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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2012


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Daniel McCrimons, M.D. Hill Physicians provider since 1993. Uses Hill inSite, Hill EHR, RelayHealth and Ascender for eligibility, eClaims processing, electronic health records, practice management, secure online communications, ePrescribing and eReferrals.

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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

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PRESIDENT’S MESSAGE Implementing Best Practices in Health Care

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How to Dispose of Your Medicine Cabinet Contents

David Herbert, MD

Ann Gerhardt, MD

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EDITOR’S MESSAGE Celebrating Human Achievement

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Still Seeing Stars?

Kelly Albin, MD

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Were the Prince of Denmark the Medicare Administrator

Gerald Rogan, MD

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Of Bottles and Bitters

Jack Ostrich, MD

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New Name, Same Ailment

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Walk with a Doc

Nathan Hitzeman, MD

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e.Letter to SSV Medicine

5 “Fear”

John Loofbourow, MD

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Health Reform in 2012 – Crunch Time, Part Two

Adam Dougherty, MPH, MS III

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What’s New in Stem Cell Research?

Francisco Prieto, MD

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A Posit on Destroying Outdated Drugs

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Local Student Thinks Big

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From the CMA

IN MEMORIAM Michael H. Robbins, MD

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Meet the Applicants

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Board Briefs

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Classified ads

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Meet Jeanne Conry, MD

Albert J. Kahane, MD, FACOG, FACS

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Medi-Cal Managed Care

Assemblymember Richard Pan, MD, MPH

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 website. Contact the medical society for permission to reprint.

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our cover photo shows a copy of the lost bronze original by sculptor Myron (470-440 BC). Its ongoing popularity is attributed to the representation of the athletic ideal. Discus-throwing was part of the ancient pentathlon, dating back to 708 BC. It has been part of the Summer Olympic Games since the first modern games in 1896. Technique is just as important as strength in discus throwing, and it takes years to perfect. Champion throwers tend to be older than those in other sports. The men’s world record for the 2 kg discus throw is held by Jurgen Schult of Germany with a throw of 74.08 meters (242 ft) in 1986. The women’s world record for the 1 kg discus throw is held by Gabriele Reinsch of Germany with a throw of 76.80 (252 ft) meters in 1988. Editor Nathan Hitzeman, MD, reflects on the Olympics in his column, page 4.

September/October 2012

Volume 63/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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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.

Position Available:

2012 Officers & Board of Directors David Herbert, MD President Demetrios Simopoulos, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD, Secretary District 2 Jose Arevalo, MD Ann Gerhardt, MD Lorenzo Rossaro, MD District 3 Bhaskara Reddy, MD, Treasurer District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristen Robinson, MD District 6 J. Dale Smith, MD

mmended By re Doctors.

2012 CMA Delegation Delegates Alternate-Delegates District 1 District 1 Robert Kahle, MD Reinhart Hilzinger, MD District 2 District 2 Lydia Wytrzes, MD Margaret Parsons, MD District 3 District 3 Katherine Gillogley, MD Ruenell Adams, MD District 4 District 4 Earl Washburn, MD Russell Jacoby, MD District 5 District 5 Elisabeth Mathew, MD Anthony Russell, MD District 6 District 6 Marcia Gollober, MD Karen Hopp, MD At-Large At-Large Alicia Abels, MD Jason Bynum, MD Richard Gray, MD Robert Forster, MD David Herbert, MD Maynard Johnston, MD Richard Jones, MD Alexis Lieser, MD Norman Label, MD Robert Madrigal, MD Charles McDonnell, MD Rajan Merchant, MD Janet O’Brien, MD Richard Pan, MD, Kuldip Sandhu, MD Assemblyman Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD Vacant CMA Trustees 11th District Richard Thorp, MD Barbara Arnold, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

Urgent care, full-time, partnership We are seeking a board certified FP, IM, or EM trained physician who is interested in long-term stability and partnership. The Doctors Center is an urgent care office in Fair Oaks with extended hours. We are a singlelocation practice and have a close relationship with physicians in our community. We see a wide variety of interesting patients and procedures typical for urgent care. We are almost fully electronic in our charting and billing, and all records are complete by the time the patient leaves our office (no after-hours charting).

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CMA President-Elect Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair George Meyer, MD Sandra Hand, MD John Ostrich, MD Albert Kahane, MD Robert LaPerriere, MD Gerald Rogan, MD John Loofbourow, MD Gilbert Wright, MD Adam Dougherty, MS III John McCarthy, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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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. ©2012 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

Implementing Best Practices in Health Care By David Herbert, MD HOW WE LOOK AT THE QUALITY of health care has fundamentally changed over the past 50 years, as evidence-based guidelines for the management of many common problems have replaced individual physicians just doing their best. American researchers have done most of the research that has identified these best practices, yet we have struggled to implement them consistently. Our failure to consistently follow these evidence-based best practices is usually not due to lack of knowledge, or even lack of intent. In my own field of critical care, it is widely accepted that low tidal volume ventilation improves outcomes in ARDS, and a recent study confirmed that most intensivists not only agree, but indicate that this is how they practice. Yet when the tidal volumes in their patients were measured, only a minority were receiving this strategy. Similarly, the benefits of treating patients with myocardial infarctions with aspirin, statins, and beta blockers have been well known for years. But multiple studies showed that as recently as a few years ago, only about two thirds of appropriate patients typically received this bundle of interventions. For hypertension, the CDC has found that only 44 percent of known hypertensive patients have their blood pressure adequately controlled. And the list goes on with disappointing results in diabetes control, cancer screening, vaccinations, hospital-acquired infections, patient safety measures, and more. The consequences of inconsistent adoption of medical best practices are significant, both for our patients’ health and our own practices. Our

performance is becoming more public courtesy of regulatory agencies and quality groups like HEDIS and Leapfrog, and reimbursement is increasingly tied to outcomes, with even more of this to come as a part of health care reform. While we may not agree that this is the ideal way to improve health care, it is the wave of the future. Fortunately, our inability to consistently adopt these best practices is not uniform. All of these areas have some bright spots of successful implementation. But why have some physicians succeeded more than others? It is not that physicians who have achieved more success are smarter than the rest of us, nor have they succeeded by simply trying harder. Instead, the data indicate that success requires the adoption of systems that remind and guide physicians (and patients!) to do the right thing. And systems need to be more than providing education and hoping that practice change will follow. Hope is not a plan! The basics of successful systems seem simple enough: measure and track a best practice and make following the guidelines as easy as possible. Of course, the devil is in the details, and the challenges of the details have too often kept us from setting up such processes in our practices. Now is the time for us to help our patients and ourselves by recognizing that our good intentions need to be coupled with effective systems if we are to consistently deliver the quality of care that our patients have a right to expect, and working to design the systems in our own practices that will accomplish this. davidherbert166@gmail.com

September/October 2012

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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Editor’s Message

Celebrating Human Achievement By Nathan Hitzeman, 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.

COMING HOME FROM A DAY at the office or hospital and watching the Olympics is almost surreal. Instead of elderly ladies with heart failure, demented men with urinary retention, and noncompliant diabetics with kidney failure – here are perfectly-conditioned athletes at their peak performance doing the unimaginable. Michael Phelps suspended over water as master of the butterfly stroke. Gabby Douglas arched in midair above the balance beam. McKayla Maroney with a flawless vault that mesmerizes you time and time again in slow-motion replays. Chinese divers disturbing only a few molecules of water. Instead of filling out disability forms for my questionably-disabled back pain patient, here is Oscar Pistorius (the “Blade Runner”), a bilateral amputee with prostheses, running the 400 meter. Also, for the first time ever, every country represented had a female athlete participant. Even fully-clothed Muslim women were sprinting. Health, beauty, and competitive passion stir our souls to wonder what else we are capable of. As physicians, we witness the human spirit help people transcend horrific injuries or illnesses. We also see bodies that have withstood a marathon of abuse that would seem impossible. Think about your cirrhotic alcoholic patient who refuses to die. Becoming a physician is a feat of training in and of itself. Months of practice-test MCATs. Four years of trying to absorb thousands

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of medicines, procedures, and differential diagnoses. Physicians, like athletes, come in all flavors. Some are naturals. Some have to work hard to keep up with the pace. Some are gracious winners and losers, some aren’t. Some are afraid to show their weaknesses; others are not. Drug reps court us just like McDonald’s and Coca-Cola do the Olympics. We often anguish days or months over an event that went horribly wrong – trying to trace our missteps. And yet we get up each morning again and run the track of medicine, eager to see what the human body can achieve, still marveling that we are a sum greater than our parts, always defying reductionist understanding, despite our best attempts. We are lucky in that we can win medals every day with our patients. That should be enough. That should be our goal. hitzemn@sutterhealth.org

1-800-901-5830 • • • • • •

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


e.Letter to SSV Medicine Universal Health Care: Why can’t we all ride at the front of the bus?

Dear Dr. Hitzeman, Thank you for your article on Universal Health Care. I wonder if “Health Care for Humanity” based on “Habitat for Humanity” might be a better option. A healthy society needs the help of every person – and free health care would not encourage some to help others as much as “Health Care for Humanity.” If you search YouTube.com for  “Time Banking on Good Morning America,” you will find a nice introduction to Time Banking www.youtube.com/ watch?v=uR8ArHGgA7A. Wouldn’t it be nice if there were a “Health Care for Humanity Time Bank”?  The uninsured

would donate an appropriate amount of time in community service (doing things like mentoring kids at risk for joining gangs, or helping stressed teachers in difficult schools), and then they would get the health care they need just like the fully insured. The uninsured receiving health care would be expected to “pay” for health care received with hours of community service. I hope everyone gets the health care they need – but I also hope they help others as much as they are being helped. Bruce Burdick, MD bburdick@surewest.net

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.

Fear By John Loofbourrow, MD No one else was around When our eyes first met. The wind had shut down The parking lot was wet.

He ran up to ask To use my cell phone; But I drove away fast And left him alone.

But he wasn’t there That other man’s son. So to prove that I care I undid the undone.

He was young, and tall Disheveled and gaunt, As he lounged at the wall Of the darkened restaurant.

The cold wind cursed me And called up more rain. His frantic eyes shamed me, And I turned back again.

While the waning night Called up the dawn, I recalled the sight Of the man who was gone.

I quick-locked the door Started the car, And groped the floor For an iron tire bar.

What else could I do To undo a bad deed Done to someone who Was in some sort of need.

And sat there alone, With that coward who’d run; We pulled out our phone And called 911. john@loofbourow.com

September/October 2012

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Health Reform in 2012 – Crunch Time, Part Two By Adam Dougherty, MPH, MS III This is the second piece in a two-part series on a decisive year in health care policy. IN THE WAKE OF THE RECENT Supreme Court ruling of the Affordable Care Act (ACA), and in anticipation of the November elections, the drama of 2012 has only just begun. The future of our new American health care system remains an uncertain one, but the potential paths forward have indeed grown clearer.

Supreme Court Debrief

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.

As the dust begins to settle after the Supreme Court’s ruling, it is worth recapping what actually happened and what it means. Starting in 2014, every qualifying American citizen will be obligated to have health insurance coverage. While my correct prediction wasn’t entirely accurate as far as Justice vote breakdown,1 I’ll point out that I was in the extreme minority among peers and colleagues in even coming close! That being said, I will admit I did not sleep much the night before the ruling, and I may have PTSD from the moment of sheer terror when CNN initially botched the call. In the ruling’s supporting opinion, Chief Justice John Roberts explains that the mandate does not fall under the jurisdiction of the Commerce Clause. Rather, he interprets it as legal through the taxation authority granted to Congress. In its simplest interpretation, yes, the mandate is a tax. More accurately, though, it is a monetary penalty on those individuals who choose not to purchase health insurance. Contrary to some doomsday shock jocks, this is not “the biggest tax increase on the middle-class in our history,” as the vast majority

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of rational Americans would opt for some form of health insurance anyway. More so, there will be exemptions from the mandate for individuals with religious objections, for those who can’t afford insurance even with the exchange subsidies, and for those between jobs. For the handful of individuals who take freedom to the extreme by voluntarily foregoing health coverage, they will see an annual penalty on their tax returns that will theoretically subsidize the health care that they eventually might need. It is also worth noting that no one will go to jail for not having health insurance, as the law explicitly prohibits the IRS from “aggressive efforts to collect the penalty.” Instead, penalty collection will most likely occur through withholding of tax returns. The Medicaid aspect of the Supreme Court ruling was also significant, as the court felt that obligatory expansion of eligibility to 133 percent of the federal poverty level ($15,000 for an individual, $30,000 for a family of four in 2012) was beyond Congress’ authority. This provision has huge financial implications for states, counties, businesses, health providers, and patients as it is almost wholly federally funded. Despite the Feds picking up the bill, several conservative governors have jumped on the opportunity to refuse this piece of Obamacare. Unfortunately, these are the states which have some of the highest uninsured rates and would precisely be the ones to benefit most once enacted in 2014. While many of the quick responses from the likes of Rick Perry and Bobby Jindal might merely be political pandering, the chorus of local opposition will undoubtedly


rise from county hospitals, health insurers, state medical societies, and patient advocacy groups. Similar knee-jerk reactions took place in the 1960s with the original creation of the Medicaid program, which all states eventually ended up implementing despite it being completely voluntary. I predict that most states will fall into line to tap into the 2014 revenue stream. To those who worry that this “investment” in Medicaid expansion will bury us in debt, the nonpartisan Congressional Budget Office (CBO) says otherwise. With the ruling, they now estimate that the ACA will cost $84 billion less over 11 years than what was originally forecasted. By expanding the pool of insured persons and reducing expensive rescue care, they estimate an overall reduction in the national deficit by $109 billion over this time frame.2 Of note, California is expected to fully implement the expansion, bringing coverage to over three million previously uninsured Californians. The ACA has now survived all three branches of government, and the Supreme Court seal of approval will allow the state-based health insurance exchanges to move full speed ahead. Many state legislatures will still opt out of creating their own exchanges, but the law allows for a national exchange to fill these gaps. In the meantime, the law continues to quietly roll out new consumer benefits, with the most recent being the Medical Loss Ratio standard for health insurers. Under this standard, health plans are required to spend at least 80 cents of every dollar on actual health care services instead of on marketing, profits, and overhead. And if they don’t? Then their customers get a rebate check for the amount they underspend on actual care – which was the case this year for 12.8 million Americans to the tune of $1.1 billion, averaging $151 dollars for each family.3 Skimming off fewer health care dollars for profit or executive compensation probably appeals to most health care consumers. Of note, Medicare, despite all its critics, has significantly lower overhead costs than private insurances spending 97 cents of every dollar on actual care.4

November and Beyond Looking to the November elections, it is not unrealistic to call 2012 a referendum on health reform. Public opinion of the law is still largely divided, half in favor and half opposed.5 In a one-term presidency scenario (and an accompanying Republican sweep of the House and Senate), we would see extensive reversals of the last two years. While the “Repeal on Day One” slogan is effective at the podium, laws cannot be overturned in one swift executive order. Given the near impossibility of obtaining 60 seats in the Senate (the filibuster-proof level needed to pass anything anymore), Republicans would use the Reconciliation Process to overturn/augment many budget-related items, including the mandate penalties, Medicaid expansion funds, and terminating the insurance exchange subsidies and the Public Health and Prevention Fund. If the President prevails (in either a split legislature or Republican legislature), the vast majority of ACA provisions would remain, no matter how many Presidential vetoes are exercised. Hence, 30 million individuals would still gain insurance coverage, and the Medicaid program would be fundamentally preserved. In either scenario, a continued focus on the deficit will remain, as the post-election lame duck session requires dealing with the failed Super Committee and its looming $1.2 trillion in “sequestration” cuts, which would spell substantial reductions to Medicare, Medicaid, and other health programs. Regardless of the election outcome, harder questions remain with the biggest drivers of the long-term deficit including the projected spending in Medicare and the flawed SGR formula. Medicare eligibility age extension, assetbased cost sharing, expanded value-based purchasing, and the Independent Payment Advisory Board (IPAB) are a few of the more controversial but necessary strategies being considered. Bold steps may be taken in the ensuing 113th and 114th Congresses to address long-term health spending as the nation recovers from the Great Recession, and the medical

If the President prevails (in either a split legislature or Republican legislature), the vast majority of ACA provisions would remain, no matter how many Presidential vetoes are exercised.

continued on page 9 September/October 2012

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What’s New in Stem Cell Research? By Francisco Prieto, 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.

IN 1998, DR. JAMIE THOMSON of the University of Wisconsin and his group announced a breakthrough in modern biology when they developed a technique to isolate and grow human embryonic stem cells (hESC) in cell culture. The implications became apparent almost immediately: to take such cells and grow replacements for defective body parts. They imagined new beta cells for diabetes, dopaminergic neurons for Parkinsons, regenerated nerve cells for spinal cord injury, and much more. Because these cells came from human embryos, however, this research also generated immediate controversy. This was in spite of the fact that many would be derived from embryos discarded by the thousands since the advent of in vitro fertilization over 30 years ago. In 2001, former President George W. Bush announced that the National Institutes of Health (NIH) – the 800-pound gorilla of biomedical research – would allow research to proceed on cell lines that had already been created (many of them since found unusable for various technical reasons), but would not fund any work on new cell lines. Many in the biomedical community feared that this would be a huge setback for the field. Promising science students interested in stem cell research might find themselves severely limited, and would have to look outside the U.S. for research opportunities. In California, former state Senator Deborah Ortiz proposed a state research program of up to $1 billion, but her proposal made little headway. Then, Robert Klein, a California real estate developer and attorney whose son has type 1

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diabetes, saw the potential to build a coalition of disease advocacy groups and to launch a much more ambitious initiative campaign around this issue. Spokesmen included actors Michael J. Fox and the late Christopher Reeve. In November of 2004, voters passed the initiative by a margin of almost 60 to 40 percent.

Disease Advocates A unique feature of Proposition 71 was the creation of a board to oversee the distribution of research grants. Ten positions on the board, or one third of its constituency, would consist of “disease advocates.” This is where I, a humble family doctor with a history of volunteer work for the American Diabetes Association, entered the picture. Out of the blue, I received a call from the treasurer’s office one day to ask if I would consider serving on the new Independent Citizens Oversight Committee that would help to build what would become the California Institute for Regenerative Medicine (CIRM). Stepping into this role was a bit like being a reverse version of Mark Twain’s Connecticut Yankee. In my case, the magicians with the almost impossibly-advanced technology were the scientists pushing the boundaries of this new field, while the treatments I used every day in 21st century medicine began to look a bit like the poultices and bloodletting of medieval healers. Even with my medical training, the scientific material I had to learn about was a bit daunting. I had no idea when I joined the board that Sonic Hedgehog is a mammaliansignaling pathway and not just a video game. Furthermore, articles about long non-coding


RNAs and Notch signaling rarely made it onto my reading list. A number of critics have questioned the presence of disease advocates on the board. Some suspected that we could never understand either the financial or the scientific issues, and that advocates would have a narrow and exclusive focus on the disease they suffered from or represented. Almost the opposite has occurred: all of the advocates on the board have gained a working knowledge of the science and all have stayed open-minded to the breadth of its application. As my fellow advocate, Jeff Sheehy, wrote in Nature Medicine in 2010, “The presence of vocal, engaged patient advocates has added an indispensable dimension to the proceedings in measuring research quality. Advocates tend to focus on a project’s ability to benefit people – not just drive scientific curiosity – which keeps even basic biomedical research grounded in its ability to produce concrete health benefits.” One of the hopes for this initiative was that it would stimulate interest in the field and attract the best researchers in the country and the world to California. That has largely come true. As an example, Dr. Jamie Thomson and many others have brought their labs and talents to California, while virtually every California medical school and biomedical research lab (e.g. the Salk Institute) has created a stem

cell research facility. UC Davis has gone from zero stem cell research to becoming a multimillion-dollar facility doing some of the most outstanding work in the field.

One of the

Creating Stem Cells

this initia-

There have been surprises thus far. With further understanding of the development of stem cells, researchers learned how to “create” stem cells from skin fibroblasts – essentially dialing them back to a stem-like state. The CIRM has begun to push aggressively to move this research towards the clinic. We recently approved our second round of “disease team” grants. The goal is to bring together basic researchers with promising ideas and important leaders with industry experience, and to develop these ideas into potential treatments that will be ready for an Investigational New Drug (IND) application to the FDA within four years. We don’t know how many of these projects will bear fruit within this time span, or how many more years it will be before a stem cell cure for a major disease might be announced, but my father, also a physician, taught me that one of the most important things I could give a patient was hope. I think the CIRM and California’s willingness to invest in something that has never been done before gives us all reason to hope.

tive was

hopes for

that it would stimulate interest in the field and attract the best researchers in the country and the world to California. That has largely come true.

prietof@sutterhealth.org

Health Reform in 2012 continued from page 7 profession will continue to have a central role to play in shaping these decisions. How health reform translates from words on paper to what happens in our exam rooms is a process still unfolding. Now more than ever, it is essential for current and future physicians to be engaged in the conversations and deliberations that will shape our evolving American health care system.

1 Dougherty, A., “Health Reform in 2012 – Crunch Time, Pt. 1”, SSV Medicine, May/June 2012. 2 Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision, Congressional Budget Office, July 24, 2012. 3 Health Care Law saves consumers over $1 billion, US Department of Health and Human Services, June 21, 2012. 4 Steffie Woolhandler, Terry Campbell, and David U. Himmelstein, “Costs of Health Care Administration in the United States and Canada,” The New England Journal of Medicine, August 21, 2003, 768–75. 5 Kaiser Health Tracking Poll: Early Reaction to Supreme Court Decision on the ACA, Kaiser Family Foundation, June 2012.

apdougherty@gmail.com

September/October 2012

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Local Student Thinks Big UC DAVIS MEDICAL STUDENT Keisuke Nakagawa is passionate about improving the health care system. When the California native decided to go back to school to study medicine, this was foremost in his mind – that and his father’s experience without health insurance. ”My father was uninsured for 10 years,” says Nakagawa, a second-year medical student at the UC Davis School of Medicine. His father suffered from atrial fibrillation, something he did not tell his family. A month after he finally qualified for health insurance through Medicare, he suffered a heart attack. Because of his father’s illness, Nakagawa is specializing in cardiovascular surgery, but the treatment of disease isn’t the only thing on this medical student’s mind. “I want to connect the puzzle pieces of practicing medicine and (setting) policy,” he says. After getting an undergraduate degree in biology from Cornell University in Ithaca, NY, Nakagawa received a Fulbright Scholarship to go to Bangladesh for a year to work on a micro health insurance project for rural villages. Under the auspices of the Bangladesh Rural Advancement Committee, a nongovernmental organization, he set up an inexpensive form of health insurance there for the tiny country’s rural poor. But this was a lot easier said than done. The first roadblock he ran into was the lack of familiarity with American-style health insurance. “The (Bangladeshi) people did not understand the concept of premiums, copays and cost sharing,” he says. It was much easier for them to understand something they already had. “Everyone had a cell phone, so they all understood a pre-paid phone plan.” So Nakagawa reshaped his idea into one that was

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easier for people to adopt and understand. “We put together a pre-paid pregnancy program.” Taking this concept a bit further, he started a nonprofit organization called Global Health Bridge, and created an interactive cell phone health program that would help pregnant women in rural India. The interactive voiceresponse system Nakagawa created automatically reminds women of their pregnancy checkups, gives them information about where they are in their pregnancy and allows them to report problems. “Rather than using text, we use a voice response system because most villagers are illiterate.” After his forays into the third-world, he moved to Washington, DC, and was offered a job at the Congressional Budget Office where he worked on the analysis of the Patient Protection and Affordable Care Act. It was this final experience that inspired him to go to medical school. He applied to UC Davis because of its commitment to serving the underserved and its leadership in telemedicine. To gain experience in organized medicine, he joined the American Medical Student Association (AMSA), and in 2011, he served as co-president of the organization. Under Nakagawa’s leadership, AMSA received a Medical Student Community Leadership Grant from the CMA Foundation. The money is used to fund two projects that Nakagawa is active in, UC Davis “Mentorship Nights” and “Be a Medical Student for a Day.” He says he enjoys these projects because it allows him to connect the dots of his experience in health care for pre-med students. From the examining table to public policy, there is a place for physicians to affect the outcome of health reform, Nakagawa says. “We don’t really teach enough of the big things in health care.” Reprinted from the CMA. Photo by David Flatter.


Meet Jeanne Conry, MD Local President-Elect of ACOG will oversee a large national OB/GYN society

By Albert J. Kahane, MD, FACOG, FACS

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 FIRST HAD THE PLEASURE of meeting Dr. Jeanne Conry in the early 1990s when we both served on the Legislative Committee of District 9 (California/Hawaii) of ACOG, The American College of Obstetricians and Gynecologists. It was obvious to me, even then, that this young, dedicated and articulate physician was a positive force for medicine, and especially for women’s health. It was not long after that she became District Chair, soon moving on to the national office of the college, by which time this writer had retired. Jeanne was the second of five children born to a mother who was an RN, and a father who was an FBI agent. They both encouraged her to pursue an education as far as it would take her. The result was an undergraduate degree from CSU Chico, and a PhD in biology from the University of Colorado. She then did environmental consulting. After moving to California, she attended UC Davis, receiving her MD in 1982, and she remained there for her residency in OBGYN. It is of note that all of this was accomplished while raising two children. She subsequently joined the staff of Kaiser Permanente, where her enthusiasm for a fully integrated pre-conception health program was her goal. This resulted in improved access to care and to reproductive choice. At KP now, the majority of prenatal patients are seen for their first visit at six to eight weeks gestation! In addition to her regular staff duties, she also serves on wellness projects in the community. Here she tries to improve health as measured by

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decreasing the variability of results. In California, maternal mortality has tripled in the past decade! Her attempts to improve this include management of chronic medical conditions of women’s health, both in pre-conceptional and inter-conceptional care. Her professional interest also includes menopausal health and teaching. (She is an Associate Clinical Professor of OBGYN at UC Davis.) In addition to her clinical interests and activities, she has managed to integrate them into her administrative role at KP Roseville where she is Assistant Physician-in-Chief. It was her vision, ambition, and leadership during her 20-plus years which resulted in the construction of a three-story, state-of-the-art Women and Children’s Center as an attached addition to the existing hospital. The center opened in 2008, and has been enthusiastically received by both patients and staff. As an advocate of healthy living by diet, exercise and preventive care, she leads wellness activities in the northern Sacramento Valley for members and employees, as well as employer groups, to improve worksite health conditions. Dr. Conry believes that much remains to be done in the legislative arena regarding medical liability, quality and delivery systems. It is her opinion that the Affordable Care Act still falls short in terms of medical liability reform. Other issues that she believes require attention are the shortage of physicians, and the status of nurse practitioners, nurse midwives and physician continued on page 14


Medi-Cal Managed Care Where does the buck stop?

By Assemblymember Richard Pan, MD, MPH, Chair of the Assembly Committee on Health IN THE EARLY 1990S, Medi-Cal faced rising costs and poor access to health care providers, problems that continue to plague the program. The state Department of Health Care Services (DHCS) began experimenting with Medi-Cal and Denti-Cal managed care and implemented Geographic Managed Care (GMC) in Sacramento County as a pilot program in 1994. As the state made the transition, there were only vague references toward evaluation criteria and methodology and authority for local decision-making. Sacramento County established a commission to oversee the GMC program, which was chaired by past-SSVMS Executive Director Bill Sandberg, but the commission was disbanded a few years later in frustration since the state allowed it little authority and did not share timely, accurate data with the commission on the GMC plans. In 2010, the Sacramento First 5 Commission published a report on Sacramento’s GMC DentiCal program, which showed shocking neglect by DHCS of the program and, more importantly, of the children. Utilization of dental services was as low as 5.5 percent of beneficiaries in one GMC plan compared to a statewide utilization of 41.3 percent, and overall utilization of children 0-3 years was 6.7 percent compared to 15.9 percent statewide. Calls to selected dental offices accepting Denti-Cal GMC plans revealed that not all staff knew or complied with GMC policy and professional recommendations that children should be seen by “the first birthday or the first tooth.” A substantial proportion of Sacramento GMC children did not receive a preventive service, although the plans received per-member, per-month payments for all

children. In addition, Sacramento GMC DentiCal costs were comparable to an equivalent fee-for-service system. Many problems were also found with DHCS oversight of GMC Denti-Cal. Monitoring of plans was reactive, not proactive, and data from internal monitoring reports may have been untimely, inaccurate or incomplete. The First 5 report noted that the department was not aware that an entire GMC plan’s data was missing from a report until it was pointed out by the Commission’s consultant. It also appeared that the Medi-Cal Dental Services Division did not have the capacity in the number or type of staff positions to fulfill oversight responsibilities for the Sacramento GMC Denti-Cal. These problems were no secret to dentists and physicians on the front lines, like myself, providing care to children on Medi-Cal who seemed unable to obtain care for their oral health problems. When these problems were brought to light by the Commission and subsequently given public attention in a Sacramento Bee article published in February 2012, public officials including Senator Darrell Steinberg and County Supervisor Phil Serna took action. I brought together patients, plans and providers at a hearing on the history of the GMC Denti-Cal program, and partnered with Senator Steinberg to pass legislation to increase state oversight and local engagement over the Sacramento GMC Denti-Cal program. The story of the 18-year “pilot” is not over, but it holds important lessons for Medi-Cal managed care, especially given the proposed movement of large numbers of Medi-Cal beneficiaries into managed care including the aged, blind and disabled transition, the

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Transitioning MediCal into managed care, however, does not absolve the state and DHCS of the responsibility for the care of MediCal beneficiaries and appropriate oversight of plans.

dual eligible (Medi-Cal and Medicare) pilot, expansion of managed care in the remaining fee-for-service counties, the elimination of Healthy Families, and expansion of Medi-Cal into the adult population as a result of the Affordable Care Act. As a physician who cares for many patients on Medi-Cal, I am acutely aware of the numerous problems with the Medi-Cal program including inadequate payment and high administrative burden on both practices and beneficiaries. Managed care expansion has been touted as a means to improve provider access through plan networks and to improve quality through better care coordination. In addition, managed care is expected to reduce costs with over $600 million in state savings expected from the dual eligible pilot. Transitioning Medi-Cal into managed care, however, does not absolve the state and DHCS of the responsibility for the care of MediCal beneficiaries and appropriate oversight of plans. Many of the patients being transitioned, the aged, blind and disabled and the dual eligible, are among the most vulnerable and have existing networks of care involving primary care and specialty physicians, other health care professionals, and community supports. Disruption of these networks may have serious, even fatal, consequences for the health and well-being of these patients. It is insufficient for DHCS to respond only to complaints. Waiting for an outside entity to identify departmental neglect, as happened with Sacramento GMC Denti-Cal,

is unacceptable. DHCS must take proactive action to monitor the impact of managed care on Medi-Cal beneficiaries through direct contact with beneficiaries and their providers and establishing and implementing evaluation criteria and methodologies prior to implementing managed care transitions. DHCS should partner with patient, physician and other provider groups in developing appropriate evaluations, and DHCS needs sufficient staff capacity to conduct the oversight needed to protect patients. In addition, DHCS should have substantive stakeholder involvement in Medi-Cal. Like Medicaid programs in some other states, Medi-Cal should have a payment advisory commission composed of physicians and other stakeholders that has direct access to Medi-Cal data and analysts and can provide the legislature and administration with recommendations to improve quality and access in the Medi-Cal program. Sacramento County’s 18-year experience with GMC Denti-Cal demonstrated that the buck has to stop with the state for Medi-Cal managed care. The state cannot pass responsibility for insufficient or inappropriate care of Medi-Cal beneficiaries onto the plans. DHCS has to exercise oversight and evaluation of Medi-Cal managed care and that can only occur with the active involvement of stakeholders who are given the authority and means to hold the state and DHCS accountable. We should expect nothing less. richard.pan@asm.ca.gov

Meet Jeanne Conry continued from page 12 assistants. With help from the members of the college, she plans to devote much of her energies as ACOG President to these issues. Historical perspective: In writing this brief biography, I could not help but reflect upon the fact that in 1965, the year that I joined KP, there were only two female OBGYN specialists in all of Sacramento County and its environs. They were Dr. 14

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Eleanor Rodgerson, and Dr. Shirley Gunn, both now deceased. How our community has changed − for the better! This is true for medicine in general, not only OBGYN, wherein 50 percent of the residents in training are women. ajmdkx955@gmail.com


How to Dispose of Your Medicine Cabinet Contents By Ann Gerhardt, MD THE ALAMEDA COUNTY BOARD of Supervisors recently approved an ordinance requiring pharmaceutical companies to establish programs to dispose of expired and unused drugs. Predictably, pharmaceutical industry representatives object to the requirement. They cite the lack of evidence that drug take-back programs have delivered any benefit to the environment or to humans. They are correct – there is a lack of evidence that take-back programs work, but not because studies have been negative: There just aren’t good studies yet, because they are very difficult studies to do. In spite of the companies’ disingenuous criticism, the pharmaceutical industry is voluntarily paying for a similar program in San Francisco to test its effectiveness. Alameda County’s is the latest effort to help people dispose of expired or unused medications. Unfortunately, proper disposal methods are not common knowledge and some people just don’t care. As my Aunt Gussie used to say, if she didn’t use something in the first 100 years, she might need it in the next 100. However, the Environmental Protection Administration (EPA), Drug Enforcement Administration (DEA), and Food and Drug Administration (FDA) don’t have that philosophy. And at least some people care about discarding ineffective, expired medications and minimizing the chance that toddlers and pets might suffer from toxic, inadvertent ingestion. People have wondered about proper pharmaceutical disposal for a long time. The FDA tried to help with its 2010 guidelines. They first recommend delivering unused or expired medications to a medicine take-back program

for disposal. See a list of locations at the end of this article. Private waste management companies typically deal only with bodily waste and syringe and lancet disposal. California law does not lump pharmaceuticals into banned hazardous household waste, but most of the official waste disposal centers accept them. Some pharmacies do take back medications, so give yours a call. Take-back collection facilities incinerate the drugs, which certainly keeps them out of the environment. Some criticize the environmental effect of the fire and of cars driving to and from the facility. We can’t have it all.

Take-Back Day September 29 The DEA has scheduled a fourth National Prescription Drug Take-Back Day on Saturday, September 29, 2012 from 10AM to 2PM. The last national take-back day was hugely successful, with citizens delivering 552,161 pounds of unwanted or expired medications to 5,659 take-back sites on April 28th of this year. Takeback sites in all 50 states and U.S. territories participate. The DEA’s collection site locator database will be available in late August, or you could call 800-882-9539. The take-back option sometimes doesn’t work for controlled substances like narcotics, however, since the DEA strictly regulates those. Federal law does not permit take-back programs to accept controlled substances unless they get specific permission from the Drug Enforcement Administration to do so, and they arrange for full-time law enforcement officers to receive the controlled substances directly from the member of the public who seeks to dispose of them.

September/October 2012

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Dead people are a real problem. One scientist estimates that 17.9 million kilograms of their unused medications are flushed into the sewage system annually.

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If no take-back center is available, the FDA suggests mixing medicines with an unpalatable substance, such as kitty litter or used coffee grounds, placing the mixture in a sealed plastic container or bag and throwing the container in the household trash. Since plastic never degrades, so long as the container isn’t popped open when the trash is compacted, the contents don’t spill out and mix with the environment. Controlled substances pose a conundrum, since the DEA worries more about diversion to people who might abuse them than it does contamination of ground-water and a population-wide high. It is illegal, according to the Controlled Substances Act of 1970 (CSA), for a person with a valid prescription to give unused narcotic medication to another person or entity, without first obtaining permission to do so from the local DEA Special Agent in Charge. To do so, you can file DEA Form 41 online or by mail, in triplicate. So the FDA suggests that drugs that can kill with a single dose (like narcotics) should be flushed down the toilet if there is no take-back program available and you don’t feel like donating to your neighbor via DEA Form 41. The list of should-flush medications includes those containing fentanyl, morphine, methylphenidate, meperidine, diazepam, hydromorphone, methadone, tapentadol, oxymorphone, oxycodone and sodium oxybate. Why the list includes diazepam and not other benzodiazepines or sedatives is unclear, if not illogical. Dead people are a real problem. One scientist estimates that 17.9 million kilograms of their unused medications are flushed into the sewage system annually. The coroner’s office is supposed to receive medications from the homes of dead people to help determine cause of death. Believe it or not, the coroner’s office flushes 92 percent of those medications. Less than one percent are incinerated and seven percent go into the decedent’s household trash. Nursing homes have to deal with unused medications which they legally don’t own. Hazardous pharmaceuticals deserve special mention. The Resource Conservation and

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Recovery Act (RCRA), which amended the Solid Waste Disposal Act, defines a hazardous waste as one with the potential to cause or significantly contribute to mortality or serious illness and that poses a substantial threat to human health or the environment when improperly treated, stored, transported, disposed of, or otherwise managed. The Act specifies dangerous medications in its P and U lists. The P list includes warfarin (Coumadin), arsenic trioxide, epinephrine, phentermine, nicotine, physostigmine. The U list includes various chemotherapeutic drugs, chloral hydrate, chloroform, diethylstelbesterol, lindane, Phisohex, mercury, paraldehyde, phenacetin, phenol, reserpine, resorcinol, selenium sulfide (in shampoos), streptozotocin and warfarin. A separate “Toxicity” list includes drugs containing arsenic, barium, chromium, mercury, selenium, silver, lindane and M-cresol (in some insulins). Ignitable drugs deserve special caution. Believe it or not, some common drug formulations meet the definitions of ignitability. Erythromycin gel, Texacort solution and Taxol all contain more than 24 percent alcohol by volume and these, as well as amyl nitrite inhalers, silver nitrate applicators and Primatene aerosol may be flammable. Dilution (down the toilet) would dissipate ignitability. Or take them to a take-back program and let them worry about blowing up. The RCRA does not specifically say how we should dispose of P-list, U-list and ignitable drugs. It merely requires that we and the manufacturers dispose of them in a way that won’t endanger health. Is it oxymoronic to say that making sure we use the entire container of toxic drugs as directed, so that there is none to discard, is the least toxic disposal method? A take-back program is probably the best option. How bad are drugs in the environment? While scientists have found trace amounts of these medications in the water supply, the FDA states that “the majority of medicines found in the water system are a result of the body’s natural routes of drug elimination (in urine or feces). Luckily, the body has metabolized most of the dangerous medications to less- or inactive substances prior to excretion. Even opiates


eventually oxidize to inactive substances. It’s not so simple though. The human body alters many drugs to inactive forms prior to excretion in urine and stool. Others, excreted by humans in an unaltered form, are degraded by sewage treatment or exposure to water, bacteria and air. A few, like the anti-seizure drug carbamazepine, which the body modifies before excretion in urine, are turned back into the active form upon contact with water. Others, which the body inactivates by attaching them to chemical blockers (like a glucuronide), become re-activated when the blocker is cleaved off in sewage treatment. Medications and their by-products that have a charged surface don’t significantly attach to the subsoil, and leach readily into groundwater aquifers. Non-charged drugs, like steroids, attach well to soil and are found in very low levels in ground or drinking water. That doesn’t necessarily predict safety: Estrogen metabolites bind to the subsoil and disperse into water in very small quantities, but enough to feminize some fishes and frogs and change the ecosystem. Thus, to predict levels of active pharmaceuticals and by-products in the environment, and specifically drinking water, one must know their biodegradability, metabolic pathways including attachment to other substances, and adsorption characteristics. A Berlin water study found disappearance of 99.9 percent of caffeine with sewage treatment, but removal of only eight percent of carbamazepine (Tegretol) and none of clofibric acid (a cholesterol-lowering medication). The class of drug doesn’t predict clearance uniformly: Of the NSAIDs, indomethacin remains intact and only 17 percent of diclofenac and 23 percent of ketoprofen are degraded, but almost all naproxen disappears with sewage treatment. If you are totally frustrated at this point, I have a few other suggestions:  Box them up with fancy paper and a bow and “re-gift” them.  Use larger pills for Mankala stones or Go pieces.  Since the most effective and least utilized disposal method is incineration, perhaps

Burning Man can incorporate a public service component to their get-together, combining a take-back program and incineration. Just don’t inhale.

Take-Back Locations: • Some pharmacies have take-back programs. • North Area Recovery Station Household Hazardous Waste Collection Facility, 4450 Roseville Rd, North Highlands, CA 95660. Phone 916-875-5555. • City of Folsom Household Hazardous Waste Colletion Program, Folsom, CA 95630. www. folsomhazmat.com or call 916-355-8350 to schedule a pick-up. • Yolo County Household Hazardous Waste Collection Facility, 44090 County Rd 28H, Woodland, CA 95776. Phone 530-666-8729. • WPWMA Household Hazardous Waste Collection Facility, 3195 Athens Ave, Lincoln, CA 95648. Phone 916-645-5230. • El Dorado Hills Fire Station. 3670 Bass Lake Rd, El Dorado Hills, CA 95762. Phone 916-933-6692.

The human body alters many drugs to inactive forms prior to excretion in urine and stool.

algerhardt@sbcglobal.net 1 Heberer, T. Tracking persistent pharmaceutical residues from municipal sewage to drinking water. J Hydrology. 2001:266:175189 2 Ruhoy IS & Daughton CG. Types and quantities of leftover drugs entering the environment via disposal to sewage – Revealed by coroner records. Sci Total Environ. 2007;388:137-148 3 FDA website: http://www.fda.gov/Drugs/ ResourcesForYou/Consumers/BuyingUsingMedicineSafely/ EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ ucm186187.htm#MEDICINES 4 DEA website and http://www.deadiversion.usdoj.gov/drug_ disposal/non_registrant/s_3397.pdf

PLANET

E L LY

Kelly Rackham [916] 616 6270 planetkelly@me.com www.planetkelly.com Out-of-this-world design

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Still Seeing Stars? By Kelly Albin, MD Kelly Albin, MD, is a second-year resident of the Sutter Health Family Medicine Residency program in Sacramento. She is a former lacrosse player and the NCAA Woman of the Year 2004.

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.

DURING MEDICAL SCHOOL AT UCSD, I was Mary’s lacrosse coach. One of the scariest moments of my life was watching her defend an opponent ball carrier driving to cage. Mary tripped, hit the ground … and was out like a light. Then she began to have a seizure right there on the turf. As a former athlete, I recall concussions as common occurrences and minor setbacks for otherwise avid players. During college, one of my teammates was out for a concussion for almost a month; but she looked fine to me, and at the time we didn’t quite understand why she couldn’t have just sucked it up. Now, as a family medicine resident, I have come to appreciate concussions as a public health epidemic. As I rotate through the boroughs of Sacramento specialty clinics including neurology, pediatrics, pediatric neurology, emergency medicine, and sports medicine, I’m on a mission to find the perfect answer for how to manage concussions. Not surprisingly, each field has a favored approach, and there are not a lot of evidence-based answers. Traumatic Brain Injury (TBI) is broadly defined as a change in mental status after a head injury of any severity. The Centers for Disease Control and Prevention (CDC) estimates 1.7 million Americans have TBI yearly, most in the form of “mild” TBI, or concussion. Concussions can range from just vague confusion to temporary loss of consciousness. Other symptoms include headache (85 percent), balance difficulties/dizziness (80 percent), feeling “slowed down” (70 percent), difficulty concentrating or reading, sensitivity to light,

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and fatigue. About half of those afflicted report memory difficulties. Typically, most symptoms resolve within five days.1 However, parents, coaches and clinicians should realize that many athletes have subtle learning or cognitive deficits that may not be overtly apparent. My concern for Mary grew when I discovered that – a few years earlier in high school – she had a concussion as well. And she didn’t feel better after a few days of rest. In fact, she had headaches, concentration problems, and difficulty in school for months afterwards. This problem gets coined “post-concussive syndrome,” a vague constellation of symptoms that basically lasts longer than a typical concussion. On my neurology rotation in medical school, I enjoyed playing “Where’s the lesion?” when doing physical exams or reading imaging films. With Mary, you would just wave your hand around her whole head. Scans are typically normal. Labs are normal. It’s all clinical diagnosis without a single abnormal test you could grip onto. The experts tell me that the neuronal ion channels get mucked up in the brain-quake, that there is inflammation you cannot see on imaging, and that it can take some time for the neuronal milieu to right itself. After this first concussion in high school, Mary rested for a while and tried a few times to start running again and to get back to school. But every time she tried, she would come home exhausted with a pounding headache. That said, it took Mary a full year to recover and to return to playing sports again after her initial concussion. When to do imaging for concussion is also debatable. Dr. Jeff Tanji, a UC Davis sports medicine physician and partner of the Sacramento Valley Concussion Care Consortium project, gave me his simplified approach: “Imaging indications are simple. If worsening


status, then image.  Realize that the images are normal in the vast majority of concussions, so you order only to look for a visible bleed, but it does nothing to assess severity of the concussion or the return to activity status.” Turns out Mary’s previous concussion (which was especially severe) put her at high risk for a repeat concussion. A seizure with concussion is uncommon and can happen with a first-time concussion, but in Mary’s case was probably a manifestation of significant accumulated brain injury. Repeat concussions also lead to slower recovery.2 The days of “shaking it off” and getting back in the game are clearly over. Nearly all sporting organizations require that athletes with signs of concussion be removed from competition for that day. Determining when it is okay to get back out there is less clear. Most guidelines recommend return-to-sport when players are symptom-free. But vague symptoms like “fogginess” and “difficulty concentrating” can be hard to quantify, or players might not want to acknowledge they have subtle lingering symptoms. So how are concussions being managed in the big leagues? The NFL has instituted strict guidelines that prohibit return to play for anyone suspected of concussion. One would expect the brawlers in the NHL to be on the cutting edge of concussion management, but only recently have they announced that players should actually “leave the sideline” to be assessed for concussion. The US Olympic Committee has strict guidelines for return-toplay for all athletes regardless of sport.3 The guidelines are conservative and are commonly used elsewhere, but like much in concussion medicine, it is Level C evidence (consensusopinion based.) California’s high school sports governing body recently mandated that any high school athlete be cleared by a physician prior to returning to sports following a concussion. In fact, the new California law AB25 states that “student athletes suspected of sustaining a concussion or head injury must be immediately removed from school-sponsored athletic

activity. Subsequently, the student athlete must be evaluated and receive written clearance from a licensed health care provider.” Some of our local high schools are starting to administer baseline neurocognitive assessments in order to compare pre- and post-concussive performance and to assist in guiding returnto-play decisions. Paper- and computer-based assessment tools are available, but these tools are fairly new and have not been well validated in terms of outcome. Mary did end up going to the ED and, of course, they scanned her brain…clean as a whistle. She had a surprisingly smooth recovery period, was cleared by her neurologist, among other specialists, and did return for our last game of the season. But, ultimately, she chose not to continue playing contact sports because of her risk for further concussion. There is some evidence that two or more concussions may be associated with long-term learning disability and impaired academic performance.4 Moreover, more severe disorders such as chronic traumatic encephalopathy and early-onset dementia in former professional boxers and former NFL players suggest that cumulative TBI may lead to permanent severe sequelae that is poorly understood. This past month I have been glued to the Olympic Games, watching record after record being broken by bigger and stronger humans. Unfortunately, there is no way we can make our brains stronger, and concussions are still commonplace. Watching Abby Wombach – with her 5’11’’ frame and 170 pounds of muscle – head soccer balls into the goal makes me wonder if I would really want to try to defend her. Perhaps I will encourage my kids to be swimmers and just worry about sunscreen. For physicians encountering concussions in the office or on the field, there is a tool box available through the CDC at www.cdc. gov/concussion/HeadsUp/physicians_tool_kit.html which has downloadable forms to assess and follow patients with concussion. albinkc@sutterhealth.org

The days of “shaking it off” and getting back in the game are clearly over.

1,2 Guskiewicz, K. M. et al. JAMA 2003;290:2549-2555 3 Clinical Journal of Sport Medicine 2009; 19:185-200 4 Collins, M. W. et al. JAMA 1999;282:964-970

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Were the Prince of Denmark the Medicare Administrator By Gerald Rogan, MD To test, or not to test: that is the question. Whether ‘tis nobler in the mind to suffer The slings and arrows of high dose radiation, Or to take arms against the risk of cancer, And by early detection, cure it. To die: to sleep No more from an incurable lung cancer; or to defeat it. But what of an invasive test for suspected cancer, And its complications, when no cancer is found? Ay, there’s the rub! For in that complication death may come. But should one shuffle off the CT coils, And take the risk of late detection? Must give one pause. There’s the respect that creates the wisdom of debate: For who would bear the whips and scorns of higher costs, And who would be oppressed? Is the proud guideline contumely1 or no: The pangs of despised overtesting or delay in death? Ay, insolence of an open debate from which a test may be spurned Or from which a patient’s merit yields embrace; When payment might insurance cover With no copay? Would insurance the fardel2 bear Whilst one grunts and sweats under a weary premium? But that the dread of a looming death, The undiscover’d country from whose panic No uninsured returns, puzzles the collective will And makes us rather inflame those ills we have Than fly to cost-benefit that we know not of? Thus conscience does make cowards of us all; And so the native hue of resolution Is sicklied o’er with the pale cast of unknown effectiveness, And coverage questions of great pith3 and moment4 With this regard their currents turn awry, And lose the name of action. − Soft you now! The fair federal budget, in thy orisons5 Be all our deficits remember’d. jerryroganmd@sbcglobal.net 1 Contumely: Rude; Rude language or behavior; scorn, insult. 2 Fardel: A pack, budel; a burden. Middle English, from Old French, diminutive of farde, package, from Arabic farda, single piece, pack, bundle, from farada, to be separate; [see prd in Semitic roots.]

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3 Pith: here pith demonstrates its evolved denotation of “strength or vigor.” 4 Moment: denotes “consequence, importance” in this context. 5 Orisons: Speech or prayer.


Of Bottles and Bitters By Jack Ostrich, MD A FEW WEEKS AGO I MET WITH Jim Hamill, Julian Holt, and the indefatigable chairperson of our Historical Commitee, Bob LaPerriere, on the second floor of the Society building on Elvas Avenue. We were not there to share repartee and a glass or two of Amontillado. Oh, no. Rather, our purpose was to cull and winnow the Medical History Museum’s vast collection of “patent” medicine bottles, most dating from the 19th century. Bob had asked George Wagner, a local expert on collectible bottles, to be there to give us his opinion regarding the monetary value of the various bottles, so under George’s direction, we segregated the valuable from the relatively worthless ones and ended up with 36 bottles that merit consideration for special display. Among those that did not make the cut were bottles for “Newell’s Pulmonary Syrup” and “Dr. Kline’s Great Anti-Bilious Elixir.” I, myself, chose four bottles that merited attention, not because they are particularly valuable, but because of their medical or historical interest. They are “Mrs. Winslow’s Soothing Syrup,” “Dr. J.G.B. Seigert & Hijos” bitters, “Lash’s Bitters,” and “Lydia Pinkham’s Vegetable Compound,” the last being perhaps the most famous patent medicine in American history. Two of the products had inspired a total of three musical compositions − two for Mrs. Winslow and one for Miss Pinkham. In the late 1890s, the Ohio State Glee Club included in its repertoire a song called “Peanuts” that made humorous reference to Mrs. Winslow’s syrup. And the British composer, Sir Edward Elgar, created a composition for a wind quintet called Adagio Cantabile “Mrs. Winslow’s Soothing Syrup.” Based on a ribald Irish drinking song, “Lily

the Pink” made the top of the charts in the UK in 1968 as performed by the irrepressible trio known as “Scaffold.” It’s jolly good fun to Google the song and the group and to watch the YouTube video performances.

“Patent” Concoctions In the 18th and 19th centuries, there were hundreds of so-called “patent” concoctions available to the public, and until the passage of the Pure Food and Drug Act in 1906, many contained toxic, potent and addicting substances such as cocaine, morphine, heroin (originally a Bayer trademark), cannabis, strychnine, mercury and radioactive metals often made palatable, for lack of a better term, with high concentrations of ethanol and/or methanol. I wondered to myself whether any questionable products were still for general unrestricted sale, and wanted to know how goes the world of patent medicines in 2012. Turns out, it goes well. So I went to some “health food” stores. In one I found a product called “Cellfood” that cost $39.95 for a one-fluid-ounce bottle that resembled one that might contain eye drops. The package insert said that Cellfood “cleans and tunes up the body throughout the day” and “is absorbed quickly and efficiently by every cell in the body” and its efficacy was due to “78 ionic minerals, 34 enzymes, 17 amino acids, electrolytes and dissolved oxygen ... and utilizes a unique watersplitting system.” Not your father’s water-splitting system, no sirree. The claims for Cellfood resembled those made by most of the companies that had made the stuff that had been contained in our bottle collection. I opted not to buy any Cellfood, mainly because I doubted that SSVMS would have reimbursed me. Instead, I went September/October 2012

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immediately home and started to write about Mrs. Winslow and Dr. Seigert and Miss Pinkham and whoever Lash was. Never did figure that out.

Mrs. Winslow’s Soothing Syrup Mrs. Winslow’s Soothing Syrup was one of the most popular anodynes on both sides of the Atlantic since its introduction in New York City in 1849. It continued to be sold in the UK until 1930. No one knows who Mrs. Winslow was, very unlike Lydia Pinkham or Dr. Seigert. In any case,

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the active ingredient in Mrs. Winslow’s product was morphine sulfate, 65 milligrams per fluid ounce, in an ethanol base. Dosage was one-half teaspoonful every four to six hours and it was promoted by extensive advertising to be effective for fretful babies and infants suffering with pain of teething or colic. A report by Dr. A.B. Hirsch in the American Medical Journal in 1884 described a case of inadvertent opiate poisoning in a 20-month-old male child. His mother diagnosed colic after the tyke had eaten a bit of apple, and she gave him some Soothing Syrup more or less according to Mrs. Winslow’s directions. She said that he was quite agitated, so she thought that much of the syrup had been spit up or spilled, so she may have miscalculated and overdone her dosing a bit.

When the little fellow became stuporous after his fifth dose in about 12 hours, she called Dr. Hirsch to take a look, and he noted pinpoint pupils, profound lethargy, irregular respirations, thready and weak pulse and properly diagnosed opiate overdose. The mom was instructed regarding the dangers inherent in Mrs. Winslow’s product and the child recovered. The AMA, in editorials and public advertisements, regularly condemned the dangers of what the organization called all similar “baby killer” preparations. We will never know how Mrs. Winslow’s syrup tasted, but however it did taste, luckily it was foul enough that the little boy in Dr. Hirsch’s report spit out a good deal of it, otherwise he might not have survived. But most of us know what “bitters” taste like. Hence the term, eh? The general category of

September/October 2012

Lydia Pinkham’s Vegetable Compound was, no doubt, the bestselling patent medicine in the United States in the 19th century.

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Photos by Bob LaPerriere, MD, and Kent Perryman, PhD

bitters was promoted for pretty much anything that ails you. All were extracts of weeds and herbs, and most were in an ethanol base. Some had exotic names and were variously said to be based on “secret recipes” purloined from physicians in the Far East, or closer to home, based on ancient American Indian multi-herbal brews, the formula for which had been given to a lucky white man by a grateful tribal shaman after the white man had saved the tribal chief’s oldest son from being trampled by a stampeding herd of buffalo. Must have happened a lot because there were a lot of “Indian” bitters, including “A. Lancaster’s Indian Vegetable Jaundice Bitters.” Other bitters carried names such as “Big Bill’s Best Bitters,” “Zu Zu Bitters” and “Hunkidori Stomach Bitters” − presumably to be used when one’s stomach was not hunky-dory.

Seigert & Hijos The most famous was Lash’s Bitters, but the most interesting was the formula created by Dr. J.G.B. Seigert and labelled “Dr. J.G.B. Seigert & Hijos.” An unopened bottle of Lash’s Bitters was analyzed not long ago and found to contain 20 percent ethanol, 0.03 percent methanol, small amounts of a variety of organic acids and sugars, trace amounts of copper, iron and zinc and 440 milligrams of lead per 15 milliliters. The lead may have been leached from the glass, but that is not certain. Might have just been a bad batch. Dr. Seigert was a real life Prussian physician and soldier of fortune who managed to get to South America after the Napoleonic wars, and he became Simon Bolivar’s surgeon general. He and the general were headquartered for a time in Angostura, Venezuela, where Dr. Seigert whipped up a batch of bitters designed to ward

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off tropical diseases of all sorts and keep Bolivar and his men in tip-top shape. The city changed its name to Ciudad Bolivar in 1846, but the bitters remained named for Angostura. The present distinctive bottle with the bright yellow cap and oversized label still bears Dr. Seigert’s signature, and the company is still owned and run by his descendants. It is made in Trinidad. Its formula is patented and secret, contains almost 45 percent alcohol and is now used commonly as a flavoring agent in foods and cocktails, most famously in the Manhattan cocktail. It costs about $8 for a four-ounce bottle. I have a feeling that Dr. Seigert and General Bolivar consumed most of the doc’s bitters mixed with a couple of ounces of Barbados rum and, when available, topped with ice imported from New England. Ice from the northern climes of America and Europe was harvested in the winter, stored in giant ice storage houses and sent by ship to equatorial regions when the northern harbors were themselves ice-free. At the same time on the other side of the world, the Brits were mixing their aqueous quinine-based bitters with gin so as to minimize their malaria risk and make life a bit more bearable in the Khyber Pass. A century later, the dapper Commander Whitehead, as spokesman for Schweppes, told us that his company’s quinine water was “curiously refreshing.” When mixed with gin and topped with a bit of fresh lime and ice, it certainly is.

Lydia Pinkham’s Lydia Pinkham’s Vegetable Compound was, no doubt, the best-selling patent medicine in the United States in the 19th century. The ingredients were bland and generally non-toxic, and the ethanol content was 20 percent. Nyquil


cough syrup is 25 percent ethanol. Lydia was a very successful entrepreneur, wrote most of the advertisements herself, put her picture on her labels and directly aimed her product at women, telling them that it was especially effective for various perimenstrual distress and pain, and when their menstrual life was over, they could continue to take it confident that it would relieve the

miseries of menopause. Her original formula, and the one now manufactured by the Numark Laboratories in New Jersey, contain black cohosh (among other herbal extracts) which has been touted as mildly effective for a variety of female complaints. There have been reports, not scientific, but reports, that taking Lydia Pinkham Tablets prior to conception greatly increases the likelihood of conceiving a female. In 1922, her daughter, Aroline, founded the Lydia E. Pinkham Clinic in Salem, Massachusetts that is still operating, and offers free childhood immunizations and low-cost or free maternal and child health care. Lydia’s picture is still on the label of the modern versions of her “compound” and tablets. Her spirit is alive and well, just as the patent medicine industry is. See all of you at our museum. At least come to see the bottles.

In the 18th and 19th centuries, there were hundreds of so-called “patent” concoctions available to the public, and until the passage of the Pure Food and Drug Act in 1906, many contained toxic, potent and addicting substances.

jmost119@aol.com

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

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not-for-profit since 1948

For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.

September/October 2012

25


New Name, Same Ailment Can you match some old-fashioned ailments with their modern equivalents?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Brain Fever Catarrh Consumption Putrid fever Grippe Humid tetter Jail fever or ship fever Low spirits Lues venereal Morphew Mortification Podagra Stopping Variola Winter fever Rose cold Quinsy Horrors Ague Dry bellyache Bronze John Foetor Oris Green sickness Morbilli Rag-Picker’s Disease

a. Eczema b. Tuberculosis c. Depression d. Gout e. Smallpox f. Influenza g. Nasal and throat inflammation h. Syphilis i. Constipation j. Scurvy k. Gangrene l. Meningitis m. Malarial fever n. Lead poisoning o. Anthrax p. Measles q. Bad breath r. Yellow fever s. Typhus t. Delirium tremens u. Anemia v. Tonsillitis w. Diphtheria x. Hay fever y. Pneumonia

References Old Disease Names, www.homeoint.org/cazalet/oldnames.htm Old Names of Diseases, www.rootsweb.ancestry.com/~armissis/diseases.htm Old Names for Illnesses and Causes of Death, www.comportone.com/cpo/genealogy/articles/names_illinesses.htm

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ANSWERS: 1. Brain fever (l. Meningitis) 2. Catarrh (g. Nasal and throat inflammation) 2. Consumption (b. Tuberculosis) 4. Putrid fever (w. Diphtheria) 5. Grippe (f. influenza) 6. Humid tetter (a. Eczema) 7. Jail fever or ship fever (s. Typhus) 8. Low spirits (c. Depression) 9. Lues venereal (h. Syphillis) 10. Morphew (j. Scurvy) 11. Mortification (k. Gangrene) 12. Podagra (d. Gout) 13. Stopping (i. Constipation) 14. Variola (e. Smallpox) 15. Winter fever (y. Pneumonia) 16. Rose cold (x. Hay fever) 17. Quinsy (v. Tonsillitis) 18. Horrors (t. Delirium tremens) 19. Ague (m. Malarial fever) 20. Dry bellyache (n. Lead poisoning) 21. Bronze John (r. Yellow fever) 22. Foetor Oris (q. Bad breath) 23. Green sickness (u. Anemia) 24. Morbilli (p. Measles) 25. Rag-Picker’s Disease (o. Anthrax)

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 Posit on Destroying Outdated Drugs “For safety and medico-legal reasons, all medications should still be destroyed when reaching the manufacturer’s date of expiration.”

Context: It is well documented that most drugs are safe and effective far past the manufacturer’s stated date of expiration. See Dr. Scott Sattler’s essays, “A Costly Illusion,” SSV Medicine 2011 Editions, May/June and July/August; “Many medicines prove potent for years past their expiration dates” by L.P. Cohen, Wall Street Journal, March 28, 2000, www.terrierman.com/ antibiotics-WSJ.htm; and FDA-DOD SLEP Shelf Life Extension Program: www.shelflife.hq.dla.mil/ (access requires a  .gov or .mil email address.) NOTE: Posits are aggressive statements intended to promote discussion. Therefore comments are particularly relevant. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors. Results: Among 56 responses and 21 comments, 13 members agreed with the posit.  Among the 21 comments, 18 were in disagreement. Commentary follows: Despite the evidence, I feel beholden to defensive practices. I’m only a 4th year student, but that is the refrain I have heard constantly from my teachers. It’s incredibly frustrating. — Shahram Ahari, MS IV Ninety-nine percent of drugs remain safe and effective. I suggest that if there is no money to reassess the studies of each drug, then the outdated meds should be distributed with “WARNING” at a reduced price. —Evalyn Horowitz, MD The date of expiration is determined by how far out the manufacturer tests the potency

of the drug. It is not determined by when the drug begins to lose its potency. —Terry J. Zimmerman, MD Ideally, yes; however, we have no choice in the EMS world. Medications (morphine and benzodiazepams) are simply becoming unavailable to EMS providers, putting patients in jeopardy and inflicting unnecessary pain and suffering. —Jack Wood, DO I disagree; these meds are probably effective for years beyond the date of expiration! — Harvey Matlof, MD This is a great source of perfectly good meds for 3rd world humanitarian medical work! — Brian Wippermann, MD I agree ESPECIALLY for medical-legal reasons. I can see it now...”Dr. Ostrich told dad that his blood pressure medications were still all right to use even though the expiration date was six months ago, and when he was in the emergency room with his stroke the doctor there said dad’s blood pressure was ‘out of control’ and Dr. Ostrich should have given him a fresh supply!” —John Ostrich, MD It is not so much a safety issue. It could be medico-legal issue. What is NORCAL’s position? —Kuldip Sandhu, MD It seems like such a waste to destroy expired medications when so many people in our society cannot afford expensive medications. I am sickened by all the medications that get destroyed in our offices due to expiration dates, but a legal problem could occur should a patient get a reaction to an expired medication.  How about all the poor people

September/October 2012

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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This is a huge waste of the health care dollar.

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in underdeveloped nations that would benefit from these medications if somehow all these medications could be gathered up one month before or one month after expirations dates and Fed Ex’ed to Haiti, Africa or Central America to be distributed by medical personnel to needy people.  Oh, to dream!! — Jose Cueto, MD Although there is some resistance from foreign countries to allowing the use of these medications, education could allow for the use (free supply) of the medications in third world countries where little or no medications are available. —Brett Christiansen, MD This is one we can blame on our legal friends. I feel it would be nice to give outdated samples to patients, but nobody should take on that legal headache. —Jeffery Rabinovitz, MD This is certainly true for any medications used during one’s medical practice. For personal use, however, one should realize that any change past the expiration date usually only relates to potency. One notable exception is tetracycline and its derivatives, which decompose into products that can cause renal toxicity. —James Affleck, MD The expiration date is a fantasy to increase the profits of the drug companies. There may be some drugs with a need for a legitimate expiration date, but they are a front for destruction of perfectly useful medicine. Witness the drug companies taking back unsold medications from pharmacies and repackaging them with a new expiration date. Also consider good old aspirin; it deteriorates about one percent per year. — Patrick Clancy, MD Since we are unsure of meaningful metrics indicating expiration, we should use best information or manufacturer’s expiration date until we have a scientific valid metric.  Unnecessary waste will be the result, but safety will be optimized. —Robert Forster, MD More detailed, scientific studies/data could help us make an intelligent response, even if it is unfavorable to the manufacturers. Med-legal reasons should not be reasons. —Albert Kahane, MD Expiration dates were originally intended as last dates TO BE SOLD, not that they had to be

Sierra Sacramento Valley Medicine

destroyed by end user. And, if the issue is not some kind of toxicity… the only concern is loss of effectiveness. This will vary per med, be gradual, and according to how it was stored. It should be up to the individual to use judgment in using, or check with their doctor. Medical facilities, however, are obliged not to dispense outdated meds, and thus need to dispose of them. I personally have used very old meds on myself, with success. It would be ideal if pressure could be applied to pharmaceutical companies to verify or revise these dates, perhaps even show supporting data. Otherwise, one could conclude that the dates chosen are self-serving marketing decisions. —Nancy Gilbert, MD We send outdated drugs to underdeveloped countries for their use without issues. Safety is much less of a concern than medico-legal. Drugs destroyed properly cost money, and if not done properly, can hurt our environment. It is a sad waste to destroy useful resources. — Kenneth Corbin, MD This is a huge waste of the health care dollar. Drug companies should be forced to put the “real” expiration date on drugs instead of allowing them to resell “outdated” drugs that they know are in fact NOT past the real expiration date. —Denise Satterfield, MD It is a waste of money and resources; the consumer has to spend more money because he is discarding good medicine and has to buy more. It is bad for the environment because most of the discarded meds end up in the trash or down the toilet contaminating our soil. I understand that the military has a program of retesting outdated drugs for efficacy, and because they continue to use outdated drugs, they are saving millions of dollars/year. The “expiration date” is only the minimum time of retained efficacy required by the FDA. We are wasting tons of money by not requiring manufacturers to evaluate ongoing efficacy and adjusting the “expiration” accordingly. —Debra Johnson, MD Until the expiration dates are based on periodic assays of a drug’s continuing potency, the arbitrary discarding of perfectly good (and often very expensive) pharmaceuticals is a huge waste of precious health care resources


and contributes to the excessively high cost of medical care in the U.S. without improving outcomes. —Mark Blum, MD I personally feel that the short expiry dates are a concoction to bleed the pockets of the people who need the medications and to keep the manufacturers monetarily sound — a big expense for health care and the patients. In the past, we would take the expired drugs and use them in remote village missions and achieve the same cures or alleviations as we did the day after it was manufactured, some till 7-10 years after the MFG expiry date. Now all these locations have bought into the lie and demand that all medication have valid expiry for six months after entry into these areas. Not only is (disposing of outdated medication) a money drain, this practice has polluted our waters and soil. —Elisabeth Mathew, MD No need to enrich big pharma any more − now if you can just fix the malpractice lawyers … —David Naliboff, MD The first sentence says it all. There is nothing wrong with these drugs and they remain useful for years after they “expire.” Posted expiration dates are more for manufacturers’ income protection than for public safety. — Joanne Berkowitz, MD For liquid medicines and cow’s milk that I buy at the store, probably best to honor the expiration date; but for most other pills, I would guess that they keep more like the Spam in my pantry – just as delicious five years later as it was days after coming off the processor! —Nathan Hitzeman, MD In extreme poverty or need, (these) medications may be needed. —Alan Galbreath, MD There is no evidence of any harm arising from drugs that sit in our cabinets past their purported expiration date.  The very fragile patient who could conceivably suffer when taking pharmacologicallyinactive drugs is using medications

as prescribed and not holding medications past expiration dates. We do not need more regulations that provide no benefit to society.  —Bruce Barnett, MD A recent Sacramento Bee article, “California County to Vote on Rx Drug Disposal Bill,” indicates Alameda County would be the first in the nation to make pharmaceutical manufacturers responsible for disposal of expired and unused drugs. California law does not include pharmaceuticals in banned hazardous household waste. Turning household medications into a collection facility is best and sites nearby can be found online. Landfill disposal is preferred to adding medications to waste water. Flushing meds is not recommended, especially for antibiotics. For security reasons, controlled substances such as narcotics and stimulants, however, can go into the waste water but cannot be turned in to a collection facility unless law enforcement is present. —Sandra Hand, MD

September/October 2012

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In Memoriam

Michael H. Robbins, MD 1952-2012

ON JUNE 7, 2012, SACRAMENTO suddenly lost neurosurgeon Michael H. Robbins, MD at the young age of 60. Mike, foremost, was a devoted family man who was married to his bride of over 30 years, Margo, and with whom they had three wonderful children: Bradley (a sports psychologist and swimming coach), Zachary (a resident in anesthesiology at Tufts) and Erica (pursuing a master’s degree in family counseling at St. Mary’s College). The most recent apple in Mike’s eye was his grandson, Elijah, a gift from the union of Zachary and his daughter-inlaw Esther. One of Mike’s missions in life was to provide diverse opportunities for Michael H. Robbins, MD his family, including private schooling at the Brookfield, Jesuit and St. Francis Schools, swim team participation at Park Terrace and Arden Hills, and theatre plays and the Sacramento Ballet. He was always quick to volunteer, and he took pride at being the starter for his children’s swim meets and the successes they each achieved in the water. Mike and Margo moved to Sacramento 32 years ago for him to train in neurosurgery at UC Davis after finishing medical school at the Medical College of Ohio in Toledo. After residency, he spent a year in Detroit practicing neurosurgery and then returned to Sacramento where he joined Dr. John Yen. His practice at Mercy General, Methodist, and Folsom Hospitals was well-respected by patients and those who worked with him. Mike put on a different hat during the last year taking care of his wife Margo as she received chemotherapy for lymphoma. He cooked, attended treatment sessions, managed a busy practice, and served as Chief of Surgery

at Mercy General Hospital, first-vice president of the California Neurosurgical Society, and Chief of the Orthopedic/Neurosurgeon Division of Hill Physicians Medical Group. I thought I knew Mike after being his friend for over 25 years, until I listened to the stories told by many of the over 350 family members, friends, and colleagues who attended his memorial service at Valley Hi Country Club on June 14. Four of Mike’s high school friends flew out to pay their respects and told of his athletic prowess in the pool, on the track, and on the football field, and the admiration he had from the student body. John Yen, MD, told us that Mike was his first, only, and last neurosurgical partner, mentioning his skill, decisiveness, coolness under stress, and friendship. Steve Cohen shared how Mike helped his son, Joey, refine his game of golf and taught him some lessons in life. His son Brad told us that he admired and respected his father so much that he wanted to be “just like” him. Margo told us that two days before he passed away that they had bought new wedding rings and renewed their vows as a celebration of Margo completing her rigorous course of chemotherapy. Mike and Margo were ready to start a new chapter in their life when he was unexpectedly and prematurely taken from us. There isn’t a day that I look at a golf ball and don’t think of the many fun times we shared. He always stressed the superiority of neurosurgery by telling me that an orthopedic surgical residency is four years crammed into five, and that the best way to hide $50 from an orthopedic surgeon is to put it in a book! Mike was larger than life, a character with character. His devotion to family, his dedication to medicine, his wit, and friendship will be missed by all. — Stephen Howell, MD

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Sierra Sacramento Valley Medicine


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.

Ahmadpour, Nasrollah, Pulmonary/Critical Care Medicine, Shiraz University, Iran 1996, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040 Aizenberg, Debbie A., Otolaryngology, McGill University 2003, UCDMC, 555 W. Ranch View Dr #2005, Rocklin 95765 (916) 295-5700 Azevedo, Robert A., OB-GYN, Stritch School of Med/Loyola 1988, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7405 Balwanz, Christopher R., Internal Medicine, University of Nebraska 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Gillott, Douglas L., OB-GYN, Tulane 1992, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055

Luh, George YC., Radiology/NeuroRadiology, Loma Linda University 1992, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Goradia, Tushar M., Neurosurgery, Harvard 1992, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3670 Gulati, Vikant, Emergency Medicine, Thomas Jefferson University 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Generao, Suzanne E., Urology, Georgetown University 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Barami, Kaveh, Neurosurgery, University of Cincinnati 1989, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Herron, Daniel E., Radiology/Breast Imaging, University of Washington 1988, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Charles, Robert J., Emergency Medicine, University of Washington 1997, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

Jin, Frank FY., Family Medicine, Henan Medical University, China 1984, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Chopra, Rajiv K., Radiology, UHS/The Chicago Medical School 2002, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Keck, Kevin W., Internal Medicine, UC Davis 1975, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 784-4050

Chui, Cynthia K., Internal Medicine/Anesthesiology, George Washington University 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 Cua, David J., Otolaryngology, University of Illinois 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322 Deane, Sean G., Allergy & Immunology/Internal Medicine, UC Davis 2004, Mountainside Allergy & Immunology Group, 4801 J St #B, Sacramento 95819 (916) 452-6222 Derkacs, Jessica H., Emergency Medicine, UC Los Angeles 2009, 1600 Eureka Rd, Roseville 95661 (916) 784-4050 Dunbar, Richard W., Anesthesiology, Loma Linda University 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 Essayyad, Thamir M., Emergency Medicine, George Washington University 2007, Emergency Medicine, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Gambetta, Dario A., OB-GYN, Loma Linda University 1988, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5300

Lyubanskyy, Yuriy V., Internal Medicine, Donetsk State Medical University, Ukraine 1997, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916)784-4050 Mahajan, Anjlee, Internal Medicine, Albert Einstein 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Martin, Donald H., Family Medicine, Case Western Reserve 1979, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Mattu, Uppinder K., Internal Medicine, Virginia Commonwealth University 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 McClanahan, W. Clinton, Ophthalmology, UC San Francisco 1987, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015

Kensky, Herman A., Nuclear Medicine, University of Maryland 1978, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040 Khaderi, S. Khizer, Ophthalmology/NeuroOphthalmology, University of Utah 2002, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6310 Khan, Wajahat M., Internal Medicine, University of Karachi, Pakistan 1991, Mercy Medical Group, 7911 Laguna Blvd., Elk Grove 95758 (916) 733-5801 King, Rebecca L., OB-GYN, University of Oklahoma 1996, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-405 Klooster, Curt H., OB-GYN, Oral Roberts School of Medicine 1982, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055 Koehler, Sara L., OB-GYN, Albany Medical College 2003, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-3080 Laurence, Brett R., Infectious Disease, Temple University 2006, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040

Moezardalan, Koorosh, Gastroenterology, Tehran University 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Mullin, Deanna E., OB-GYN, Tufts University 1998, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4148 Niswander, David G., Anesthesiology, Medical College of Pennsylvania 1982, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 Oh, Sang-Rog, Ophthalmology/NeuroOphthalmology/Oculofacial Plastic, Johns Hopkins 2003, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015 O’Malley, Peter L., Pediatrics, Georgetown University 1997, UCDMC, 1370 Prairie City Rd, Folsom 95630 (916) 985-9300 Pant, Mahesh C., Radiation Oncology, University of New Mexico 1996, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-2730 Paulsen, Jeremy D., Emergency Medicine, University of Southern California 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 continued on page 35

Lindgren, Leslie R., OB-GYN, Rush Medical College 1995, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5300

September/October 2012

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Board Briefs July 23, 2012 The Board: Received a presentation regarding the CMA/ SSVMS partnership with Wells Fargo Advisors to create a member benefit. Received a report from Donald O. Lyman, MD, chair of the Public and Environmental Health Committee, regarding activities undertaken by the committee and its members in the 2011-2012 year. Received a report from Jose A. Arevalo, MD, regarding the Sierra Health Foundation’s Sacramento Region Health Care Partnership, a coordinated philanthropic nonprofit provider and community clinic initiative to strengthen the health care safety net in the Sacramento Region. The goal of the Health Care Partnership is to find ways to improve access, care coordination and quality of the region’s primary care system. Also included in his report was information regarding the Sierra Health Foundation’s Healthy Sacramento Coalition. The goal of the coalition is to reduce tobacco use, obesity, death and disability due to chronic disease, reduce health disparities, build a safe and healthy physical environment, and improve the social and emotional well-being of Sacramento County residents. Approved the 2012 Second Quarter Financial Statements. Received a report that the California Medical Association Foundation (CMAF) has been awarded a grant from Wellpoint, Inc. to develop and implement a Walk with a Doc Program. SSVMS is working with the CMAF, CMA and the SSVMS Alliance to implement the program in the Sacramento area. Walk with a Doc was created by Dr. David Sabgir, a cardiologist who practices in Ohio. The program strives to encourage healthy physical activity in people of all ages. Physician-led one-hour walks will be

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Sierra Sacramento Valley Medicine

held in local parks throughout our community on Saturday mornings throughout the year. Each walk will start with a physician providing a 10-minute talk about healthy living. A kickoff event will be held on Saturday, September 29, 2012 at Capitol Park starting at 8:30 am. Assemblymember Richard Pan, MD, along with other dignitaries will speak about healthy living and the benefits of walking. SSVMS is looking for other physician-members to lead similar walks during the year. Unanimously endorsed the candidacy of Lee Snook, MD, for 2013 CMA Vice Speaker. Approved appointing Jason Bynum, MD, to CMA Alternate-Delegate At-Large Office #13. Approved to endorse with amendments the 2012 CMA Resolution, “Awareness and Prevention of Bullying,” authored by Jason Bynum, MD. Approved the 2012 Nominating Committee Members as follows: Chair, Alicia Abels, MD, Immediate Past President; Ruth Haskins, MD, District 1 (North Area); Pat Samuelson, MD, District 2 (Central Area); Barbara Arnold, MD, District 3 (South Area); Ulrich Hacker, MD, District 4 (El Dorado County); Anthony Russell, MD (Permanente Medical Group); Marcia Gollober, MD (Yolo County); Richard Jones, MD (Member At-Large); Katherine Gillogley, MD (Member At-Large). Approved a letter of support for the Dental Society’s “First Tooth or First Birthday” campaign. Approved a letter to the Sacramento City Council supporting continued funding for community water fluoridation. Approved that effective January 1, 2013, membership for resident and fellow members will be available at no cost throughout the years of their residency and fellowship training.


Approved the June 25, 2012 and the July 23, 2012 Membership Reports: For Active Membership — Nasrollah Ahmadpour, MD; Debbie A. Aizenberg, MD; Robert A. Azevedo, MD; Kaveh Barami, MD; Rajiv K. Chopra, MD; Cynthia K. Chui, MD, David J. Cua, MD, Sean G. Deane, MD; Richard W. Dunbar, MD, Thamir M. Essayyad, MD, Dario A Gambetta, MD, Douglas L. Gillott, MD; Tushar M. Goradia, MD; Daniel E. Herron, MD; Frank F-Y Jin, MD; Wajahat M. Khan, MD; S. Khizer Khaderi, MD; Rebecca L. King, MD; Curt H. Klooster, MD; Sara L. Koehler, MD; Leslie R. Lindgren, MD; George Y. Luh, MD; Yuriy V. Lyubanskyy, MD; Donald H. Martin, MD; Deanna E. Mullin, MD; David G. Niswander, MD; Sang-Rog Oh, MD; Peter L. O’Malley, MD; Mahesh C. Pant, MD; Jeremy D. Paulsen, MD; Myrza R. Perez, MD; Olena Perry, MD; Gary W.

Roach, MD; Katharine H. Rutherford, MD; Myo Shin, MD; Joan O. Slachman, MD; Christina A. Tan, MD; Jane Tsai, MD; David Y. Uyeno, MD; Ghalib M. Wahidi, MD; Renee J. Yang, MD; Roger Y. Yang, MD. For Government Membership — Laurel A. Waters, MD. For Resident Membership — Laren D. Tan, MD. For Reinstatement of Active Membership to Former Members — Antony R. Boody, MD; Robert J. Charles, MD; Paul E. Kaplan, MD; Kevin W. Keck, MD; Herman A. Kensky, MD; Lisa Y. Law, MD; W. Clinton McClanahan, MD. For Resignation — Bruce N. Burdick, MD; Richard E. Harr, MD; Lewis C. Hou, MD (transferred to San Mateo); Sonya M. Jackson, MD (moved to San Luis Obispo); Ashby Wolfe, MD (moved to Oakland).

Meet the Applicants continued from page 33 Perez, Myrza R., Pediatric Pulmonology, Louisiana State University 2000, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4190 Perry, Olena, Internal Medicine, Crimea State Medical University 2003, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000

Slachman, Joan O., Pediatrics, SUNY, Stony Brook 1981, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4190 Tan, Christina A., Internal Medicine, University of the Philippines 1991, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Raman, Raghav, Radiology, University of Auckland, New Zealand 2001, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Tan, Laren D., Pulmonary/Critical Care Medicine, Loma Linda University 2009, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Roach, Gary W., Anesthesiology, University of Texas, Houston 1979, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705

Tsai, Jane, Internal Medicine, First Shanghai Medical University 1990, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3400

Rutherford, Katharine H., Family Medicine, Georgetown University 1985, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Uyeno, David Y., OB-GYN, Medical College of Wisconsin 1994, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055

Shin, Myo, Geriatric Medicine, Institute of Medicine, Burma 1970, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5300

Verzosa, John D., Family Medicine, Loma Linda University 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Wahidi, Ghalib M., Internal Medicine, Chicago Medical School 2005, Mercy Medical Group/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5079 Waters, Laurel A., Pathology/Nuclear Medicine/ Administrative Medicine, UC Davis 1978, Employment Development Department, 800 Capitol Mall, MIC 29, Sacramento 95814 (916) 654-8621 (Government) Watkins, Garth S., Psychiatry, University of North Carolina 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Yang, Renee J., Ophthalmology, Northwestern University 2001, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015 Yang, Roger Y., Emergency Medicine, Wayne State University 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Zinn, David H., Emergency Medicine, Brown University 2008,The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

September/October 2012

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Classified Advertising

Office Space

Doctor-Mentors Needed

Office Space for Lease: Corner of 39th and J Street, 850 sf, fully serviced. Rent negotiable. Contact R.J. Frink, MD at 916-801-5276 or email at rjfrink@surewest.net.

Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: eabrezinski@ucdavis.edu.

Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494. Share Office: Surgeon looking for another doctor or medical professional to share a brand new office on Scripps Drive, Sacramento. (916) 924-1400; (916) 718-8882.

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• HIPAA compliant • Inventory of charts to support retention requirements For an estimate please call SOURCECORP Deliverex Tim Ash – Sacramento Area Manager 916-452-3695 x302 timash@srcp.com 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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Sierra Sacramento Valley Medicine


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NORCAL Mutual 5% Risk Management Discount Additional 2% Discount SSVMS Membership

Learning from Lawsuits: Strategies and Resources for Reducing Risk

Date: September 27, 2012 Time: 6:00pm - 8:00pm Dinner provided Where: Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 Register: Visit www.ssvms.org and click on “Events” Contact: SSVMS (916) 452-2671 Info@ssvms.org Cost: SSVMS Members Free NORCAL Insureds Free Nonmembers $99 CME Information and Disclosure

The faculty members— Katt Todd-Schwartz, Esq. and Katie Theodorakis—have no relevant financial relationships to disclose. Planners from NORCAL include Jo Townson (Supervisor, CME) and Christina Cassady (Supervisor, Risk Management)—both of whom have no relevant financial interests to disclose. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of NORCAL Mutual Insurance Company and the Sierra Sacramento Valley Medical Society. NORCAL Mutual Insurance Company is accredited by the ACCME to provide continuing medical education for physicians. NORCAL Mutual Insurance Company designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Who’s getting sued for medical malpractice these days and how can they protect themselves? For some answers, you are invited to a special dinner and CME event jointly presented by Sierra Sacramento Valley Medical Society and NORCAL Mutual Insurance Company. Two experts in the fields of risk management and the law will provide keen insights into current trends in medical malpractice lawsuits — and you’ll learn some new and innovative ways to reduce the risks you face every day. Space is limited, so register for this free event today!

Educational Objective By analyzing closed malpractice claims (i.e., reviewing the causes of errors and strategies to prevent such errors), this educational activity will support your ability to apply risk management best practices that support patient care and increase defensibility in the event of a claim.

Faculty Kat Todd-Schwartz, Esq, Schuering, Zimmerman & Doyle, LLP, is an attorney focused on medical malpractice defense. She was born and raised in Alberta, Canada, and practiced law in Canada for two years before moving to California, where she has practiced since 2002. She has a particular interest in assisting acute care facilities with conservatorships and the placement of patients who lack capacity and do not qualify for state funding. Side note: Ms.Todd-Schwartz represented Canada in two Women’s Rugby World Cups, 1998 in Holland and 2002 in Spain. When she can, she travels around the United States as a coach and mentor to referees. Katie Theodorakis is a Risk Management Specialist at NORCAL Mutual, with over 15 years of experience in healthcare risk management. She has worked extensively with physicians to reduce their liability risks and improve patient safety. She began her risk management career at the University of California, managing the professional liability program for a large urban hospital.

Discount Reminder for NORCAL Insureds Eligible NORCAL insureds can apply this CME activity toward their 5% risk management discount on their 2013 premium (for Jan. 1 renewals, the deadline for earning the two required NORCAL CME credits is October 3, 2012). If you are also an SSVMS member, you can increase the discount to 7% by earning three NORCAL CME credits instead of two!


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Our numbers add up to great claims support for your practice. * Physicians Insurers Association of America Risk Management Review: 2011 Edition. **Jena et al. Research Letter, Online First: Outcomes of Medical Malpractice Litigation Against U.S. Physicians. Archives of Internal Medicine. May 14, 2012.

Call 1-800-652-1051 or visit norCalmutual.Com Proud to be endorsed by the Sierra Sacramento Valley Medical Society.

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September/October 2012