggi, Jason Eberhart—Phillips, Sandra Hand, Bette Hinton, Robert Jacoby, Alexander Kelter, Robert LaPerriere, Charles Maas, Stephen McCurdy, Margaret McCusker, Robert Meagher, Connie Mitchell, David Root, Glennah Trochet Scholarship and Awards — Drs. Byron Demorest, Chair, Ruenell Adams-Jacobs, Frank Boutin, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kaplan, Abdul Khaleq, Lionel Lee, Mark Levy, Caroline Peck, Patricia Samuelson Wellness Committee – Drs. Michael Parr, Chair, Lee Snook, Captane Thomson, Robert Treat
Board Briefs November 13, 2006 The Board: Approved procedures for reviewing and approving investment performance and pension plan administration. Amended the Money Purchase Pension Plan to designate the trustees as responsible for the direction of the investments in the plan. Approved the 2007 Budget and the 2006 Third Quarter Financial Statements. Approved Third Quarter Investment Reports and Recommendations by Smith Barney. Approved a Resolution for the Bank of Sacramento on addition of an employee’s automatic payroll deposit. The Home Security Act requires banking institutions that have online banking, inter fund and extra fund transfer arrangements with clients to have any changes approved by their organization’s Board. Approved the Continuing Medical Education Policy & Procedure Manual and the Appointment of Denise Satterfield, MD as CME Committee Chair. Approved the following 2006 SSVMS Award recipients: Golden Stethoscope Award to William G. Bush, MD; Medical Honor Award to John M. Chuck, MD; Medical Community Service Award to the UC Davis Student-Run Clinics. Approved the Membership Report: For Active Membership — Michael J. Abate, MD; Richard E. A. Brunader, MD; Andrew G. Burt, MD; Carolyn F. Dennehey, MD; Elizabeth M. Gonzalez, MD; Karun F. Grossman, MD; Michael A. Hogarth, MD; Virginia Joyce, MD; Alison L. Juozokas, MD; Mithlesh C. Sharma, MD. For Government Membership — Vivian E. Worn, MD For Reinstatement to Active Membership — James W. Brode, MD For Retired Membership — Lloyd L. Rich, MD For Annual Renewal of Postgraduate Leave of Absence — Connie Mitchell, MD For Annual Renewal of Special Leave of Absence — Derek J. Wong, MD For Resignation — Margaret S. Chao, MD (moved to New York); Kai-ey Chen, MD (transferred to PlacerNevada); Meera Chong, MD (moved to Loma Linda); Lisa
Sierra Sacramento Valley Medicine
O. Craig, MD ( moved to Walnut Creek) John H. Howard, MD; Michael J. McNerney, MD (transferred to San Luis Obispo). Dr. John Loofbourow, Editor, announced that information regarding the Society’s Essay Contest for high school Juniors and Seniors will be mailed to all high schools in El Dorado, Sacramento and Yolo Counties. The Society’s Essay Contest for all medical students and resident members will be sent electronically. The award for each contest is $500. It can be increased through voluntary donations to the Community Service, Education and Research Fund.
December 11, 2006 The Board: Approved the Board Review of SSVMS Financial and Investment Performance Policy. The policy establishes a written procedure for assuring the SSVMS Board of Directors receives adequate and timely information about the performance of Medical Society (1) financial statements; (2) investment returns on Society-held funds; (3) and the SSVMS Money Purchase Pension Plan. Approved the Investment Policy, Objectives and Guidelines for the Employee Money Purchase Pension Plan. The policy will: (1) Define and assign the responsibilities of all involved parties; (2) Establish a clear understanding for all involved parties of the investment goals and objectives for Plan assets; (3) Offer guidance and limitations to all Investment Fund Managers regarding the investment of Plan assets; (4) Establish a basis for evaluating investment results; (5) Ensure that the Plan assets are managed in accordance with the Employment Retirement Income Security Act of 1974 (ERISA) and regulations pertaining thereto; (6) Establish the relevant investment horizon for which Plan assets will be managed. Approved 2007 Committee Appointments. Approved the Membership Report: For Active Membership — Amy W. Black, MD; David N. Katz, MD; Suzanne C. Koopmans, MD; Maria F. Lewis, MD; Don C. Loomer, MD; Gweneth Poon, MD; Patricia A. Yost, MD. For a Change in Membership Status from Retired to Active 65–20 — Kuppe Shankar, MD
Meet the Applicants The following applications have been referred to the Membership Committee for review. Information pertinent to consideration of any applicant for membership should be communicated to the committee. — Charles H. McDonnell, III, MD, Secretary AGADI, Smitha G., Internal Medicine, Kempegowda Institute, India 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6097
HO, Phuong N., Emergency Medicine, St. George Univ, West Indies 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600
MEALEY, Forest H., DO, Internal Medicine/ Pulmonary Critical Care, Western Univ of Health Sciences 2002, UCDMC, 4150 V St #3400, Sacramento 95817 (916) 734-3566 (Resident)
BLACK, Amy W., Orthopedic Surgery, Univ of Chicago 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000
HUANG, Andrew H., General Surgery, Jefferson Med Col 2006, UCDMC, 2315 Stockton Blvd., #6309, Sacramento 95817 (916) 734-2724 (Resident)
NAGARAJ, Haritheertham, Pulmonary/Critical Care Medicine, Univ Madras, India 1991, Pulmonary Medicine Associates, 6660 Coyle Ave #350, Carmichael 95608 (916) 482-7621
BOODY, Antony R., Orthopedic Surgery, Loma Linda Univ 2001, Western Sierra Orthopaedic Center, 4300 Golden Center Dr #C, Placerville 95667 (530) 344-2070
HUSSAIN, Saba, Family Medicine, St. George’s Univ, West Indies 2001, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-2644
CHAKRABARTI, Indro, Neurosurgery, Columbia Univ 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490
KHAN, Amer H., Child Neurology, Sind Med Col, Pakistan 1989, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6072
CHEW, Stanley H., Internal Medicine, UC San Francisco 1976, 5025 J St #309, Sacramento 95819 (916) 453-1946
KATHOL, Shannon L., OB-GYN, Univ of Nebraska 2002, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055
CHIEN, Lynn, Emergency Medicine, Duke Univ 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600
KONG, Erin, Anesthesiology, Univ of Connecticut 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7718
CHINN, Marc K., Pediatrics, UC San Diego 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2549
KOOPMANS, Suzanne C., Neurology, Texas A & M Univ 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106
CURRAN, Thomas J., Pediatric Surgery, Univ Southern California 1987, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5982
KORSHKOV, Yury, Anesthesiology, Novosibirsk Med School, Russia 1984, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000
DUDLEY, Lewis T., Radiology/Pediatric Radiology, Med Col Wisconsin 2000, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300
KUMAR, Munish, Family Medicine, Punjabi Univ, India 1988, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670
HARTY, Patrick A., Radiology/Interventional Radiology, Creighton Univ 2000, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300
continued from page 34 For Retired Membership — Kieran J. Fitzpatrick, MD; James J. McCusker, MD. For Resignation — Robert J. Charles, MD (moved out of state). Serving as the Administrative Members of BloodSource, approved Lawrence Salinas, Executive Director of Governmental Relations for the University of California, Merced, to his first 3-year term on the BloodSource Board of Trustees.
LEWIS, Maria F., Family Medicine, UC Davis 2003, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-2644 LIN, Susan S., Emergency Medicine, Jefferson Med Col 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 LOOMER, Don C., Radiology/Interventional Radiology, Uniformed Services Univ 1991, Radiological Associates of Sacrament, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300
NAMIQ, Asraa L., Pathology/Cytopathology, Univ of Baghdad, Iraq 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2302 NASIR, Hasina, Family Medicine, Mymensingh Med Col, Bangladesh 1988, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6789 PADILLA, Joahnna A., OB-GYN, Univ of Santo Tomas, Philippines 2000, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-2612 POON, Gweneth, Radiology, UC Davis 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 ROLDAN, Guadalupe, Family Medicine, Boston Univ 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2332 SEHMBEY, Kulwinder S., Anesthesiology/Pediatric Anesthesia, Ross Univ, Dominica 2001, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990 SERGEYEVA, Yelena Y., Internal Medicine, Kazan Med Institute, Russia 1991, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5100 SZYTEL, Sasha L., Pediatrics, UC Los Angeles 2003, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5439 TYBURSKI, Mark D., Physical Medicine & Rehabilitation, George Washington Univ 2001, The Permanente Medical Group, 2120 Professional Dr, Roseville 95661 (916) 771-6627
LUSZCZAK, Michael H., DO, Emergency/Family Medicine, College of Osteopathic Med of the Pacific 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651
YIP, Peter T-J., Family Medicine, UC Davis 2001, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 746-4744
McCLOUD, Michael K., Geriatrics/Internal Medicine, Ohio State Univ 1976, UCDMC, 2660 W. Covell Blvd., Davis 95616 (530) 792-8544
YOST, Patricia A., OB-GYN, Univ Nevada 2002, 2277 Fair Oaks Blvd., #355, Sacramento 95825 (916) 927-3178
McCUE, Kelly A., OB-GYN, Univ Cincinnati 1995, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-6946
ZAVOD, Matthew B., Otolaryngology/Facial Plastic & Reconstructive Surgery, Jefferson Med Col 1999, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-2626
Positions Available PART-TIME PHYSICIANS for urgent care center. Hours flexible. BC/BE in FP, IM, EM preferred. Competitive compensation and malpractice paid. Kim Marta, MD. The Doctors Center, 4948 San Juan Ave., Fair Oaks, CA 95628. (916) 966-6287.
Doctor’s Placement p/u Nov/Dec 06
Office Space Medical Buildings-Mercy San Juan Hospital. South Sacramento locations also available (916) 224-9100. West Sacramento Medical Office Space to Rent. Conveniently located. 1-4 exam rooms, 600-1000 sf. Full services available. Contact Liz: (916) 275-3747.
Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning
Since 1973 • Max Uden, Owner • (916) 455-5880
URGENT CARE PHYSICIAN, FT/PT. Email: Kendallrbauer@aol.com Fax: (916) 783-6049 or Call: (916) 783-0101 BUSY PRIMARY CARE CLINIC in Midtown area seeks PT and FT MDs. Multi-lingual staff. Competitive Compensation. Please call (916) 275-3747 or fax resume to (916) 760-0837.
• • • • • • •
Membership Has Its Benefits!
Free and Discounted Programs for Medical Society/CMA Members Auto/Homeowners Insurance
Mercury Insurance Group 1-888-637-2431 www.mercuryinsurance.com
Billing & Collections
Avis: 1-800-331-1212 (ID#A895200) Hertz: 1-800-654-2200 (ID#16618)
Clinical Reference Guides-PDA
EPocrates 1-800-230-2150 / www.epocrates.com
I.C.System 1-800-279-6620 / www.icsystem.com
Conference Room Rentals
Medical Society (916) 452-2671
MBNA 1-866-438-6262 / Priority Code: MPF2
Corporate Express /Brandon Kavrell (916) 419-7813 / email@example.com
Practice Management Supplies
Histacount 1-888-987-9338 Member Code:11831 www.histacount.com
Infinedi – Electronic Clearinghouse 1-800-688-8087 / www.infinedi.net
Healthcare Information Technology Products
KLAS / HIT Consumer Satisfaction Reports 1-800-401-5911
Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...
Marsh Affinity Group Services 1-800-842-3761 CMACounty.Insurance@marsh.com
HIPAA Compliance Toolkit
PrivaPlan 1-877-218-7707 / www.privaplan.com
Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com
Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma
Notary Service/Free to Members
Medical Society (916) 452-2671
Security Prescription Pads
Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php
UCG Decision Health 1-877-602-3835 / www.decisionhealth.com
Travel Accident Insurance/Free
All Members $100,000 Automatic Policy
Sierra Sacramento Valley Medicine
Two $500 SSVMS Essay Competitions High School Juniors and Seniors are invited to enter. Essay Topics Address one of the following statements / questions: 1) No nation or state can afford unlimited medical care for all people within its borders; California must limit medical care expenditures. How can this best be done? 2) Californians want to assure or provide full and equal medical care to all people within the state. How can this best be done?
Medical Students and Resident Physicians are invited to enter this essay competition. Background: The World Health Organization estimates that in 2005 almost 4 million infants died from neonatal problems and another 4 million children died from respiratory infections, diarrhea, malaria, and measles. Essay Topic What can the world do to end the annual toll of infant/child/societal death and suffering?
This acrylic painting, “Nasturtiums,” is by Terri Sacré, an administrative analyst at Mercy San Juan Medical Center who works closely with physicians. It originated with a series of photos taken two years ago in the herb garden of Freestone Bakery, in the small town of Freestone near Bodega. It took her about 6 months to complete the painting, working in her spare time.
Published on Jan 14, 2007
Published on Jan 14, 2007
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...