2011-Jan/Feb - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2011

Independent But Not Alone.

Richard Lewis, M.D. Hill Physicians provider since 1993.

Uses Hill inSite, Hill EHR and RelayHealth for eClaims processing, electronic health records, practice management and secure online communications with patients.

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. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Your health. It’s our mission.

Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

Sierra Sacto Valley (Dr. Lewis).indd 1

2/3/10 9:25:01 AM

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Let’s Talk About Sex

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“Doesn’t Anyone Die In Their Sleep Anymore?”

Alicia Abels, MD

Nathan Hitzeman, MD

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e.Letters to SSV Medicine

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CONVERSATONS Hibbard Williams: Early Years of Family Practice

David Gunn, MS IV

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At the Scene

Matt Joseph, MD

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New Law Requires Student Pertussis Immunizations

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Board Member Profile

Alicia Abels, MD

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Assault on Conscience

Stephen A. McCurdy, MD, MPH

Glennah Trochet, MD

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2011 SSVMS Committees

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I Flunked My Treadmill

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Where Do You Begin?

Andrew Klonecke, MD

Phil Dirksen, MD

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Our Predictions for 2011

34

New Applicants

John Ostrich, MD

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The One Health Approach to Help Mountain Gorillas

35

Board Briefs

36

Classified ads

Kirsten V.K. Gilardi, DVM, DACZM

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Annual Meeting

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below.

Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.

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 in a series of covers by Dr. David A. Evans, an otolaryngologist with the Sacramento Ear, Nose and Throat Surgical and Medical Group, whose area of special interest is pediatric otolaryngology.

The scene in Old Sacramento was captured in June, 2010, using a 7-exposure high dynamic range, or HDR. “I was fortunate that the train engineer stood still during the 7 exposure bracketed sequence,” said Dr. Evans. The HDR technique emphasizes the steam from the smokestack and the reflection in the polished train. The wide angle lens exaggerates the perspective along the water hose.

Volume 62/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

Dr. Evans’ photos can be viewed online at www.davidaevans.com.

January/February 2011

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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.

2011 Officers & Board of Directors Alicia Abels, MD President David Herbert, MD, President-Elect Stephen Melcher, MD, Immediate Past President District 1 District 5 Robert Kahle, MD, John Belko, MD Secretary Louise Glaser, MD District 2 Robert Madrigal, MD Jose Arevalo, MD David Naliboff, MD Steven Chen, MD Anthony Russell, MD Michael Flaningam, MD District 6 District 3 J. Dale Smith, MD Bhaskara Reddy, MD, Treasurer District 4 Demetrios Simopoulos, MD 2011 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Vacant 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 David Herbert, MD Richard Jones, MD Robert Kahle, MD Norman Label, MD Charles McDonnell, MD Janet O’Brien, MD Kuldip Sandhu, MD Boone Seto, MD Earl Washburn, MD

Alternate-Delegates District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Anthony Russell, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Russell Jacoby, MD Maynard Johnston, MD Robert Madrigal, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Gerald Upcraft, MD Vacant Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD Very Large Group Forum Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Chair Stephen Melcher, MD Robert Forster, MD George Meyer, MD Ann Gerhardt, MD John Ostrich, MD David Gunn, MS IV Gerald Rogan, MD Nathan Hitzeman, MD Gilbert Wright, MD Albert Kahane, MD Robert LaPerriere, MD Lydia Wytrzes, MD John McCarthy, MD Managing Editor Webmaster Graphic Design

Ted Fourkas Melissa Darling Planet Kelly

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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 most 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 DAWN M. HAYES, M.D. 20 Years of Urgent Care and Primary Care Experience KIMETTE M. MARTA, 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.

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

Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2006 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year.

Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

Sierra Sacramento Valley Medicine

President’s Message

Let’s Talk About Sex

By Alicia Abels, MD I am one of those people who suddenly breaks into song — sometimes out loud — when triggered by a phrase, thought or even sometimes just a word. The other night, while sitting in our January SSVMS Board meeting listening to Dr. Glennah Trochet’s presentation on STD statistics in Sacramento County, it was no surprise that I started singing to myself...”Let’s talk about sex, baby.” Literally.

Our “babies,” well at least the 15 to 19-yearold female population in Sacramento County, have given us the distinction of leading the state in chlamydia infections. Cases of both chlamydia and gonorrhea jumped in females and males of all ages in the 3rd quarter of 2010 to the highest levels of any quarter since chlamydia became a reportable disease.

With recent county budget cuts, positions and programs have been slashed in the Health Department, leaving few resources for contact tracings. At present, contact investigation will continue only for pregnant women, untreated syphilis and gonorrhea — untreated chlamydia will be investigated as workload permits.

This led to discussion about the late medical consequences of chlamydia for these young women and the subsequent costs to them both emotionally and economically — not to mention costs to health plans, as these women find out later in life that they are infertile and seek treatment for that.

The STD infection rates of chlamydia, gonorrhea and, yes, even syphilis are increasing in our county. The STD increase has occurred since budget cuts were made. We have to find ways to educate our parents and ”babies” without county resources. Any ideas?

You may wonder why a PM&R specialist is talking about sex. In my specialty, it’s not the usual ice-breaking topic with patients. However, I do make an effort in the initial or second visit

to try to talk about sex, with my traumatic brain injury, spinal cord injury and stroke patients in particular, because other docs may not bring up the topic of sex after disability.

Disabled patients are still sexual beings. I talk about it with my patients with back pain.

It’s amazing how many patients are relieved when their doctor brings up the topic of sexual activity, as many of them are hesitant to bring up sexual dysfunction, let alone talk about STDs. How often do you talk about sex with your patients?

With the song still humming in my head after the board meeting, I caught part of the Daily Show with Jon Stewart, who ran an old clip about STDs on the increase in senior communities in Florida. We can’t afford not to talk about sex with them, too. (You can find the hilarious and somewhat distasteful video clip by searching the Internet for “Daily Show, Senior, STD.”) With both credit and apologies to Salt-NPepa (1991), here’s a just slightly altered version of their still relevant song, “Let’s Talk About Sex”: (Punch it, Docs Yo, I don’t think we should talk about this Come on, why not?

People might misunderstand what we’re tryin’ to say, you know?

No, but that’s a part of life) Come on, Docs Let’s talk about sex, baby Let’s talk about STDs Let’s talk about all the good things And the bad things that may be Let’s talk about sex...”

It’s good medicine and good public health. aabels.ssvms@me.com January/February 2011

The STD increase has occurred since budget cuts were made.

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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e.Letters to SSV Medicine Looming Health Care Changes Almost nothing will affect the practice of medicine over the next two decades more than PPACA [the Patient Protection and Affordable Care Act]. An expandable timeline on the Kaiser Family Foundation website has the facts of implementation year by year through 2018. [http://healthreform.kff.org/timeline.aspx?gclid=CO 6Dg8felqYCFdtg2god0izang] Consider how each element would affect patients and physicians.

Maybe it is worth a series of posits addressing each item on the Kaiser timetable.

In addition to these changes, we have the entire IT implementation plan by Medicaid and Medicare and Federal IT care management IT overhaul (that few know about). Of course, 2014 will be chaos.

— Robert Forster, MD

The IOM v. Vitamin D Scientists

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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There is continuing commentary, new information and hype about vitamin D. In response, the U.S. and Canadian governments asked the Institute of Medicine (IOM) to assess the data and make recommendations for daily intake.

The IOM concluded that “rigorous” testing substantiates only the importance of vitamin D in promoting bone growth and maintenance.

It felt that studies addressing other potential benefits provide “often mixed and inconclusive results and could not be considered reliable.”

Vitamin D researchers are disappointed, in that the IOM seemed to discount a huge volume of research by some of the world’s eminent calcium/vitamin D scientists. Robert Heaney, MD, from Creighton University, the guy that I’ve always looked to for the last word on calcium and vitamin D, was quoted as saying, “I don’t think this does anything to create confidence in IOM recommendations.” He and others were asked to review it, but he “certainly do[es] not approve of this report.”

Sierra Sacramento Valley Medicine

The problem is that the IOM was ultraconservative in its assessment of the literature. That’s what the IOM is supposed to do — consider as valid only large, blinded and controlled intervention trials. Those take time and money, and the only such vitamin D trials completed so far have concerned bone health.

Most of the newer vitamin D work concerning other disease processes is based on epidemiological inference, small intervention trials and in vitro and animal data. My review in the September/October issue of SSVMS Medicine summarizes what has been published, acknowledging the “soft” nature of some of the data. Large intervention trials have yet to be completed. But there is a strong consensus at vitamin D conferences and in the literature that vitamin D influences health in many more ways than its effect on bone.

As with most bursts of enthusiastic research, the final “truth” will lie somewhere between the zealots and the naysayers. We have seen with cholesterol and blood sugar that original recommendations for “normal” eventually fell to much lower numbers in order to achieve optimal health. Remember the days when the “normal” range for cholesterol reached to 300 mg/dl or more, because those levels were seen in pools of volunteers who hadn’t yet had their heart attacks? Ancel Keys knew cholesterol was linked to heart attacks in the 1960s, but it was not until the 1980s that august bodies like the IOM progressively lowered lipid level goals.

The IOM did revise upwards, by 300 percent, the Recommended Dietary Allowances (RDA) for vitamin D for non-elderly adults. It set the Vitamin D RDA at 600 IUs per day, except for those older than 70 years, who should consume 800 IUs per day. It doubled the upper limit of tolerable intake, from 2,000 IU to 4,000 IUs per day, referencing kidney and tissue damage that occurs at intake of about 10,000 IUs per day.

The IOM recognizes that most people do not consume 600 IUs per day, but felt that people were achieving adequate blood levels, above a 20 ng/ml threshold, to promote optimal bone health. To me, this is the most disappointing conclusion. Study after study confirms that parathyroid hormone (PTH) is not optimally suppressed until vitamin D levels exceed at least 30 ng/ml. Some of the best work documents an inflection in the PTH/vitamin D curve at a vitamin D level of approximately 35 ng/ml, after which PTH plateaus.

Suggestion: Consider the options (or a combination). (1) Become a sun-junky. (2) Drink a ton of fortified milk (currently at 100

IU vitamin D per 8 oz.) and eat fatty fish. Or (3) take a supplement providing 600–2000 IU vitamin D per day (you pick the dose, depending on your personality and presumed risk).

After a few months of doing that, have vitamin D levels checked if you are on higher doses used for osteoporosis, if you have any disorder that affects absorption or causes malnutrition, or if you are one of the worried well with good insurance or lots of money. Then go outside and get some weight-bearing exercise, which will help prevent chronic disease as much or more than will vitamin D. — Ann Gerhardt, MD

At the Scene

By Matt Joseph, MD The flares came first, red harbingers dotting the road, a broken line of fire leading us to the site where mass and velocity had been transformed into a sprawl of twisted steel frames, broken glass, blood. Cars crept by, furtive and funereal, not wanting to look or look away. We stopped because I was a doctor, newly minted from medical school, uncertain and naked without a stethoscope or hospital around me.

The Mustang was crumpled and black, its engine’s hot bulk resting where the driver once was, mutinous machinery enacting its revenge upon a reckless master — he reclined in the back seat, head cocked,

eyes closed, femur protruding thick and long from a denim-shrouded thigh.

Pressing my fingers against his neck confirmed the heartbeat’s retreat, the rumble of life through his body no longer even an echo.

Soon the wailing ambulances arrived, mournful highway denizens, and we were free to leave, to drive away, the passage of each flare marking time with the rush of blood through all our channels.

We drove in silence, suspended somewhere between the crash and our final destination, each of us clinging to the sheer granite face of our lives, suddenly realizing we weren’t tethered to anything, realizing that we never were.

Reprinted from Sonoma Medicine, Fall 2010 Vol 61, Number 4

January/February 2011

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The Sierra Sacramento Valley Medical Society is pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SSVMS plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Sponsored by:

• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

Underwritten by:

Administered by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice.

54726 (1/11) ©Seabury & Smith Insurance Program Management 2011 • 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

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544

New Law Requires Student Pertussis Immunizations The new requirement going into effect on July 1 applies to both public and private schools.

By Glennah Trochet, MD, Sacramento County Health Officer Whooping cough (pertussis) was widespread in California during 2010. From January 1, 2010 to December 31, 2010 there were 8,383 cases of pertussis reported in California. Ten infants less than six months of age died from pertussis in the state during 2010.

Sacramento County has had 219 confirmed, probable or suspected cases of pertussis as of January 5, 2011. Fortunately, there have been no reported deaths from pertussis in this county so far this year.

A new law, AB 354, which takes effect in July of 2011, requires junior and senior high school students to be immunized against pertussis, and to show proof of this immunization before school entry, unless there is a personal belief or a medical exemption.

This is consistent with the recommendation by the California Department of Public Health that all Californians 10 years and older receive a booster shot against pertussis. The currently available preparation is the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine.

For the 2011-12 school year only, all students entering 7th through 12th grades will need proof of a Tdap booster shot before starting school.

This requirement: • Begins July 1, 2011.

• Will be met by receiving one dose of Tdap vaccine on or after the 7th birthday.

• Applies to all public and private schools.

• Does not affect students enrolled in summer school.

This coming school year, tens of thousands of Sacramento junior and senior high school students will require Tdap vaccine. This will place a strain on school authorities to ensure that every young person is immunized. To help, I am requesting that every healthcare provider in Sacramento County, beginning immediately, use every opportunity to provide the required immunization to all young people entering 7th through 12th grade next school year.

Please mark the Tdap immunization clearly on the California Immunization Record Card and instruct parents and guardians to take the record to the school this school term, for documentation. If a large number of students have the documentation done this school year, we can avoid large crowds and problems with attendance in our junior and senior high schools next school term.

Many schools directly access the California Immunization Registry (CAIR) to check student immunization records. We encourage you to join CAIR to help meet the new Tdap booster shot requirement. In Sacramento County call (916) 447-7063 ext.350 to join the registry.

Beginning July 1, 2012, and beyond, all students entering the 7th grade will need proof of a Tdap booster shot on or after the 7th birthday.

You can find updates on implementing this new law and information on pertussis posted at www.getimmunizedca.org trochetg@saccounty.net

January/February 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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SSVMS 2011 Committees Below are appointments by the Board of Directors for this year.

Child and Adolescent Health Services Drs. Mary Jess Wilson, Chair, Fawzia Ashar, Marcia Britton-Gray, Lindalee Huston, Maynard Johnston, Robert Meagher, Patricia Samuelson and Rachel Weinreb Continuing Medical Education Drs. Alfredo Czerwinski, Chair, Arlene Burton, Barbara Hays, Maynard Johnston, Charles Maas, Travis Miller, Denise Satterfield, Lee Snook, Jr. and Lee Welter Editorial Drs. John Loofbourow, Editor/Chair, Robert Forster, Ann Gerhardt, Nathan Hitzeman, Albert Kahane, Robert LaPerriere, John McCarthy, Stephen Melcher, George Meyer, John Ostrich, Gerald Rogan, Gilbert Wright, Lydia Wytrzes, David Gunn, MS IV, Ted Fourkas, Managing Editor Emergency Care Drs. John Tucker, Chair, J. Douglas Kirk, Vice Chair, David Berman, Michael Carl, Troy Falck, Hernando Garzon, Peter Hull, Kendrick Johnson, Joseph Karam, Robert Kozel, Norman Label, James Martel, Karen Murrell, Kelly Nations, Harold Renollet, Lynette Scherer, John Skratt, R. Steve Tharratt, Lee Welter, John Wiesenfarth, David Wisner, and John Wood; and Medical Student Guest, Irene Chen, MS II Historical Drs. Robert LaPerriere, Chair, Malcolm Ettin, Christine Fernando, Francine Gallawa, Nancy Gilbert, James Hamill, Sandra Hand, Gabor Hertz, Julian Holt, Joseph Masters, Margaret Masters, Kent Perryman, Margaret Portwood, F. James Rybka and Irma West Judicial Drs. Joanne Berkowitz, George Chiu, Jose Cueto, Barbara Hays and Boone Seto

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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, Robert Forster, Kenneth Furukawa, Richard Gray, Kern Guppy, Ruth Haskins, Edward Hearn, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Charles McDonnell, George Meyer, Gail Pirie, Margaret Portwood, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto and Gerald Simon Professional Conduct and Ethics Drs. Joanne Berkowitz, Chair, Frank Apgar, Mark Chang, George Chiu, Malcolm Ettin, Jon Finkler, Richard Gray, James Hamill, Sandra Hand, Barbara Hays, Edward Hearn, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Robert Lentzner, Ivan Rarick, Harold Renollet, Ronald Rogers, Linda Schaffer, James Sehr, Robert Treat and Glennah Trochet Public and Environmental Health Drs. Donald Lyman, Chair, Richard Sun, Vice Chair, Regan Asher, Donald Brown, Mark Chang, Clinton Collins, Anthony DeRiggi, Christine Fernando, Nancy Gilbert, Albert Kahane, Robert LaPerriere, Charles Maas, Stephen McCurdy, Robert Meagher, Connie Mitchell, Ivan Rarick and Glennah Trochet Scholarship and Awards Drs. Margaret Parsons, Chair, Ruenell AdamsJacobs, Frank Boutin, Sr., Byron Demorest, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kelly, Mark Levy, Travis Miller, Anthony Russell and Patricia Samuelson Wellness Committee Drs. Michael Parr, Chair, Lee Snook, Jr., Captane Thomson and Robert Treat

I Flunked My Treadmill

By Andrew Klonecke, MD It’s very strange to come to the realization that you most likely just experienced angina pectoris.

There were no elephants on the chest, arm or jaw pain, sweatiness, shortness of breath or nausea. Every time the treadmill program went to max speed and max incline, I would feel what I thought was burning in my trachea, and it would go away after that part of the program ended. But, the 45-minute exercise program was otherwise uneventful and I didn’t think about it again until the following Monday while on a 2-mile walk around the neighborhood with my wife, when it happened again.

Reflecting on these episodes the following Tuesday, I realized that the pattern was probably anginal — brought on by exertion and relieved by rest. I had been scheduled to go to Monterey for the new shareholders’ meeting but scheduled a treadmill beforehand for Wednesday, expecting it would be normal and I would be cleared for my trip. While I didn’t have any symptoms during the treadmill, the EKG changes were dramatic.

So, instead of Monterey, I was fast-tracked to the cardiac cath lab. The IV in the arm was a little uncomfortable but Versed made the rest of the journey fairly unremarkable — no hot flashes with the contrast, not even any pain with the femoral stick. Only the results were painful, like the news that I would be staying inhouse at Roseville until a surgery slot opened for me at Mercy General.

It was pleasant enough staying on 2S and there was lots of time to do Lotus notes and answer secure messages. I was a little surprised, though, to learn that one could order a cheeseburger on the cardiac diet. The vegetarian option was Indian and I thought it was quite good considering the other options.

The only other eventful happening was to hear “rapid response team to room 2018” at 2 a.m. That was my room! I felt okay and the monitor looked fine, so I ambled out into the hallway and was able to divert the team to room 2019, where things were apparently not going so well.

The ride to Mercy General was a little surreal, sitting in the back of the ambulance and looking back at where I had just been. In all the years that I drove I-80 back and forth to work, I had never seen the sights quite like this. It was almost like I was looking backwards at my life. I was hoping that this was not an omen.

And, getting wheeled through the emergency room at Mercy General was a real deja vu experience, because the first medicine I practiced in Sacramento was the 11 p.m. to 9 a.m. shift in that very emergency room some 29 years ago. It seemed a lot smaller and much more cluttered than I remembered, but then I probably also looked different to the ER after all those years.

The Surgery Most of Sunday was busy getting ready for Monday. I got to meet my surgeon and really liked him — just the right amount of cockiness.

Nurse Flolo drove a 16 gauge into my right arm as effortlessly as passing a hot knife through soft butter. And I could tell that the lady orderly (orderlette?) had done many a total body shave before. Father Healy stopped by to see if I wanted to pray before surgery and that was quite comforting.

Only when the sun went down and my family left for home did the demons come out.

I felt physically and mentally naked and really thought seriously about going home. I called a friend who had been on the same journey the year before, and he was able to calm me down and allay my fears.

January/February 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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I also spent a lot of time reading about heart disease and diet. I became very interested in whether I might be able to reverse atherosclerosis.

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I showed up for surgery bright and early Monday morning but had to wait for two hours because someone forgot to tell the orderly that the monthly 2-hour staff meeting was taking place. (I should note that this 2-hour delay really freaked my wife when I didn’t come out of surgery as planned at 1 p.m.)

But once I got on the operating room table, I must have gotten some really good meds, because the only two things I remembered from that first 24 hours were the anesthesiologist complaining about the ganglion in the way of his radial artery cath insertion site, and the nurses yelling at me to breathe as I was being extubated in the recovery room.

The next thing I knew it was Tuesday morning. I awoke to the sight of one of my fishing buddies, a neurosurgeon at Mercy General, telling me that I would be a new man, but not a better man. The laugh was good for my pulmonary toilet but not for the sternal pain!

The nurses were great in the ICU, and got me up and going as quickly as possible. I never knew that one body could have that many tubes coming out of it, and I was relieved to know that the really big one was a chest tube and not my foley. It seemed like something was being removed every shift. The strangest were the epicardial wires that had been placed in case I needed rapid pacing or defibrillation.

Fortunately, there was only one 6-beat run of v. tach. The epicardial wires are released by the action of the heartbeat — a little tension and off they come. You do feel the heartbeat along the wire and it feels like a little fish tugging on the inside of your chest.

The only other eventful issue in the week after surgery was severe chills, teeth chattering chills. I was sure that I was septic but the nurse reassured me that it was just the anemia. The heart-lung bypass machine tends to chew up your red cells and my hemoglobin was down to 8.0. I didn’t relish the thought of getting more constipated with iron pills and was glad to find out that I could call on prune juice for double duty: it has 10 mg of iron per 8-ounce glass. The chills lasted about four weeks.

Recovery went much better than I would

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have expected, in fact, better than when I had rotator cuff repair two years ago. Surprisingly, I didn’t experience much pain. I did use the chest pillow and I did take a few extra strength tylenols, but I didn’t feel the need to fill the narcotics prescription. The first six weeks were a lot of napping interspersed with frequent walks.

During the next four weeks, I felt pretty good and that gave me a taste of what retirement would be like; I think I will have no problem.

A Change in Diet I also spent a lot of time reading about heart disease and diet. I became very interested in whether I might be able to reverse atherosclerosis. After all, if my coronaries looked that bad, my other vessels are probably not that hot either. One of my shareholders/fishing buddies sent me several books on vegetable proteinbased eating, in place of an animal proteinbased diet, and I would have to say that I was pretty impressed by some of the data that was presented in a book called “The China Study.”

Not only is CAD associated with diets high in animal proteins, but so are several common cancers including breast, colon and prostate.

Dean Ornish at UCSF has demonstrated the ability to reverse atherosclerosis with a fourpronged treatment that includes elimination of animal proteins, exercise, meditation and community participation.

Armed with eight different books, I spent four weeks cooking all sorts of vegetable-based protein meals, some good and others not. My wife was a real sport and played along, eating everything I created, but did threaten once to go to AM-PM for a corn dog.

But, when my numbers came in (cholesterol 91, LDL 39, FBS 91, weight down 22 pounds), she became a believer and took over most of the chores in the kitchen. She found a particularly good website thru Scripps Clinic in San Diego and has shown an amazing culinary talent for such cooking. I really appreciate her support in this and throughout the whole 12 week ordeal.

We are doing vegetable protein 3–4 days per week, fish or white turkey the other days(with a 4 oz. limit on total daily animal protein intake),

have eliminated most dairy product (cappuccinos with almond milk are just fine) and are limiting total fat intake. So far so good.

So, why am I telling you all this?

Well, first of all, some of you may be wondering where I have been for the last three months. Second, I need to thank all who knew where I was and visited/called/sent cards, etc.

Please know that it was very much appreciated and that it really helped with my recovery to know that you were out there pulling for me.

Third, I think it is important for us to share our healthcare experiences so we can support each other during these crises (HIPAA be damned). The network that was there prior to surgery was invaluable for both Kathy and me, and the new network that has emerged as people began sharing their stories has been phenomenal.

sionals (including participation in the multifit cardiac rehab program), I’ve run across a lot of people with knowledge and interest in this area.

It’s time for us to take this bull by the horns and look the situation square in the face.

I hope to share my experience with the staff in Imaging as we kick off the new employee wellness campaign. One of the other elected reps and I are looking at what research is being done or could be done on dietary practices to see if any programs not quite as draconian as Ornish can also reverse atherosclerosis and decrease the incidence of cancers.

I welcome any conversation that you may wish to share on this topic. Together, we can move the PHASE program to a new level.

Andrew.Klonecke@nsmtp.kp.org

An Appeal And last, but not least, I wish to make an appeal to you personally and as caregivers.

While we have a wonderful program here at Kaiser Permanente called PHASE (Prevent Heart Attacks And Strokes Everyday), we need to do more and get better in the area of prevention, especially as it relates to nutrition.

Technically, I was a PHASE success: I didn’t have a heart attack. But, this success came at a steep cost to the healthplan ($247,896 for the surgery!) and to myself.

I consider myself fortunate and I admit that a lot of it was my fault. I’ve come across a lot of sweetbreads and cookies that I couldn’t pass up in the past. But the way for all of us is littered with a lot of bad nutritional choices and I think that it is up to us as health care providers to eliminate some of these bad choices and to show our patients the way to healthy eating.

If we can ban smoking on our campuses, why can’t we ban high-fat cooking in our cafeterias? We can become educated for ourselves and for our staff. After all, there is a new emphasis on employee wellness coming to the med centers this fall. And we can certainly share all that knowledge with our patients.

As I’ve spoken with other health care profes-

To learn more, call 866-534-3403 or visit healthcare.goarmy.com/k827.

January/February 2011

11

Our Predictions for 2011

By John Ostrich, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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One month into the new year, but better late than never, here is a truly useful article that all of us can use to keep well informed and up to speed as we enter another tumultuous year.

Another few thousand years of human history lie ahead. Unless, of course, you believe all that claptrap about the Mayan calendar that predicts the End Of Time, or something else quite unpleasant and noisome, on or about December 21, 2012, in which case you should stop reading this and get a one-way ticket to Las Vegas, max out your credit cards, see some shows and carouse to your heart’s content. Or, if you are so inclined, drop to your knees and pray for salvation.

You could do both. Many do. But I believe there will be life pretty much as we now know it at the end of next year, and, since I want us all to be ready to face this new year, I once again contacted the renowned British seer, soothsayer and necromancer, Dame Elspeth Mallory-Weiss.

Executive Director Bill Sandberg was once again willing to cut a check for her services, so she graciously agreed to focus her remarkable fortunetelling skills on our little corner of the world here in California and the USA in general so we can all plan and wager accordingly. Dame Elspeth’s fee is quite high, but, like a properly cellared bottle of ‘82 Mouton-Rothschild, she is worth every dollar, such are her clairvoyant skills.

She Fed Ex’d me several pages of foolscap written in her odd, unmistakable hand, chock full of predictions and pronouncements. I have been poring over them and translating them into usable terse prose. And here they are.

JANUARY — In his State Of The State speech, delivered via webcam from his sparsely furnished apartment near the capitol, Governor Brown emphasizes that “it is really, really, I mean, really important that we present a realistic and workable budget to the people of California this year.” He says that he fully Sierra Sacramento Valley Medicine

supports AB 1 (Sucio, D-Mermelada) which authorizes the Franchise Tax Board “to collect monies sufficient to pay all legal debts and obligations that accrue to the State of California every fiscal, or any other kind, of year.” It passes by simple majority. Some analysts say the state income tax rate will likely rise to 20 per cent and the sales tax to 10 per cent.

FEBRUARY — The Raiders defeat the Falcons — or, more precisely, Sebastian Janikowski defeats Falcons place kicker Matt Bryant — 9 to 6 in Super Bowl XLV. Janikowski’s three field goals come in the first quarter and Bryant’s both come in the last 10 minutes of play. At the end of the game, only about 20 people are in the stands at Dallas Cowboys Stadium and play-byplay announcer Joe Buck is heard snoring while color commentator Troy Aikman tries in vain to waken him. (Ed. note: Remember, folks, Dame Elspeth sent this to me four months ago !!)

MARCH — Former governor Arnold Schwarz­enegger now has his own show on the Food Channel, called “Kuchen Mit Arnold.” It features him decked out in a traditional chef’s smock and toque while working in a wood-paneled kitchen overlooking a lovely alpine valley. On his first show, he prepares Wiener Gulasch mit Spaetzle, “Just like mama used to make.” Ja. APRIL — Lieutenant Governor Gavin New­som makes his first trip to Sacramento since being elected. Not for political reasons, but rather to have dinner at Randy Paragary’s hot new upscale Mexican restaurant, El Borracho Sediento.

He pronounces the food to be superb, and tells a reporter that he will “probably come back to Sactown after the baseball season is over.”

MAY — SB 48 (Rezagado, D- Palurdo) is passed. The bill makes it illegal to display a bumper sticker that says “Keep Tahoe Blue” if the vehicle on which it is mounted has an EPA mileage rating of less than 25 mpg for city driving or

a curb weight of more than 2500 pounds.

In San Francisco, Buster Posey is batting .136 and Tim Lincecum has yet to win a game.

JUNE — Gasoline prices continue to rise, averaging around $4 per gallon statewide.

Gasoline price guru Trilby Lundberg, author of the widely quoted Lundberg Survey, explained the increasing cost during an interview on CNN. Oil in the Middle East is getting a lot more gooey for unknown reasons (“It could have something to do with global warming,” she opined) and so more energy is required to pump it out of the ground and to the refineries, and also the dollar continues to weaken, and the Swiss franc is strengthening, and the Chinese hold 90 gazillion dollars worth of U.S. Government IOUs and there are riots in Sudan and schools of great white sharks have been spotted off the Florida coast. She predicts prices will rise to $5 per gallon by the middle of 2012. But maybe not. “It depends,” she says.

JULY — President Obama meets with new North Korean president Kim Jong-un in an effort to dissuade him from the continuing capricious and random artillery bombardment of various South Korean border targets. They meet at North Korea’s only resort (no stars in the South Korea Automobile Association guidebook, five stars in the North Korea AA pamphlet) at Mount Kumgang. The First Lady and her daughters, Malia and Sasha, accompany the President and all three are heard to complain loudly over the lack of hot (or even warm) water and especially hair dryers in the guest rooms.

The two leaders play a friendly match at the adjacent miniature golf course and Kim beats Obama by a stroke when his putt on the 18th hole miraculously ricochets off one of his security guard’s feet and into the cup for a birdie.

That sets of joyous celebrations throughout the country and his father, Kim Jong-il proclaims (in Korean), “That’s my boy!”

AUGUST — In an effort to prop up the state’s dwindling treasury, Governor Brown and Lieutenant Governor Newsom announce they have signed up to be Amway distributors and that any money they earn will be placed in the general fund. “And it ought to be a lot!” says Newsom as he jubilantly exits his first Amway

meeting. They urge all state employees to sign up with Amway and donate their profits or face possible Wednesday-Thursday-Friday furloughs every other week.

SEPTEMBER — Taking its cue (not in French) from Quebec province, the Medical Board of California announces that, in addition to providing proof of competence in Pain Control and Geriatric Medicine, starting in 2013 all California licensees will have to show proof of competency in Spanish, with Modoc County excepted.

The Giants win their 50th game and remain in the cellar. Buster Posey’s batting average is .201 and Tim Lincecum’s ERA is 6.50 after his 7th win of the year.

OCTOBER — Governor Brown and Lieutenant Governor Newsom send $65,000 to the state treasury as a result of their profitable relationship with Amway. “Folks sure love that L.O.C. stuff,” exclaims Newsom, “and I use it to wash the car and my dog and my hair!” (“Not all at once, I hope,” writes Dan Walters in the Sacramento Bee) NOVEMBER — The Yankees beat the Phillies in four games to win the World Series. Nielsen ratings for the Series are the lowest ever.

Lieutenant Governor Newsom resigns his post to devote his full time to an Amway distributorship in Ypsilanti, Michigan. His wife, Jennifer, and daughter, Montana, stay behind in San Francisco, and there is talk that they will soon move to live with her parents at their Montana ranch where she and Gavin were married in 2008.

DECEMBER — Governor Brown nominates Los Angeles Mayor Antonio Villaraigosa to be the new Lieutenant Governor. He immediately signs up with Amway and says he is confident that he will be very successful selling soap in Los Angeles where, he says, “A huge number of non-English speaking Angelenos have never even heard of the wonders of L.O.C. Multipurpose Cleaner!!”

The Raiders win their second game on December 18, defeating Buffalo 6-3. The Forty Niners remain winless.

The American Dialect Society’s Word Of The Year is “hashtag.” Look it up.

Lieutenant Governor Newsom resigns his post to devote his full time to an Amway distributorship in Ypsilanti, Michigan.

John.Ostrich@kp.org January/February 2011

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The One Health Approach to Help Mountain Gorillas

By Kirsten V.K. Gilardi, DVM, DACZM, UC Davis School of Veterinary Medicine Last month’s issue contained an article about medical care in a collaborative project of the UC Davis Department of Internal Medicine and the UC Davis School of Veterinary Medicine. This article on the veterinary care aspect is adapted from Proceedings of the North American Veterinary Conference, 2011.

intervention; through actions that improve the health of the people and animals that come into contact with the gorillas; and through actions to improve the integrity of the habitats shared by gorillas, humans, domestic animals and wildlife.

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

The concept that human, animal and environmental health are inextricably linked and best considered holistically as shared, or “one,” has emerged over the last few years and is becoming increasingly accepted by physicians, veterinarians and environmental scientists.

An integrated approach to solving major emerging global health problems, like avian influenza, has been endorsed by the United Nations, American Medical Association (AMA), American Veterinary Medical Association (AVMA), Centers for Disease Control, Wildlife Conservation Society, and public health organizations across the nation and internationally.

This is not an entirely new concept. What is new is increasing cooperation between human and animal doctors who are calling for joint efforts, as well as incorporating environmental scientists and advocates in these efforts.

In 2007, the AMA and AVMA jointly called for all health professionals to embrace ”One Health” as the appropriate and imperative approach to global health crises and solutions; they have since formed a One Health Task Force.

The Mountain Gorilla One Health Program is one of the best examples of this approach to wildlife conservation. It is working to improve the health of mountain gorillas through direct

Great ape populations in the world are in decline. Efforts to conserve great apes include protecting critical habitat, fostering revenuegenerating ecotourism, and conducting field research to better understand behavior and ecology. As a result, we are likely currently experiencing higher rates of contact between wild great apes and humans than ever before.

Therefore, wild great apes are increasingly at risk from interactions with humans. The apes sustain injuries by becoming entangled in snares intended for other wildlife. Pathogens from humans, or emerging new pathogens from human-induced changes in habitat, can create novel interactions that threaten sustainability of great apes in the wild. Indeed, humanhabituated chimpanzees in the Tai Forest, Cote d’Ivoire, have experienced lethal outbreaks of respiratory disease related to human pathogens.

Because mountain gorillas and humans are genetically closely related, the potential for transmitting infectious pathogens between humans and gorillas is high, especially because mountain gorillas are an immunologically naïve and susceptible population.

Furthermore, mountain gorillas live in a region supporting the densest human populations in Africa. Approximately half the world’s mountain gorillas are habituated to human pres-

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Danger to Mountain Gorillas

ence for research and ecotourism, which brings thousands of people from local communities and around the world into direct and indirect contact with mountain gorillas annually.

The One Health Program In the 1980s, renowned primatologist Dian Fossey grew increasingly concerned about the number of mountain gorillas injured or killed by poachers. Mountain gorillas were caught in snares set for other wildlife and suffered limb and life-threatening injuries.

At an international primatology conference, Fossey met Ruth Morris Keesling, a trustee of the Morris Animal Foundation (MAF), and asked for her assistance in securing veterinary care for wild mountain gorillas. Keesling arranged for the MAF Board of Directors to meet Fossey and see the mountain gorillas; but just days before their scheduled trip, Fossey was murdered.

Nevertheless, Keesling pressed ahead with plans, establishing the Mountain Gorilla Veterinary Project (MGVP), the first effort of its kind to treat free-ranging wildlife in its native habitat. For 25 years, the MGVP has been helping mountain gorillas survive by providing life-saving veterinary care for human-caused or life-threatening illness and injuries; it remains the only source of veterinary care to mountain gorillas in the wild.

The MGVP has recognized that survival of mountain gorillas is integrally linked, not only to the health of the gorilla population, but to the health of the other wildlife species, domestic animals and humans. Gorillas live in close proximity to both wild and domesticated animals, as well as humans.

Park workers and ecotourists bring foreign pathogens into the parks. At the same time, gorillas venturing close to surrounding populated areas come into close contact with domestic and companion animals, and are exposed to other infectious diseases.

Conversely, gorillas can introduce germs and bacteria to humans and other animals that can pose health risks. As a One Health-oriented program, the MGVP has strived to maintain and ensure the long-term health of mountain gorillas

through veterinary intervention, health monitoring and research on gorillas, wildlife and domestic animals, as well as community (human) health and capacity-building in the area of veterinary science and wildlife conservation.

Recognizing the tremendous potential in affiliating with a research and service institution, the MGVP partnered with the UC Davis School of Veterinary Medicine’s Wildlife Health Center (WHC) in 2009 to establish the Mountain Gorilla One Health Program (www.vetmed. ucdavis.edu/whc/programs/mountain_gorilla.cfm).

The WHC currently houses 14 epidemiologists, disease ecologists and ecosystem health clinicians and their staff.

In addition, the WHC draws upon expertise of another 60 participating faculty members from many disciplines addressing emerging zoonotic disease and ecosystem health. The UC Davis School of Veterinary Medicine is at the forefront of wildlife health research and training. It embraces the One Health perspective as the essential and relevant framework for training tomorrow’s leaders in veterinary medicine.

...survival of

Veterinary Intervention

population,

Daily operations of the program on the ground take place in Rwanda, Uganda and the Democratic Republic of the Congo, where nine project veterinarians and support staff and facilities and equipment are located. MGVP veterinarians work closely and collaborate with wildlife authorities in all three mountain gorilla range countries (ORTPN in Rwanda, ICCN in the Democratic Republic of the Congo, and UWA in Uganda) and with other non-governmental organizations.

Habituated mountain gorillas are observed daily by veterinarians or park trackers for clinical signs of disease. If an animal is seriously injured or ill due to a human-related threat, the MGVP either darts the animal with medication (e.g., an antimicrobial), or chemically immobilizes the animal to treat it. Animals are not temporarily moved to a hospital or clinic for treatment.

Decisions to clinically intervene on an ill or injured gorilla are made in close consultation with the appropriate wildlife authority and

but to the

January/February 2011

mountain gorillas is integrally linked, not only to the health of the gorilla

health of the other wildlife species, domestic animals and humans.

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with partner organizations, and are conducted according to established protocols for remotedrug delivery, immobilization, anesthesia and monitoring, biological sample collection and handling, anesthetic recovery, and post-anesthetic monitoring. As well, veterinarians follow detailed protocols for conducting comprehensive post-mortem examinations on every retrievable carcass. Veterinarians generate reports every time they enter the park to observe gorillas or to administer clinical care.

Mountain

Human Health Initiatives

gorillas are

The MGVP was one of the first great ape conservation programs to institute an employee health program (EHP) to safeguard the health of an endangered species in the wild.

Since 2001, the MGVP has provided annual health screening (physician examinations, disease testing, anthelmintic treatment) and health education to all conservation workers: veterinarians, researchers, and hundreds of park trackers, guides, and wardens, and their spouses.

For most park workers, the MGVP’s EHP has meant a significant improvement in their level of health care.

As well, through the EHP, vision impairment was diagnosed in many park workers, who then received eyeglasses from the MGVP, enabling them to better perform in their jobs. Recently, with the advent of the Mountain Gorilla One Health Program, occupational health and infectious disease specialists have come together to revise and expand the scope of the EHP to include conservation workers’ children.

The Mountain Gorilla One Health Program is also providing leadership in Rwanda and Uganda for a major international USAID-funded project, PREDICT, to detect and prevent emergence of zoonotic diseases from wildlife that could pose a pandemic threat to people. (www. vetmed.ucdavis.edu/ohi/predict/index.cfm)

the only great apes whose numbers in the wild are increasing: a recent census estimates that there are now 786 mountain gorillas in the world.

Animal Health Initiatives Most people living in the communities that surround mountain gorilla parks are subsistence farmers who cultivate a plot of land for food for their families. Some farmers also hold one or two dairy cows, to produce milk for consump

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tion and sale. The Mountain Gorilla One Health Program has instigated a Model Farm program in Rwanda and Uganda; motivated and dedicated individual farmers convert their farms into a more healthy environment for their cows and a more healthy and prosperous life for their families.

These model farms feature shaded concrete pads for holding cows (to prevent tick-borne infections), water catchment systems built off the roofs of the cow sheds (resulting in greater hydration for the cow and greater milk production), and a manure-capture system that feeds a digester (to produce methane for cooking gas and lighting).

The Mountain Gorilla One Health Program has completed a model farm in Rwanda and in Uganda, and has several others coming on line. The program also conducts a broad-scale rabies vaccination program for domestic dogs in communities surrounding mountain gorilla parks.

Extreme Conservation Mountain gorillas are the only great apes whose numbers in the wild are increasing: a recent census estimates that there are now 786 mountain gorillas in the world. Some would argue that this is the result of “extreme conservation” — an unprecedented and seemingly unsustainable level of intervention by governments, organizations, and individuals to ensure survival of the species.

Alternatively, one could argue that “extreme conservation” is a success story: that it is a real-world example of how people can ensure survival of a great ape species through attention, management, commitment and investment — to the animals, habitats, communities that surround them, and governments.

Human-habituated mountain gorilla groups in the Virunga Massif have grown at a higher rate than non-habituated gorilla groups. This greater population growth is largely attributable to health monitoring and veterinary intervention.

The Mountain Gorilla One Health Program’s approach appears to be working. kvgilardi@ucdavis.edu

Annual Meeting

Annual Meeting Alicia Abels, MD, is the Medical Society’s 137th President; she is the fourth woman and the first specialist in physical medicine and rehabilitation to hold that position. Dr. Abels succeeded psychiatrist Stephen F. Melcher, MD, at the SSVMS and Alliance Annual Awards, and Installation Dinner on January 21, at the Sacramento Hyatt Regency.

The Society’s highest award, the Golden Stethoscope, went to Dr. William J. Au, a neurologist known for his clinical investigations of multiple sclerosis and Alzheimer’s disease and for his expert, thoughtful and supportive patient care. His work led to a stage play depicting Dr. Au and several patients. Born in China, he received a bachelor’s degree at UC Berkeley and an MD at UC Irvine; his neurology residency was at UC Davis. Dr. Au was the first director of neurological services at Sutter Hospitals, and later became chief of staff. He now chairs the Board of Directors of Sutter Medical Group. He is also an accomplished trombonist and a jazz aficionado.

The Medical Honor Award for a contribution of great significance to community health was presented to Dr. Faith T. Fitzgerald, Professor of Medicine and Assistant Dean of Humanities and Bioethics at UC Davis Medical School. Since joining UCD in 1980, she has been recognized as an inspiring educator and expert diagnostician. Her presentation on illnesses of famous people, a “Magical Medical Mystery Tour,” is an annual feature at lectures of the Sierra Sacramento Valley

Museum of Medical History.

Helen Thomson, recently retired from the Yolo County Board of Supervisors, was presented the Medical Community Service Award, given to a non-physician making a significant contribution to a medical or public health problem. As a supervisor facing serious cuts to medically indigent care and problems with access to specialty care, she pulled together four major health systems and other stakeholders to lay out successful strategies for mitigating these problems. As a supervisor, and earlier as Chair of the Assembly Health Committee, she has been a tireless leader, convener and advocate for public health.

Jerilyn Marr received the Alliance’s highest honor, the Dorothy Dozier Helping Hands Award. Margery Scott Marshall won the Alliance’s CMA-A Dedicated County Member Award, for devoting her time, energy and talents to the Alliance.

January/February 2011

Dr. Alicia Abels, the 2011 President of SSVMS, with her mother, Marie, and close friend, Steve Lindall.

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Annual Meeting

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Annual Meeting

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Dr. Byron Demorest, the chair of the Scholarships and Awards Committee, is flanked by Dr. Claire Pomeroy,Vice Chancellor and Dean, UC Davis Medical School, and five medical students.

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Dr. John Ostrich holds a gold miner trophy, recognizing his retirement after 23 years of service as a delegate to the California Medical Association

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Part of the UC Davis contingent -- most of them medical students -- at the Annual Meeting.

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Dr. Alicia Abels with Helen Thomson, winner of the Medical Community Service Award. Mrs. Thomson is a recently retired Yolo County Supervisor and former member of the State Assembly.

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Dr. Herbert Bauer blows out candles on his 101st birthday cake.

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Three UC Davis medical students: from the left, Annahita Sarcon, Christian LaRoe and David Gunn. David is a frequent contributor to SSVMS Medicine.

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Part of the pre-dinner crowd at the Annual Meeting.

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Dr. Paul Phinney, Chair of the CMA Board of Trustees and candidate for CMA President-Elect, and his wife, Suzanne.

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Members of the SSVMS Board. From the left, Drs. David Herbert, President-Elect; Robert Madrigal; Anthony Russell; Steven Chen; Bhaskara Reddy, Treasurer; Alicia Abels, President; Dale Smith; Stephen Melcher, Immediate Past President; Jose Arevalo.

10 Dr. Alicia Abels, left, with Dr. Faith T. Fitzgerald, winner of the Medical Honor Award.

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January/February 2011

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Annual Meeting

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14 11 Dr. Stephen Melcher (left), SSVMS President in 2010, and Assemblyman Dr. Richard Pan, SSVMS President in 2004.

12 From the left, SSVMS Alliance President Barbara Andras; Jerilyn Marr, winner of the Dorothy Dozier Helping Hands Award; Margery Scott Marshall, the CMA-Alliance County Member of the Year; and Celeste Chin, President Elect of the Alliance.

13 Dr. Herbert Bauer, center, together with Dr. Captane and Helen Thomson.

14 AMA Delegate Dr. Barbara Arnold (standing), with SSVMS Treasurer Bhaskara Reddy, MD, and his wife, Sharan Reddy, MD. 15 Dr. William J. Au, winner of the Golden Stethoscope Award, with his wife, Yvonne, and son, Brandon.

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Sierra Sacramento Valley Medicine

“Doesn’t Anyone Die In Their Sleep Anymore?”

Can we afford our continued last ditch efforts to prolong life?

By Nathan Hitzeman, MD While doing rounds with residents recently, we attended an end-of-life extubation for a 67-year-old man with malignant hypertension on longstanding dialysis. He was known to just about everyone in our hospital.

After dozens of admissions over the past years for hypertensive emergencies, fluid overload, problems with his shunts and grafts, sepsis, and even some cardiac arrests, some of us had started to think of him as invincible.

He was so often in the hospital that to see him occasionally in clinic felt like a rare treat and in some way a medical triumph.

I never recalled him looking too happy, and his wife went through the constant agony of wondering if “this one” would be the one that did him in. Furthermore, he wasn’t mentally all there following a resuscitation a few months back.

Dozens of family members paid their respects. Things seemed to be going well. Then he was extubated, and we all watched, and watched, and watched…

Over the next 7 hours, family and staff came and went while our patient went through myoclonic jerks and respiratory distress. Nurses did their best to give medication and to suction secretions. It wasn’t a pretty sight or a merciful death to see him choking and gasping.

As he finally succumbed in front of an exhausted wife and medical team, we all sighed in relief and a tearful resident next to me asked, “Doesn’t anyone just die in their sleep anymore?”

I realized then that we had been watching him die much longer than the last 7 hours.

Scenarios like this are playing out more often. Implantable defibrillators and pacemakers ensure that hearts of the elderly don’t suddenly stop and result in a painless, merciful death.

Older folks are routinely offered dialysis and concerned family members often talk them into it. Geriatric patients with cancer who don’t respond to initial treatments might rotate through a Russian roulette of experimental cocktails before expiring in an emaciated pile of bones — and sometimes alone.

Some “cardiac cripples” with stents and bypasses get admitted every time they dare to eat out at Sizzler, and heart failure remains the number one cause of inpatient admissions nationwide. And with ventilators around, pneumonia is no longer “the old man’s friend.”

Rather, could it be that advanced medical technology has become his worst enemy? As a physician witnessing the wards of the undead, I wonder what cruel disease spiral will ensnare me in later years.

When I step back and look at healthcare in this country, I have deep reservations about whether living longer is living better. Can we afford our continued last ditch efforts to prolong life?

Seventy percent of all medical care dollars are spent on 10 percent of the population.1 Thirty percent of yearly Medicare expenditures are for 5 percent of beneficiaries who die.2 About a half million Americans have end stage renal disease and are consuming an ever larger piece of the Medicare pie. Chronic disease is riddling January/February 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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A painting of Madame Mazois on her deathbed,

by Henri Regnault (1866).

In the end, though, inordinate spending on end-of-life care leads to that dreaded “rationing” of healthcare, since there is a fixed pot of money.

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our country at alarming rates. Welcome to the United “Chronic Disease” States of America!

Despite $2.3 trillion dollars a year spent on healthcare (or about $7,600 per person), the U.S. has some of the worst health outcomes among industrialized countries — who, unlike us, manage to insure all of their citizens for a fraction of what we spend.3,4 How much better would the quality of life be if the majority of healthcare money was spent on preventing disease, promoting fitness and activity, a pleasant work environment, time off from work to spend with family, or adequate and affordable housing for our population?

About 25 percent of total health care costs are attributable to substance abuse and addiction, yet only 1 percent of health care spending covers direct substance abuse treatment.5 How about addressing that issue a bit better!

And if you consider overconsumption of food as an addiction, then two-thirds of our country has a problem. But rather than address the obesity problem, our government actually abets it through subsidizing a high sugar/high fat corporate food industry.

Doctors are not innocent, either, in falling short on cost-effective end-of-life care: a specialty-biased RVU committee overincentivizes procedures and underincentivizes talking with patients. Hence, the sometimes appropri-

Sierra Sacramento Valley Medicine

ate “less is more” approach is superceded by “more is more.”

Adding to the quagmire is a lawsuit-happy society that has nervous doctors offering any treatment with a chance to help and frequent “shotgun” work-ups to make sure nothing is missed. Anyone looking at U.S. healthcare from the outside must see a circus act of inefficiency, greed, poor communication, ignorance, and bureaucracy.

In the end, though, inordinate spending on end-of-life care leads to that dreaded “rationing” of healthcare, since there is a fixed pot of money. Rationing in other countries takes the form of actually following evidenced-based medicine, or through those highly criticized “queues” where people may have to wait several months for nonurgent care.

Rationing in our country takes the form of not insuring 1 out of 6 human beings who live here. Which form of rationing sounds more ethical? Other ways in which we are already rationed is through high copays, high deductibles, and patients losing their coverage when seen as “losses” by insurance companies. If you don’t think your healthcare is already being rationed, think again!

Granted, end-of-life care decisions can be tricky, especially when the patient is not a coherent participant in the discussion. I have seen some of my own family members trudge through neurodegenerative demise and dialysis dwindles.

But what I do know is that we are entering a “perfect storm” era of overutilization and aggressive end-of-life management that we cannot afford and is not making us “better.” Life is a terminal condition, and we as a doctors and patients need to accept that fact.

The geriatric population is expected to double by 2030.6 How have we prepared for this?

Well, our hospitals are in the red. All levels of government are nearly bankrupt and ineffectual. The population is largely clueless on what end-of-life care discussion is or should be, and opponents of any meaningful healthcare reform have labeled as “death panels” any team

efforts in trying to come up with an organized approach to end-of-life care.

I am not pretending to have the answers here, but the following are some resources and articles pertaining to end-of-life care that I have found helpful.

• POLST form to designate end-of-life (EOL) medical wishes. Found in various languages at www.capolst.org. Finally a one page form that makes sense, glows in the dark, and is easy to fill out. A recent study showed that only 31 percent of patients with advanced cancer had EOL discussions. EOL expenditures were about 36 percent less for these patients as compared to patients without EOL discussions. Furthermore, patients with EOL discussions had better quality of death in their final week.2 • Consider the patient’s and family’s values.

A June 18, 2010 article by Katy Butler in the New York Times is a heart wrenching, firsthand account of one daughter’s struggle to try to get her demented father’s pace-

maker turned off. Read it with tissue in hand. Found at www.nytimes.com/2010/06/20/ magazine/20pacemaker-t.html?pagewanted=all • Read a physician’s perspective. If you haven’t read the August 2, 2010 New Yorker article by the prolific writer/surgeon Atul Gawande, it really sums up everything wrong with end-oflife care in our country. Found at www.newyorker.com/reporting/2010/08/02/100802fa_fact_ gawande.

• Seek out more information on your organization’s hospice programs. A nice article by Sutter Hospice director Dr. James McGregor describes how hospice prolongs survival, reduces costs, and leads to better care. It can be found in the 2008 SSVMS archives7 online at www.ssvms.org/publications. hitzemn@sutterhealth.org 1 Bodenheimer T, Berry-Millett R. Follow the money – controllling expenditures by improving care for patients needing costly services. NEJM. 2009;361(16):1521-1523.

2 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life.

Arch Intern Med. 2009;169(5):480-488.

3 Hartman M, Martin A, Nuccio O, et al. Health spending growth at a historic low in 2008.

Health Affairs.

2010;29(1):147-155.

4 Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):27892791.

5 Brady TJ. Treating a disease as a disease. San Francisco Medicine.

2010;83(5):18-19.

6 Retooling for an Aging America: Building the Health Care Workforce. Report by the Institute of Medicine. 2008.

Found at www.iom. edu/Reports/2008/ Retooling-for-anAging-AmericaBuilding-the-HealthCare-Workforce.aspx 7 McGregor J. Living longer – hospice and palliative care. Sierra Sacramento Valley Medicine 2008;59(3).

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Conversations

Hibbard Williams: Early Years of Family Practice

By David Gunn, MS IV Dr. Hibbard Williams was dean of the UC Davis School of Medicine from 1980–1992, and had a key role in its development. He was interviewed in November, 2010.

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Dave Gunn: Tell us a little bit about UC Davis’ School of Medicine inception.

Hibbard Williams: It began in 1966, when [Dr. C. John] Tupper was recruited by the Chancellor of the University to be the dean.

They took in their first class in 1968 (graduated 1972). It was a time when the state felt strongly that there was an imbalance of physician care centered in the cities. We needed more primary care physicians in the smaller communities.

Tupp’s mandate was to build a school that would produce fine physicians that would populate the small communities in northern California. He got the school started very quickly, in two years, with the help of seven initial department chairs — “the lucky seven.”

He developed the school using temporary facilities, and for their clinical work they used the county hospital. There were 40-some-odd students in the first class.

DG: And how did Tupper shape the student’s experience to push students towards primary care in rural areas?

HW: First he had to get a commitment from his key faculty to try and do this. He began to get a cadre of faculty and students who were interested in primary care, and a curriculum that supported that.

DG: So, by having people who were “proprimary care,” students would be exposed to that and give it more weight than they would otherwise.

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HW: The Department of Family Practice played a major role in attracting students to family practice.

DG: In my conversations with Faith Fitzgerald, we wondered how you push students towards family practice when they may not have any idea where their talents lie until they are in the midst of their education. So, to make “a primary care school,” has at its foundation some assumptions.

HW: Well, you get exciting, dynamic faculty members who become role models for the students who are interested in primary care.

I think they did that, from what I know.

Everyone knows that even though students come into medical school with very strong leanings towards one field or another, students are likely to change their minds as they become exposed to other areas…

I met with a lot of faculty and departments when I arrived, to see what the consensus was.

I sensed they wanted to grow, to add programs, to improve research activities... but not at the expense of primary care.

DG: That sounds like quite a challenge.

HW: Yeah, it was. We started in the fall of 1980, and within about a month of my arrival there was a crisis. It dealt with quality assurance issues in the cardiologic surgery and kidney transplant department. Our cardiologists were referring outside of the system, the state regulators came in based on those complaints, a big study was done to objectively evaluate our service, and the national press was involved.

The biggest disaster was that it destroyed the morale of the school for a while. But out of it came some good things, like our quality

assurance program. We emerged from that with a model QA program that was copied by other institutions. So that was a setback, but by 1984 we were back on track. We replaced a bunch of department chairs, most external candidates from a national search.

DG: With such a new school that was founded with a strong sense of purpose, having external candidates brought in [to replace department chairs], do you think that diluted the social fabric? Do you think that could have affected the trajectory of the school’s mission?

HW: I think it had the potential to do that, but I don’t think it did, at least as long as I was dean. Ranking lists for family practice programs consistently put us near the top. Even though we were expanding into subspecialties and research, we still had strong family practice.

DG: How successful do you think you were in meeting the faculty’s desire to grow and diversify?

HW: I think we did a pretty good job at it.

The 1980s was a period of growth, the research budgets went up, the amount of research dollars went up, the amount of research dollars per faculty went up even more. And at the same time, the family practice programs were being recognized...

DG: What was the metric by which you measured the success of the family practice programs?

HW: By their research, by their presentations at national meetings, by the number of their members who held national positions in family practice organizations. They have research programs, and they always got recognition, and the amount of dollars you can generate is generally less when compared to big active research programs...

DG: How much conversation do you have with the current dean?

HW: Almost none, I see her socially at events. Joe [Silva] and I are friends, so we’ll have lunch.

DG: I ask because I wonder how much continuity the school’s original foundation has in perpetuity because of longitudinal meetings between deans.

HW: Well, there’s a progression in any school.

Most schools change over time. Hopefully, the faculty as a group directs that change. Some change is to be expected, almost always coming from the dean meeting with faculty members. I know both Joe and Claire did that.

DG: I speak with a lot of classmates and alumni, and the general theme is not, “When is UC Davis going to get more NIH money?

This school is out in the boonies and no one is paying attention to us.”

What they are saying is, “Why isn’t UC Davis putting out more family practice docs? It used to, and now it’s not. Why?” HW: There’s a marked reduction over the entire country, the mood of the nation has changed. I think that’s a good challenge for Davis to maintain that. They need to expand programs into that area, and have done so with telemedicine run by Tom Nesbitt.

DG: What do you think is different between the students today versus when you were dean?

HW: I think there’s a feeling among health professionals that it’s not the profession it used to be. There’s less interest in a medical career than there used to be, particularly in primary care. It’s the toughest of specialties, you’ve got to know everything and you’ve got to know it well. It’s so much easier to focus on one area. It’s the worst paid, of all the specialties. And it takes more time, so less time for your family. You put those two things together.

DG: Summarize what medicine used to be like, for those who are too young to remember.

HW: You could spend time with patients, you weren’t pushed to see the patient and write a note in 10 or 12 minutes. You could admit patients to the hospital, take some time working with their problems and they could stay there a week, not just two or three days. Students could spend more time with them.

DG: And when do you think that really started to change?

HW: The 1990s on, I think.

DG: When I read about the history of family practice, it seems as though it had its demise after World War II, when many generalists went on to specialist practice and additional training.

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There’s less interest in a medical career than there used to be, particularly in primary care. It’s the toughest of specialties, you’ve got to know everything and you’ve got to know it well.

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HW: It’s true, the programs after the war favored specialty training.

DG: So if you could make a change to produce more family docs, what would you do?

HW: Every person after age 18 should serve one or two years of mandatory public service, in this case you would have some loan repayment for physicians. After that you could do special-

ization in a field...

The National Health Service Corps should be expanded to allow students to have an opportunity to practice in a community for a couple years. The data, I think, show that students who are exposed to this way of life stay in it. dgunn11235@gmail.com

Board Member Statement and Profile Our Medical Society is among the largest in California. The Board of Directors includes the officers of the society, and representatives from each SSVMS membership district and the CMA and AMA. All are elected by the membership, so that information and access is vital to a well-run and representative organization.

For a complete listing of names and addresses of board members please log on to www.ssvms.org.

Alicia Abels, MD USC School of Medicine Physical Medicine and Rehabilitation SSVMS President

Please contact me by email at: aabels.ssvms@me.com

Why do I serve on the Board? A respected friend asked me to serve on the Board and I reluctantly agreed. To my surprise, the Board experience has been fun, and enlightening. It keeps me “in the loop” about what’s going on in the society, in the community, and beyond so that I feel connected to docs in other specialties and settings throughout the region.

I am a native Sacramentan. I was an undergraduate in electrical engineering at MIT for two years, and then attended UC Davis for two more, graduating with a bachelor’s degree in zoology. (They don’t even call it “zoology” any more.) After USC medical school, I attended UC Davis for my residency.

Physical Medicine & Rehabilitation became my specialty after mentoring by the late Jim Lieberman, former chair of that department at UCD School of Medicine. I first met him as an undergrad on summer break, while trying to decide what to do with my life. PM&R was a perfect choice for me — I liked neurophysiology, technology, gadgets, believed in the power of exercise, communication with patients and their families. PM&R has tremendous flexibility with numerous practice subspecialty areas and settings — cardiopulmonary rehab, cancer rehab, AIDS rehab, stroke, spinal cord

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injury, industrial rehab, pediatric rehab, sports medicine, electrodiagnostics, etc. It offers so many choices within the specialty that you can pretty much pick whatever area you’d like, and then decide to either work at a hospital-based practice, military-based, or office-based practice, or any combination of the above.

You can even modify your practice every few years if you get bored! Now, it seems, everyone “works” in a team, but PM&R was really the first specialty that proffered this multidisciplinary approach as part of residency training.

I have never regretted the decision. My free time is spent mostly with family. Steve and I share a love of the outdoors and like to spend time together on boards: sailboards, skis, snowboards and Indo boards.

My mother, always happy and optimistic, is my life role model and is a past president of the Alliance.

Assault on Conscience Attacks on conscience are often cloaked in the language of compassion and human rights, yet in fact represent real and present danger to precisely those values.

By Stephen A. McCurdy, MD, MPH I will practice medicine with conscience and in truth. — UC Davis New Physicians Oath Over recent years I have watched with growing unease as events unfold that portend an historic and ominous turn for medicine and society. These developments are designed by their authors to remove the critically important right of physicians to practice according to conscience.

Although these developments affect many areas of practice, at “ground zero,” there are highly charged topics, most notably abortion and physician-assisted suicide. These are being used as levers to pry away protections that have existed for millennia, at least in the ideal if not always in practice. Attacks on conscience are often cloaked in the language of compassion and human rights, yet in fact represent real and present danger to precisely those values.

Conscience serves at least two purposes for physicians. First, it allows the physician to practice within the bounds of personal and shared moral integrity. Both the personal and shared aspects are necessary for a proper understanding of conscience.

Those arguing against the right to act according to conscience often attempt to trivialize it by portraying conscience as a personal quirk that should never be allowed to interfere with a patient’s wishes.

Yet conscience is most properly understood in the sense of an informed conscience — one that has seriously wrestled with the issue, including thoughtful consideration and engagement with opposing views; that has reached conclusions based on ethically accepted prin-

ciples; and that reflects the reasoned deliberation and sensibility of more than a few scattered individuals. (Indeed, the word “ethic” refers to norms held by a group, or community.) The informed conscience thus distinguishes itself from personal whim through its foundation on accepted ethical norms and its shared and open nature.

The second purpose served by conscience is less well recognized than maintenance of integrity, but equally important. That is, conscience allows the physician to practice medicine in a manner that best serves the patient, apart and separate from considerations of moral integrity.

Injury to this principle is best seen with recent and ongoing attempts to legalize physician-assisted suicide in California. There have been several attempts in the California Legislature to compel physicians to offer or refer for physician-assisted suicide for their patients with a condition likely to be fatal within a year.

(Most recently, AB 2747, sponsored by Berg and Levine, May 2008.)

I can imagine no greater vulnerability than that of patients just informed that they have a terminal disease. In the maelstrom of negative emotions accompanying such news, a patient offered physician-assisted suicide may accept that offer, thereby foregoing the opportunities for unexpected improvements, to grow spiritually, to heal sundered relationships, to experience joy and hope, and to bring these to others.

Yet the original text of the proposed law made no provision for the physician who, knowing his or her patient, decides such a discussion is not in the patient’s best interest. Even the

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Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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Will we punish our fellow physicians because they take their Hippocratic promise seriously?

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physician with no compunctions against physician-assisted suicide per se would not have had the latitude to refrain from offering or referring for it in specific patients for whom the physician thought the discussion especially inappropriate.

Fortunately, the language legalizing physicianassisted suicide and compelling physicians to offer or refer for it was removed prior to passage of AB 2747. Yet this was not the first such effort in California, and it is unlikely to be the last.

Most U.S. medical schools have some version of the Hippocratic Oath sworn at graduation. These generally not only acknowledge the primacy of conscience, but also include an affirmative pledge to it. Here at UC Davis, the second line of the UCD New Physicians Oath declares, “I will practice medicine with conscience and in truth.”

What does this mean for the physician asked by the patient to provide or refer for a treatment that the physician believes is not in the patient’s best interest?

Many of us occasionally see patients who demand treatments that, while useful for some, are inappropriate and potentially harmful in their specific case. Having read about these treatments on the Internet, they are certain they need them and determined to have them. This situation differs from the cases in which we refer for specialty expertise with the goal of furthering the patient’s best interest. Are we required to provide treatment or referral despite a conviction that the desired treatment is not in the patient’s best interest?

At present the answer to that question is “no.” The general principle is that patients have essentially absolute freedom to decline care, but they do not have an unlimited right to compel it. And so it should be. Patients have rights, of course, but as physicians we are engaged to help patients heal, not to be forced into assisting in harm.

To not allow the physician to act according to conscience upends the relationship with the patient.

In effect, the patient becomes the physician, deciding on what care is appropriate, and the physician merely provides the necessary techni-

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cal expertise. This is contrary to our historical values and endangers the patient, our profession, and society. The last century provides many examples of societies in which physicians were no more than technicians; this history should give us pause before embracing such a paradigm.

Abortion and physician-assisted suicide are perhaps the most polarizing issues in society and the medical community today. Their highly fraught nature can cloud reasoned judgment; we must guard against attempts to use them to destroy the principle of conscientious practice that has for so long characterized our calling.

Yet there are editorials in our most prestigious medical journals advocating that physicians unwilling to participate in abortions be barred from practicing with reproductive-age women. In the example of abortion, a woman wishing to obtain an abortion may do so, without forcing involvement of physicians who conscientiously object. Insistence on forcing participation — under threat of loss of board certification, license, and livelihood — is gratuitous and mean-spirited, akin to poking a vengeful finger in the eye of those with whom we disagree.

Will we punish our fellow physicians because they take their Hippocratic promise seriously?

I hope not. I hope we, as a community of physicians, regardless of our own positions on controversial issues, can agree that forcing some of our members to participate in procedures contrary to their conscience, even indirectly through compulsory referrals, violates our historical ethics and our (and society’s) most fundamental interests. samccurdy@phs.ucdavis.edu Dr. McCurdy is Professor and Director of the University of California, Davis Master of Public Health (MPH) Program. He is board-certified in Preventive Medicine (Occupational Medicine) and Internal Medicine. The opinions expressed here are his own and do not necessarily reflect those of the University of California or its Regents.

Where Do You Begin?

Thirty Years in the Democratic Republic of Congo (formerly Zaire).

By Phil Dirksen, MD Do you begin with the era of oppressive peace under the corrupt nepotistic dictatorship of Mobutu Sesse Seiko?

Or the 1994 Rwandan genocide human disaster?

Or the indiscriminant destruction of the refugee camps in 1996 containing 1.2 million people?

Or the assassination of Kabila and the “First World-War of Africa” (1998–2003) with the loss of 5 million lives (most from disease and starvation)?

Or the ongoing undeclared militia and guerrilla war claiming 45,000 lives per month, and tens of thousands of women and girls savagely raped, mutilated and left infertile and incontinent of urine and often feces?

In 1981, a young surgeon with his brave wife and two children (11 and 9-years-old) entered eastern Zaire (bordering Rwanda and Uganda) as the only surgeon for the Kivu Province with 2.5 million people. The hand-carried “threepiece” endoscopy equipment set (gastroscope, bronchoscope and colonoscope) made it as far as customs in Goma, Zaire, where we watched as the bronchoscope end was crushed by the forced closure of the case. Now eastern Zaire had the first and only “two-piece set” of endoscopy equipment.

From 1981 thru 1989, we grew our family in beautiful, tropically lush, peaceful rural eastern Zaire while establishing or re-establishing two hospitals, two nursing schools and 33 health centers. Since 1990, my wife and I have returned for annual 6–7 week medical/surgical mercy missions.

My wife, Zana, and I returned from our annual medical mercy mission of repairing

rape victims of war, performing complex surgical procedures, training Congolese surgeons, teaching English, equipping women with life and work skills, and assisting in the New Hope Center — a grief therapy and counseling center for war orphans and child soldiers.

A word regarding influences in my formative years and personal philosophy. Leaving a wheat farm in Kansas and elementary teaching, my parents moved to the Hopi Indian Reservation in northern Arizona where I, with three siblings, spent 10 years of our early life. My parents were involved in faith-based development of education and agriculture and would say they had never worked harder in their lives, earned less money, or been more at peace with themselves and with God. Growing up, I was, and still am, an avid reader. One story I read was the life of Jim Elliot, “Thru Gates of Splendor.” This man was martyred in 1952 in Ecuador doing faith-based translation work.

Among his diary entries were these words: “He is no fool who gives what he cannot keep to gain what he cannot lose.”

My personal life philosophy and goal has been: to invest myself in people — developing, training, modeling, mentoring people. Investing time, energy and money in motivated, deserving individuals, in my humble opinion, is truly people empowerment and “sustainable development,” a buzzword in the development community.

I like to think of any small contribution we might have made — more often accidentally than planned — as developing and empowering, not just people, but teams, “teams of hope.”

The synergy of a team is truly greater than the

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Zana Dirksen flanked by the Shona team, whose colorful clothing hides crude metal braces.

sum of the pieces.

So where do you start this year’s six weeks in the Congo — Aug/Sept/Oct, 2010?

It’s 8 p.m. and we’re waiting for the stinky/ noisy generator to “give-it-up” to — what? City electricity? The operator has probably at long last gone either to sleep or out drinkin’!

Our ongoing, daily reliably unreliable electricity meneno (Swahili for “problem”) competes with our arrival saga in DR Congo 6 weeks ago.

The 33 hours of flying time were concluded

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Steam rises from the front of the disabled minivan.

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with the 4-hour mini minivan “trip” (Kigali, Rwanda, across the border into Goma, DR Congo). The “arrival trip” only required stops for overheating and having to buy water (right off a kid’s head).

The mini minivan spent a week in the garage on arrival, and, after numerous “repairs” on the cooling system, and new shocks, we were all set for an uneventful departure the first of October. Our patience not to be denied, the mini minivan again overheated on the first long upgrade across the border out of Goma. We turned around, returned to Gisenyi, Rwanda (the border town across from Goma) and negotiated for a “road-warrior” proven minivan with chauffeur. Enough excitement as we thankfully made our return flight out of Kigali.

Sooo... what did you do this year for six weeks in the Congo — Aug/Sept/Oct, 2010?

Dr. Phil saw 20 plus consultations per day, performed 62 major surgical procedures, taught surgical techniques to 13 Congolese doctors and had 5 medical students in externships.

Zana assisted in furnishing the patient rooms of the growing Signers Medical Center, sewing and installing drapes and curtains, and distributing gift packs to the new mothers on the maternity ward. She taught the director of the New Hope Center for grieving children (war orphans) how to bake and decorate cakes.

She encouraged the women at Shona (Swahili for “to sew”). These are a group of handicapped women who were dependent on a charity organization and living in a handicap center. Now these four handicapped ladies have been taught to sew, earn their own livelihood, and happily live together independently.

And, most importantly, Zana organized all the medical supplies, equipment and suture, and, each morning, selected all the necessary material and filled Dr. Phil’s “needs request” list for the day’s surgery.

The 13 Congolese physician/surgeons came from large government and NGO (non-government organization) hospitals up and down the 350-mile length of the Kivu Province. They were vetted and selected by the provincial medical inspector (equivalent to our Minister of

Health). Dr. Dominique Baabo is a personal friend and 10-year mentored colleague and physician-in-chief from Rwanguba, our rural health zone reference hospital located 60 miles north of Goma. He is one of my best protégés with a successful vesicovaginal fistula (VVF) repair rate approaching 90 percent. He also shares my philosophy of continuing an active clinical surgical practice, including training and teaching, while fulfilling his full time administrative responsibilities.

One of the conditions is that the physicians selected for this surgical training must come with their operating room (OR) team, consisting of at least their anesthetist, OR assistant and OR supervisor. The training team will include myself, my personal CRNA of 25 years — who will take “vacation” from his other responsibilities — and the head OR nurse/assistant and supervisor trained through our nurse-practioner institute and hospital at Rwanguba.

The surgeons will bring their own “teaching material,” i.e. large goiters (past the chin and

often with substernal components); enlarged prostates with complete outflow obstruction, often with suprapubic drainage in place; recurrent and or fistulized hernias; complicated vesico and recto vaginal fistulae with failed repairs elsewhere.

Yes, SGBV (sexual and gender-based violence) remains epidemic in eastern DR Congo. Horrific, mutilating vaginal, bladder and rectal injuries continue to be inflicted on defenseless women and girls. This sexual brutality is used as a weapon of war in oppression control of the civilian population.

Multiple repairs were performed during our recent medical mercy mission for vesicovaginal fistula (VVF) and rectovaginal fistula (RVF). VVF is an abnormal communication between the bladder and vagina, resulting in the continuous leakage of urine through the vagina. Due to my 30 years of successful experience, the complex, failed and “impossible” cases are saved for our annual medical mercy mission.

All the surgeries performed this past six

ing vaginal, bladder and rectal injuto be

The logistics and expenses for organizing the Dirksens’ annual "pilgrimage" are considerable and many people and organizations contribute to make it happen. These are expenses of their last trip.

mutilat-

ries continue

The Cost of One Journey

7/25/2010 7/19/2010 8/5/2010 8/5/2010 8/5/2010 8/5/2010 8/6/2010 8/6/2010 8/8/2010 8/9/2010 8/11/2010 8/17/2010 8/17/2010 8/25/2010 8/30/2010 8/30/2010 8/31/2010 9/6/2010 9/6/2010 9/21/2010 10/2/2010 10/22/2010

Horrific,

2 roundtrip airline tickets to Kigali, Rwanda, depart 25 Aug return 21 Oct 6 footlockers for surgical supplies 12 10ml vials of Kenalog -10 for keloid infiltration-Liddy's Pharmacy 4 boxes of #12 stainless steel surgical blades - 100/bx-Havel's Inc. specialty suture for fistula repair - Med-Vet International powderless surgical gloves - Allegro Medical Biogel surgical gloves - Mohawk Medical Travel Document Systems - DRCongo visas & fees x 2 people surgical headlamp & battery pack - Eastern Mountain Sports surgical headlamp - Als Sports surgical headlamp - Amazon.com specialty suture for fistula repair - MedStar Inc. specialty surgical instruments for fistula repair-V.Mueller Division Excess luggage/footlockers of surgical supplies - total of 10 pieces Anesthetic agents/meds for 6 wks of surgery Construction of Incinerator at Signers Medical Center Aid for Dr. Bahati's family whose house burned social case-surgery for a 70 yo widow c complete uterine prolapse local purchase of a large surgical instrument tray with 65 instruments 20 Swahili songbooks and 20 Swahili Bibles for the chaplaincy at Signers Kenya visas x2 1/2 of needed partial tuition scholarships, $75/student for ITM - 88 students

$3,886.98 $120.00 $239.76 $75.83 $37.75 $56.10 $137.94 $563.00 $85.40 $53.73 $47.07 $152.29 $822.86 $800.00 $585.00 $362.00 $250.00 $250.00 $600.00 $304.00 $100.00 $3,300.00

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inflicted on defenseless women and girls.

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Two patients with catheter drainage after fistula repair.

weeks in Goma were complex procedures performed for multiple failures, from 3 to 7 times, of prior attempted repairs elsewhere.

These cases required advanced techniques of repair and provided opportunity to demonstrate and train Congolese fistula surgeons in the performance of these complex approaches, including the Martius bulbocavernosus pedicled flap for reinforcement of tenuous repairs and construction of a neourethra. Schuchardt vaginal releasing incisions were used to reach fistula in scarred, constricted vagina (one case had vaginal length reduced to only 1.5 cm). As of our departure, all repairs proved successful with watertight closure of fistula.1 I just heard a very terrible story.

A frail young woman in dirty tattered clothing came into the consultation room and wearily sat down, tightly clutching a cloth-covered bundle on her lap. She lifted up the kikwembe (a strip of cloth used as clothing), revealing a child with a large swollen deformity on the upper back. “Aha,” I thought, “Pott’s Disease,” i.e., tuberculosis of the spine.

The story spilled out in a flat monotone voice. My mind strayed from some of the awful details as I looked at vacant eyes staring far off into space.

One year ago, her village had been attacked, people beaten and hacked to death and others

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shot. Her 2-year-old child was savagely hit across the back and left for dead. She was told to lie down and “not move” as the soldiers repeatedly raped her, three, four, five, six times. She felt like a dead person, a corpse. Then someone said, “Your baby is moving.” And so it was, but its back was broken and below the waist it was completely paralyzed. That was the large swelling on the upper back of this small child.

The vicious cycle of internally displaced people (IDPs) continues in eastern Congo. The suffering and devastation that has occurred in their land has affected over two-thirds of the population. This suffering, devastation, disease and starvation again worsened in January of this year. Combined DR Congo army and UN peacekeepers in joint operations attempted to disarm and dislodge various well-armed and wellentrenched guerilla groups in eastern Congo.

Because of this renewed fighting and associated atrocities and retaliation, thousands of people have been trapped and are fleeing into refugee camps. People in churches in the nearby city of Goma take in 20, 30, 40 people … and more, into their 15 x 24-foot single-room “homes.” The resilience and compassion of these people is truly incredible and incomprehensible!

Hundreds of thousands of people remain as internally displaced people in north Kivu (eastern DR Congo). They hide in the forests or seek shelter with other families. Those who have reached UNHCR camps have access to food, non-food assistance and some medical help.

However, the majority are still in the forest or living with host families and do not have the support present in the camps.2 These suffering people without “hope of healthcare” find care in our 30 health centers and several small hospitals, including Rwanguba Hospital (100 km north of Goma) and Signers Medical Facility in Goma (provincial capital of North Kivu with 800,000 people). Thanks for your support of our compassionate medical staffs making possible care for these IDPs. Speaking for the healthcare teams of compassion and excellence represented in the stories above, we gratefully thank the many

of you who strengthen us with your thoughts, prayers and support. You are truly the heroes who make this annual medical mercy mission happen, touch lives and give hope to hundreds of suffering people in eastern DR Congo. If you are interested in further information and involvement, see our website at: www.compassioncongo.org and click on “How you can help” on the upper toolbar on the home page. sacpkd@comcast.net 1 See the article on Reuters AlertNet written by Katie Ngugen: “Rape on the rise in wars despite UN resolution” 20 Oct 2010 http://www.alertnet.org/db/ an_art/57964/2010/09/20-161421-1. htm 2 See the video clip, “Helping The Displaced in North Kivu” embedded in the link below from the 2010 UNHCR country operations profile - Democratic Republic of the Congo: http://www. unhcr.org/cgi-bin/texis/vtx/page?page=49e45c366 Also see the link below from an IRIN report posted on ReliefWeb entitled:DRC:IDPs hiding in North Kivu forests: http://www.reliefweb.int/rw/ rwb.nsf/db900SID/MGAE-824JWM?OpenDocument &RSS20

Dr. Phil Dirksen in the OR, teaching fistula repair to women obstetricians.

Your care makes all the difference.

Trevor Austin Kott — Oct '06 - Apr '07.

Still inspiring people to give hope to patients in need.

There are those who give blood and there are those who stand ready to give marrow should a match be found.

To the medical professionals who care for every man, woman and child who receives these precious gifts, www.bloodsource.org

|

not-for-profit since 1948

thank you for your support of every patient in need.

January/February 2011

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. — Robert A. Kahle, MD, Secretary Barnett, Bruce P., Family Medicine, Harvard 1975, California Prison Healthcare Services, PO Box 4038, Sacramento 95812 (916) 708-9933

Miranda, Deejay N., Pediatrics, American University of Caribbean 2002, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5463

Camfield, Karen D., Pediatrics, UC Los Angeles 1982, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5429

Stewart, Katherine S., Family Medicine, University of Southern California 1985, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5200

Godil, Fouzia, Internal Medicine, Dow Medical College, Pakistan 1991, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5238 Kalyan, Ranjani R., Infectious Diseases/Internal Medicine, Ross University, Dominican 2002, Pulmonary Medicine Associates, 5 Medical Plaza #190, Roseville 95661 (916) 786-7498

Thadwal, Baljeet S., Anesthesiology, Victoria University of Manchester, England 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 Wise, Trenton D., Pediatrics, University of Virginia 1999, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5434

Lo, See S., OB-GYN, UC Los Angeles 2005, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5300

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Sierra Sacramento Valley Medicine

Board Briefs December 13, 2010 The Board: Extended appreciation to outgoing Directors Michael C. Lucien, MD and Charles McDonnell, III, MD, for their service on the Board.

Approved the 2010 Third Quarter Investment Reports and Recommendations.

Approved the nomination of Louise Glaser, MD, to fill the one year remaining in the term of Director Office #10 representing District 5 (The Permanente Medical Group).

Approved the 2011 appointments to committees.

Approved the Membership Report: For Active Membership — Karen D. Camfield, MD; Sandy S. Cho, MD; Fouzia Godil, MD; Dennis S. Kumata, MD; See S. Lo, MD; Deejay N. Miranda, MD; Jonathan S. Rittenbach, MD; Amadeu F. Santos, MD; Katherine S. Stewart, MD; Suzanne R. Sweidan, MD; Baljeet S. Thadwal, MD; Trenton D. Wise, MD. For Reinstatement to Active Membership — Barth L. Wilsey, MD. For Return to Active 65/20 Active Membership — Jose M. Abad, MD. For Annual Renewal of Illness Leave of Absence — Douglas R. Schuch, MD. For Retired Membership — Frederick X. Delgado, MD; Leonard E. Rasinghe, MD; Howard M. Slyter, MD. For Resignation — Caroline C. Hahn, MD (moved to Texas); Dawn A. Mudie, MD (moved to Texas); Tracy M. Skolnick, DO (joined the DO Society); Daniel P. Winder, MD (moved to Washington).

January 10, 2011 The Board: Welcomed the 2011 President, Alicia Abels, MD, and extended appreciation to outgoing President, Stephen Melcher, MD, for his leadership in 2010.

Welcomed new Directors Steven Chen, MD, and Louise Glaser, MD. Continuing as Directors in 2011 are: David Herbert, MD, President-Elect; Jose Arevalo, MD; John Belko, MD; Michael Flaningam, MD; Robert Kahle, MD; Robert Madrigal, MD; David Naliboff, MD; Bhaskara Reddy, MD; Anthony Russell, MD; Demetrios Simopoulos, MD; and J. Dale Smith, MD. Elected Robert Kahle, MD, 2011 Secretary and Bhaskara Reddy, MD, 2011 Treasurer.

Received formal notification from Executive Director William Sandberg that he will retire as of December 31, 2011.

Received an update from Glennah Trochet, MD, Sacramento County Public Health Officer, concerning reductions in the County Division of Public Health’s budget and workforce, as well as the elimination of several programs because of reduction in county funding. Also, received an update concerning the increase in STDs in the county, the pertussis outbreak in California, city water fluoridation and flu vaccinations.

Appointed Assemblyman Richard Pan, MD, to fill Alternate-Delegate Office #11 to the CMA House of Delegates for the 2011–2012 term.

Requested staff to schedule appointments with legislative representatives at the CMA Legislative Leadership Day scheduled for April 5 in Sacramento.

Approved the Membership Report: For Reinstatement to Active Membership — Ronald A. Rogers, MD. For Active 65/20 Membership — Stewart E. Teal, MD. For Retired Membership — Anthony J. DeRiggi, MD; Paul B. Lim, MD; Ivan R. Schwab, MD. For Resignation — Sherellen B. Gerhart, MD (moved to San Francisco); Peter L. James, MD (moved out of area); Daniel Lopez-Uribe, MD (transferred to LACMA); Patricia Y. Tan, MD (transferred to Solano County); Lisa J. Van-Ert, MD; Peter T. Yip, MD (transferred to San Joaquin County).

January/February 2011

35

Classified Advertising

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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.

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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

Membership Has Its Benefits!

Free and Discounted Programs for Medical Society/CMA Members Auto/Homeowners Discounted Insurance

Mercury Insurance Group 1.888.637.2431 or www.mercuryinsurance.com/cma

Car Rental / Avis or Hertz

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Clinical Reference Guides

Epocrates discounted mobile/online products www.cmanet.org/benefits/epocrates_guides.asp

Conference Room Rentals

Medical Society 916.452.2671

Credit Card

CMA rewards credit card, Bank of America 1.866.598.4970

Office Supplies/Equipment – Staples, Inc. Save up to 80%

Members-only discount link www.cmanet.org/benefits

Healthcare Information Technology (HIT) www.cmanet.org/hit Resource Center HIPAA Compliance Toolkit

PrivaPlan Associates, Inc. 1.877.218.707 / www.privaplan.com

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

Marsh Affinity Group Services 1.800.842.3761 www.marshaffinity.com/assoc/cma.html

Legal Services & CMA On-Call Documents

800.786.4262 / www.cmanet.org/member

Magazine Subscriptions 50% off subscriptions

Subscription Services, Inc. 1.800.289.6247 / www.buymags.com/cma

Medic Alert

1.800.253.7880 / www.medicalert.org/cma

Merchant Services/Payroll Services/ Check Management

Heartland Payment Systems 1.866.941.1477 www.heartlandpaymentsystems.com

Practice Financing Reduced Loan Administration Fees

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Reimbursement Helpline Assistance with contracting or reimbursement

CMA 1.888.401.5911

Security Prescriptions Products

RX Security www.rxsecurity.com/cma.php

Travel Accident Insurance/Free

All SSVMS Members $100,000 Automatic Policy www.ssvms.org/about/downloads/ travel-accident-ins.pdf

Sierra Sacramento Valley Medicine

Serotonin Surge Charities presents

Friday, April 1st, 6:30pm to 9 :30pm at the Arden Hills Resort Club & Spa A food, wine, and fashion show fundraiser for the following clinics and organizations that serve the medically uninsured: Bayanihan Clinic, Clinica Tepati, CommuniCare Health Centers, CSERF’s SPIRIT Project, The Effort, Folsom Family Clinic, Health & Life Organization (HALO), Imani Clinic, Joan Viteri Memorial Clinic, Mercy Clinic Loaves & Fishes, Mercy Clinic North Highlands, Mercy Clinic Norwood, Paul Hom Asian Clinic, White Rock Family Clinic and Willow Clinic

Classic Party Rentals First Responder Sierra Sacramento Valley Medical Society Sutter Medical Group ●

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Please join us and emcee Mark Kreidler as we learn more about safety net medical care, enjoy fine wines and sweet and savory foods, and honor Dr. Claire Pomeroy, Vice Chancellor and Dean, UC Davis School of Medicine.

Sacramento Cal Expo

Senders Wines

Fashion Show:

Graphics:

Photography:

Media Sponsors:

Signage:

Website:

Event Produced By:

For sponsorship and donor information, please contact John Chuck, M.D. at 530-757-4114 or john.chuck @ kp.org.

To register to attend, go to www.serotoninsurge.org or contact Tina Bozzini at 530-757-4121 or tina.bozzini@ kp.org.

Cost is $100 per person. Early bird registration by February 18th is $75.

Serotonin Surge Charities is a 501(c)(3) public benefit non-profit organization (tax ID#68-0411254).

Mutualinvestment You invested everything in building your practice and reputation.

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Call NORCAL Mutual today at 800.652.1051. Or, visit www.norcalmutual.com.

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