2012-Nov/Dec - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2012

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EDITOR’S MESSAGE Best Medical Home may be the Patient’s Home

Nathan Hitzeman, MD

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Museum Donations Help Bwindi, Uganda

George Meyer, MD, Scott Kellermann, MD, and Bob LaPerriere, MD

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PRESIDENT’S MESSAGE Medical Student Education in Sacramento

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Pupil Rights: Bullying

Jason Bynum, MD

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“Lo Siento”

Casey Johnston, MA, MS IV

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A Window of Opportunity

Sandy Damiano, PhD, and Marcia Jo, JD/MBA

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Rise of the Anti-Constipation Movement

David Herbert, MD

Jack Ostrich, MD

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Walking for Health

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Memorable House Call Stories

Aileen Wetzel, Executive Director

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SSVMS/CMA 2012 Education Series

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BOOK REVIEW “God’s Hotel” by Victoria Sweet

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Preparing for My Weight Loss Surgery

Nathan Hitzeman, MD

12 TEACH-MS

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Board Briefs

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Meet the Applicants

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Classified ads

Reviewed by Gerald Rogan, MD Mayra Betancourt MS II, Jennifer Melgar MS II, and Gaber Saleh MS II

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 This issue’s cover image was provided by Sacramento otolaryngologist Dr. David A. Evans, devans@sacent.com.

“The California State Capitol has been photographed countless times and makes a very photogenic subject. The dome is much more difficult to photograph at night because the flood lights make it very bright compared to the surrounding grounds. The exposure meter of a camera will tend to overexpose the dome while leaving the grounds in deep shadow. In order to expand the dynamic range to something approaching what the eye perceives, I created this image by blending multiple images with different exposures (bracketed images).”

November/December 2012

Volume 63/Number 6 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.

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

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 Robert Madrigal, MD Norman Label, MD Rajan Merchant, MD Charles McDonnell, MD Richard Pan, MD, Janet O’Brien, MD Assemblyman Kuldip Sandhu, MD Vacant Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD CMA President 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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Our Hours Are Changing, But Not Our Commitment.

For over 30 years, the physicians at The Doctors Center have always been available to assist you throughout the year. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 12 hours a day, 7 days a week.

When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia.

We take care of your patients’ immediate needs and refer them back to you for on-going care.

Prior to November 1, The Doctors Center is open from 8 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for multiple HMO’s and PPO’s.

Starting November 1, The Doctors Center new hours will change to 8 a.m. to 8 p.m.

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine ANITA H. BORROWDALE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

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

The Doctors Center Medical Group Inc.

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

Editor’s Message

Best Medical Home may be the Patient’s Home

By Nathan Hitzeman, MD ARE WE MISGUIDED IN THINKING we can create the perfect one-stop shop for our patients?

Inviting ficus plants, subtle interior lighting, bubbling fish tanks, and colorful murals are nice; but when I got my podiatry visit statement for $400 for a 15 minute toe check, I wished I had listened to that little piggy and stayed home.

As nice and convenient as playing with our office gadgets and firing off EMR prescriptions is, I wonder just how much good we are doing for our patients in terms of prolonging their lives. What if our efforts were concentrated on the home front?

What if every block had community promotoras to check in on every neighbor, and vaccines came to the patients. Add on nutrition services, wellness block parties, physical therapy and safety checks. Sometimes I learn volumes about my patients from looking in their fridges, seeing their medication stockpiles and crazy

pill management schemes, how they hoard items, or are overrun by cats. With modern day navigation systems, it is not hard to map out reasonable home visit rounds. In some ways, I think there is no greater respect you can give your patient than that of your time and interest in seeing how they live.

The editorial board was impressed by the wealth of responses to our inquiry of our members’ home visit experiences. As you will see (page 22), the home visits didn’t always occur at the home, nor on the ground, for that matter! And, as Dr. David Dozier reflected on one visit, a picture is worth a thousand words. How valuable these precious glimpses are into our patients’ lives, and how rare they are becoming. hitzemn@sutterhealth.org

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.

November/December 2012

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Museum Donations Help Bwindi, Uganda

By George Meyer, MD, Scott Kellermann, MD, and Bob LaPerriere, 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.

THE SSVMS MUSEUM OF MEDICAL HISTORY is located at 5380 Elvas Avenue in Sacramento and is open free to the public Monday-Friday, except for holidays. Recently, the museum needed to consolidate its storage space and has had to relinquish many items.

The SSVMS museum often receives duplicate items, or items not appropriate for display. These include surgical instruments, glass syringes, hypodermic needles, otoscopes, ophthalmoscopes, blood pressure gauges, EKG machines, and other medical paraphernalia.

We recently sorted through over 50 boxes of acquisitions and sent five boxes of surgical instruments, an EKG machine, two ResusciAnnies and five boxes of other items as mentioned above to Africa, specifically Uganda.

The Bwindi National Park in southwest Uganda borders portions of the western part of the Democratic Republic of Congo (previously known as Zaire). One of its extraordinary features is its biodiversity: it has an incredible array of flora and fauna. The Bwindi Forest is a refuge for 350 mountain gorillas (one-half of the world’s population) and is home to an indigenous people group − the Batwa pygmies.

In 1993, the Bwindi was designated as a World Heritage Site to protect the endangered mountain gorillas. In the process, the Batwa pygmies were evicted from the park. Without title to land, the Batwa were given no compensation, no land, shelter or other support and they became conservation refugees.

Enter Dr. Scott Kellermann, a family practitioner from northern California. In 2000, he and his wife Carol did a medical survey on the Batwa and found that their life expectancy was only to the age of 28 with a meager income

Sierra Sacramento Valley Medicine

For further information, go to www.bwindihospital.com or www.kellermannfoundation.org.

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of $25 per year. In 2001, he and Carol relocated to the Bwindi. For the first few years they lived in a tent, learning the language, customs and traditions of the people and conducting mobile health clinics. Three hundred to five hundred patients per day would be treated at these clinics which were held under trees adjacent to the forest. For those with severe malaria, quinine would be administered through IVs hung from the overhead branches.

Eventually a hospital was built, and recently a new operating room has been completed. The hospital provides care for more than 100,000 people, including tourists who come to the area. About 40,000 patients are seen each year and 2,000 require admission. The maternal death rate has been reduced by more than 60 percent due to the provision of quality prenatal care, well-trained delivery nurses and access to Cesarean sections. Currently the most common diseases treated are HIV, malaria and diarrhea. A host of other tropical ailments are also treated.

The public health effort has markedly decreased the infant mortality, tuberculosis rates and maternal-to-child transmission of HIV. The hospital now has 112 beds and has been recognized as the best hospital in Uganda for the past three years. The staff of 115 people includes doctors, nurses, midwives and other health workers and support personnel. Seventy percent of them are from the local area, with the remainder from other parts of Uganda.

Currently a nursing school is under construction which will graduate registered nurses.

Interested doctors and nurses from the U.S. are encouraged to come to assist. ssvmsmus@winfirst.com

President’s Message

Medical Student Education in Sacramento A landscape that is changing faster than most

By David Herbert, MD MEDICAL STUDENT EDUCATION has changed significantly during the past decade, and education in our community is changing faster than most. Not only are there new ways of teaching students at UC Davis, but we are seeing the entry of two new medical schools into the Sacramento region: Drexel and California Northstate, each with their own approach to post baccalaureate medical education.

Many of our community physicians are involved in the clinical education of medical students, but most are largely unaware of these changes, and so I will use this month’s expanded column to share news from each of these institutions. I hope that you find this to be as interesting as I have.

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UC Davis Mark Servis, MD, the Senior Associate Dean for Medical Education, provided much of this information.

The UC Davis School of Medicine has continued to grow and evolve in its role as Sacramento’s largest and best-known academic medical institution. It maintains major clinical affiliations with Shriners, Sacramento VA, and Kaiser Permanente Medical Centers. Some highlights from recent curricular initiatives in 2012 include: • The admissions process now uses the Multiple Mini-Interview (MMI) process to select from an extremely talented pool of competitive applicants (about five percent are admitted). In place of the traditional 45-minute applicant interview, MMI is a

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fast-paced, timed circuit of 10 stations, each featuring a 10-minute exercise designed to assess teamwork, impromptu problemsolving and communication skills.

Student support services have been augmented with the Office of Student Learning and Educational Resources (OSLER) led by Dr. Joanna Arnold, and with the Office of Student Wellness led by Dr. Andreea Seritan. Students can access learning specialists, counselors, and career advisors, and participate in wellness and prevention workshops to help them successfully navigate the academic, personal and professional challenges of medical school.

Inter-professional teaching programs have been developed with students from the Betty Irene Moore School of Nursing and the masters program in public health and informatics. First-year medical students learn physical exam basics with family nurse practitioner and physician assistant students. In the fourth year, an inter-professional study module entitled, “Enhancing Patient Safety in Health Care,” integrates quality of care outcomes into medical education.

Five Master Clinical Educators have been selected who each spend one day a week teaching clinical skills to second- and thirdyear medical students. Clinical reasoning, diagnostic skills, and the art of medicine are emphasized.

Several hybrid courses in the pre-clinical curriculum combine online teaching with

November/December 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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our community partners and the contributions of dedicated volunteer faculty!

Drexel University

small group active learning in the classroom. This initiative reverses the traditional roles of lectures and homework, with lectures viewed online outside of school and subsequent discussion and analysis in the classroom. The opening this year of the new California Telehealth Resource Center provides high-tech classrooms as part of a telemedicine learning center and an entire floor devoted to medical simulation training in the Center for Virtual Care.

• The third-year clinical experience is changing with the initiation of longitudinal, continuous, integrated clinical clerkships.

A single six-month rotation combines internal medicine, primary care, psychiatry and neurology.

• Three Underserved Communities Leadership Pathways programs attract many students: Rural PRIME for students interested in rural practice, San Joaquin Valley PRIME for students interested in meeting the needs of the underserved in the Central Valley, and TEACH-MS for students interested in working in urban underserved areas. Each of these programs has distinctive curricular elements and experiences to equip students for serving underserved populations.

Students at Drexel University share classroom learning in the Interdepartmental Medical Science program.

The UC Davis School of Medicine continues to depend on and appreciate the engagement of

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Sierra Sacramento Valley Medicine

Sandra Kirschenmann, Associate Vice Provost of Drexel University in Sacramento, kindly shared information about Drexel’s program for college graduates who want to get a taste of what medical school is about − and I suspect this may offer some students an increased chance of admission to medical school.

Drexel University College of Medicine is one of the newest and largest medical schools in the country. In 2002, the former Hahnemann University and the Medical College of Pennsylvania, which had previously merged, became a part of Drexel University. The medical schools had been founded in 1848 and 1850, and Drexel itself in 1891. The Drexel Center for Graduate Studies in Sacramento opened in 2009.

One of the programs offered at the Sacramento campus is Drexel’s innovative Interdepartmental Medical Science (IMS) program, which is designed to allow students the opportunity to test their preparation, motivation, and commitment to medicine.

Established in 1981, the one-year IMS program has assisted students interested in applying to medical, dental, optometry, podiatry, chiropractic, or other health profession schools.

The IMS program closely mirrors what firstyear medical students experience. The students typically attend classes Monday through Friday for five to nine hours per day and stay longer to study in small groups. The first year also includes weekly practice shadowing with Kaiser Permanente physicians. Some of the IMS classroom instruction is provided by Sacramento faculty, but the bulk of instruction and videoconferencing is from Drexel’s College of Medicine in Philadelphia.

In this hybrid learning atmosphere, the Sacramento students take the same courses and exams as Drexel’s first-year medical students.

Among the first class of Sacramento IMS students who entered in 2010, 86 percent are now in

medical school, and the rest have secured jobs in medical-related fields.

Additionally, Drexel and Kaiser Permanente are working to create medical student clerkships at Kaiser’s three area medical centers to begin in the summer of 2013.

California Northstate University Thanks to Rikki Corniola, PhD, and Robert Suskind, MD, Founding Dean of the College of Medicine, for much of this information.

CNU may soon be the newest medical school in the country. Many of us already know Joe Silva, MD, who is helping to get the school up and running. CNU has purchased a large facility in Elk Grove which is being remodeled to serve as the home for the first two years of classes, as well as to house the CNU College of Pharmacy, as it moves from its present location in Rancho Cordova.

CNU is one of the first investor-owned medical schools to seek LCME accreditation in the United States. If all goes well with the accreditation process, CNU plans to admit its first class in 2014. Like Drexel’s Sacramento campus, CNU does not have its own hospital and so is affiliating with community physicians and hospitals to provide clinical rotations.

CNU is approaching the first two years of medical school differently from the traditional discipline-based curriculum that most of us experienced. Instead of learning anatomy, physiology, pharmacology, and so on in separate courses, the students will be studying a system-based basic science curriculum linking the musculoskeletal, cardiovascular, pulmonary, renal, and other systems with their relevant anatomy, pathophysiology, pharmacology, etc.

This basic science curriculum is framed by the 120 basic ways in which the body responds to disease. Each of the system-based units has eight to 10 presentations. As an example, diseases of the GI system can present with complaints such as nausea, vomiting, diarrhea, constipation, and/or abdominal pain. Each of the 120 clinical presentations has an associated algorithm, case examples, and a clinical skills lab for the students.

By linking the basic sciences with clinical presentations, students will have a framework for understanding and retaining the basic science material while being introduced to a systematic approach to the clinical presentation of patients.

Five new medical schools in the U.S. are using this educational process, and students have done quite well on their step one and two USLME examinations, as well as on their clinical performance during their third and fourth year clinical rotations.

CNU has hired several of its basic science faculty, who with their clinical colleagues in the community are developing the final curriculum for the medical school.

There is much to

Editorial Comments

like in these

So what are we to make of these changes?

There is much to like in these developments.

Sacramento has a wealth of clinical material and many talented clinicians and teachers who are not presently engaged in teaching. Having new schools to utilize these resources should benefit our entire community, and indeed should complement rather than threaten our long-standing educational powerhouse, UCD. As we face a worsening physician shortage locally and nationally, it is encouraging to see new and expanding medical schools in our community. I’m also encouraged by the new approaches being taken to educate students.

Although I enjoyed, and continue to value my traditional medical school training (which from the perspective of our present students seemingly involved oil lamps, leeches, and books on parchment), I suspect that I would have benefited from the new approaches being developed at UCD. And the innovative presentation-based curriculum at CNU might finally answer the age-old medical student lament of, “What does this basic science have to do with practicing medicine?”

We are indeed fortunate that our community is so involved in medical education.

developments.

Sacramento has a wealth of clinical material and many talented clinicians and teachers…

davidherbert166@gmail.com

November/December 2012

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Executive Director’s Message

Walking for Health

By Aileen Wetzel, Executive Director

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.

ACCORDING TO THE AMERICAN Heart Association, walking has the lowest dropout rate of any physical activity. Think it doesn’t do any good? Think again. Walking for as little as 30 minutes a day can have the following health benefits: • Reduce the risk of coronary heart disease • Improve blood pressure and blood sugar levels • Maintain body weight and lower the risk of obesity • Enhance mental well-being • Improve blood lipid profile • Reduce the risk of osteoporosis • Reduce the risk of breast and colon cancer • Reduce the risk of Type 2 diabetes Walking is low impact; easier on the joints than running. It is safe – with a doctor’s okay – for people with orthopedic ailments, heart conditions, and those who are more than 20 percent overweight. In addition, research has shown that you could gain two hours of life for each hour of regular exercise!

The national Walk With a Doc program was created by Dr. David Sabgir, a board-certified cardiologist who practices in Ohio, and who strives to encourage healthy physical activity in people of all ages to reverse the consequences of a sedentary lifestyle. SSVMS is now pleased to announce the launch of our own local Walk with a Doc program.

Walks will be held on Saturdays lasting about an hour each, and they start with a physician giving a quick five to ten minute talk about healthful living. We need physician volunteers to lead walks and to help promote the program to the community. Skills required: Enjoy the benefits of walking, be enthusiastic, and enjoy meeting and motivating people.

To volunteer, contact Kris Wallach, Program

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Director, at (916) 453-0254 or kwallach@ssvms. org.

SSVMS is partnering with the American Lung Association and Breathe California to sponsor three walks in November, which is COPD and Lung Cancer Awareness Month.

Walks will be led by SSVMS members and Fellows in Critical and Pulmonary Care from UC Davis Medical Center. Walks are free and open to anyone. Encourage your patients and their families to join us! Registration is at 8:00 am; Walk at 8:30 am.

Saturday, November 3, 2012 Tahoe Park 8th Avenue and 61st Street, Sacramento Saturday, November 10, 2012 UC Davis Arboretum Wyatt Deck on Old Davis Road, Davis Saturday, November 17, 2012 Southside Park Between W and T Streets at 6th Street, Sacramento awetzel@ssvms.org

November/December 2012

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Book Review

God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine. Author: Victoria Sweet1 ISBN 978-1594488436, Riverhead Books Publisher 2012, 384 pp, $27.95

Reviewed by Gerald Rogan, MD DR. VICTORIA SWEET IS AN INTERNIST and medical historian. Her book, God’s Hotel, A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine, describes her experiences in patient care and facility management before the makeover of San Francisco’s Laguna Honda Hospital, perhaps the last almshouse in the U.S. An almshouse is a facility that accepts chronically ill persons who are not likely to get better, yet who need regular long term physician supervised medical care, sometimes for years.

Most interesting to me, God’s Hotel explains medical practice concepts through a historical perspective from 900 years ago, emphasizing the 12th century published work of Hildegard of Bingen, an almshouse practitioner.

Hildegard’s published medical writings helped guide generations of almshouse caregivers until superseded by “Western Medicine.”

Hildegard emphasizes the difference between a recipe and a prescription – concepts increasingly meaningful today to help physicians and patients navigate the synergistic benefits of holistic, complementary, Chinese, and Western

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

medicine. Applying Hildegard’s concept viriditas, a metaphor for spiritual and physical health, Sweet explains how the innate self-healing capability of our bodies can be blocked by non-medical factors. For example, for patient Terry Becker, the viriditas barriers which blocked healing of her bedsore were poor nutrition, inadequate sleep, an unsafe environment, and environmental turmoil. Her key to cure was a proper health recipe in addition to a prescription for proper wound care.

As with patient TB, Dr. Sweet applies Hildegard’s diagnostic and treatment methods to her modern-day decision making. Hildegard’s parameters include those which are promoted by complementary life-style practitioners: food types, amount, temperature, and timing; exercise and rest; sleep environment; clothing; stress; relationships; sex; body positioning; and home life.

Physicians and practitioners can take a lesson from God’s Hotel to guide patients toward more effective treatment of selected chronic diseases: diabetes, hypertension, high cholesterol, obesity, fibromyalgia, osteopenia, chronic fatigue syndrome, ADD, and perhaps PTSD. Medical practitioners often embrace a professional responsibility to improve a patient’s health status by focusing on drugs and other billable physician services, rather than by giving more weight to a recipe and barrier removal which requires a patient’s commitment to understand and follow. Dr. Sweet points out the role of shared responsibility to regain health.

Jerryroganmd@sbcglobal.net 1 www.victoriasweet.com

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Sierra Sacramento Valley Medicine

at your dental plan It’s Open Enrollment time for the Sierra Sacramento Valley Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

During Open Enrollment only, members may join as an individual or as a group with your employees.

Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families).

Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2013.

Call a Client Service Representative at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

Sponsored by:

Underwritten by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

56409 ©Seabury & Smith, Inc. 2012

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

TEACH-MS Addressing the need for primary care in urban underserved communities

By Mayra Betancourt MS II, Jennifer Melgar MS II, and Gaber Saleh MS II HEALTHCARE CHANGES IN THE Affordable Care Act will benefit many. However, the increased demand for primary care physicians may disproportionately affect patients in underserved areas. In 2011 the UC Davis School of Medicine established the Transforming Education and Community Health for Medical Students (TEACH-MS) Program. Funded by the American Recovery and Reinvestment Act and Health Resources and Services Administration, TEACH-MS is designed to train medical students for primary care careers in urban underserved areas.

The Problem Most California regions barely meet the standard for supply of primary care physicians1 and the number of medical students choosing primary care careers remains small.2 Not only will the need for primary care physicians in underserved communities increase, but such physicians are also called upon to be leaders in improving health, equity, and quality. We hope to be those leaders.

The TEACH-MS Solution 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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TEACH-MS offers six UC Davis medical students per year an opportunity to develop to their full potential as advocates for underserved communities. The TEACH-MS curriculum includes four-year longitudinal care experiences alongside primary care physicians at two local community clinics for the medically underserved: the Sacramento Primary Care Clinic and the Transcultural Wellness Center.

Third-year clerkships are specifically tailored to provide opportunities for continuity between inpatient and outpatient care. The goal is to

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improve a patient’s global medical experience as well as transitions of care.

Another foundation of TEACH-MS is the concept of cultural humility. The TEACH-MS Summer Institute on Race and Health is a cultural humility-based four-week experience that uses seminars, discussions and selfreflection exercises to examine racial and ethnic disparities in health and health care. Medical students reflect on their own racial stereotypes and how to address them in order to better serve the community.

The Summer Institute also emphasizes learning about California’s Central Valley.

Students learn about the cultures and ethnicities that form different communities within the Central Valley, as well as talk to community leaders and elders. Students have the opportunity to learn about migrant health, and can visit a family-owned farm and assist them in the fields.

TEACH-MS students understand that addressing the problem of healthcare disparities means moving beyond the four walls of the exam room.

TEACH-MS students learn about their patients’ home environment as well as their work environment. TEACH-MS students accompany collaborators from Harm Reduction Services (HRS) in Oak Park on home visits.

HRS is devoted to high-risk populations. For example, HRS provides HIV-positive clients with transportation to doctor visits and counseling to assure compliance with medications. HRS is also an advocate for support systems and encourages clients to attend drug rehabilitation or support group meetings. HRS staff members serve as excellent role models as they develop

Summary and an Invitation

long-term relationships with their clients.

The TEACH-MS curriculum emphasizes inter-professional learning and teamwork through didactic experiences and through shadowing with UC Davis nurses and clinical pharmacists. By seeing the importance of other members of the healthcare team, we learn the significance of working together for the benefit of the people we serve.

The goal of the TEACH-MS program is to nurture and support students to become superb primary care physicians in diverse and disadvantaged communities. We are continually looking for ways to expand the curriculum with new clinical experiences and to enhance our collaborations with health professionals, community members and community organizations. We seek to provide enriching and mutually-beneficial experiences to all of our partners. As TEACH-MS embarks on its second year, we are excited to make a positive impact on our most vulnerable populations, one student at a time.

Left to right: Jennifer Melgar, Gaber Saleh, Mayra Betancourt.

mayra.betancourt@ucdmc.ucdavis.edu 1 California HealthCare Foundation, 2009.

2 http://jama.jamanetwork.com/article.aspx?articleid=182531

Student Reflections The selection process for TEACH-MS included writing an essay on why we were interested in joining the program and what we hoped to gain from it. Here are some reflections we’ve gathered from students thus far: “I knew that I could not see myself practicing medicine anywhere else, but in the community that helped shape me into the person that I am today.”

“I joined TEACH-MS with the hopes that it would help me develop into the physician that my community needs.”

“So far, TEACH-MS has far exceeded my expectations. Not only is it providing me with the knowledge and tools that I will need as a primary care physician, but it has also given me a family of mentors and colleagues whom I can count on during my medical school journey.”

“I’ve learned my own cultural biases and how they affect my treatment of patients. I hope to use this in my future as a physician to recognize when my biases are at play and how they could be affecting the treatment of my patient.”

November/December 2012

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Pupil Rights: Bullying

By Jason Bynum, 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.

A LOCAL COMMUNITY ORGANIZATION has begun to address the issue of a nationallyimportant, and growingly-publicized concern, the issue of bullying. A recently-passed law identified the problem, and mandated more formalized action be taken within the school districts to address bullying. Jim Kelleher, Continuity Administrator of Kaiser Foundation Hospital in the South Sacramento region, pulled together several physicians, community activists, school officials, sociologists, and community religious leaders to see what could be done to address the issue.

On September 7, 2011, Governor Jerry Brown signed Assembly Bill 9 (Ammiano), amending Section 234 of the Educational Code.

The most salient points of this law state: Section 234.1 (b) (1) A requirement that, if school personnel witness an act of discrimination, harassment, intimidation, or bullying, he or she shall take immediate steps to intervene when safe to do so.

(2) A timeline to investigate and resolve complaints of discrimination, harassment, intimidation, or bullying that shall be followed by all schools under the jurisdiction of the school district.

This law is commonly referred to as “Seth’s Law,” and was endorsed by the ACLU, Gay-Straight Alliance Network, and the National Center for Lesbian Rights. The law is named after Seth Walsh, a 13-year-old boy from Tehachapi, in Kern County. Seth was gay, and had been the victim of daily bullying of a relentless nature. His mother, in testimony, approached the Tehachapi Unified School District on several occasions about the treatment of her son. The bullying continued, and Seth ultimately hanged himself in September of 2010. The school district’s deficient action prompted a federal investigation, and ultimately was the nidus for the passage of AB 9.

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As a child/adolescent psychiatrist, I am very interested in this subject as I often deal with depressed, anxious, or angry children, and the subject of bullying is common. In addition, the newest form of bullying, “cyber bullying,” is an issue with which the psychiatric literature has had difficulty in researching as the technology far outpaces the speed of research.

The community group felt that a reasonable approach to the bullying issue was to gather information from school district officials which led to the implementation of AB 9, then see where to go from there. What we found in the first few meetings of this community group was fascinating.

First, we all realized that being the victim of some sort of bullying, or even bullying others, was a universal experience within our own lives.

We were struck by the fact that bullying almost seemed a “right of passage” through childhood, which we all experienced. We reviewed some psychiatric literature in which bullying is associated with suicide, anxiety, depression, substance abuse, and conduct disorders.

The school officials and sociologists gave fascinating information as to the “culture of bullying” with which certain schools may be affected, and some of the actions with which to address these cultures. We even watched some YouTube videos on the personal impact young people shared, as well as pieces of the movie “Bully,” a heart-wrenching documentary following a young boy through middle school.

While the information was valuable and interesting, we are faced with the dilemma of what to do with this information to make an impact. Clearly, the school district has the largest audience, as well as the most common venue for bullying to occur. The institution of a no-tolerance policy, along with the now-mandated administrative response

will have powerful implications. How do we physicians play a role? The difficulty is in translating the macro-based school approach to the very individual approach in the physician’s office and is somewhat of a struggle for me.

This is still a work in process, but in the months to come, I foresee several opportunities for physicians to have impact on this effort.

The first comes through information.

We will be developing a short screening tool to be completed in the pre-appointment paperwork within the pediatrics clinics at Kaiser. Secondly, identifying a referral process and streamlining this process will be of value to get kids expeditiously from screening to a specialist. Not all kids will need treatment for bullying, but a protocol to give information to parents concerning their rights within schools, identification of depressive or anxious symptoms, and treatment options will be of value. Thirdly, educating our own mental health

providers on how to support our patients, not only personally, but also in returning to school, to address the issues through this administrative process will be important.

This is an approach we are beginning to take through the Kaiser Permanente system.

How do I broaden this approach to other large healthcare organizations, as well as rural communities and private practitioners? This is where my involvement in SSVMS will be invaluable, as the ability to communicate with leaders within other organizations and their local communities to organize this effort is an opportunity not present elsewhere.

I encourage interested readers to contact me about this grassroots effort. In my estimation, we can make a real impact on an important issue in the community in which we all live. jbynum23@me.com

November/December 2012

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Lo Siento

By Casey Johnston, MA, MS IV Halloween laughter awakens the golden tree-lined streets outside, Two babies cry almost harmoniously in the labor and delivery ward.

They signify life, vitality, and beginnings, Yet painfully remind the woman in bed 45 of what happened today.

A tiny, dark-haired newborn clothed in a crisp blue and green striped onesie, Rests peacefully on a soft blanket.

A single half-open red rose lies across his chest, Which has not provided breaths since within the womb.

The baby’s father sits in the corner with his head in his hands.

The baby’s mother lies in the hospital bed against two pillows.

Other family members and close friends line the room, Out of view from her tear-blurred gaze.

Her older sister, with hands clasped and eyelids weighed by exhaustion, Interprets what the doctor is saying.

“Considering the circumstances, I think it went well,” he says.

“Lo siento.”

Thirty-two weeks is a long time to nourish a seed, To protect, to cherish, to nurture.

Ultrasound showed a two-vessel cord, a diaphragmatic hernia and facial anomalies, But there was kicking just yesterday.

A nurse remarks that God knows everyone and every tear we cry.

She says He knew the fate of the baby, And that he would return to Him. But why did He let this happen?

Children dressed as ghosts, pirates and princesses Skip from house to house outside, asking for treats.

Not this little one.

He rests on the foot of the bed, not alive to know the love surrounding him.

casey.nevitt@ucdmc.ucdavis.edu

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A Window of Opportunity

By Sandy Damiano, PhD, Deputy Director, and Marcia Jo, JD/MBA, Heath Program Manager Primary Health Services, Sacramento County DHHS DESPITE YEARS OF RECURRENT budget reductions, the State Department of Health Care Services (DHCS) created a window of opportunity for every county in California. The Low Income Health Program (LIHP) was created in the State Medicaid 1115 waiver known as California’s Bridge to Reform (November 2010).

This program allows the county to draw down federal reimbursement for health care expenditures to LIHP enrollees. Each county has the option to participate. This is a major transformation of services to low income childless adults historically served under Welfare and Institutions 17000, known as the medically indigent services program.

• What is the LIHP? The LIHP offers health care coverage to low income childless adults (19-64 years of age) who are county residents and U.S. citizens, or who meet the federal definition of a qualified immigrant and must not be subject to the five-year bar on federal eligibility. Sacramento County has set the income requirements at zero67 percent of the Federal Poverty Level (FPL).

• What are the covered health services?

Physician services including specialty care, emergency care services, acute inpatient hospital services, prescription and limited non-prescription medications, physical therapy, podiatry, prosthetic and orthotic appliances and devices, radiology, laboratory services, medical equipment and supplies and a minimum core mental health benefit are all provided. Benefits largely mirror Medi-Cal Managed Care, and network adequacy requirements are also similar.

• How is the LIHP designed?

Sacramento County selected Molina Healthcare as the “LIHP Health Plan.” In partnership, the county and Molina have created a network. Our vision for LIHP primary care

medical homes includes Federal Qualified Health Centers (FQHCs) and FQHC Look Alike Clinics: Health and Life Organization (HALO), Midtown Medical Center, Sacramento Native American Health Center, Sacramento County Clinic and The Effort. CARES, a licensed community clinic, will also participate along with Molina Medical Group, Sacramento Family Medical Center and Galt Medical Center. This provides a variety of primary care locations in several areas throughout the county.

For implementation, we will begin the network with Sutter Health and Dignity Health.

Hospital systems voiced concerns about balancing the burden of safety net services. The county and Molina made a commitment to start the LIHP with two hospital systems in place. We are striving to involve all four systems, and we estimate at least one more hospital system will join later in the project. This partnership among the county, Molina Healthcare, hospital systems, local FQHCs and medical groups is timely and unique.

• The Bridge Client applications will be screened for LIHP eligibility beginning October 2012 with an effective date of November 2012. Services to enrollees begin in November. Sacramento County has a Geographic Managed Care (GMC) model of Medi-Cal Managed Care with four commercial health plans. Sacramento County is the only county in the state utilizing a Medi-Cal Managed Care Health Plan for the LIHP. This means enrolled LIHP beneficiaries will not have to change providers when the LIHP transitions to Medi-Cal in January 2014. Developing the LIHP forged new partnerships which we hope will continue to flourish and strengthen our safety net. damianosa@saccounty.net jom@saccounty.net November/December 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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Rise of the Anti-Constipation Movement What you weren’t taught in your grade school history class

By Jack Ostrich, MD “IF YOU WOULD KNOW WHY domestic friction exists, why children are bad, why boys run away from home ... why perfectly sane and sober folks suddenly develop the most outrageous cantankerousness, the cause is not in original sin, nor the influence of psychic currents; it is more likely to be found in the vicious company of militant bacilli in the colon ... (and) ... what we call sin is due to what the physician calls stasis.” −Frank Crane, 1916 Frank Crane was an American Presbyterian minister who wrote hundreds of popular homilies called “Four Minute Essays” that were published widely and gathered in book form in the 1910s. And as the above excerpt illustrates, he was mightily influenced by the theory of autointoxication and its social sequelae.

The Colectomy Approach

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.

At about the time that Crane was preaching and writing in America, London surgeon Sir William Arbuthnot Lane preached a similar message about the human colon. He believed that the entire colon was a vestigial organ and functioned only as a cesspool which, unless whipped into action by the daily ingestion of paraffin oil (now called mineral oil) and an occasional cathartic, as well as avoidance of certain foods, would harbor toxic bacteria. He speculated that such bacteria produce dangerous byproducts responsible for diseases of all sorts.

Furthermore, these live bacteria, sitting around in a sluggish colon, were likely to be absorbed and lead to febrile illness.

Lane was, by all accounts, a charming and

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highly-intelligent man and a superb surgeon.

One would assume he was quite regular in his bowel habits as well. His friends called him Willie. For playgoers, Lane was undoubtedly the inspiration for the character named Cutler Walpole in George Bernard Shaw’s “The Doctor’s Dilemma” which premiered in London in 1906.

In the play, Walpole has discovered a previously-unknown intestinal structure called the nuciform sac. That sac, when unable to empty itself properly, would become “full of rank ptomaines” and the absorption of those toxins into the bloodstream, and thence throughout the body, would lead to all sorts of somatic and psychic mayhem. Removal of the sac was, of course, curative.

Most of Lane’s colleagues and the general public believed him when he wrote that absorption of ptomaines and live bacteria from the colon “is the cause of all the chronic diseases of civilization, I have no doubt.” One of his American friends commented: “I wish I were as sure of anything as Lane is about everything.”

Lane was about getting results. If one failed thrice daily mineral oil or other laxatives, then colectomy was the only answer. Lane perfomed hundreds in the early 20th century. Eighty-five per cent of his patients were women and his mortality rate was just under ten percent − considered very good at that time.

As the science of bacteriology and the specialty of gasteroenterology advanced, the theory of autointoxication lost credibility, as did Lane. But British preoccupation with intestinal

stasis predated Arbuthnot Lane by over 200 years.

Lifestyle and Granola Approach In 1693, the great English political philosopher John Locke, who had received a medical degree from Oxford in 1674, worried in print about his own “costive” colon and how his costiveness related to his general sense of feeling not well. He urged his fellow citizens to set aside a certain time every day (morning after breakfast was best) to “strain oneself so as to obtain a stool.” Even then, Locke would have had a wide choice of patent laxatives, such as Turlington’s Elixir Of Life and Daffy’s Elixir Salutis (elixir of health), formulated by Thomas Daffy.

It was generally agreed upon by the public and their physicians alike that constipation was pandemic and responsible for a multitude of human miseries. It was also clear that constipation was much more common among city folk and almost unheard of in the countryside where the denizens lived a more physically-active life and ate “coarser” foods.

In the 1830s, American preacher and health reformer Sylvester Graham invented “Graham’s Flour” and distributed recipes for Graham flourbased bread and muffins and, yes, crackers. As one contemporary mused, “There is no greater evil in Graham’s mind than white bread.” His bread and crackers lost popularity by about 1860 during the Civil War. The cause was taken up again by a Seventh Day Adventist preacher-physican named John Harvey Kellogg. Dr. Kellogg became the director at his church’s Western Health Reform Institute and Sanitorium in Battle Creek, Michigan, in 1876. His younger brother, Will, was the business manager. John disliked the word “sanitorium” and changed the spelling to “sanitarium.” The “San” had opened in 1866 to help care for Civil War wounded, and it became a federal hospital in 1943. Senators Robert Dole and Daniel Inouye, both wounded in WWII, were among those treated there.

Kellogg’s keystone treatment for the thousands who flocked to the San (about 300,000 clients until its closure in 1943), was

dietary. The first thing that Dr. Kellogg had to fix was your colon. No meat for you, and lots of bran and other “bulk” and “roughage.” And daily, effortless production of copious frothy, minimally-odoriferous stools was the sign that things were on the mend.

He coined the term “granola” in 1877 to describe his own mish-mosh creation of baked Graham flour with bran, nuts and other whole grains. One of his early patients, Charles William (“C.W.”) Post, saw the commercial potential for Kellogg’s various creations. He watched how Kellogg made his bran and wheat and corn-based foods, and started his own company, marketing Grape Nuts in 1898 and Post Toasties in 1906.

John Kellogg’s brother, Will Kellogg, was frustrated by John’s inability to see the possible profit in his own cereal inventions, so he took it upon himself to start mass production

November/December 2012

Photo by Kent Perryman.

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of breakfast cereals.

Kellogg’s Corn Flakes were introduced in 1902, and it is Will’s signature, not John’s, on the box. John died in 1943 at age 91 and younger brother, Will, at the same age in 1960. C.W. Post committed suicide at age 59. The Kellogg Company continues to dominate the world’s breakfast cereal market to this day.

Quick Fix Approach But for all that was known, and for all the promotion that went into the dietary treatment of constipation, most folks in Europe and the New World preferred to rid themselves of toxic waste by ingesting a convenient laxative or by using some sort of device or gadget to stimulate their large intestines. As noted earlier, mostly herb-based laxatives (gentle ones were called “aperients” and harsh ones “drastics”) were popular in the 17th century and remain so today.

Thomas Daffy’s Elixir Salutis depended on an herbal extract called scammony for its action. Many physicians, however, preferred the reliability of calomel, or chloride of mercury; but the awful toxicity of that product became clear and it was little used by the end of the 19th century.

The most popular ingredients today are cascara, senna and bisacodyl. Ex-Lax, still a very popular brand since its debut in 1906, used to depend on phenolphthalein, as did Correctol and the cleverly-named Feen-A-Mint.

But phenolphthalein was found to be possibly carcinogenic and was off the market by 1995; and now Ex-Lax relies on senna to promote

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regularity. If plain Ex-Lax fails to help, then one can try Ex-Lax Ultra which contains bisacodyl, also sold as Dulcolax.

In 1904, Nobel Prize winner-to-be, Elie Metchnikoff (he was awarded the prize in 1908 for helping elucidate the phenomenon of phagocytosis), began to promote the regular ingestion of live lactobacillus which, he said, would displace the “bad” bacteria in the colon.

Commercial production of lactobacilli-laden yogurts and milk (kefir) began soon thereafter and continue into our time where they have recently grown in popularity. Metchnikoff, incidentally, knew and consulted with Arbuthnot Lane and probably influenced the surgeon’s concept of autointoxication.

“Natural” products, like lactobacilli, have always attracted a following. Pulverized bran and psyllium seed, especially the latter, are best sellers. The first famous psyllium product, called Serutan, sponsored many radio and TV shows from the 1930s to the early 1970s. Its catch-phrase was “Serutan is Nature’s spelled backwards.” Today we have Metamucil. Spelled backwards is licumatem, which looks as if it should mean something, but does not.

Mineral-rich waters extracted from “natural” springs have been used extensively since the 17th century. From England came Epsom Water, now available in powder form as Epsom Salts, both dependent on the laxative effect of magnesium salts. In the USA, Pluto Water, from a source called Pluto Spring near French Lick, Indiana, became one of the perennially best-selling items in American pharmacies from the early 1890s to around 1930.

Some people opted for the directness of enema treatment, and Fleet enema is still a good seller. But the most famous enema treatment product in the 19th century was the “J.B.L. Cascade,” designed by Dr. Charles Tyrrell. Dr. Tyrrell also recommended that his customer buy and use his “J.B.L. Antiseptic Tonic” instead of warm tap water. The AMA had Dr. Tyrrell’s tonic analyzed and discovered it to contain table salt, borax and food coloring.

Dr. Tyrrell persisted, however, and promoted his own “Dr. Tyrrell’s Rectal Soap” to be used

prior to the insertion of his “Cascade.” It came “in the form of sticks tapering toward one end.” So if your water closet was dimly lit, the likelihood of mistaking the feel of Doctor Tyrrell’s rectal soap for the heft and shape of your grandma’s lye soap was pretty slim.

“J.B.L.,” by the way, stood for “Joy. Beauty.

Life.”

Not to be outdone by Dr. Tyrrell, Dr. T.E. Young created, promoted and sold many thousands of hard rubber, and later Bakelite sets of rectal dilators that, he said, would stimulate natural passage of stool and restore the tone of a worn out and flabby anal sphincter. They could be left in place while one slept and were best inserted after application of Dr. Young’s Pile Ointment, sold separately.

Preoccupation with colonic health and its relation to the general health of mankind continues unabated. The research done by Denis Burkitt starting in the 1960s provided some scientific basis for the recommendation of a

“high fiber” diet. In 1975, Dr. David Reuben’s book, “The Save Your Life Diet,” was on bestseller lists for over a year. Humorist Dave Barry wrote, “The international symbol for the middle class should be a stick drawing of a little person trying to read the fiber content on a cereal box.”

“Saturday Night Live” parodied a TV ad for Total cereal with one for “Colon Blow” cereal that “delivered 30,000 times more fiber than ordinary high fiber cereals.” There is now on the market a laxative product called “Colonblow.”

It costs $32.95 for a “full treatment” and is available only by mail. Its website declares that it is “always shipped discreetly.” It lists its active ingredients as senna, cascara, fig extract, prune juice powder, magnesium sulfate and psyllium.

If it doesn’t work, see your doctor. Fast. jmost119@aol.com REFERENCES “Inner Hygeine - Constipation and the Pursuit of Health in Modern Society” by James C. Whorton, Oxford University Press, 2000.

November/December 2012

These items and more can be seen in the SSVMS Museum of Medical History.

Photos by Kent Perryman.

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Memorable House Call Stories BACKGROUND: Until the 1940s, most health care in the U.S. and Europe was given by physicians in the homes of their patients.

For example, William Carlos Williams was a famous house call physician/poet. Hospitals were often for the poor who could not afford to pay a physician to come to the home. Some modern-day local physicians – albeit nowhere as many as before – have done or still do house calls. We asked SSVMS members to share some of their most memorable house call stories.

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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The daughter called me because her father had just died and her mom, my patient, was hysterical with grief. I tried to find out more on the phone, but the sound of wailing drowned out the daughter’s voice, so I grabbed my usual house call garb − sports jacket and stethoscope – and stepped into the cooling LA night.

“It happened right there.” The daughter pointed across the street, while wiping tears from her eyes. Her father was coming back to the apartment with a bouquet of flowers for her mom – it was their 50th wedding anniversary.

A car hit him on Riverside Drive. He died. The ambulance and police had come and gone.

“Mom can’t take this; it’s too much. I told her last week I have AIDS.” For a moment the room filled with more hopelessness than I could handle. I had no words. I had no cure. So I drove to the hospital down the street and brought back valium. − Bruce P. Barnett, MD, JD News Years Night. I received a call from a woman who was calling about a congregation member who called her for help because she had back pain. It was 11PM. The patient was one of my partner’s patients, an 85-year-old

Sierra Sacramento Valley Medicine

white female who lived with her daughter, a nurse, but the daughter had gone to see her sister in Walnut Creek and knew she should only be gone a few hours. Rather than send a cross-town church member to pick this woman up and take her to ER, and the fact she lived within a mile, I called her myself. She was complaining of right flank pain for six hours.

No significant past medical history that was relevant. ROS−Non-contributory except it was painful when she moved. I went over to see her myself, trying to spare everyone involved, including the ER, an unnecessary visit.

I was at her house in 10 minutes and she greeted me at the door. Exam was unremarkable except for mild distress over the pain, tenderness over the right upper paraspinous muscles and limited lumbar motion. Neuro exam negative.

I told her that the problem was muscular and recommended she take a pill (Vicodin) I had in my medical bag, get into bed and rest, and come and tell her daughter to see me or my partner in my office in the morning.

The next day about mid-morning, a woman walking with the patient I had seen the night before, hardly recognizable as she was energetic and thanking me for coming to the house, stopped by my office door. Her daughter, the nurse, chimed in, “Are you Dr. Mandaro?” Yes, I said. “You know when I got home at midnight and mother told me a doctor had come by the house and gave her a pill for her back pain and told her to rest, I thought she was hallucinating.” That made my day. −Stephen L. Mandaro, MD When I was a senior medical student at the University of Washington, I was assigned a housebound patient. She was from Russia

and spoke no English, but her daughter spoke some. On my first visit with her, I did a full comprehensive physical exam. The mother and daughter began chatting in rapid Russian and laughing. The daughter summarized: “You are very thorough and will become a professor.”

On my second visit, I was overwhelmed with the smell of onions. My patient had an onion poltice on her head treating an area of cellulitis.

We agreed she could continue this and also began her on a course of antibiotics − not sure what took care of the problem.

Another house call, when I was a junior at the University of Washingon, occurred during the summer. I was doing a psychosocial study of childhood poisoning. Part of my project was a long questionnaire that I used with the parents. My visit that day was to a father who lived in rural Seattle. He worked at Boeing Field and flew his own Cessna to work. I came out to do the interview and was told by his wife that he was on their little landing strip working on

his plane. He said he would be happy to do the questionnaire, but would I mind doing it while he tested his repairs. OK−we took off. I had never been in a little plane before; the strip was short and I was convinced we would crash into the huge evergreens that surrounded his little field. Once in the air, he said he could not concentrate on the questions and fly, so he said “you fly” and he would write out the answers, which we did for 30 minutes while I steered the plane around Seattle. I think this cured me of any interest in flying small planes.−Jim Margolis, MD In my role as Medical Director for Bristol Hospice, I made a home visit to see an elderly gentleman with end-stage CHF and COPD who had just been discharged from the hospital after a two-week stay for respiratory failure. Several attempts to extubate him in the hospital were unsuccessful and he was sent home (per his request) for terminal extubation and was

Your care makes all the difference.

Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

|

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.

November/December 2012

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expected to die within minutes-hours. I was in the home to supervise the extubation and help the family understand the process. To my great surprise, he did not die after his extubation. In fact, over succeeding weeks he was able to discontinue oxygen, became ambulatory and able to eat, and enjoyed quality time with his family. Eight weeks after his “terminal extubation,” he died quietly in his sleep after a good day. −Mark Blum, MD

After I examined her, she asked if I would look at her dog’s eyes…

I have made house calls to almost every dying patient who could no longer get to my office. The one that sticks in my memory, though, is one to another doctor’s patient when I was on call on a Sunday. An elderly lady was ill at home and the niece called to get help. I told her to take her to the ER (sounded like pneumonia). The niece said she couldn’t afford it and could I come to see her? The house was near my office, so I agreed. The lady was weak and, by the time I got there, had fallen. She absolutely refused an ambulance and was too heavy to lift, so we ended up moving a mattress from a bed to the floor, so she could have something to lie down on, and I called in an antibiotic. −Ann Gerhardt, MD I went to visit an elderly lady with an eye infection at her home and took my indirect ophthalmoscope to view the retina of her eye since she said her vision was bothering her, as well. After I examined her, she asked if I would look at her dog’s eyes to see if it had cataracts. Having not done that before, and assuming her dog was friendly, I thought, hey, what a great idea. As I proceeded to look into that dog’s eye with the bright ophthalmoscope, it for some reason, took affront to me, and lunged at me to bite me. Luckily, I moved my hands quickly enough to avoid injury.

Since then I have continued avoiding veterinary ophthalmology in an uncontrolled setting.

Submitted by 10-fingered Bob Bellinoff. If my name were Frodo, it would have been a different story. −Robert Bellinoff, MD Ambulance service was slow 25 years ago to

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my hamlet 18 miles south of town, so I carried a fishing tackle box full of basic meds of the day: cedilanid, mercuhydrin, aminophyllin, adrenalin, morphine sulfate and alongside, oxygen. In the fog, ambulances would take an hour and on the other end, no emergency rooms were staffed like today. A few times for pulmonary edema, I mixed all of the above drugs in one syringe except the adrenalin and slow pushed it into an antecubital vein, taping down an 18-gauge needle (no intracaths). A couple of years later, defibrillators became available, so I had one of those, too. One hot day, I got a call to a truck yard where a large truck driver was lying there on the gravel and the forklift driver was doing CPR − learned it watching TV shows, he said later. The paddle sensors showed V fib, and I immediately shocked him. No luck.

Pushed an amp of bicarb and one of lido and zapped him again, this time he converted into a useful rhythm. He made it. Never had to use the defibrillator again. −Henry Go, MD Teaching moments come in many places, but house calls produce some of the most memorable. The resident accompanied me to the home of an elderly patient with dementia.

A lovely home in a middle-class neighborhood where her adult son tended to her needs.

He greeted us in the living room and we chatted. When we said we wanted to see his mother, he proudly took us to the kitchen where she was lying on a plastic tablecloth, his idea of efficiently dealing with her daytime incontinence. We promptly made arrangements for a trip to the hospital and a call to adult protective services.

On another house call, seeing the rather quiet, introverted, single, elderly female in the office, there was just something about her that could not be understood. She agreed to allow the medical student and me to visit. How instructive it was to enter her paranoid world where several rooms were barred to keep the “El Salvador” invaders out of her apartment.

Delores was starting to demonstrate cognitive impairment and lived alone, so it

was a great opportunity to visit with a medical student. Opening the door to her dilapidated house, we had to step back before we could step in, so overpowered were we by the smell of cat urine. Cat feces, cats, clutter everywhere as we carefully made our way through the limited walking space. Bathroom space belonged to the cats whereas the kitchen was overstocked with cans and foods collected and forgotten.

A garage was also filled with “stuff.” Delores was oblivious to the intrusion of her space. I am happy to report that, with help from our case manager, Delores now happily and wheeze free, lives in a memory board and care home and her only cat is of the fluffy stuffed variety. −Marion Leff, MD My most memorable house call was when I was a resident in Milwaukee. I went to visit the home of an elderly man who was demented from tertiary syphilis. They were poor and had no transportation; their home was one of many “shotgun” houses that make up the housing complexes in that large area.

The outside of the home was barely surviving; the inside was neat and fairly clean, but all of the furnishings were old and worn. He was in the back bedroom and I was escorted there by his wife. He lay on his side, toward the wall. He conversed, but not coherently. I did my examination and administered the Penicillin – it didn’t seem to hurt him much. I was struck by the impact of poverty on how people live. I recently drove through that neighborhood; it hasn’t changed much. Experience is a much better teacher than pictures.

My most memorable event that was not a house call was when I recently went to visit a patient in rural Sacramento County. I had never been there, and I pulled up to what turned out to be the wrong house. The house was dilapidated. It was a warm, dark summer evening.

The screen door hung open. I

knocked and was told to “come in.” Sitting in the small living room were a man − tall, skinny, scraggly shoulder-length hair and his companion − a pale, dark-haired woman with no teeth. Both, I would say, were in their late 30s. There were two folding chairs in the room and a TV – nothing else – except the German Shepherd and the Pit Bull. I was clearly in the wrong place. He directed me next door where I learned they had some “issues” with drugs. There are probably hundreds of these barely-surviving people living just under the surface of our communities. Again, experience is everything. −Thom Atkins, MD As a young family doc who does occasional house calls, I made two house calls to a young obese girl with Prader-Willi syndrome. She was conversant with a happy disposition, but she was developmentally-delayed and liked to consume any food item in sight. During the first visit, she was snacking on junk food and

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…it gave me an appreciation for how much a person’s wellness depends on factors outside the medical office.

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drinking juice during the whole 45 minutes I was there. This was between meals. Her family was pretty obese as well. They were loving, but there wasn’t much of a schedule, nor rules enforced. Later that year, the girl was admitted for sepsis and was intubated. She had a long recovery complicated by steroid myopathy from her sepsis treatment. She had to learn to walk again.

The family received a variety of in-home services afterwards, part of which was nutritional in nature. At a follow up home visit, the whole family looked healthier, had more structured eating habits with healthier food choices, less video games, more family time at the dinner table, and foods were kept secured in high cabinets in the kitchen. The girl used a walker to get around, and we practiced laps around the dinner table together. She showed me her favorite Dora the Explorer toys. I’m not sure what, if any, difference I made. Sometimes it takes a crisis to make meaningful changes happen. But I was glad that I could witness this transformation, and it gave me an appreciation for how much a person’s wellness depends on factors outside the medical office. −Nate Hitzeman, MD All healthcare organizations are tightening their belts and pushing their workers to do more with less. Chronic understaffing of the clinic where I work has forced physicians into support staff roles in order to keep our practices up and running. A patient scheduled for surgery in less than a week had his pre-op appointment cancelled due to a scheduling error and no appointments were available at a time he could come in. He had not received his pre-op paperwork and stated he was not coming in to pick it up because he could not miss the time from work and was supposed to have received the packet in the mail weeks before. There was no time to mail it.

When the clinic staff presented me with this information, mentioning that the patient seemed exceptionally angry, I could see no choice but to deliver the pre-op packet to the patient’s house myself. Leaving the office at 6

Sierra Sacramento Valley Medicine

PM, I drove about 20 minutes to the patient’s house, and parked my car across the street and walked to the front door. As I searched for a doorbell, I sensed some eyes on me. I knocked on the door, nervous, then I saw it. It was a dog, medium-sized, black and white, some type of terrier, standing next to a bush by the driveway, glowering at me, crouched.

I backed away, hair on my neck standing up, and the dog sensed my fear (as they do) and took the upper hand. He began to bark, taking steps toward me as I backed out into the deserted street. I pressed the button on my car key to open the locks and made a run for it. I got into the car and slammed the door before the dog got to me, but he was in the street, barking ferociously now. It was then that I realized I no longer had the pre-op packet in my hand. I turned the car around (after locking the doors, again) and drove slowly by the patient’s house, looking. The white envelope was on the ground in front of the front door, where I must have dropped it. The front door remained closed. I figured that would have to be good enough and headed home. −Amy Williams Black, MD Sunday evening, Feb. 16, 1964: I was on call for our GP group and made a house call to the patient of my partner, a multipara. A middle-aged man answered the door. There were several people in the room, an elderly woman, a young couple, and two children, who were attentively watching a TV. “Thanks, Doc,” said my host, and without another word, pointed to an obviously pregnant woman lying on the couch on a plastic sheet covered with clean towels. Adjacent were a bassinette and more towels. The TV screen held a grainy black-and-white image of Ed Sullivan standing stiffly, arms crossed, grimacing and pursing his lips as if he had just sucked a lemon. I spoke with the patient, who answered clearly over the TV noise. Her cramps had been regular, frequent, and gathering in intensity for the few hours, after she broke water.

“Do you think I should examine you in the bedroom?” I asked.

“No, Doc, don’t think I can make it. They’re

About 10 years ago I acquired a patient in her late 30s with advanced Multiple Sclerosis.

She had failed on all the conventional therapies at the time, was nearly quadruplegic, quite dysarthric and required an indwelling urinary catheter. Her mother almost always came with her, having had to arrange ambulance transportation, for 15-20 minutes of trying to manipulate symptomatic meds. I learned that Lynn lived with her husband, Alex, about 15 minutes from my home in Orangevale, so I started seeing her on house-calls every two or three months, when I had a weekend off.

To my surprise, Alex has advanced and progressive ALS (Lou Gehrig’s disease), but was initially up and about with a walker. They both slowly and inexorably deteriorated, and Lynn has since died. But I think they liked the visits, as their diseases rather isolated them. On one visit, late in her course, I noticed remnants of a small party the day before − their 25th anniversary. On top of the piano was a silver-framed picture of the two of them on their wedding day. Two more handsome, cheerful, intelligent creatures could not be imagined. Had they been

able to foresee their future on that day, they probably would have thought that they would find a way to overcome any difficulties they might ever face. I went home and held my wife very close for a very long time. −David F. Dozier, Jr., MD

What did former SSVMS presidents Jack Ostrich and John Whitelaw do during the week of September 16, 2012?

1.

2.

3.

4.

5.

They They They They They

stopped smoking. bought new socks. found their keys. finally registered to vote. both made a hole-in-one.

Answer: 5

pretty strong. Everything’s ready.” As I began to examine her, she directed her attention back to the TV. She was crowning. Very quickly, very quietly, very smoothly, to the strains of I Wanna Hold Your Hand, a small healthy boy was delivered followed immediately by the placenta. I remembered, “This is the third weekly Beetles Sullivan show.”

So we listened to “All My Loving” as I attended the baby, wrapped up the placenta, and massaged the uterus. Bleeding was minimal.

“It’s best to go to the hospital now,” I said.

“OK,” she said absently, turning back to Sullivan. “Jack’ll take us after the show.” −John Loofbourow, MD

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AD INDEX BloodSource............................................................................23 Connections.............................................................................10 Hardy Erich Brown & Wilson...................................................13 Marsh.......................................................................................11 NORCAL Mutual Insurance Company.........Outside Back Cover Radiological Associates.............................................................9 Schuering Zimmerman & Doyle.................... Inside Front Cover Sierra Treatment Center..........................................................25 Sutter Community Connect........................... Inside Front Cover The Doctors Center...................................................................2 Tracy Zweig Associates...........................................................27 UC Davis.........................................................Inside Back Cover Walk With a Doc.............................................Inside Back Cover Wilke Fleury.............................................................................15

PLANET

E L LY

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

“Hygienic Osculation” Though they affirm A deadly germ Lurks in the sweetest kiss; Let’s hope the day Is far away Of antiseptic bliss.

So, pray, let me philosophize; To sterilize a lady’s sighs Would simply be outrageous; I’d much prefer To humor her And let her be contagious.

From The Annual of the Children’s Hospital Training School for Nurses, published by The Student Nurses, June 1924.

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Preparing for My Weight Loss Surgery

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.

I’M NOT READY TO GO UNDER the knife just yet. In fact, my BMI currently falls under the normal range. But by the looks of things around me – and with the holidays upon us – it’s just a matter of time before I fall victim too.

Two thirds of us Americans are overweight or obese – and climbing. A diabetes expert friend of mine once said, “I was at an airport in Atlanta recently, everyone was so huge, and I thought I was going to catch diabetes!”

California is perhaps a decade or two behind Atlanta statistics, but a complacent man is a foolish one. To prepare myself for the inevitable, I’ve taken to reviewing as much as I can about the history of bariatric surgery – how it began and where it is heading. The following I share with you in case you are in preparation too.

I’ve been intrigued with bariatric surgery ever since hearing about a “Roux” and a “Y.” The Y seemed to visually agree with me as it describes how the anastomosed bowels reside.

The Roux derails me and makes me think of something culinary – and indeed, it is the Roux limb that carries the digested food – although, apparently it is the name of the Swiss surgeon who first described the procedure circa 1900.

Terms like stomach stapling and gastric banding seem intuitive. Other descriptors are more perplexing: like the biliopancreatic diversion, the duodenal switch, and the sleeve gastrectomy (see diagrams). To simplify, it might be best to think of bariatric surgeries as falling into one of the following general categories: “malabsorptive,” “restrictive,” and “combined malabsorptive and restrictive.”

Before I review the different methods and how they came about, let me say that no

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technique is perfect, and each carries significant risks (although, so too does remaining morbidly obese). America’s currently fragmented health care system does not make it an ideal time to get our weight loss surgery. Follow-up can be atrocious. I’ve seen Blue Cross Medi-Cal patients referred as far as Fresno to have the surgery done and return up north just in time to have complications. (Try asking the ambulance driver to take you back to Fresno!)

Two months ago on the inpatient service, I saw two patients who had bariatric surgeries years ago. They had chronic pain and were reduced to “GI cripples,” as one resident put it.

Neither wished, in hindsight, that they had had it done. Neither recalled what exactly had been done anatomically speaking. Trying to consult a gastroenterologist to scope the patients was problematic, given the anatomical uncertainties.

And then there was my well-insured clinic patient who was talked into a “lap band” and didn’t lose any weight (despite multiple injections into his port and admonishments from his surgeon that he wasn’t following his diet). He entered Medicare territory and the surgeon no longer accepted his insurance, and now he goes to a nearby academic center to figure out how to get the lap band removed, and how to get a more substantial bariatric surgery done.

I had another patient mysteriously die last year following dramatic weight loss from a gastric bypass, and I’ve often wondered if he killed himself (a Utah study showed bariatric surgery patients to be about thrice as likely to commit suicide – about two out of 1,000 people at a seven-year follow up). Bariatric surgery

patients also require a lifetime of laboratory surveillance for nutritional deficiencies. These biannual labs do not come cheap, and when folks lose their insurance, they do not come at all.

On the other hand, I’ve seen good outcomes too. A young lady who slimmed down into a gorgeous physique and got a better job, found romance, got pregnant, and is now a happy single mom. By the way, obstetricians bite their nails monitoring these patients in pregnancy. I’ve seen folks shake off their diabetes and hypertension.

Authors of bariatric studies do embellish this by only publishing results at one to two years out – the time when most patients have achieved peak weight loss and before they start gaining it back!

I’ve also seen patients who have been able to take up a sport or hobby again thanks to the mobility afforded them by the weight loss.

Thanks to the study in Utah, we also now have evidence that bariatric surgery decreases mortality (NNT = 100 over seven years).

And now for the A-to-Z history of weight loss surgery with special emphasis on the letter Y…

Malabsorptive Methods Astute surgeons had long noted that patients who lost a good portion of their intestines due to a medical illness lost weight as a result. But it was not until the 1950s that surgeons at the University of Minnesota thought to create “short gut syndrome” on purpose for their obese patients. Richard Varco, proclaimed to be the “best technical surgeon” of the bunch, performed the first jejunoileal bypass (JIB) in 1953. But it was Arnold Kemen and John Linner who gave the first published report in 1954 of their similar surgery on Ruth Dvork, a 5-foot-4inch, 385-pound lady.

Dr. Linner had been doing research on selectively removing parts of dog intestines at the time. When he mentioned this to his patient in passing, she insisted that he try the technique on her. As Dr. Linner states in a 2007 essay, there was “no investigative review board at the time and little concern for litigation.” Ms. Dvork subsequently had three more surgeries over the next 17 years: two to treat gastrointestinal

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Astute surgeons had long noted that patients who lost a good portion of their intestines due to a medical illness lost weight as a result.

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hemorrhage, and one to improve the weight loss. She ultimately seemed to benefit from the weight loss surgery.

The first JI bypasses were not much more than reconnecting the jejunum to the ileum and bypassing a large segment in between. The segment was either left blind (which sometimes led to “blind loop syndrome”), anastomosed to the transverse colon for companionship, or excised from the corpus altogether (the latter done by the Swedes). JI bypasses were commonly done for the next 15 years. Diarrhea and nutritional deficiencies were rampant, but seemed manageable. Ultimately though, one third to one half of these patients developed liver failure or cirrhosis.

In 1979, Italian surgeon Nicola Scopinaro introduced the biliopancreatic diversion (BPD).

The surgery consisted of two steps: a limited gastrectomy (about a one-third reduction) and a long biliopancreatic malabsorption limb.

Basically, the ileum is transected, and the distal cut end brought all the way up to the diminished stomach, and the proximal cut end with the bile and pancreatic juices is reattached further down on the ileum. This gives a Y configuration with a very long malabsorption limb from the gallbladder/pancreas, and a very short Y stem where the common intestinal channel runs only 50 cm before dumping into the cecum.

The upside is that this is the most effective weight loss surgery to date. The downsides are crazy diarrhea, anemia, protein deficiency, anastomotic leaks, stomal ulcers, bone demineralization, and dumping syndrome (where a large bolus of carbs fast-tracks right through the stomach and overwhelms the small intestine and endocrine system).

In 1988, Canadian Picard Marceau added a “duodenal switch” to the BPD. He introduced a sleeve gastrectomy where the greater curvature portion of the stomach was removed, and the antrum/pyloric sphincter was preserved.

This technique added a “restrictive” feature and eliminated stomal ulcers and dumping syndrome; however, diarrhea and nutritional deficiencies persisted.

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Restrictive Methods The premise of restrictive methods is making a smaller stomach which accepts less food and leads to early satiety (unless one wants to vomit). Almost two decades after his colleagues brought us the intestinal bypass, University of Minnesota’s Edward Mason performed the first weight loss gastroplasty in 1971. The stomach was near-completely horizontally partitioned (think Korea) while still communicating at the greater curvature side. Weight loss was not great.

A series of surgeons sought to perfect the gastroplasty throughout the 1970s and tried communication channels midway between the curvatures, mesh techniques, creating a circular window halfway across the stomach to use as an anchor point, insertion of a silastic ring, and finally vertical partitioning to quarantine the greater-curvature side of the stomach (think Soviet-era Germany).

In 1980, Dr. Mason aptly culminated these ideas by performing the vertical banded gastroplasty. This technique uses staples, a circular window anchor point, and a banded narrow channel hugging the lesser curvature to produce a 15-mL stomach pouch just distal to the esophagus. This is fondly referred to as the “thumb-size stomach.” The benefits of the surgery are avoidance of anastomosis (and risk of leakage) and no malabsorption. The downsides are that patients do not lose as much weight as with the intestinal bypasses.

Also, about five percent of patients develop problematic strictures of the banded channel.

Gastro-gastric fistulas may also occur.

During the 1980s and 1990s, surgeons were enthralled with the idea of putting a tight belt externally around the stomach rather than stapling it into sections. In 1993, Dr. Belachew performed the first laparoscopic adjustable banding bariatric surgery. In 1999, the first robotic gastric banding surgery was performed; in fact, it was the first robotic surgery ever! In 2001, the FDA approved the “lap band.” The benefits of the lap band are its reversibility and adjustability. Its weaknesses are possible slippage, erosion through the wall, gastric

obstruction, and less weight loss than with other techniques.

Combining Malabsorptive and Restrictive Methods – The Rise of the Gastric Bypass In 1966, during the heyday of the jejunoileal bypass (JIB) but before the advent of the biliopancreatic diversions (BPD) and pure gastroplasties, Edward Mason (yes, that same guy again) pioneered what would become the modern day Roux-en-Y. Adapting the Billroth II gastrojejunostomy to weight loss, he basically decapitated the upper stomach horizontally and attached it to jejunum. The stomach was made functionally smaller (restrictive method), and part of the intestine was bypassed (malabsorptive) – but not as much as with the JIB and soon-to-be discovered BPD. The vertical banded gastroplasty developed

by Dr. Mason in 1980 was married to his gastric bypass technique of 1966 by a Dr. Salmon in 1988. In 1993, Drs. Wittgrove and Clark performed the first laparoscopic Roux-en-Y. Currently, 90 percent of our 140,000+ annual bariatric surgeries are gastric bypasses. Weight loss nears that of BPD, but side effects are fewer.

Still these patients need to be closely monitored for follow-up complications and nutritional deficiencies.

New Fads As mentioned above, Canadian Picard Marceau introduced the sleeve gastrectomy to his “duodenal switch” BPD surgery in 1993.

With this method, 80 percent of the greater curvature side of the stomach is removed leaving a thin “sleeve” of a stomach behind. Since 2006, this sleeve technique has been used as a first stage to a gastric bypass. About half of patients may suffice with just the sleeve alone.

Implantable electric stimulators have become popular for the heart, spine, and brain.

In 1995, Dr. Cigaina implanted electrodes in the stomach wall of a patient and placed the battery pack in the wall of the rectum. Although considered minimally invasive (I might beg to differ based on the location of battery pack),

weight loss was suboptimal.

Endoluminal methods of restriction and bypass are being studied (imagine the intestinal equivalent of a female condom). In 2001, Dr. Evans demonstrated a balloon device that takes up space in the stomach. In 2006, polyethylene sleeves were inserted into pig intestines serving as “levees” which avoid absorption of digested food through the duodenum and jejunum. An analogous device would be the endovascular grafts used for aortic aneurysms.

In conclusion, the journey of bariatric surgery is just beginning. Clearly there is no end to how surgeons want to mess with our insides.

In fact, one surgeon friend of mine chuckled, “If there is more than one operation for a particular disease, then that means we haven’t figured out the right one yet!”

Hopefully, this review will help you and me to make the right decision someday. Until then, eat, drink, and be merry!

Please feel free to email Dr. Hitzeman for more articles which speak to the aftercare of bariatric surgery patients.

hitzemn@sutterhealth.org

1800s: How to Tell Whether a Person is Dead or Alive Apply the flame of a candle to the tip of one of the great toes of the supposed corpse, and a blister will immediately rise. If the vitality is gone this will be full of air, and will burst with some noise if the flame is applied to it a few seconds longer; if life is not extinct, the blister will be full of matter and will not burst. The public will doubtless be glad to know of a simple test which can be used even where there is no reasonable doubt, and thus free the mind from future misgivings as to whether or not a friend of relative might not after all have had some life left when the body was treated as a corpse. Though very few are actually buried alive, many more may be abandoned as dead while life is still in them, and then die from being handled and exposed as corpses are. The test, therefore, should be applied as soon as life is supposed to be extinct, and before an undertaker is called in.

“Out of the Doctor’s Bag,” 1990 publication of the Sacramento History Center.

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Board Briefs September 10, 2012 The Board: Received an annual update regarding the Community Service, Education and Research Fund (CSERF), the Society’s 501(c)(3) charitable organization, from Ms. Kris Wallach, Program Manager, and Dr. Jack Rozance, Chair, of CSERF’s SPIRIT Management Committee. The following programs are maintained within the organization: Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT), the Adopt-a-School Program, the William E. Dochterman Medical Student Scholarship Fund and the Sierra Sacramento Valley Museum of Medical History.

Approved the purchase of two tables at the CMA Foundation Annual Gala October 14, 2012 honoring SSVMS Member and Past President, Paul R. Phinney, MD as CMA’s 2013 President.

Unanimously approved a recommendation to the CALPAC Board of Directors concerning county medical society recommendations to CALPAC for support, neutrality, or non-support of a candidate for State Senate, State Assembly or Congress.

Approved a revision to Reduced Dues Policy 500-16, to eliminate the 25 percent second year discount for firsttime regular active members and continue to provide a 50 percent reduction for the first year for first-time regular active membership. The revised policy is effective January 1, 2013.

Approved the 2012 Second Quarter Financial Statements, Investment Reports and Recommendations.

Approved revisions to Policy 200-01, SSVMS Involvement in Political Activity and Support of Candidates for Public Office and Political Campaigns, that clarifies the use of SSVMS facilities for political fundraisers and candidate events.

Approved the re-nominations for another term on the CALPAC Board of Directors for Demetrios Simopoulos, MD, representing Senate District 1, and Lee Snook, MD, representing Senate District 6.

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Approved the Scholarship and Awards Committee recommendation to provide grants from the William E. Dochterman Medical Student Scholarship Fund to the following individuals: Ali Alvandi, 1st year student at UC Davis School of Medicine; Brandon J. Cortez, 1st year student at UC San Diego School of Medicine; Tony Cun, 2nd year student at UC Los Angeles David Geffen School of Medicine; Andrea L. Nos, 3rd year student at Loyola University Stritch School of Medicine; Daniel C. O’Brien, 3rd year student at UC Davis School of Medicine.

Approved the Membership Report: For Active Membership — Christopher R. Balwanz, MD; Jessica H. Derkacs, MD; Don M. Fernandez, MD; Vikant Gulati, MD; Nina K. Hansra, MD; Ben M. Hunt, MD; Karly A. Kaplan, MD; Seshadri Kasturi, MD; Brett R. Laurence, MD; Jennifer C. Lee, MD; Anjlee Mahajan, MD; Uppinder K. Matu, MD; Koorosh Moezardalan, MD; Alastair T. Mondala, MD; Nikki H-T Pham, MD; Steven Z. Paik, MD; Raghav Raman, MD; Mohammad S. Reza, MD; Rachel E. Rockford, MD; Lisa M. Sprowl, MD; Vinod Trivedi, MD; Chor Vang, MD; John D. Verzosa, MD; Garth S. Watkins, MD; Ellen M. Wiegner, MD; Mindy A. Young-Reeves, MD; Nanfei Zhang, MD; David H. Zinn, MD. For Resident Membership — Oma N. Agbai, MD; David J. Boudreault, MD; Katherine T.S. Cayetano, MD; Sharon J. DiPierro, MD; Jeffrey S. Fountain, DO; Isaac Kim, MD; Charles A. Poon, MD; Bajinder S. Sidhu, MD; Kristin Sohn, MD; Allen K-L Tong, MD; William W. Tseng, MD; Jeffrey R. Willis, MD. For Reinstatement to Active Membership for Former Members — Suzanne E. Generao, MD; Mark W. Roberts, MD. For Resignation — Sobha Kollipara, MD (Transferred to Placer-Nevada Medical Society).

Dropped for Nonpayment of 2012 Dues — Richard C. Lynton, MD.

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.

Agbai, Oma N., Dermatology, Temple University 2010, UCDMC, 3301 C St #1300, Sacramento 95816 (916) 734-6111 (Resident Member)

Hansra, Nina K., Dermatology, UC San Francisco 2008, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 631-3010

Pham, Nikki HT, Family Medicine, UC San Diego 2008, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-4040

Anderson, Ivan B., Cardiovascular Disease, University of Nevada 2008, UCDMC, 4150 V St #2400, Sacramento 95817 (916) 734-3761 (Resident Member)

Hunt, Alexandra Y., Family Medicine, University of Washington 2012, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., Sacramento 95816 (916) 731-7866 (Resident Member)

Poon, Charles A., Pulmonary Critical Care Medicine, Loma Linda University 2006, UCDMC, 4150 V St #3400, Sacramento 95817 (916) 734-2812 (Resident Member)

Bellum, Venugopal, Family Medicine, UHS/Vijay Awada Kakatiya, India 1999, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Boudreault, David J., Plastic Surgery, St. Louis University 2005, UCDMC, 3301 C St #1100, Sacramento 95816 (916) 734-7844 (Resident Member) Cayetano, Katherine T., Pulmonary Critical Care Medicine, Univ of the East, Philippines 2000, UCDMC, 4150 V St #3400, Sacramento 95817 (916) 734-2812 (Resident Member) Cragun, Jeffrey R., OB-GYN, UCLA 1982, Folsom OB-GYN, 1735 Creekside Dr, Folsom 95630 (916) 983-3500 Danielson, Daren S., Thoracic Surgery, Univ Minnesota 1997, Sac Cardiovascular Surgeons, 5301 F St #111, Sacramento 95819 (916) 452-8291 DiPierro, Sharon J., Pediatrics, Alpert Medical School of Brown University 2010, UCDMC, 2516 Stockton Blvd., Sacramento 95817 (916) 734-5177 (Resident Member) Fernandez, Don M., Pulmonary Critical Care Medicine, Michigan State University 1999, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040 Fisher, Stephen N., General Practice/Radiology, University of Illinois 1966, 1321 Howe Ave #225, Sacramento 95825 (916) 564-2225 Foondos, Theodore J., Family Medicine, Uniformed Services Univ 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Fountain, Jeffrey S., DO, Radiology, Michigan State University 2007, UCDMC, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member) Freeman, Allison C., Family Medicine, UC Irvine 2012, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., Sacramento 95816 (916) 731-7866 (Resident Member) Goshike, Deepika S., Family Medicine, UHS/ Vijayawada Osmania, India 2002, Mercy Medical Group, 1700 Prairie City Rd, Folsom 95630 (916) 351-4800

Hunt, Ben M., Thoracic Surgery, UC San Francisco 2006, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Posten, John, DO, Family Medicine, Touro University 2012, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., Sacramento 95816 (916) 731-7866 (Resident Member)

Jacob, N. John, Psychiatry, Medical College of Calicut, India 1986, Mercy Medical Group, 1792 Tribute Rd #350, Sacramento 95815 (916) 924-6400

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

Jian, Brian J., Neurosurgery, University of Pittsburgh 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490

Reza, Mohammad S., Family Medicine, Ross University 2007, Mercy Medical Group, 550 W. Ranch View Dr #3000, Rocklin 95765 (916) 409-1400

Kaplan, Karly A., Plastic Surgery/Microsurgery/ Breast Construction, University of Florida 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Roberts, Mark W., General Surgery, Loma Linda University 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Kasturi, Seshadri, Urogynecology, Sri Ramachandra Medical College, India 2004, Urogynecology Consultants, 87 Scripps Dr #310, Sacramento 95825 (916) 779-1160 Kim, Isaac, Family Medicine, UC Davis 2011, MercyMethodist Family Residency Program, 7500 Hospital Dr, Sacramento 95823 (916) 681-1900 (Resident Member) Lee, Jennifer C., Internal Medicine, Drexel University 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Mahesh, Saradha O., Internal Medicine, The Tamil Nadu/MGR Medical Univ, India 2003, Mercy Medical Group/Mercy-Methodist Hospital, 7500 Hospital Dr, Sacramento 95823 (916) 423-3000 Mondala, Alastair T., Family Medicine, University of Santo Tomas, Philippines 1996, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Rockford, Rachel E., Emergency Medicine, Pennsylvania State University 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Sidhu, Baljinder S., Pulmonary Critical Care/Sleep Medicine, St. George’s University 2006, UCDMC, 4150 V St #3400, Sacramento 95817 (916) 734-2812 (Resident Member) Sohn, Kristin, Pediatrics, University of Nevada 2012, UCDMC, 2516 Stockton Blvd., Sacramento 95817 (916) 734-5177 (Resident Member) Sprowl, Lisa M., Family Medicine, UHS/The Chicago Medical School 2009, Mercy Medical Group, 4400 Duckhorn Dr #100, Sacramento 95834 (916) 575-8000 Taylor, Aisha R., OB-GYN, Temple University 2006, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-3080

Moulin, Aimee K., Emergency Medicine, Univ of Southern California 2002, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010

Tong, Allen K-L, Internal Medicine, Dartmouth Medical School 2007, UCDMC, 4150 V St #3100, Sacramento 95817 (916) 734-2812 (Resident Member)

Niedbalec, Erica C., Internal Medicine, Albany Medical College 2009, Mercy Medical Group/Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 983-7400

Trivedi, Vinod, Infectious Disease, Patna Medical College, India 1995, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040

Paik, Steven Z., Internal Medicine, UHS/The Chicago Medical School 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 627-7971

Tseng, William W., Pulmonary Critical Care Medicine, Dartmouth Medical School 2007, UCDMC, 4150 V St #3100, Sacramento 95817 (916) 734-2812 (Resident Member) continued on next page

November/December 2012

35

Classified Advertising

Office Space 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.

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.

Medical Record Document Management • Medical records storage • Quick delivery • Image conversion of paper records to attach to your EMR • Secure, confidential shredding • 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

Membership Has Its Benefits!

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

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

Car Rental / Avis or Hertz

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

Clinical Reference Guides

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

Conference Room Rentals

Medical Society 916.452.2671

Credit Card

CMA rewards credit card, Bank of America 1.866.598.4970

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

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

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

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

Insurance Marsh Life, Disability, Long Term Care 1.800.842.3761 Medical/Dental, Workers’ Comp, more… www.CountyCMAMemberInsurance.com Legal Services & CMA On-Call Documents

800.786.4262 / www.cmanet.org/member

Magazine Subscriptions 50% off subscriptions

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

Medic Alert

1.800.253.7880 / www.medicalert.org/cma

Merchant Services/Payroll Services/ Heartland Payment Systems 1.866.941.1477 Check Management www.heartlandpaymentsystems.com Practice Financing Reduced Loan Administration Fees

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

Reimbursement Helpline Assistance with contracting or reimbursement

CMA 1.888.401.5911

Security Prescriptions Products

RX Security www.rxsecurity.com/cma.php

Travel Accident Insurance/Free

All SSVMS Members $100,000 Automatic Policy

Meet the Applicants continued from page 35

Visit our magazine archives to catch up on previous issues. Just use your smart phone to scan this code:

Vance, Michael C., Orthopedic Surgery/Hand & Upper Extremity, University of Cincinnati 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5275

Willis, Jeffrey R., Ophthalmology, University of Maryland 2011, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6603 (Resident Member)

Vang, Chor, Family Medicine, UC Davis 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95852 (916) 973-5000

Young-Reeves, Mindy A., General Surgery, UC Davis 2007, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4144

Wallach, Stacey J., OB-GYN, SUNY-Stony Brook 1995, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-6821

Zhang, Nanfei, Opthalmology (Glaucoma), Duke University 2007, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015

Wiegner, Ellen M., Radiation Oncology, Stanford University 2007, Mercy Medical Group, 3301 C St #550, Sacramento 95816 (916) 556-3200

36

Sierra Sacramento Valley Medicine

Walk With A Doc is a FREE walking program for anyone who is interested in taking steps to improve their heart health.

Each walk is hosted by a friendly local physician.

In addition to the numerous health benefits you’ll enjoy just by walking, you’ll also get the chance to talk with the doc while you walk.

Upcoming Walks: Date: Saturday, November 3, 2012 Location: Tahoe Park, Sacramento 8th Avenue and 61st Street

Date: Saturday, November 10, 2012 Location: UC Davis Arboretum, Davis

Walking for as little as 30 minutes a day can reduce your risk of coronary heart disease, improve your blood pressure and blood sugar levels, elevate your mood, and reduce your risk of osteoporosis, cancer and diabetes.

Sponsored by:

Wyatt Deck on Old Davis Road

Date: Saturday, November 17, 2012 Location: Southside Park, Sacramento

co-sponsored by:

Between W and T Streets at 6th Street

WHO CAN ATTEND: ANYONE. Bring a friend!

TIME: Registration starts at 8:00 a.m.

Walk starts at 8:30 a.m.

www.ssvms.org/Programs/WalkWithADoc.aspx

CREDITS AWARDED

RISK MANAGEMENT

22,689

CmE

To improve patient safety, you need to stay on top of best practices. That’s why, as shown by the 2011 numbers above, we provide you the risk management advice you need, when and how you want it. It’s why we provide industry-leading CME online and through Claims Rx, our monthly publication based on closed claims. And why we tailor solutions to help with your specific risk issues. The results include 98% policyholder retention, the highest-level CME accreditation and reduced risk for you.

Call 877-453-4486 or visit norCalmutual.Com Proud to be endorsed by the Sierra Sacramento Valley Medical Society

Our passion protects your practice