Page 1

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2010


As a physician, your liability exposure isn’t limited to the practice of medicine. You also need to consider your risks as a business professional–risks that go unprotected by your medical malpractice coverage.

T

he Sierra Sacramento Valley Medical Society sponsors a high-quality and responsive medical office insurance policy that provides comprehensive business insurance coverage tailored specifically for physicians like you. Only this SSVMS sponsored policy offers you well-rounded coverage, the reliability of the SSVMS endorsement, specialized expertise and physician-focused service–all at an economical price.

SPONSORED BY:

UNDERWRITTEN BY:

Some of the Important Highlights of this Cost-Effective Insurance Policy: • Coverage to compensate you for lost income to help pay ongoing expenses while your practice is unable to function after a loss–even helping to cover lost profit.

ADMINISTERED BY:

• Pays damages, medical bills, as well as attorneys’ fees and other legal expenses should someone trip and fall or injure themselves while visiting your practice. • Protects your practice if patient information or

other sensitive data is accidently publicized, stolen or released. Even a nominal technical malfunction could accidentally release protected information, damage your reputation, expose you to lawsuits and other legal complications. Legal defense, assistance to affected individuals and other needed and costly services are included. Don’t assume the same policy that you automatically renew each year is still the best coverage for your practice. This SSVMS sponsored insurance program can make sure that you are not paying more to insure your practice than you need to.

47080 (1/10) ©Seabury & Smith Insurance Program Management 2010 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

s

For more information or a quote, please call a Marsh Client Service Representative at 800-842-3761, or e-mail CMACounty.Insurance@marsh.com


Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE The Challenges — and Stresses — for Physicians

17

Annual Meeting

21

Thanks from the Winner of SSVMS’ Highest Honor

Jane O’Green Koenig, MD

Stephen F. Melcher, MD

7

This Year’s an Ungluck

John Ostrich, MD

22

A Posit on Dealing Directly with Patients, not Insurers

9

Do No Harm: Vaccinate Yourself

25

Anthony W. Russell, MD, MPH

Doctoring, Eyes, Raccoons and Health Insurance

11

Pot War Collateral Damage

Ann Gerhardt, MD

John Loofbourow, MD

13

Another Friday

Nathan Hitzeman, MD

14

Voices of Medicine

29

Bones From Dinky Creek

David Hadden, MD

31

Thank You, Dr. Fields

David Gunn, MS III

Del Meyer, MD

34

New Applicants

16

The Four Leaf Clover

35

2010 SSVMS Committees

Donald V. Hummel, MD

36

Classified ads

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 is the first of a series of covers by Dr. Gordon Love, a pathologist who spends a lot of time looking at specimens under a microscope — and often photographs them. This rainbow of colors is actually uric acid crystals in urine magnified 400 times, from a patient with gout (a disorder of purine metabolism). Sometimes uric acid crystals can be seen in specimens from “normal” individuals after a meal (like meat) rich in purines.

Volume 61/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Uric acid forms crystalline plates that reflect light under “phase microscopy.” Dr. Love explains. “Phase microscopy cancels out all light except that which is out of phase after passing through a structure.” Hence the colors.

January/February 2010

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. 2010 Officers & Board of Directors Stephen F. Melcher, MD President Alicia Abels, MD, President-Elect Charles McDonnell, III, MD, Immediate Past President District 1 District 5 Robert Kahle, MD John Belko, MD District 2 David Herbert, MD, Jose Arevalo, MD Treasurer Michael Flaningam, MD Robert Madrigal, MD Michael Lucien, MD, David Naliboff, MD Secretary Anthony Russell, MD District 3 District 6 Bhaskara Reddy, MD J. Dale Smith, MD District 4 Demetrios Simopoulos, MD 2010 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 Marcia Gollober, MD At-Large Alicia Abels, MD Satya Chatterjee, MD Richard Gray, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Charles McDonnell, MD Stephen Melcher, MD Janet O’Brien, MD Kuldip Sandhu, MD Earl Washburn, MD

Alternate-Delegates District 1 Robert Kahle, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Reinhart Hilzinger, MD Robert Madrigal, MD Mubashar Mahmood, MD Rajan Merchant, MD Connie Mitchell, MD Anthony Russell, MD Gerald Upcraft, MD Vacant Vacant

CMA Trustees 11th District Richard Pan, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, MD Very Large Group Forum Paul Phinney, MD

Don’t Let The Flu Bug Your Patience. The physicians at The Doctors Center are available to assist you during the cold and flu season. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 14 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. The Doctors Center is open from 8:00 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for multiple HMO’s and PPO’s.

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine KATHLEEN K. QUADRO, M.D. Board certified in Family Medicine

We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287

The Doctors Center Medical Group Inc.

The Doctors Center new hours are 8 a.m. to 10 p.m.

AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor William Peniston, MD Robert Forster, MD Robert LaPerriere, MD Gerald Rogan, MD F. James Rybka, MD Gordon Love, MD Gilbert Wright, MD John McCarthy, MD Lydia Wytrzes, MD Del Meyer, MD George Meyer, MD John Ostrich, MD

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

Managing Editor Webmaster Graphic Design

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.

Ted Fourkas Melissa Darling Planet Kelly

2

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


President’s Message

The Challenges — and Stresses — for Physicians By Stephen F. Melcher, MD This article expands on comments by Dr. Melcher at the SSVMS Annual Meeting. Bill Sandberg tells me that it has been 19 years since we have had a psychiatrist as SSVMS president. And it may be that we’ve never needed one more than now. Stress levels are running pretty high: • We are trying to get through the worst recession since the 1930s. •  We are fighting for — and sometimes against each other — for health care reform. • And it is clear there will be fewer dollars for all of us to take care of our patients. If these things haven’t strained our emotions, I don’t know what would. When I joined the board of SSVMS, I never imagined becoming your president one day. I grew up on the East coast and vowed never to leave — only to end up in Texas for 12 years. I then moved to California. I should have learned: never say never. I’ve learned a lot on the medical society board that should help me as president. • I’ve learned that no matter how hard I try, I will unintentionally offend someone. If that happens to be you, then I apologize in advance. I am a big believer in the words of Oscar Wilde: “A true gentleman is one who is never unintentionally rude.” •  I’ve learned that when a problem seems insurmountable, reaching out to the incredible pool of talent in this organization can produce unimaginable results. •  And I’ve learned how to wear multiple hats at once and to remember which hat I’m wearing when I speak.

When I represent you in this position it doesn’t matter who I work for, it doesn’t matter what department I chair or which medical staff I’m president of. It only matters that I have SSVMS interests at heart. Somehow I feel this year picked me. Our county mental health hospital just went from an effective census of about 125 patients a day down to 50 patients a day. Many mental health providers fear a reduction of their census down to 16. These patients, most of them without any type of insurance, and without any advocates for them, are flooding our county emergency rooms and psychiatric hospitals. They are costing far more to treat in this process. In a time of health care reform, this just seems, pardon the phrase, crazy. I hope that one of my first tasks as president will be to see how we can come together as an organization to try to help this population just as the hospital council is trying to do. There are other areas in which physicians have a role to play.

In a time of health care reform, this just seems, pardon the

The Economy. The unemployment rate in Sacramento County is over 12 percent, and many people are losing their health insurance. The county and state are experiencing unprecedented budget woes, which are having a devastating impact on services to the medically indigent. Increasing numbers of people aren’t getting the care they need. And many more are contributing to the overcrowding and inappropriate use of our emergency rooms. As physicians, we may not be able to change the economic climate, but we can do something

January/February 2010

phrase, crazy.

3


to help people in their time of need. For example, we can volunteer our time and skills to programs like SPIRIT, which most of you know provides compassionate medical care to the uninsured so they can lead healthy and productive lives. We can volunteer at a local school, sharing our health knowledge and serving as positive role models to our youth. We need stronger collaboration and integration between all of our local health organizations to address the critical health care needs of our communities.

Ideally, the new reform agenda will make care ultimately more affordable for everyone who gets health care in America. And that’s something we can all agree would be a good thing.

Health Reform. Many organizations have been very vocal and strong supporters of national health care reform — advocating that every American have health care coverage, and wanting every American to have continuously improving care. Ideally, the new reform agenda will make care ultimately more affordable for everyone who gets health care in America. And that’s something we can all agree would be a good thing. But whatever results from healthcare reform, we know that providing the best and most cost-effective health care in the years ahead is going to require a relentless pursuit of prevention, a comprehensive electronic medical record system, and a commitment to patient safety. When these elements are present, we know that health outcomes improve measurably and costs drop significantly. As a medical society, we should strongly support these elements. We’re all aware of The Institute of Medicine’s report that found close to 100,000 Americans a year die from medical errors. Perhaps lesser known is a Rand study that found patients receive only 55 percent of the recommended

4

Sierra Sacramento Valley Medicine

treatment for preventive care, acute disease and chronic conditions. This is unacceptable. The use of a fully integrated electronic medical record, like those at several local hospital systems, is helping to reduce medical errors and helping physicians take better care of people, particularly those with chronic conditions and co-morbidities and reducing the complications of their care. Additionally, if all physicians ensured that every patient received all recommended preventive services, we would dramatically lower the incidence of heart disease and strokes, prevent nearly all deaths from cervical and colon cancer, and diagnose breast cancer earlier. As a medical society, we must also continue to raise awareness about, and find creative ways to grow our physician population in this community, especially in primary care, which will be desperately needed in order to care for an expanded insured population under reform.

SSVMS Membership. Finally, as president, I would like every physician in this community to know the benefits of being a member of the Sierra Sacramento Valley Medical Society and the collective power we have to push for better quality care in our community and to foster a more satisfying working environment for ourselves. Currently less than half of the physicians in our tri-county area are members and I hope you will help me spread the word about this great organization to your peers in the year ahead. My thanks to Chris Stincelli, Bill Sandberg and all the SSVMS staff who not only helped put on an outstanding Annual Meeting, but who also work every day to make SSVMS such a successful organization. My thanks also to Dr. John Loofbourow, for his outstanding contributions as editor of this magazine. It is an honor to serve in this position and I can only hope to fulfill the responsibilities of this office as well as my predecessors have. As a psychiatrist I spend most of my time listening. I hope to carry that trait forward in my role as your president. Steve.Melcher@kp.org


This Year’s an Ungluck Dame Elspeth returns, older, cheaper, with her predictions for 2010.

By John Ostrich, MD As many of you must know by now, Dame Elspeth Mallory-Weiss is the premier fortuneteller of the past 60 years and the greatest since Nostradamus. Now almost 90 years old, she lives with her fifth husband, Lord Richard Amplegelt, in the picturesque Cotswold village of Upper Crudneyon-Thames, famous among beer aficionados as the home of the Olde Frothingslosh brewery. There she continues to ply her trade and makes a tidy living in the private practice of predicting the future and necromancy. These days, she told us, there is more money in necromancy. Dame Elspeth gained fame in the USA when, in 1950, soon after Elizabeth Taylor married Nicky Hilton, she predicted accurately that Ms. Taylor would eventually marry eight men, two of them with the same last name. In a recent BBC interview, she said, “After Miss Taylor had married Mr. Hilton, I correctly predicted that she would eventually be married eight times and two of her husbands would be consecutively surnamed Burton. I knew one would be actor Richard Burton, but I thought the other would be magician Lance Burton. And I also thought that her last husband would be Hungarian Baron Imre Fortensky, not the Yank commoner Larry Fortensky. But at least I got all the names correct and in order.” (Editor’s Note: Here they are — Hilton, Wilding, Todd, Fisher, Burton, Burton, Warner, Fortensky.) We at the Editorial Committee had not contacted Dame Elspeth for a few years as her fee had become quite steep and Bill Sandberg refused to pay her going rate, which was 7,500 pounds or two cases of properly cellared 1975 Mouton-Rothschild.

But this year Dame Elspeth told us that she would produce “a brief but accurate list of prognostications for you folks in Sacramento” for a more modest fee. She admits it is difficult to connect psychically with a backwater such as Sacramento, but we think she did an honorable job for us. And here are her forecasts.

January Speaking in German from an unknown location, Governor Schwarzenegger declares the California state budget to be “ein furshlugginer ungluck” (freely translated — a screwedup disaster), and, saying that desperate times require desperate measures, he fires the entire Departments of Motor Vehicles and Fish and Game. Still in German, he says that “hardly anyone bothers to renew their licenses anymore and who cares if there are northern pike in Lake Davis anyway.” He thereby saves the state $10 billion or so. Thirty to go.

February Having fired Tom Cable, Raiders owner Al Davis assumes the head coaching job for himself and soon thereafter re-hires, as his assistant, former coach Lane Kiffin whom he had fired in 2008 and who recently had taken a job as head coach at USC. Davis is quoted as saying, “I always thought Lane was a brilliant football man and I am pleased as punch to be able to work with him again.” Governor Schwarzenegger disbands the Highway Patrol saying — again from an unknown site and in German — “No one obeys the speed limit anyway” and saves the state another $5 billion. Twenty-five to go.

January/February 2010

Governor Schwarzenegger disbands the Highway Patrol saying — again from an unknown site and in German — “No one obeys the speed limit anyway”...

5


March

July

The California Medical Association is outraged when SB 6742 (Bonkers, D-Santa Anita) is introduced and rapidly becomes law. It permits chiropractors “to perform minor surgeries such as tonsillectomies and removal of ingrowing toenails” as well as “setting, manipulating, immobilizing and/or surgically stabilizing spinal subluxations.”

A state budget is still not completed. Governor Schwarzenegger has not been seen in public for almost 6 months. He communicates mainly by calling in to morning drive-time talk shows in Los Angeles, Fresno, San Francisco and Sacramento and continues to speak only German. Some believe he is living in the same apartment complex as Jerry and Hillary, while others say he has left his family and is living a reclusive life in Potsdorf, Austria, has grown a long beard and gained fifty pounds (22.7 kg in Austria).

April

He vows

conduct all

Gubernatorial candidate Jerry Brown announces his switch to the Green Party, and moves in to a 900 square foot apartment near the capitol. He vows never again to use a petroleum-powered vehicle and says he will conduct all the business of his present office and his upcoming campaign electronically, mainly by tweeting. He says that Ed Begley, Jr., has agreed to run with him as Lieutenant Governor and announces as well that his wife of five years, Anne Gust, has left him and is now living with Whoopi Goldberg.

the business

May

never again to use a petroleumpowered vehicle and says he will

of his present office and his upcoming campaign electronically, mainly by tweeting.

Acerbic debate over how to fix the state budget goes on, and everyone in the legislature seems to agree that disbanding DMV, Fish and Game and the CHP has helped a great deal, but more revenue is needed. SB 7854 aims to help. It places a 5 percent surtax on purchases over $5,000. Author Senator Ivan Stoops (D-Geronimo City) defends the tax-tax. “Only rich people can afford to buy anything worth five thousand dollars anyway, and they won’t give a rat’s behind about a measly five per cent extra tax. If they don’t like it, let ‘em shop at Wal Mart like everybody else.” It passes easily.

June United States Secretary of State Hillary Clinton divorces Bill, resigns her post, announces publicly that she is going to devote herself to “green” causes and politics, and soon afterwards moves in with Jerry Brown. Brown says that, if elected, he will push for a bill making illegal the “serving of red meat” at any California school cafeteria or public restaurant.

6

Sierra Sacramento Valley Medicine

August The dispirited Giants fall below .500 after their star pitcher, Tim Lincecum, enters a drug rehab program in Mississippi. The debate over the state budget goes on. Bills to increase revenues abound. AB 84091 (Dinkum, D-San Boracho) calls for a 10 per cent tax on state lottery winnings. It passes easily. AB 89618 (Blatsky, D-San Palooka) requires a five dollar tax on every 18-hole round of golf, but a refund can be requested at the end of the year if the player can prove that the score for the round was under 70 or over 110. There is, however, a 25 per cent tax on the refund. It also passes.

September While the Legislature works feverishly to produce a budget, other important issues continue to occupy the peoples’ representatives. In the spirit of Proposition 2 from 2008, which required commercially raised chickens to have enough room in their cages “to lie down, stand up, fully extend their limbs and turn around freely.” Senator Rosa Mariachi (D-San Loco) introduces SB 46942 that requires “every commercially raised and maintained honeybee” to have at least “two cubic inches of personal space” in every hive. Apiarists protest that hives almost five feet on a side would be impossible to take care of and to transport to venues where they are needed to pollinate commercially important crops. It passes with little debate.


October The budget deficit has risen to about $45 million, and the legislative debate drones on — Monday through Friday only. Stopgap measures are everywhere to be found. The governor announces (in German) that he is happy with the UC Board of Regents decision to stop the teaching of English literature and creative writing in the UC system. The elimination of all UC departments of English will save the state about $300 million annually. Speaking by telephone from an unknown site, on “Good Morning Fresno,” Schwarzenegger says (in German), “No one speaks English anymore anyway.”

November Newly elected Governor Jerry Brown and Lieutenant Governor Ed Begley, Jr., announce “a new era” for California. Brown says he plans to establish a new state “Department of Green” to be paid for by the elimination of the departments of Consumer Affairs and Rehabilitation. He says it will “make California the leader

in the Green Revolution” and he says he will appoint his roommate, Hillary, to run the new department. “Her credentials are impeccable,” he says. Republican senator Bob Pleindugaz (R-San Colocado) says, “I disagree. She is quite peccable.”

The budget deficit has risen to

December As the Legislature continues to work on a budget fix, Governor Schwarzenegger and Governor-elect Brown jointly and happily announce that a low interest $50 billion loan jointly floated by the governments of Mexico and China has saved the day, fiscally speaking, for the state. There are only two strings attached. One is that all maps in California and in all public school textbooks be revised to show Los Angeles as “El Pueblo de Nuestra Senora La Reina de Los Angeles de Porciuncula” and from now on, it is illegal to offer forks, knives and spoons to patrons of Chinese restaurants.

about $45 million, and the legislative debate drones on — Monday through Friday only.

John.Ostrich@kp.org

“Because of you, our holidays are much brighter.” Jaime Suarez, father of twin boys who are alive today by the gift of precious blood.

www.bloodsource.org

|

not-for-profit since 1948

“I’m able to hold these perfect little boys in my arms because the precious gift of blood, and the medical professionals to care for my twins, were there at the critical moment that saved their lives. As a father, you mean everything to me. Because of you, my boys are with me today. Yes, you do save lives.” Watch Jaime’s story at w w w. b l o o d s o u r c e . o r g / h o s t . h t m

January/February 2010

7


Independent But Not Alone. Randy Winslow, D.O. Hill Physicians provider since 2004. Uses Ascender preventive care reminders, RelayHealth online communication tools and Hill’s EHR for a comprehensive solution to patient care, practice management and ePrescribing.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Your health. It’s our mission.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

Sierra Sac B/W Dr. Winslow.indd 1

3/16/09 4:55:18 PM


Do No Harm: Vaccinate Yourself Unvaccinated health care workers spread influenza to the most vulnerable people in our communities. Why are we allowing this?

By Anthony W. Russell, MD, MPH With so much concern in the air about influenza, we healthcare providers must not lose our heads. Looking at the broader picture of influenza is critical at this time, for we know that California’s regular influenza season tends to peak in February, and we know that it kills approximately 36,000 people in the United States every year. Today, seasonal influenza is a disease mostly preventable through vaccination, and the vaccine is safe and effective. Approximately 100 million doses are distributed in the U.S. annually. Influenza is easily spread and mutates more readily then many other viral infections. So why are less than half of American health care workers getting vaccinated? Health care workers are on the front line of exposure to influenza and we are a vector for its spread. Even if asymptomatic during the initial days of the illness, an individual can infect others. Unvaccinated health care workers spread influenza to the most vulnerable people in our communities. Why are we allowing this? We know the youngest and oldest members of society suffer the highest morbidity and mortality from the seasonal influenza viruses. Complications from nosocomial influenza infections are particularly burdensome on patients with chronic medical conditions and other factors who make frequent visits to hospitals and medical clinics. Influenza in these vulnerable populations results in protracted illnesses, extended hospital

stays, higher health care costs, and even death. It is our responsibility to protect our patients, families, colleagues, community, and ourselves by not becoming vectors for influenza. Intensive Care Unit (ICU) patients in general tend to experience more virulent infections with higher rates of medication resistance than other people infected in our communities. So it was surprising to hear about a study from Johns Hopkins in early 2009 by Daugherty showing that their ICU health care workers reported suboptimal levels of influenza personal protective equipment (PPE) adherence. This finding in a high-risk setting is particularly concerning, with nearly 40 percent of ICU health care workers self reporting poor adherence with influenza PPE while 53 percent reported poor adherence by their colleagues. Suboptimal adherence and considerable gaps in knowledge indicate that health care workers are at a significant risk of being infected and of transmitting a nosocomial infection. Kaiser Permanente Northern California (KPNC) tracks its health care workers’ seasonal influenza vaccination rates. The data show that the enactment of California’s SB 739, which created the Hospital Infectious Disease Control Program, triggered an 8 percent bump during the 2007–2008 influenza season. KPNC health care employees’ immunization rates for the past flu seasons improved slightly, starting at 45 percent during the 2006– 2007 flu season and going to 54 percent during the 2008–2009 flu season. The data show an January/February 2010

9


Given the current influenza immunization rates among health care workers, we are likely doing a great deal of harm.

increase in physician immunizations from 65 to 76 percent during that same time. The response to voluntary influenza vaccination recommendations for health care workers has been dismal — only 36 percent of U.S. health care workers received an influenza vaccination in 2002. Despite local, state and national efforts to encourage seasonal influenza vaccination, the overall immunization rate among health care workers in the United States remains unacceptably low at approximately 40 percent. Even among health care centers using highly organized and aggressive campaigns to promote immunization of health care workers in California, the majority remain unvaccinated. Influenza vaccination for health care workers is recommended by the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Advisory Committee on Immunization Practices (ACIP), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Several states have enacted legislation requiring seasonal influenza vaccination for workers in long-term care facilities. New York

CMA Policy: Influenza Immunization for Health Care Workers The following three sections are from Resolution 701a-09 adopted recently by the House of Delegates of the California Medical Association. RESOLVED: That CMA support universal annual seasonal influenza vaccination of all health care workers with direct patient contact; and be it further RESOLVED: That CMA support state efforts to educate health care workers about the importance of receiving the seasonal influenza vaccine; and be it further RESOLVED: That CMA support the current CDC recommendations for vaccinated health care workers with regard to seasonal influenza and support enhanced infection control policies for health care workers who are not vaccinated by requiring them to wear appropriate personal protective equipment when within a specified proximity of any patient while providing care during the influenza season defined by the Director of the California Department of Public Health.

10

Sierra Sacramento Valley Medicine

State recently enacted legislation mandating that health care workers get a flu vaccine, but a state court temporarily suspended its implementation due to the lack of vaccine and the looming deadline to either be vaccinated or be terminated. Then the New York State Health Commissioner fully suspended the mandate due to limited vaccine supplies. The New York State Health Department still plans to make this mandate permanent when flu vaccine supplies are adequate. A handful of institutions across the country including Virginia Mason, Johns Hopkins, Emory, and Grady Hospital Systems have successfully mandated that health care workers receive the influenza vaccination. In Sacramento, UC Davis Health System’s medical staff recently voted to approve and enact a mandatory policy for their health care workers. It may be time for California to enact a statewide mandate requiring that all health care workers receive the influenza vaccination, exempting those who have medical contraindications. Protecting our patients, families, and ourselves should be our first priority. We need to recall our Hippocratic Oath, “Above All, Do No Harm.” Given the current influenza immunization rates among health care workers, we are likely doing a great deal of harm. Anthony.W.Russell@kp.org References A complete list of 30 references appears with the online edition of this article at ssvms.org. 1 National Foundation for Infectious Diseases (NFID). Immunizing Health Care Personnel against Influenza: A Report on Best Practices. September 2007. http://www.nfid.org/HCWtoolkit/ BestPracticesToolkitDocument.pdf Accessed July 12, 2009. 2 Elizabeth L. Daugherty, MD, MPH; Trish M. Perl, MD, MSc; Dale M. Needham, MD, PhD; Daugherty EL, Perl TM, DM Needham, et al; The use of personal protective equipment for control of influenza among critical care clinicians: A survey study. Crit Care Med 2009; 37,1210-1216. 3 Fiore AE, Shay DK, Haber P, et al. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. 2007;56(RR-6):1-54. 4 Dash GP, Fauerbach L, Pfeiffer J, et al. APIC position paper: improving health care worker influenza immunization rates. Am J Infect Control. 2004;32:123-125. Abstract 5 Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet. 2000;355:93-97. Abstract


Pot War Collateral Damage By John Loofbourow, MD CMA’s Institute for Medical Quality, IMQ, offers California counties the opportunity to have county jail medical care periodically evaluated by experienced professional surveyors. Pre-survey assessment precedes a one or two-day survey/review based on more than 60 standards of administration, personnel/training, medical care/treatment, medication use/control, medical records, and medico-legal matters. The survey includes numerous one on one interviews with administrators, staff, correctional officers, and inmates. Accreditation provides county government an independent outside critique of jail care and offers a reduced risk of outcomes subject to litigation. Despite the probability that prisoners may not always tell the whole truth, many surveyors find inmate interviews very significant. Most of what is related by prisoners has merit and can be verified. I like to interview inmates who are limited to Spanish. There is always boilerplate informational postings and forms in that language, variously but adequately redacted. But in Northern California jails with less than 1,000 inmates, Spanish bilingual jail staff are uncommon, far less than one per shift, or 1 per 500 inmates overall. These jails often rely on inmates to inform one another of the details of jail routines, which are, in any event, felt to be quite obvious. Furthermore all jails have phone interpretation available at all times. Jails are county facilities, as contrasted with state or federal prisons. While jails share some characteristics with their Big Sister correctional facilities, jail inmates generally have a shorter average stay. There is often a high rate of recidivism, related to drug/alcohol or mental illness. There is a closer interaction with the local community. Nonetheless, two factors are chang

ing the mix of jail inmates. First, Federal correctional institutions are overcrowded for several reasons including the ”War on Drugs.” Second, counties are at the bottom of the taxation pecking order, with insufficient operating funds. The federal government, which can print money at will, is able to offer much needed cash to counties that have extra jail space. The result is that many federal prisoners are housed in county jails, where they are a source of much needed revenue. And many are Pot War Prisoners. The Spanish speaking federal inmate I find most often in Northern California county jails is the Marijuanero. While some are illegal immigrants, others are immigrant citizens or native born ethnic whites. Below are excerpts from typical interviews. All three, when arrested, admitted guilt, feeling they knew the risks, and deserve punishment under the law. None had a way to pay bail or hire private legal counsel. Two have been imprisoned for more than one year awaiting information about a court hearing. They can’t find out when that may take place. Two were first confined in Sacramento County jail for many months, finding detention there to be so exceptionally cruel and dehumanizing that one seriously considered suicide. (The Sacramento County jail does not elect to be surveyed by IMQ. The record of suicide and litigation there is a disgrace.) All the prisoners whose interviews are reported here found their small rural jail medical care and jail custodial care reasonably good, and their jailers considerate with few exceptions. In addition the jails where these three inmates were incarcerated were judged highly by IMQ reviewers. The inmate’s names are fictitious but the histories are as related. I have omitted questions January/February 2010

The result is that many federal prisoners are housed in county jails, where they are a source of much needed revenue.

11


about jail health, to focus on a political disease: the collateral economic and societal damage from our war on drugs.

Alberto.

I am waiting for a hearing because I’m illegal and worked in marijuana. No one can tell me anything.

12

Alberto Somoza is age 45, stocky, with a congested, pock-marked face. He speaks broken English but can usually be understood. JL: How long have you been in the U.S.? AS: Since 1975. JL: Where are you from originally? AS: Guatemala. JL: Did you cross the Mexican border on the famous railroad? Where half the illegals die? AS: I did. I was 12 years old. Usually I rode the rails, under or on top. It took me 18 months to get to the U.S. I crossed in Arizona, on foot. JL: Are you a citizen now? Married? Have children? AS: Yes to all. Two children. I have always worked in construction. JL: So why are you here? AS: Construction work crashed in 2008. Me, too. We had a home, a car, the essentials and a little more. But I had many bills; I couldn’t make expenses on unemployment. Soon we lost the car, and couldn’t make house payments; it was going to be foreclosed. My cousin was a drug dealer, mostly weed. He got 80 kg and hired me to bring him buyers. I did, but one was a federal agent. End of the road. JL: So you are both in jail? AS: My cousin got away. JL: I thought drug dealers had a lot of money, and take care of their own. Didn’t he hire you a top level lawyer? AS: That money and those lawyers are not for the little people. I tried to hire a lawyer but didn’t have the money. I did get a public defender. And I got 15 years. The defender said he could have got that cut to 5 if I would tell them where my cousin was. But I didn’t know, and still don’t. JL: Your family? AS: Last I knew they’re in Mexico; the kids were having problems because they don’t speak much Spanish. But they’ll learn. I hope the justice system will learn too, and let people like me out early. Then I’ll go and find them, and Sierra Sacramento Valley Medicine

my life, again.

Hermilio. Hermilio Ruiz, age 19, is an illegal immigrant. He is thin, almost gaunt, fair skinned, with a classic Gallic face, and well-trimmed curly black hair. JL: Where are you from? HR: Colonet, Baja California Sur. JL: How did you get here? HR: A coyote. JL: Across the desert? HR: No. By car. It was expensive, $3,000. JL: How was it done? HR: I went to a house in Tijuana. There were several of us. They went through thousands of green cards with photos, and found one that looked like me. It was Hermilio, and now so am I. They fixed my hair and mustache. Two of us got into the trunk of a car. A lady drove. We had signals, the radio, when to keep absolutely quiet. We passed the border OK, but had to stay put because sometimes cars get stopped farther north. After about nine hours we got to a house near here. We cleaned up, had a meal, and slept. In the morning they gave us $30, and drove us to a hardware store where we could look for work. But there wasn’t any. Soon I was starving, had no money left, or place to stay, slept in the woods. JL: What are you doing in jail? HR: Finally after a week a man asked me if I’d like to work on a pot farm in the hills, and of course I agreed. About three weeks later the farm was raided. Most people got away but I didn’t. JL: How long have you been here, and when will you get out? HR: I’ve been here 9 months. I am waiting for a hearing because I’m illegal and worked in marijuana. No one can tell me anything.

Joseph. Joseph Hansen is 50 years old. He has a pendulous gut, a long thin gray ponytail, and a smooth flat face with snow melt aqua eyes. He walks with a broad based gait, and a limp he lays to a childhood infection. He speaks with some precision and clarity. He is openly friendly, and does not project bitterness or discouragement about his situation.


JL: Joseph, What are you doing in jail? JH: It was a traffic stop. JL: When? JH: Two years ago. JL: But so long for a traffic ticket? JH: Well. It was a traffic stop but there was some pot in the back. I was making a delivery; a sort of mule in a car. More like a jackass. JL: Sounds like you might make a plea bargain if you provide some information. Agree to testify. JH: I’m not that suicidal. JL: Where are you from? JH: Wisconsin. I was a CPA in Marysville. But I got divorced and that means broke, failed, lost. Crazy. Funny thing is I never even touch any drugs, not even alcohol. I don’t even smoke. I just was way behind on my credit cards, couldn’t keep up payments and desperate; went for the gusto. Went greedy and stupid. JL: You may have trouble finding work when you get out, with a felony. JH: That’s so. But I’ve worked for myself before and I’ll do it again. I don’t need an employer to take me on. JL: When? JH: When I’m 65 unless I can get off for good behavior sooner. Maybe the country will change our ideas about drugs. I hope so. It’s stupid. It’s mindless cruelty in the name of goodness. Like a witch burning. I ask you: What are the economic, moral, and societal costs of such a war? While most of the pot war Spanish speakers are illegal, I include two other types of low level pot criminal simply to make clear that while Spanish speakers predominate, many pot prisoners are citizens, Spanish speaking or otherwise. Our overcrowded jails and prisons contain many low level pot prisoners, who are held for long periods at a higher cost than a college education. They don’t have as much legal counsel as Guantanameros. Their confessed or alleged crimes are the result of trying to make a living rather than trying to kill in the name of All­ah. These cases are not high profile; for that

Our overcrowded jails and prisons contain many low level pot prisoners, who are held for long periods at a higher cost than a college education. very reason to ignore them is twice as shameful to society, as, say, to ignore animal cruelty. Even if the use of marijuana is as harmful as alcohol, tobacco or obesity, it seems cruel and stupid to make criminals of those who sell or use it. Where is Justice when injustice doesn’t make the evening news? Wherever. john@loofbourow.com

ANOTHER FRIDAY By Nathan Hitzeman, MD H urt my back Y ou can fix it D ouble my dose R eally need my refill O ther docs don’t understand C hronic pain like you do O ut of a job D on’t like my life O ut on the street N obody’s helping me E xcept you doc!

1-800-901-5830 • • • • • •

33 years of medical experience 1,600 Northern California physicians 45 well-trained & professional operators State of the art computer technology Discounted rates for new SSVMS accounts Spanish, Chinese and Russian spoken

January/February 2010

13


Voices of Medicine A case of H1N1, a war on many fronts, communicating with new generations.

By Del Meyer, MD

We are at war, and we had better understand that, and act like it.

14

Down with a Case of the Flu.

Who is Our Enemy?

Emily Dalton, MD, wrote her final President’s Message in the December issue of The Bulletin of the Humboldt-DelNorte County Medical Society. It was on “Health Care Reform” and she was in bed with the flu. …It is hard to believe that when I started the State of California was seriously considering a plan for a statewide program of health insurance for all Californians (a la Massachusetts), and as I finish Schwarzenegger slashed funding for the Healthy Families program, Medi-Cal and Medicare, while the federal government is working on health care reform… As I have been writing this I have been bedridden for 6 days with what is most likely H1N1. Fever, cough, headache, muscle aches and tremendous malaise — enough to make one sorry for the pigs! According to the health department virtually all “ILI” (influenza-likeillness) has tested positive for H1N1, and in pediatrics one cannot avoid a heavy exposure to whatever is circulating. A pediatric intensivist from UCSF came up for a conference and described how unnerving it is to be in the ICU at UCSF right now: it is full of pregnant women on ventilators with H1N1. What an eerie and unsettling image! I can see how this virus would do that — even vaccinated, the first day I got it I could feel the deepest portions of my lungs get irritated and full of what felt like necrotic phlegm. I am finally able to take brief walks without feeling utterly exhausted. But enough whining — on to better things… To read her original column, go to the website at www.humboldt1.com/~medsoc/images/bulletin and click on the December 2009 issue.

An editorial, “On Finding Ourselves at War,” by Guest Editor Kenneth Y. Pauker, MD, appears in The Bulletin, Fall 2009, of the California Society of Anesthesiologists. We are at war, and we had better understand that, and act like it. Although we are reluctant soldiers in what has become an expanding and intensified struggle for the safety of our patients and the viability of our profession, fight we must. We cannot simply be conscientious objectors for the reason that we are ethically obliged to secure ground that was made sacred by — and inherited from — our forebears. Arrayed against us are forces that seek to redefine who we are and what we do. There are those who, to advance their own economic and political agendas, fully intend to divide our House of Medicine and enslave and muzzle us, to break our spirits, to further alienate us from the patients whose welfare has always been at the heart of our medical journey. There are others, so-called “do-gooders” and health care planners, who mean well enough, but who, with their imperfect understanding of the nittygritty of the actual practice of medicine, would restrict us, redirect us away from the essentials of our professionalism, create hurdles and diversions that distract us and consume our time and energies, and to boot, visit upon us a plague of unintended consequences. And then there are the usurpers — circling, lurking, and pouncing on opportunities as they present themselves, trying to carve out a little something more for themselves. So who are we? We are the descendents of Hippocrates, practitioners of an ancient method of discourse and learning, perpetual learners —

Sierra Sacramento Valley Medicine


an inquisitive, reasoning, obsessive, and compulsive lot.... We are protectors of our patients… So who, then, is the enemy with whom our relations have devolved to the point of war? First and foremost, powerful and essentially unchecked as we have seen merger after merger and the amassing of monopsony power, are the health insurers. They have over time ceased being insurers in the common vernacular, but now see themselves as guarantors, regulators, protocol makers, evaluators, and profit makers for executives and investors… Next on my hit parade of “enemies of the state” of grace are plaintiff attorneys and our (more appropriately, “their”) system of adjudicating claims of medical malpractice. We have been told over and over that what we have in California, MICRA, is the best system in our nation. To me that is not nearly good enough. We still have essentially a lottery, lawyers sharking around continually in search of a really big hit. Pretty much none of this is about the “Truth of the Matter,” but rather it is all about money, pure and simple, and sometimes a whole lot of money… And last, but certainly not least, we are at war with ourselves, our alter egos in other specialties who all too often want what they need for themselves, no matter the cost to others in the House of Medicine. Our state and national medical professional societies are fractionated and often nonfunctional. We contribute to organizations within medicine that lobby against the positions of one another. As Pogo wisely observed, “We have met the enemy, and it is us.” We must discuss and find a better way to advance our positions, form new alliances across specialty lines… This editorial represents the views and opinions of its author and not CSA policy. The entire article is on the CSA website at www. csahq.org/pdf/bulletin/ednotes_58_4.pdf

Getting Ready for New Generations. “Social Media — Fad or Fundamental Shift?” is the subject tackled by Sue U. Malone, executive director of the San Mateo County Medical Association, in the September issue of the society’s Bulletin.

Every day we are hearing more and more about the wave of social media that surrounds us. Is it a fad or a new way of life? Perhaps it is not a fad but a revolution. Some Interesting Stats: • By 2010, Generation X* will outnumber Baby Boomers*. Already 96 percent of Gen Xers have joined a social network. Compare the time it took various forms of communication to reach 50 million users: • Radio – 38 years • TV – 13 years • Internet – 4 years • iPod – 3 years • Facebook – 100 million users in 9 months • iPod – 1 billion users in 9 months •  YouTube – 100,000,000 videos, is the second largest search engine •  Qzone - China’s social network has 300 million users 80 percent of Twitter usage is on mobile Does this mean email is passé?… To assist you, we are planning to redevelop our Web site to better serve members and the public. The new site will provide a selfservice online membership locator, directory, and profile, which will permit physicians to create their profile and update their directory listing, join or pay membership dues online. The system will be designed to run with limited administrative oversight aside from regular posting of new content. The site will provide both the general community and physicians with local health-related resource locations, allow members to create and manage classified listings, and furnish the tools for physicians to create a full Web presence…. Physicians will also have the opportunity to share content from our site to Facebook via SMS text message as well as Twitter *Footnote: These are approximations, as opinion varies: Baby Boomers - born 1946– 1964; Generation X - 1965–1981, Generation Y - in the 1980s and thereafter. Her article can be found at the SMCMA website: www.smcma.org/bulletin/issues/BULLETIN09SeptemberF.pdf

Our state and national medical professional societies are fractionated and often nonfunctional.

DelMeyer@MedicalTuesday.net January/February 2010

15


The Four Leaf Clover By Donald V. Hummel, MD I am an orthopedic surgeon, retired since 2003. I spent the last 13 years in solo practice, the first 20 years in a group setting. During my career, I had the opportunity to see myriads of interesting cases. I’ve always had a ton of respect for physicians in a similar setting who could compile their data and come up with something interesting and meaningful. My problem always seemed to be “inadequate sampling” or “lost to followup”. Recently, I was answering a questionnaire sent out by our medical society and thought that something that would give the magazine some flavor would be a “clinical anecdote,” which leads me to:

Her frown suddenly changed to a smile as she held it and studied it.

16

Since I’ve been a small boy, I’ve always had a penchant for finding four leaf clovers. I don’t know why. Somehow my eyes just seem to be able to pick them out. My golfing friends claim that because my game is so lousy, I’m usually looking at the ground (probably more truth than fiction). As a community orthopedic surgeon, I cared for a wide variety of general orthopedic conditions: fractures in children and adults; degenerative joint disease and hip and knee replacement; tendonitis of all types; and a lot of “aches and pains.” One thing I learned a long time ago is “listen to the patient” — always be tuned in to their problem. Be upbeat. Never tell a patient “Nothing can be done.” As Osler said, if one could not do anything else, “change the position of the pillow.” One Wednesday evening, I received a call from the Mercy San Juan emergency room. Mrs. X, an 82-year-old lady had fallen, fracturing her hip. I had cared for both her and her husband in the past — both active community people (she never missed a garage sale). When I met her in the emergency room, she was totally devastated — in pain from the injury, Sierra Sacramento Valley Medicine

yes, but more from the realization of what had happened. Severe depression was setting in. “I guess this is it; I won’t be able to live independently, will I?” “We’ll do the best we can, Mrs. X, and if all goes well, you’ll be in the hospital a few days, a week or so in a convalescent facility, and then back home.” The surgery went well. The next day, however, she was still quite depressed. On Saturday morning, walking across the lawn next to the hospital parking lot, I spotted a four leaf clover. As I walked into her room, her demeanor was as before. So I held the four leaf clover in my hand, presenting it to her. “Look, Mrs. X, your luck has changed. This is for you. I found it coming in from the parking lot.” Her frown suddenly changed to a smile as she held it and studied it. Objectively, this probably had little to do with healing, but she seemed to be almost instantly energized. She spent about a week in the convalescent hospital and returned to her home. Several weeks later, I saw her in the office. As I entered the exam room, she was smiling and upbeat. “Look what I have.” She pulled a pendant from her neck — inside it the four leaf clover. So what do we have here? The four leaf clover seemed to change her attitude from pessimism and despair to optimism and hope. And perhaps, the act of “finding” it on the hospital grounds gave some kind of aura that we, the hospital staff, “cared” about her. And isn’t this what we should be doing with all of our patients? Hope goes a long way in helping our patients recover. dvhummel@sbcglobal.net


Annual Meeting Stephen F. Melcher, MD, became the Society’s 136th President at the SSVMS and Alliance Annual Awards, Installation and Dinner on January 22, at the Sacramento Hyatt Regency. Dr. Melcher is also the first psychiatrist to hold the position in the last 19 years; he succeeds Charles H. McDonnell, III, MD, a radiologist. Winners of awards: Dr. Jane O’Green Koenig received the Golden Stethoscope, the Society’s highest award. Dr. Koenig joined the nephrology team at the Sutter Hospitals in 1983, and became medical director of the dialysis unit. She was co-director of the Sutter heart transplant program begun in 1987, and has been active in the renal, hepatic and pancreas treatment programs at Sutter and UC Davis. She is a pioneering physician who made a unique and valuable contribution to the patients who needed her and physicians and surgeons who depended on her. Dr. Joanne Berkowitz was presented the Medical Honor Award for a contribution of great significance to community health. After serving on a number of SSVMS committees, she became the Society’s first woman President in 1996. Since 1991, she has been active on the California Medical Association’s District 11 Delegation and numerous committees. In 2002 she joined CMA’s Board of Trustees, serving for seven years. In addition to work with civic organizations, Dr. Berkowitz has been a volunteer physician for 14 years with the SPIRIT program, providing medical care to indigent patients. Robin Affrime, chief executive officer of CommuniCare Health Centers, and David Katz, MD, CommuniCare’s medical director, received the Medical Community Service Award, for a significant contribution to a medical or public health problem. Founded in 1972 as the Davis Free Clinic, CommuniCare has grown to a network of five clinics in Yolo County, providing primary medical and dental care, behavioral

health services, health education and outreach. Celeste Chin was presented the Alliance’s highest honor, The Dorothy Dozier Helping Hands Award. She is currently programs chair. She is also active in the Discovery Museum, where she was responsible for bringing the Challenger Learning Center to Sacramento, and the Sutter Foundation where she has been actively involved in fundraising events . Katie White, who could not attend the meeting, won the Alliance’s CMA-A Dedicated County Member Award. She has held numerous positions joining the Alliance in 1972 including chairing three Sacramento Cooks Events and serving as President for three terms.

January/February 2010

Incoming SSVMS President Dr. Stephen F. Melcher (left) receives the gavel from immediate Past President Dr. Charles H. McDonnell, III.

Stephen F. Melcher, MD, with his partner, Richard Graves, MD.

17


1

4

5

18

Sierra Sacramento Valley Medicine


3

7 1 Dr. Jane O’Green Koenig (center), holds the Society’s highest honor, the Golden Stethoscope. Her friends and colleagues are (from left) Beth Livoti and her husband, Lou Livoti, MD, and Roger Lieberman, MD, and his wife, Sue Mortensen.

6

2 Eight Members of the 2010 SSVMS Board of Directors: From the left are Doctors Charles McDonnell, Stephen Melcher, Bhaskara Reddy, Robert Madrigal, Alicia Abels, Anthony Russell, Jose Arevalo, and Demetrios Simopoulos.

3 Joanne Berkowitz, MD, the recipient of the Medical Honor Award, and her husband, William Murphy. 4 SSVMS Treasurer David Herbert, MD, (left) and BloodSource President George Chiu, MD. 5 Board Member Robert Madrigal, MD, and wife, Maritza. 6 The Alliance table listens to the evening’s entertainment. 7 Phyllis Demorest and Byron Demorest, MD, (left) talk with Clifford Marr, MD, and Jerrilyn Marr.

January/February 2010

19

Photography by Katherine Boroski and David Flatter

2


1

2

3

1 Dr. John Loofbourow, editor of Sierra Sacramento Valley Medicine, and his wife, Lilianna.

5

20

Sierra Sacramento Valley Medicine

2 The Medical Community Service Award went to CommuniCare Health Centers. From the left are Chief Financial Officer Sherry Cauchios, Board President Christian Serdahl, MD, Chief Executive Officer Robin Affrime, and Medical Director David Katz, MD.

4

3 Among the medical students in attendance, from the left: Shahram Ahari, Zachary Schwartz, Aleksandra Belova, Ryan Ribeira, Nazanin Izadpanah, and Ekama Onofiok. 4 Comedian Tim Lee. 5 SSVMS Alliance President Gabriella Neubuerger (left) with Celeste Chin, recipient of the Dorothy Dozier Helping Hands Award, and Past President Marla Bommer.


Thanks from the Winner of SSVMS’ Highest Honor Jane O’Green Koenig, MD, received the 2009 Golden Stethoscope Award.

Dr. Koenig has devoted her long and successful career to nephrology and transplant medicine. She joined a Sacramento nephrology group in 1983 following an internal medicine residency at USC and UC Davis, and fellowships in nephrology and transplant medicine at USF and UCD. A pioneer in transplant medicine, she is medical director of the Sutter program and has made unique and valuable contributions to her patients and her specialties. Dr. Koenig was honored not only for her many awards and professional accomplishments, but specifically for her devotion to her patients as they transited extremely trying treatment. Her personal and human qualities have been the keystone of her practice. In accepting the award she commented as follows:

I want to thank my family, all of whom made sacrifices in their lives and their dreams over the years, so that I could pursue my dreams. Any recognition that has come to me rests on the shoulders of the many wonderful medical professionals and people I have had the honor to work with and know — and even call friend. And to the patients who have honored me with their trust and faith over the years in some of the most difficult and frightening times of their lives. I feel great gratitude, for where would I be as a physician without them and their courage. Thank you.

I want to thank the members of the Medical Society who felt that I was worthy of this honor. I decided at a very young age that I wanted to be a physician, and I dedicated myself with great determination to reaching that goal, hoping that determination would help me do it well. I had no idea at that time that medicine would offer me so much more than I could give back. I believe I have grown as a person watching the strength and dignity of the human spirit as patients and their families and loved ones have struggled with the very basics of life, catastrophic life altering events and death. They have helped me to become a better physician and a better person. I have developed a greater understanding of and compassion for personal failure, an increased patience for expectations not met and a better ability to celebrate those expectations that are fulfilled.

Dr. Jane O’Green Koenig and her husband, Dr. William Koenig.

January/February 2010

21


A Posit on Dealing Directly with Patients, not Insurers “Physicians should refuse to be agents of the Public/Private insurance complex, by negotiating fees and payment only directly with patients.”

Among 93 responses, a majority of 55 percent disagreed with the posit; three respondents were undecided. Slightly edited comments from 28 members follow:

While insurance has made payments to physicians seemingly easier and painless, in the long run they have taken the patient out of the equation and led to an unreasonable demand for services and care.

22

Ever since physicians “bought in” to the third party payor concept and decided they were above participating in the “business of medicine,” abdicating this responsibility to third parties, we have merely been part of the fodder utilized by insurers to make profits for themselves and their stockholders. When will… [we] stop accepting crumbs from the table as the endpoint of a successful negotiation.... When will we…relegate the “third parties,” profithungry interlopers in the healthcare system, to an administrative role only. The healthcare system should not be a vehicle for “For-Profit” companies and their stockholders to dilute the “healthcare provider-patient relationship,” and skim 40-45 cents off the top of every healthcare dollar. I resigned as a CMA delegate after a resolution I entered concerning this very matter was efficiently shelved by the “powers that be” in the CMA at that time. Unless things have radically changed, the CMA is an organization run by large medical groups (the “Health Chains”) who…employ and control physicians.... Until physicians understand that the system cannot run without them and are willing to stage a job action to support their autonomy and patients’ rights, all changes (like the present so-called healthcare reform which, without a “public option” will only fatten insurers pockets and

Sierra Sacramento Valley Medicine

solidify their control of healthcare payments) are less than window dressing…. I applaud the Phoenix Mayo docs.... I myself do not participate in managed care, but do accept most PPOs. This policy will change before the end of the year, as I cancel all of my contracts and go strictly feefor-service. It’s a damn hard row to hoe, but my relationship is with my patients, not the profit hungry, stock price-driven insurance industry. — Michael P. Goodman, MD …Why do most of us “take assignment” from Medicare today? Because when we did not we often could not collect, either in a timely manner or at all, from the patient, even though Medicare had reimbursed them for our services. This was back in the 70s and 80s and most of us decided it was better to get some payment (albeit discounted) from Medicare than to get none at all. The physician’s specialty and the demographics including average income of where one practices will influence one’s decision. — Ralph Koldinger, MD Though I agree with this concept, it is impractical due to so many who do have insurance. However, the government programs (i.e., Medi-Cal and Medicare (especially) have caused undue damage to physician reimbursement abilities. — Richard Gray, MD While insurance has made payments to physicians seemingly easier and painless, in the long run they have taken the patient out of the equation and led to an unreasonable demand for services and care. — Pankaj Patel, MD The patients can use the superbill and any notes they request to argue with the insur-


ance companies. This will be the fastest way to educate the public on the problems with our current system and will lead to further overhaul of the system by public demand. — Janet Abshire, MD Fee-for-service is one of the big contributors to our health care system dysfunction in this country. — Thomas J. Curran, MD Perfection of “means” and confusion of “goals” seems to define our generation of health care. The goal should always be the patient and the patient welfare only! — Sat Giri, MD Health insurance is there for a reason. People cannot afford catastrophic care and even everyday care would be unaffordable for many, particularly seniors and people with chronic healthcare issues. Health insurance helps people get the care they need without worry. Physicians should be given more freedom to negotiate fees without fear of anti-trust so that the fees paid by insurance companies are fair. But not by cherry picking the wealthy out of the system. — Joanne Berkowitz, MD I agree. Things will only get worse in the future, and physicians need to grow some business sense. — Robert Tang, MD That would severely compromise the therapeutic doctor/patient relationship. — Dineen Greer, MD Selfishness is unbecoming to our profession. — Captane Thompson, MD The best “single payer” for medical care will be the patient or patient’s family. Catastrophic insurance with high deductible may be best for many. The wasteful effects of prepaid medical care were revealed in the RAND Corporation’s “Healthcare Insurance Experiment” — see “Health Care Crisis, or More Misinformation?” page 2 of Liberty Link, Volume 2, Issue 2, at www.sacramento.ca.lp.org/Newsletters.php — Lee O. Welter, MD We are just insurance/gov’t agents...medicine is neither a right nor should it be free, but like groceries should be affordable as per patient needs as opposed to being dictated... — Spencer Silverbach, MD I believe in universal health care. — Hartej S. Uppal, MD

My father, who was also a Family Physician, taught me that “it is always the patient’s money,” and I should be careful how I spend it. That is true whether it is cash from their wallet, their tax money, or from their insurance premiums. A physician should always be the agent of and acting as an advocate for their patient, regardless who happens to write the check on a given day. A doctor who thinks that accepting the insurance company’s check makes them the company’s agent might want to reconsider their choice of career. — Francisco Prieto, MD Better to focus the pt on their [own] plan for health. — Anthony A. Rayner, MD It’s much too complicated for physicians to negotiate fees directly with their patients. The same dynamic, however, would apply should patients negotiate directly with their health insurance plans. Think about how car insurance works. It’s mandatory, pre-existing accidents are irrelevant, range of plans hungry for the business. The patients are the ones that need to drive the market, not their physicians. — Phil Poor, MD A third party that is not insurers or docs should do this. — Gary Raff, MD Those MDs who want single payer medicine will need to accept single payer fees set by the payer. It would be nice for physicians to be able to negotiate fees with patients, but this type of payment is no longer realistic. — Byron H. Demorest, MD There would be a huge number of Americans who would then not have any health care as they could in no way afford negotiated fees. If there are 40 million Americans without insurance now, it will easily be twice that under this scenario. Additionally, it would leave patients who could not afford these fees with only one alternative, the emergency room, and that would create havoc and potentially force the closing of many emergency rooms which currently just get by. Better to work within the system to make it workable for all of us rather than closing the door to our patients. — Sydney Scudder, MD Wow! The first statement is laudable: The second statement is impossible. — Wayne C. Matthews, MD

January/February 2010

If there are 40 million Americans without insurance now, it will easily be twice that under this scenario.

23


I also believe that patients should do their own billing to Medicare.

there would be people doing it. — David Gunn MS III I agree; if patients understood cost of care, there would be more efficiency in the delivery and care that is provided. Insurance should be for severe illness, hospitalization, and catastrophic care.… We should have a basic health care maintenance policy that covers routine visits and vaccinations. Acute self-limiting illness should be paid for out of pocket. This would eliminate a lot of [unnecessary] tests and procedures…that may be performed more selectively. And catastrophic insurance should be for significant illness that was or is unforeseeable, such as cancer or stroke or being admitted to the hospital for acute surgery. This would be similar to collision insurance...we should break up health Like the Army care insurance into differpsychiatrist ent types of policies similar to auto policies, rather gunman, the CIA than trying to lump everyinformant suicide thing into a one size all… bomber, and the everybody would be better latest Airline off. — Rajan K. Merchant, bomber? All MD That horse has been MDs, none poor out of the barn for 50 or oppressed. years. Think of Medicare as All docs should be the new Medi-Cal. — Tom on the no-fly list! Wilkes, MD

I also believe that patients should do their own billing to Medicare. Negotiate the price with your physician, pay, and seek reimbursement on your own. It’s like getting a rebate. — Gregory Joy, MD I suppose it would be nice, not to have to deal with the restrictions that come with dealing with an organization that is at odds with providing care [and] that reduces its purpose to financial profit. But as with all things in life, nothing is all good or bad. In fact, insurance agencies are here for a reason. I have not seen physicians posting signs of their fees. And there is a reason for that as well. If it was a good idea,

Physicians can’t be terrorists. We strive to do no harm. Terrorists are poor and oppressed.

Posits are simplistic one sided statements intended to promote discussion among members. Therefore your comments are particularly relevant. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or SSVMS Board of Directors.

Occhio

24

Sierra Sacramento Valley Medicine


Doctoring, Eyes, Raccoons and Health Insurance By Ann Gerhardt, MD I get weird things. Last year my right eyeball blew a pupil and lost sensation. The MRI was normal and in two weeks it all went away. No diagnosis. Earlier, when I had tried allergy shots to make life more livable, I suddenly lost circulation to a finger and random joints swelled and hurt. It might have all been related to my immune system, but we never really knew. Six months later, the neuro-ophthalmologist attributed it to ciliary ganglionitis, but even that name tells what, not why. During the summer I seemed to need more light to read small print, but on August 1 I had a normal routine eye exam, with the same glasses prescription I’d had for years. On August 17, my life-partner, Jim, quit his job and with it went our health insurance. Six days later, I noticed light-bulb-like flashes, followed by light gray ”lace” that obscured parts of my vision when I lifted my coffee cup to drink. It took me two days to figure out that the coffee cup in my right hand was obscuring the vision of the right eye, allowing me to see lacelike scotoma in my left field of vision. By August 25, my left eye, forehead and bridge of my nose ached. Before calling my doctor, I polled my hospital friends, with a consensus of a not too worrisome vitreous detachment. My eye doctor, Dr. ClassicGoodDoctor, knew better, and demanded that I get in to see him. His even-tempered, non-committal demeanor turned to consternation as each test and possible diagnosis didn’t pan out. As I was doing special retinal pictures, he called Dr. RetinalAboveandBeyond, who was driving

home and detoured to Dr. ClasicGoodDoctor’s office to see me. Very intense and thorough, he concluded I probably had a “white spot disease” destroying the pigment layer of the retina. He gave it a long name that I memorized. His partner, Dr. RetinalB, saw me three days later for a fluorescein eye angiogram. It showed diffuse white spots, indicating inflammation, on the left eye retina. Some critical areas were spared, but the rest looked like the Milky Way. Dr. RetinalB and his partners decided it was a different long name, which I also memorized. No one knows what causes it. The “lace” and lights were characteristic of retinal diseases, but he couldn’t explain needing more light to read, the eye ache or the disconnect between my visual defects and the angiogram’s pattern of inflammation. He reassured me that it would resolve in 2 weeks to 5 months and he would fight the DMV for me if any permanent visual loss threatened my driver’s license. Since I was curious about potential inflammatory causes, given the weird happenings earlier in the year, he suggested I contact the expert at Northwestern University in Chicago, Dr. RetinalMaximoChicago, for the latest theories. All this time I worried about health insurance. I had been denied when I was 45 years old because of an asthma attack at age 16. Who was going to insure me now with a weird disease and bizarre inflammatory events at age 57? Making a decent amount of money is irrelevant, even as a doctor, if the insurance industry thinks I’m a bad risk. I could go as broke as the next guy from catastrophic healthcare expenses. In spite of a trial of Prednisone and January/February 2010

As I was doing special retinal pictures, he called Dr. RetinalAboveandBeyond, who was driving home and detoured to Dr. ClasicGoodDoctor’s office to see me.

25


Dr. RetinalB remained committed to his diagnosis, in spite of its rarity and his lack of experience with it.

26

Naprosyn, over the next week tiny random diamond-like lights (quite delightful, actually) and moving ”lava” (a bit 1960s hallucinatory) appeared and the gray lace turned much darker. It now obscured my vision, whether the right eye was covered or not, and the left eye ache and pain in the bridge of my nose were worse. By September 10, the lace was black and it seemed that I was looking through smudges on glasses. Two days later, I saw another partner, Dr. RetinalC, who noticed optic nerve swelling and pallor. The eye angiogram looked very different, with inflammation next to the optic nerve and much worse at the top and gone from the bottom of the retina. He decided I had multiple sclerosis and strongly suggested another MRI. My neurologist, Dr. Neuro, said I didn’t have MS, didn’t need another MRI and should go to see the expert in Chicago. I emailed Dr. RetinalMaximoChicago and he responded right away, even though he’s Chair of Ophthalmology at Northwestern University. He suggested I make an appointment or send him my films. I made a tentative appointment for September 24, pending the results of my next angiogram on September 18. Since there is no cure for white spot disease other than time, I didn’t want to dump my patients, cancel other planned events and rush off to Chicago if all he would do was ooh and aah and say, “Yup, that’s what you’ve got.” I stopped the prednisone since it wasn’t working and was just making me manic and sleep deprived. By now I was seeing wavy blue/ magenta distortions of my computer screen. The ”lace” fluctuated, but the most my left eye could see of anyone’s face was a right eye and ear, part of a cheek and some hair. My right eye, which used to be my bad one, was doing all the seeing, so I wasn’t seeing much at all. For the first time since childhood, I had to wear glasses. At the September 18 appointment with Dr. RetinalB, the retinal angiogram was again very different from the others, with much more active inflammation around the optic nerve and some clearing elsewhere. This appointment led me to two realizations. The problem of needing more light to read actually made the bright light

Sierra Sacramento Valley Medicine

of the exams and angiograms very tolerable. The slit lamp didn’t even make me blink. But somehow each eye exam and angiogram transiently intensified the left eye ache to the point of misery. Dr. RetinalB remained committed to his diagnosis, in spite of its rarity and his lack of experience with it. When he heard that I was thinking of seeing Dr. RetinalMaximoChicago he said, “He’ll tell you the same diagnosis that we have. Say hi to him for us.” I felt dismissed. Coming face-to-face with an unknown force destroying my vision, I considered all I would lose if it spread to my other eye. My work, seeing my grandchildren, whitewater canoeing, the play of light on the Grand Canyon’s walls … I didn’t want to be dismissed, especially when the diagnosis didn’t fit. I had been reading about white spot diseases, of which there are various types. None of what I read said anything about eye pain and none seemed to describe progressive vision loss and changing angiograms like I had. The next day, with much worse, now black, ”lace” and vision, I Fed Ex’d the angiogram pictures and eye history to Dr. RetinalMaximoChicago. His immediate reply said, “You have very unusual eyes. I need to see you. It’s not an emergency yet, but I wouldn’t wait a month.” So I rearranged my schedule, canceling patients and events and flew to Chicago. By this time, I’d become my own employee so we could get health insurance through the staff leasing company I use for my office. It would kick in quickly, but so would the new $5,000 deductible. This was going to be expensive, but at least not financially devastating. At the Northwestern clinic, a Fellow took one look at my abnormal pupil (called Marcus Gunn, seen in syphilis and other optic nerve diseases), pale optic nerve and severe visual loss and asked why I hadn’t had an infectious disease evaluation. Dr. RetinalMaximoChicago concurred. More pictures and another angiogram, which was again different from all the others, led to a referral to a neuro-ophthalmologist, Dr. GruffButNice. (Parenthetically, a retinal appointment with angiogram in Sacramento


was billed to insurance around $1,000, while Northwestern University only billed about $350. Hmmm.) After much discussion with the folks back home, I was admitted to the hospital in Chicago. Dr. GruffButNice never examined me, but the Resident-in-training was exceptional, took a good history, did a reasonable exam and genuinely acted interested in my plight. They did a lumbar puncture, complicated a bit by my arthritic, scoliotic spine. The post-angiogram eye pain, the worst it had ever been, improved by the next morning, but the post-lumbar puncture headache sucked. While in bed for the mandatory hour after the lumbar puncture, my nurse never responded to my multiple calls for relief. After the hour, I took my limp dish-rag body to the doorway, and begged another nurse to get me some relief. That’s a headache you don’t want to get. Though they felt I had Lyme disease, they sent blood and spinal fluid for umpteen other tests also. The spinal fluid was not inflammatory, so I was discharged. Dr. GruffButNice called with the results in a week. The vision was worse again the next morning. On October 1, I got an unexpected call from Dr. RetinalMaximoChicago saying that he had just thought of the diagnosis — Diffuse Unilateral Subacute Neuroretinitis (DUSN), caused by a roundworm quite common in raccoons. We discussed this year’s possible exposures, including camping at the base of Mount Shasta in August, visiting my sister in northern Arkansas (and swimming in the lake) where raccoons are prevalent, and backpacking the northwest Washington State coast. Later that day Dr. GruffButNice called and left a message that all the tests were normal. That night I couldn’t sleep. Visions of the worm reproducing in my eye and its babies setting up shop in my other eye sent anxiety bouncing off the tent walls. I emailed Dr. RetinalAboveAndBeyond. He was unaware of all that had happened since the first angiogram, but was totally willing to believe the diagnosis, saying, “One has to think ‘worm’ to make the

diagnosis of worm.” He took it all very seriously and emailed a bunch of references about DUSN to me and I searched many more online. We took advantage of Starbucks’ Wi-Fi for hours, instead of hiking. Many of my symptoms matched other DUSN cases, but it seems that everyone is different, with variable degrees of optic nerve involvement, inflammation, retinal pigment damage, visual loss and eye ache. Apparently the worm travels around, releasing toxin that damages the retina and optic nerve. The motile little bastard had spewed toxin wherever, leading to changing angiograms and intermittent eye ache. Back and forth emails led to an appointment late October 5. Dr. RetinalMaximoChicago met Dr. RetinalB at a New York meeting both were attending and explained his diagnosis. Dr. RetinalB’s email to me seemed skeptical, reminding me that no one had seen a worm on any of the pictures, but saying he would see me Monday. We had planned a hiking vacation to the less-traveled areas of Zion National Park in Utah. That week-end we backpacked into absolutely gorgeous Kolob Creek canyon. The next morning, on a side hike without packs, Jim lost his balance on a boulder, fell backward into me, and we both fell backwards over rocks and into the stream. He landed on soft me. Every one of my limbs got beat up by the rocks. I could barely stand on my right ankle. (A later x-ray showed a small fracture.) I “hiked” 6 and a quarter miles out on the sprained ankle, while Jim carried my pack. Using hiking poles to hop out of the canyon took five and a half hours, during which I noticed that I could see through only a fourth of the left visual field. I cried. For five and a half hours I worried that they wouldn’t find the worm, that my symptoms would again be minimized by Dr. RetinalB, and that I would eventually go blind in that eye. I planned to change doctors and go anywhere in the world to get my eye fixed. The doctor who originally described DUSN and its cause had died, so Latin America, where DUSN is relatively common, seemed the next best bet.

January/February 2010

Dr. RetinalMaximoChicago met Dr. RetinalB at a New York meeting both were attending and explained his diagnosis.

27


I discussed the need for anti-worm medication with infectious disease specialists, Dr. Friend and Dr. UCDavis, who each gave me completely different advice, neither having ever seen the disease.

28

At the Monday appointment, Dr. RetinalAboveAndBeyond took control. Like a kid at an Easter egg hunt, he announced that a plain color picture showed the worm. He laser photocoagulated the area, but could see the worm on the retinal surface waving at him, then diving deep. The follow-up picture showed the worm moving away from the lasered area. He re-lasered a larger area. This time it worked because the worm was closer to the deep pigment, where the laser works better. Jim says the whole thing was like Star Wars, with audible and neon green laser zaps fast and frequent, each causing an odd kind of deep eye throb. I kept limping back and forth between the picture room and the laser room. The follow-up picture showed no worm. I received a steroid injection into the side of my eye to reduce inflammation, but it didn’t feel like it helped. The prolonged procedure and possibly the worm spilling its toxic guts led to intolerable burning pain, like someone holding a match to my eye for hours. Profuse watering soaked the eye patch. I finally slept after taking pain medication left over from my last surgery, which had only required two pills. Compared to this eye pain, the surgery was a mere scratch. The next four days felt like I had just come out alive after an Indiana Jones adventure. I either slept or couldn’t do anything. I spent the time in x-ray, CT scan, the sinus doctor’s office to evaluate the bridge of the nose pain and the pathologist’s office, looking for a worm in the nasal scrapings. Dr. RetinalMaximoChicago went back to Chicago, looked for a worm and found it in a totally different place than we had. He sent the picture to Dr. Worm, an expert at Vanderbilt in Tennessee, who ID’d it as Baylisascaris procyonis, the raccoon worm, as opposed to Ancylostoma, a dog hookworm, which is the other cause of DUSN. Mine was the larger one, 1–2 mm in length and maybe a micron in diameter. Tiny. I discussed the need for anti-worm medication with infectious disease specialists, Dr. Friend and Dr. UCDavis, who each gave me completely different advice, neither having ever seen the disease. I started the medication at the

Sierra Sacramento Valley Medicine

dose described in DUSN studies. The eye ache resolved over the next three days, so I was sure the worm was dead and didn’t have any friends, at least in my eye. Follow-up pictures confirmed no worm, but I knew the Wicked Worm Was Dead by the lack of ache and the slightly improving, rather than worsening, vision. Turns out there are raccoons and Baylisascaris in all the areas I’ve visited this year and in Sacramento where I live, but none of the eye doctors here have seen this disease. I don’t eat dirt or play with raccoons. More people must be ingesting the worm and not getting the disease, or there is something special about the people who do get DUSN that allows the worm to do its damage… or people have the disease but are not getting the correct diagnosis. Moral #1: If the doctor is ignoring symptoms because they don’t fit his or her diagnosis of choice, see someone else, preferably an expert willing to listen and find a diagnosis that fits. Moral #2: All doctors should experience being a patient, especially the fear of an unknown diagnosis and the problems of communication. Sequel #1: Dr. Worm in Tennessee said that any visual improvement should occur within a few months, but there is no guarantee the optic nerve and retinal layer will regenerate. My ”lace” turned back to gray, became less dense and now obscures only the nasal half of the visual field. It has been stuck there for two months now. Sequel #2: The worm pill I took is the only medicine in my life that I’ve taken faithfully as prescribed, not missing a single dose. Baylisascaris likes many tissues in the body, including brain. Much of the brain fog that I was attributing to familial ditziness lifted after the course of medicine. I choose not to imagine other worms flitting around in my brain. Sequel #3: Few people with DUSN have such a well-documented course, with serial angiograms, so my eye has become a good teaching case. It’s sad to think that I’m finally fascinating because of a worm and a miserable experience. algerhardt@sbcglobal.net


Bones From Dinky Creek A Deputy Sheriff appears, and the Fresno coroner’s office and medicine combine efforts to identify human remains.

By David Hadden, MD, Fresno County Coroner This “Coroner’s Corner” article is reprinted from the January issue of Vital Signs, the montly magazine of the Fresno-Madera Medical Society. The Coroner’s morning briefing was well under way when a tall young man abruptly appeared in the room interrupting a lively discussion concerning the need to post a case from the previous day. He was wearing an old pair of dark washable pants and an I’m-goingto-the-mountains kind of shirt with boots to match. “Who are you?” I said, putting the question to the look on my face. “I’m a deputy sheriff.” “Sure you are.” “No, no. I’ve got some bones with me,” said the deputy. “We are going to Dinky Creek to look for the rest of this guy. We think he’s a hunter that’s been missing for a few weeks.” He thrust a plastic bag at the group. Inside were two clearly visible long bones. “Are these human?” he asked. “Looks like. Where did you get them?” Dr. Gopal inquired. “Between Dinky Creek and the Big Trees,” replied the deputy. “A guy brought them in last evening. If you think they are human, we will go up there today and look for more.” “They are clearly human — a tibia and a fibula,” opined Dr. Gopal. “How long have they been there and are they male?” were the earnest questions from the deputy. “You can’t tell how old they are after six months,” replied Dr. Gopal. “We will have a forensic anthropologist examine them and get

back to you in a few days. Let’s make sure they are male.” The deputy looked distressed. “They are quicker than that on TV.” “Yea,” I shot back. “Detectives are better dressed on TV, too.” The deputy looked offended. To change the subject he turned the bag over exposing a metal plate on the tibia. “What’s that plate?” he asked. “It’s got two lines of numbers.” Whoa. That plate was an attention getter that changed everything. This was not just another bag of bones. “That is orthopedic hardware,” I said with enthusiasm. The deputy told us he’d been looking for a missing hunter up in the Dinky Creek area for a couple of months. “We think it’s him,” he said.

Whoa. That plate was an attention getter that changed everything.

“Call his family and see if he had a leg operation,” I directed. The detective unhooked his radio and called his “boss.” In a few minutes it was confirmed that the missing hunter was never under the knife. In the meantime I called orthopedist Don Huene, MD, with whom I had previously done some forensic work. “Don, we’ve got old bones with an attached orthopedic plate about fiveinches long. There are six closely placed screw holes,” I explained to Don. “Are the screws hexagonal?” he asked.

January/February 2010

29


Everyone agreed that they were. Don replied, “That sounds like a Synthes plate.” A quick check on the internet produced the company’s phone number in Pennsylvania. A nice sounding voice answered the phone. We asked her to check out the numbers. She said the one number identified the plate as belonging to their company but she did not have a record of the second number on her computer so she would connect me with the legal department. “Are you sure? We don’t want to sue anybody,” I tried to reassure her. She insisted. I was transferred to a somewhat defensive voice identified as Joanna. After I assured her that this was a CSI thing and no trial lawyers were involved, she produced what she said were two pages of addresses from that lot number showing that that particular part was shipped all over California. I crossed my fingers, and after a few minutes

30

Sierra Sacramento Valley Medicine

she said, “Well, there was one shipped one to St. Agnes Hospital in Fresno on April 3, 1999.” I thanked her profusely and called St. Agnes. After going through several departments, we were connected to David in the orthopedic department. With the date of operation in hand, he soon identified the patient. Meanwhile, the Coroner’s Office and the sheriff’s deputies were searching their memories for Dinky Creek area missing persons. Deputy Coroner Loretta Andrews remembered a 2006 case where a body was recovered and she thought perhaps it had a missing leg. She pulled the record and brought the name to my office just as David called back from St. Agnes with a name — the same name Integrating medicine and the Coroner’s Office gave us a match and positive identification in less time than it takes to drive to Dinky Creek.


Thank You, Dr. Fields A day in the family practice rotation.

By David Gunn, MS III We had just finished the morning’s cases and were taking a lunch break to finish our notes, have a quick bite and talk about family practice career options. Nurse Lucinda came in. “Mrs. Igal is on the phone, Dr. Fields. She’s really upset and is crying. She says she is really depressed and needs to do something to make it better. She wants to talk to you.” “Sure, I’ll pick it up. Mrs. Igal, hi. Yeah, no problem. Yeah, what’s going on? Uh huh. Yeah. Yeah. Well I can do that, sure. I’ll put in an order for that right now. Sure. Now?” He looked up at me from the phone, then just as quickly back down. “Well, I’ve got a medical student here, why don’t I send him over?” I nodded enthusiastically — I had an assignment that required me to visit a patient at home to see how lives, living conditions and medical problems were connected. I got the brief review as I picked up my coat. She was an elderly Southeast Asian woman with a recent heart attack. Her husband, whom she had hated, died 7 weeks ago and now she was depressed. Oh, and she lived in an amazing mansion all by herself. I drove into the gated community, past the waterfall and down the wide and winding street. At 4’6”, the diminutive woman was dwarfed as she stood at the palm-tree entrance to her 4,000 square foot home. She was wearing red, but I could see an urgent look of eagerness mixed with a fear and isolation. It made me wonder if someone was dying within her door. I could write at length about the beautiful lakeside home she showed me — beautiful paintings, luxurious furnishings, designer clothes, intricate art and design, expensive cars she bought on a whim, giant flat screen HD

televisions, granite countertops, king-sized beds — the list could go on and on. Each of these items was useless to her; she can’t drive due to a seizure disorder, she doesn’t cook, she sleeps poorly, she doesn’t like TV and she doesn’t go out. She has no siblings and no parents. Her children live far away, visit rarely and fight with her when they do. Her husband of 50 years died in his sleep 7 weeks ago, and her world has been a blur ever since. They met each other in Vietnam while he was in the service. She defied her parents to be with him, but was never fully accepted by his family. She had never paid a bill until last week; her husband had taken care of everything up until his death. She had a housekeeper come once a week, but recently reduced the interval to once a month because there was so little traffic in her home it wasn’t getting dirty. As we wound our way to the room her husband Frank died in, she stopped to pick up a miniscule piece of detritus she spotted on her plush beige carpeting. One problem she didn’t have to consider was finances. A large monthly pension pays for any nursing home she might have to move into some day — and her home just received an offer of $460,000, which she turned down. “This house was worth 650K just last year! How can I take that offer?” she barked. She was thinking of moving down the street to the assisted living community that she’s visited three times already. “I really like it there. It would be a good place to live. I even know a few people there already.” But she won’t sell at such a loss. “I worked so hard for this house. It was the last place Frank and I had together.” Was it money, or nostalgia? I couldn’t tell.

January/February 2010

She was wearing red, but I could see an urgent look of eagerness mixed with a fear and isolation.

31


Which, apparently, was the phrase, “Proximal cause of death: Fatal Sadness.”

32

You can’t buy memories. Can you forget about a failure? We sat down and I asked her how she was feeling. She launched into a litany of vague and minor aches, pains, bodily irritations and…ear buzzing. Knowing what I would find, I gave her a physical exam anyway. Nothing of mention. “So, what do you think is wrong with me?” she asked in her extremely thick Vietnamese lilt. “I think you need to get out of this house and find a friend to spend time with,” I quipped. Silence. She started to cry. I used to think that a patient crying was a good thing — it made me feel like I was helping them have a breakthrough. Maybe, but maybe not. She started to recapitulate some of the stories she had already shared with me. She ended differently this time, wondering how her husband had died. She brought out his death certificate for me to read; her reading skills were poor, at best. She stood some 6 feet away, awkwardly alone in the center of a space of carpet distant from any furniture. She appeared to be worried about why and how he died. Apparently no one had told her, she didn’t understand, or she had been too distraught to comprehend what had happened to Frank. “I wonder how he died. Was it because he was sad?” “How do you mean?” I replied, after a pause to consider the projection. “When my son came to clean out his room they threw away all of his medicines.” I was beginning to wonder where she was going with this. TCA overdose? She paused. I waited. “I wonder if he was sad and took too much medicine.” “What were his medicines?” “He had heart disease and high blood pressure. But that’s all.” I didn’t pursue that red herring, and decided to focus on the concrete answers. “It says he had heart disease, heart failure and finally he died from a heart attack.” “Ohhh.” She drooled out the phrase as if she were unsure what those words meant, but was sure it wasn’t what she had been prepared for.

Sierra Sacramento Valley Medicine

Which, apparently, was the phrase, “Proximal cause of death: Fatal Sadness.” “That’s good news, right? He didn’t die from sadness.” My voice rose, looking for a resolution. “Yeah…” she trailed off, then sat down next to me. The progression of these emotional chords stayed away from the tonic I had hoped for. Perhaps this was her new tessitura. She told me about how Frank had been so healthy. Their last night together they had watched television in her room after dinner. “He had salmon, two scoops of rice and a lot of broccoli.” She said broccoli as if that were a very peculiar food preference for her husband to indulge in. She continued, “Later that night he said he was hungry again, so I told him to go to the kitchen. He came back in with a large bowl of strawberry ice cream. He ate the entire bowl. He asked me if he could go to bed now. I said sure.”

Last Requests “He asked me if there was anything he could do for me before he went to sleep. I asked him for an ice cream sandwich and a napkin. He brought it to me. He asked me if he could go to bed now. He went to sleep after that, and the next morning he was cold and didn’t wake up. I said, ‘Get up! You sleep too much!’ But he just lied there on his side.” She mimed a man sleeping on his side with his head resting on his folded hand. She closed her eyes and lied down on the bed very innocently, as if there were any confusion about the description. These are the recantations and reflections we remember after we lose a loved one. These vignettes of character are not the sum total of who the person was, but in my experience, there’s a resonance within these last moments that gives the person who is to die a release. Maybe I’m looking for meaning where there is none, but maybe that’s how we make our lives meaningful to begin with. “Have you ever thought maybe it would be easier just to not wake up, like your husband?”


She started to tear up again. Jesus, I was really hitting the buttons today. “No, not any more. Two weeks ago, my son called me and told me I was treating his father like a dog now that he was dead. He said I didn’t have any respect for his clothes. I said, ‘Fine you want me to die, I’ll just take all my medicine and die. It’s easy, you know!’ I hung up the phone. My son called the police and said he had made his mother upset and she was going to take all of her medicine. But now, I don’t feel that way anymore.” I kept silent. “I feel better now, already since you came to see me. My head doesn’t hurt anymore, my ears aren’t ringing now. You’re lucky, you know, working with Dr. Fields, he’s the best. I don’t want to move away from here. I couldn’t see Dr. Fields anymore.” I continued to listen to her talk about her memories of her husband, her sons. We looked at her favorite photographs and we drank apple juice through straws. She told me about her gambling habits and how Cache Creek sends a limo to pick her up. This was all she needed, a friend to talk to, someone to be with. I told her as much — she needed to find a friend or a roommate. Or sell the house and move to the assisted living community. But she balked. She wasn’t sold on leaving her home, the memories, and what was left of her husband. And as much as she didn’t want to die, she couldn’t really live. “I don’t think I can be happy again.” “Do you want to know what I think?” “Of course.” “I think you can be happy again, I really do,” I said, confidently quiet. “Yeah, I think you’re right.” She looked up and her black eyes reflected the sun that glared off of the lake. A bird took off from the water, just as another landed. The bay window muted the sound, but I could imagine the breeze and splash. We said our goodbyes, and she thanked me again for coming. She couldn’t help herself, saying goodbye three times before I left. The last time, at the door, the little woman lifted her

arms up to give me a hug. I got into my car and drove away from the palm tree lined mansion with the little woman in red still standing at the doorway when I rounded the corner.

Kenny Back in our Ivory Tower, my next patient had a brain injury in his 30s and had developed diabetes. His HbA1c was 13, there was an inability to exercise secondary to neurological damage and, to make matters worse, his marriage was in trouble. In his dysarthric speech and Japanese accent he answered my question. “So, Kenny, what are you eating all day that’s giving you an average blood sugar of 330?” “Well, I know I’m not supposed to be eating sweets, but it’s all my wife cooks. What am I supposed to do? I can’t cook since the stroke, and she just takes care of me and I have to eat what she makes. I told her I’m not supposed to eat these things, but she told me that she likes to eat cakes and pies so I had to, too.” They had been happy before the stroke. Now it looked like murder by cake. He said he was tired of being unhappy and being with someone who was unhappy. “I’m going to get a divorce. I’m going to move to the Philippines where my mom has a house she said I could live in. I’m going to find a cute girl and have some fun. I’m really going to do it.” I thought it was a great plan. Maybe. We added some Byetta, talked about how he could find some other foods to eat and made a follow-up for the next week. Or maybe I could make a home visit in… Was it Cebu?

They had been happy before the stroke. Now it looked like murder by cake.

Allison I entered the exam room for the last case of the day, wanting to be done. I saw a 6-year-old girl with her daddy, here for a cough. Her school uniform was a white button-down long-sleeved shirt, green tartan skirt, and white stockings with Mary-Janes. She was sitting on the exam table, swinging her legs in and out softly. Her big brown eyes were magnified through her thick glasses as she turned to look at me. I continued on next page

January/February 2010

33


Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Michael Lucien, MD, Secretary Amirikia, Kathryn C., General/Breast Surgery, Wayne State University 1993, 7501 Hospital Dr #305, Sacramento 95823 (916) 423-2116 Davidian, Mark M., Radiology, Stanford University 1990, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Lynton, Richard C., Internal Medicine/Medical Toxicology, Loma Linda University 1996, 1600 Creekside Dr #1400, Folsom 95630 (916) 817-8400 Masley, Crystal O., Family Medicine, Loyola Stritch 2006, Sutter Medical Group, 1201 Alhambra Blvd., #230, Sacramento 95816 (916) 739-1007 Wiesner, Jason B., Radiology, UC Davis 2001, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Winder, Daniel P., Radiology/Nuclear Medicine, University of Washington 1987, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Yu, Jeanne, Colon & Rectal Surgery, St. George’s University 2000, Sacramento Colon & Rectal Surgery Medical Group, 1020 – 29th St #350, Sacramento 95816 (916) 231-1050

Dr. Fields, continued from previous page offered my hand. “Hi, Allison. I’m the medical student working with Dr. Fields. My name is David. I hear you have a pesky cough that won’t go away?” In the same fluid motion, she shook my hand, raised her eye brow and flashed a bright smile. “Well, hello, nice to meet you David. [cough] I’ve got a bit of a cough, and it just won’t go away. I’m actually getting a little bugged by it. You see, I’m going to be on the soccer team, and I’ve got to be able to run and play. [cough].” I pulled it together. She really was too ador

34

Sierra Sacramento Valley Medicine

able. So energetic, and such a personality. The whole interaction filled me with such energy I left work that day in a great mood. But I wouldn’t want to deal with kids all day, it can get exhausting sometimes. I have always been a generalist, finding the world too big and beautiful to limit my medical practice to one tiny slice of it. Maybe that is why Family Practice, so undervalued by many, is the right place for me. Thank you, Dr. Fields. dgunn11235@gmail.com


2010 SSVMS Committees These are this year’s committee appointments by the SSVMS Board of Trustees. Child and Adolescent Health Services Drs. Mary Jess Wilson, Chair, Charles Maas, Vice Chair, Fawzia Ashar, Marcia BrittonGray, Lindalee Huston, Maynard Johnston, Robert Meagher, Patricia Samuelson, Rachel Weinreb. Continuing Medical Education Drs. Alfredo Czerwinski, Chair, Arlene Burton, Barbara Hays, Maynard Johnston, Charles Maas, Travis Miller, Denise Satterfield, Lee Snook, Jr., Lee Welter. Editorial Drs. John Loofbourow, Editor/Chair, Robert Forster, Robert LaPerriere, Gordon Love, John McCarthy, Delbert Meyer, George Meyer, John Ostrich, William Peniston, Gerald Rogan, F. James Rybka, Gilbert Wright, Lydia Wytrzes. Ted Fourkas, Managing Editor. Emergency Care Drs. John Tucker, Chair, David Berman, Michael Carl, Troy Falck, Hernando Garzon, Peter Hull, Kendrick Johnson, Joseph Karam, J. Douglas Kirk, Robert Kozel, Norman Label, James Martel, Karen Murrell, Kelly Nations, Harold Renollet, John Skratt, Steve Tharratt, Lee Welter, David Wisner, John Wood.

Medical Review and Advisory Drs. Howard Slyter, Chair, Joanne Berkowitz, Vice Chair, Denny Anspach, Jose Arevalo, Richard Axelrod, Mark Chang, Satya Chatterjee, George Chiu, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Richard Gray, Kern Guppy, Ruth Haskins, David Haugen, Edward Hearn, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Michael Luszczak, Charles McDonnell, George Meyer, Gail Pirie, Peggy Portwood, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto, Gerald Simon. Professional Conduct and Ethics Drs. Joanne Berkowitz, Chair, Frank Apgar, Malcolm Ettin, Jon Finkler, Richard Gray, James Hamill, Barbara Hays, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Robert Lentzner, Ivan Rarick, Ronald Rogers, Linda Schaffer, Daksha Shah, Robert Treat, Glennah Trochet. Public and Environmental Health Drs. Donald Lyman, Chair, Richard Sun, Vice Chair, Regan Asher, Donald Brown, Clinton Collins, Anthony DeRiggi, Christine Fernando, Sandra Hand, Gabor Hertz, Alexander Kelter, Robert LaPerriere, Charles Maas, Stephen McCurdy, Robert Meagher, Connie Mitchell, Ivan Rarick, Daksha Shah, Glennah Trochet.

Historical Drs. Robert LaPerriere, Chair, Malcolm Ettin, Christine Fernando, Francine Gallawa, Nancy Gilbert, James Hamill, Gabor Hertz, Julian Holt, Joseph Masters, Margaret Masters, Kent Perryman, Peggy Portwood, F. James Rybka, Irma West.

Scholarship and Awards Drs. Byron Demorest, Chair, Margaret Parsons, Vice Chair, Ruenell Adams, Frank Boutin, Sr, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kaplan, Paul Kelly, Mark Levy, Travis Miller, Caroline Peck, Anthony Russell, Patricia Samuelson.

Judicial Drs. Joanne Berkowitz, George Chiu, Jose Cueto, Barbara Hays, Paul Phinney, Boone Seto.

Wellness Committee Drs. Michael Parr, Chair, Lee Snook, Captane Thomson, Robert Treat.

January/February 2010

35


Classified Advertising

OFFICE SPACE FOR LEASE Medical Office for Lease. 3,000 sq. ft. — all or sublease with another surgeon. Prime location at Mercy San Juan Hospital. Call (916) 802-2122. Medical Office for Lease. One or two doctor suites. 174 Fruitridge Road. Leasing incentives. Call Will Overholtzer (916) 939-3686

Out of this world design. www.PlanetKelly.com

POSITIONS AVAILABLE “FLEXIBLE SCHEDUALING OPPORTUNITIES: Provide Psychiatry, Internal Medicine, or Family Medicine in an interesting and dynamic environment. Competitive compensation as an independent contractor or employee. Please call: (800) 882-0686 for more information.”

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

36

• • • • • • •

Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning

Since 1973 • Max Uden, Owner • (916) 455-5880

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

Car Rental

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

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

MBNA 1-866-438-6262 / Priority Code: MPF2

Office Supplies

Corporate Express /Brandon Kavrell (916) 419-7813 / brandon.kavrell@cexp.com

Practice Management Supplies

Histacount 1-888-987-9338 Member Code:11831 www.histacount.com

Electronic Claims

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

Investment Services

Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com

Magazine Subscriptions

Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma

Security Prescription Pads

Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php

Professional Publications

UCG Decision Health 1-877-602-3835 / www.decisionhealth.com

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

Sierra Sacramento Valley Medicine


13th ANNUAL CALIFORNIA HEALTH CARE The Era of Health Reform: Harnessing the Currents of Change April 9-11, 2010 • • • •

San Diego Marriott Hotel & Marina

Hospital-Physician Alignment and New Models of Practice Health System Reform: Then and Now Leadership in a New Health Care Era and more...

New for 2010: Academy Curricular Tracks • Health Information Technology • Practice Management • Leadership Development

Register by March 9th

TO REGISTER - call 800.795.2262 or visit our website at caleadershipacademy.com Continuing medical education: The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical Association designates this educational activity for a maximum of 18.25 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.


When’s the last time your insurance company paid you?

We’ve declared more than $386 million in dividends to our policyholders since 1975. That includes $14 million in dividends paid in the past year. When you become a NORCAL Mutual policyholder you own a piece of one of the nation’s top medical

Our passion protects your practice

liability insurers.

Visit www.norcalmutual.com today, or call 800.652.1051.

NORCAL Mutual is proud to be endorsed by the Sierra Sacramento Valley Medical Society as the preferred professional liability insurer for its members.

2010-Jan/Feb - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...

2010-Jan/Feb - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...