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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2014

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Medicine 3



Hygiene – Man Does not Live by Soap Alone

José A. Arévalo, MD

Jack Ostrich, MD


EDITOR’S MESSAGE Santa Claus and “low T”


SSVMS Public Health Programs Receive Awards

Nathan Hitzeman, MD

Kris Wallach, SPIRIT Program Director




A Posit on Bariatric Surgery Coverage

Aileen Wetzel, Executive Director


Covered California FAQs for Clinicians and Their Staff


The Times and Standard of Care are A-Changin’


Ann Gerhardt, MD

Medical Eponyms – A Fun Look at What’s in a Name!


Should my Daughter go into Medicine?

Nan Nichols Crussell, Managing Editor

Christian Serdahl, MD


SSVMS Election Results


The Voice of the Underworld


John Loofbourow, MD

IN MEMORIAM E.T. “Ted” Rulison, Jr., MD


2013 Education Series

James P. Hamill, MD


Board Briefs


HOD 2013 − Delegates Set Policy at Annual Meeting


Meet the Applicants


Classified Ads

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 Hopi Artist Duane Koyawena is an acquaintance of SSVMS member ophthalmologist Dr. Chris Serdahl, who submitted this photo for our cover. Duane’s work has been photographed by nurse Donna Peterson (please see the artist’s website at http://dkoyawena.wix. com/qalwungwa#!about). “Hopi life is about peace, life, respect. To Hopi, corn is life. The Katsinas that are around the world are called Angaktsinas, also known as the Long Hair Katsina. They are rain messengers. Rain provides life to corn. Rain brings life.”

January/February 2014

Volume 65/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax


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. 2014 Officers & Board of Directors José A. Arévalo, MD President Jason Bynum, MD, President-Elect David Herbert, MD, Immediate Past President District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Tom Ormiston, MD

District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Lorenzo Rossaro, MD Christian Serdahl, MD District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD 2014 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Richard Gray, MD Karen Hopp, MD Maynard Johnston, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD

District 1 Jeffrey Cragun, MD District 2 Richard Pan, MD, Assemblyman District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large John Belko, MD Natasha Bir, MD Helen Biren, MD Gregory Blair, MD Kevin Elliott, MD Alan Ertle, MD Benjamin Franc, MD Karna Gocke, MD Thomas Kaniff, MD Vijay Khatri, MD Don Wreden, MD

CMA Trustees District 11 Barbara Arnold, MD

Douglas Brosnan, MD

CMA President Richard Thorp, MD

CMA Imm. Past President Paul Phinney, MD

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Editorial Committee Nate Hitzeman, MD, Editor/Chair George Meyer, MD John Belko, MD John Ostrich, MD Sean Deane, MD Gerald Rogan, MD Ann Gerhardt, MD Lee Welter, MD Sandra Hand, MD Gilbert Wright, MD Albert Kahane, MD Robert LaPerriere, MD Adam Dougherty, MS IV John Loofbourow, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly


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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2014 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 Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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President’s Message

Setting the Stage By José A. Arévalo, MD LET ME BEGIN BY EXPRESSING how honored I am to be asked to take on this venerable and esteemed position as the 140th President of the Sierra Sacramento Valley Medical Society. I am particularly humbled to accept this gavel in a year that promises to bring a sea of change to the health care landscape of our country, state and local region. I am sure you are not surprised when I say that we physicians are on the verge of a major transformation in our profession. Most of us are aware that we are in the midst of a relative physician shortage in California, particularly in primary care and in certain key specialties. How we, as a profession, respond to this critical shortage will clearly set the stage for further transformative policies to which our legislative colleagues will feel compelled to respond. I am very proud to say that I am a doctor of medicine. “Doctor” is a revered word in our society, but I must remind you that the term - which means comes from the Latin word docere “to teach.” It is fitting that this word signifies what physicians are now expected to do best, to teach and guide our patients to deal with their disease or illness. The new paradigm for our profession is no longer the expectation of only curing disease, but rather the expectation of also preventing and managing chronic disease. At the heart of prevention is teaching, coaching and guiding. We must impart our knowledge of our art to our students as well. Our medical society must continue to create access to our local medical students so that during their very early development, we can demonstrate the importance of active involvement with our organization. One of the major challenges that we currently face is within our own ranks — a trend of disengagement and young physicians’

misunderstanding of the medical society’s value. Addressing this issue will be the single most important factor to ensure survival of our medical society for future generations of physicians. It is imperative that we show our worth to our members and potential members, and increase our ranks, not just out of the physicians’ sense of duty, but because they are proud to be members of our organization. I am happy to report that the state of our county medical society is healthy and in good standing. We are currently on a sound financial footing. We have a strong and engaged board of directors and an amazing and talented Executive Director, Aileen Wetzel, with an equally skilled and talented staff. I am deeply honored to succeed Dr. David Herbert, our President for the past two years. David is clearly going to be a hard act to follow. His leadership, professionalism, skill and charm are unmatched, and he has promised to bail me out if I get stuck. Under both David’s and Aileen’s leadership, our medical society has achieved the highest rate of growth of any medical society in the state. Thank you David and Aileen. During my tenure, I will work to continue our medical society’s emphasis on service to our local communities and to our patients. I will spearhead efforts to bring the SSVMS Board of Directors out to meet with physicians in El Dorado, Sacramento and Yolo Counties. I plan to reach out to neighboring medical societies to identify common needs, interests and ways that our societies can work together for the benefit of all patients and physicians in our area. I hope to work closely with the new UC Davis Vice Chancellor and Dean, Dr. Julie Freischlag, to promote new training opportunities for medical students with our community doctors. Finally, I am committed to strengthening the link

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.

continued on page 12

January/February 2014


EDITOR’s Message

Santa Claus and “low T” 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.

TRADITIONALLY, MY VISITS TO FAMILY in the Midwest have been the stuff of average American holiday doldrums. Overeating, tired jokes and movie references, young kids with TV-induced ophthalmoplegia, baby daddies behaving badly, and rehashing family grievances about the grandparents’ estate being mismanaged. Just before sticking my head in the oven with the turkey last season, I noticed a refreshing twist. My uncle, a consummate Santa Claus performer as well as a retired bad-ass police officer, confided in me about his “low T.” Fortunately, his astute primary care doctor had jumped on this problem and prescribed replacement for his borderline low levels. Indeed, the pathognomonic signs of fatigue, weight gain, and increasing sexual dysfunction with age could have no other biochemical basis but a lack of testosterone. Not to be left out in the cold, my male cousins quickly inquired with their doctor about “low T” and were started on this lifesaving medication. Obviously, while the medical community has learned that female hormone replacement does not benefit most women and has the potential for harm, male hormone replacement must be the way to go. According to the TV ads, if I play my cards right, I can be that fit, grayingwith-a-full-mane stud driving the convertible and throwing footballs with accuracy through suspended tires. “Low T,” you better not get in my way! After returning to the country of the Western United States, I have had my antennae up for this “low T” thing. Patients have been coming

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to me from miles around sure that their “low T” is cramping their style. One by one I find that their levels are in the low normal, but normal, range. My father and I recently went on a walk in the park, and even he asked me about “low T.” I told him that while I felt comfortable discussing hygiene products on these kinds of walks, he should really talk with his own doctor about “low T”. Sadly, despite much promise, I must confess that I am losing confidence in the “low T” theory. I’ve started telling my male patients that taking extra testosterone when testosterone levels are already normal may only serve to clog their hearts, “cancer-ize” their prostate, thin their hair, and persuade their testicles to shrink. The discordance between my message and the TV/internet ads that they see either has me labeled as a doctor stuck in the Middle Ages of medicine or as a whistleblower. Meanwhile, I’m trying to come up with a snappy ad for exercising, eating well, avoiding excess alcohol, and treating one’s wife with kindness. Still, my childhood perceptions of Santa have irreversibly taken another hit. The crackling fire, a frisky Mrs. Claus lying in her Victoria’s Secret attire, the elves asleep downstairs amidst the scattered toys in various states of disassembly, and Santa Claus feverishly rubbing Androgel on his inner thighs. How were your holidays? Feel free to send us your stories and reflections this year.

Executive Director’s Message

The Problem with Medicare Every year, physicians are threatened with large Medicare payment cuts because of the flawed Medicare Sustainable Growth Rate (SGR) payment formula.

By Aileen Wetzel, Executive Director OUTDATED MEDICARE PAYMENT methodologies have created serious access-to-care problems in El Dorado, Sacramento, and Yolo counties. The Sierra Sacramento Valley Medical Society (SSVMS) and the California Medical Association (CMA) are working on your behalf to urge Congress to pass legislation to reform Medicare payment inequities that threaten the viability of physician practices and access to care for patients. Physicians are vital to the health and economic wellbeing of our region and are substantial contributors to the state and federal tax base. According to a 2009 study by the Lewin Group, Sacramento area office-based physicians created a total of $6.1 billion in revenue, supported 26,787 jobs, contributed $4.3 billion in wages and benefits for employees, and supported $339 million in local and state taxes. Stable Medicare rates help physicians to remain in practice and to care for patients, while protecting jobs. Every year, physicians are threatened with large Medicare payment cuts because of the flawed Medicare Sustainable Growth Rate (SGR) payment formula. Physician payments lag 20 percent behind Medicare’s index of medical inflation (MEI). All other Medicare provider groups (hospitals, nursing homes, home health) have been paid according to the MEI and receive annual updates. Physician Part B payments have lagged dramatically behind the cost of running a medical practice. This is particularly troublesome in California where

private health plan payment rates are influenced by Medicare, creating access-to-care problems for all California patients. The Sacramento Metropolitan Area is the fourth largest in California after the Greater Los Angeles Area, San Francisco Bay Area, and the San Diego Area, as well as the 25th largest in the United States. Over the past decades, our area has become urbanized with higher rents, staff wages and other local costs to practice medicine. Yet, Medicare still designates El Dorado, Sacramento and Yolo counties as rural. Because Medicare has failed to update the physician payment localities, physicians in El Dorado, Sacramento and Yolo counties are underpaid by one percent each year. On a regional basis, this is equal to an annual underpayment of $3,388,669. This has caused some physicians to be paid up to 14 percent per year below what Medicare says they should be paid if our three counties were in the correct region. At the time this publication went to print, CMA and SSVMS have made significant progress at the national level urging Congress to pass legislation to reform Medicare so that physicians in El Dorado, Sacramento, and Yolo counties are paid accurately and according to their local costs to provide care. Keep an eye out for updates in our e-bulletin, SSV Medical Society News, or call the medical society for the latest news.

January/February 2014

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. 5

The Times and Standard of Care are A-Changin’ By Ann Gerhardt, MD AS A MEMBER OF HOSPITAL quality assurance committees, a reviewer for the Medical Board of California, an occasional expert consultant for malpractice cases, and the sounding board for friends’ complaints about doctors, I’m struggling with the concept of standard of care and how it seems to be changing. It is, and always was, naïve to believe that the standard would match the best care possible. That would involve complete histories, including review of systems and not using someone else’s computer entries, with the risk of garbage in, garbage out. It also means good physical exams, relevant testing, prudent consultations, compassionate and respectful patient communication, timely diagnosis, appropriate treatment and compulsive follow-up.

Legal Definition

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 legal definition of “standard of care” acknowledges that perfection is not achievable: “The watchfulness, attention, caution and prudence that a reasonable person in the circumstances would exercise…to meet the duty of care which all people (supposedly) have toward others… The ‘standard’ is often a subjective issue, upon which reasonable people can differ.” The last sentence is the problem. Many “reasonable people” believe that standard of care equals common practice, which in the past meant that of the local community. Now “community” no longer refers to local geography. We have intensive care Life Flights. National Best Practice guidelines and Internet learning opportunities have widened the

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medical community to include the entire country. Internet consult services exist for most specialties, and new technology arrives every year. But medical style still varies from place to place. In some hospitals, it is nearly impossible to have a physician call a family member to get history. Capitated systems at risk for expenses severely limit testing. Some hospitals lean heavily on physicians with long lengths of stay, even when accompanied by superior survival stats. Medical graduates follow the mold of their particular schools.

The Reviewer’s Own Definition The Medical Board guides the reviewer to his or her own definition, by drawing on “education, training, experience and knowledge of the medical literature,” including “peer review journal articles, medical texts and other authoritative reference materials, which help to define the accepted standard of care.” This is clearly not confined to a particular locale. As applied to evaluation and diagnosis, this would presumably demand that we don’t contort symptoms and signs to fit the middle of the bell-shaped curve. Following this standard might have saved the young, obese man with strong cardiac risk factors who presented with chest pain, abnormal enzymes and atypical EKG changes, was discharged from the ER with a diagnosis of pericarditis in spite of a normal echocardiogram, and soon died of a myocardial infarction. When is it “standard” to miss a diagnosis? If we were to judge all diagnostic efforts by the cases of the Massachusetts General Hospital,

most of us would fail. If an autopsy reveals an unusual diagnosis, are we culpable for missing it? If we take months to make a tough diagnosis, are we revered for eventually getting there or reviled for missing a time standard? Even Dr. House doesn’t make the correct diagnosis until the end of the show. Which “authoritative reference” materials do we use, when they often disagree? The obvious examples relate to cancer screening guidelines. A less obvious example is nutrition consults, which are rare, in spite of the fact that doctors don’t know much about micronutrient deficiency, refeeding syndrome and the nutrient consequences of extreme diets and bariatric surgery. Nutrition organizations would say a consult would be standard of care, while other august bodies are mostly mum, so what’s the standard?

The Board’s Definition The Board’s definition approximates the legal one by suggesting as standard “that level of skill, knowledge and care in diagnosis and treatment ordinarily possessed and exercised by other reasonably careful and prudent physicians in the same or similar circumstances at the time in question.” But, as practice styles change, that may not be best for the patient. A recent study in JAMA Internal Medicine found that primary care practices account for fewer than one in ten malpractice cases, but those cases are most likely to be settled or lost in a jury trial1. The authors opined that the difficult defense resulted from a failure to diagnose or delayed diagnosis, attributed to inadequate histories, testing, referrals, or follow-up. In today’s medical world, many offices miss doing these things because they have too many patients and too little time. It is much easier to catch mistakes and function competently when not harried and overworked, but the economics of large-group practices with huge overhead dictates that each doctor has a large patient “panel.” A recent NEJM editorial documents the adverse consequences of excessive patient load2. These take the form of health care associated infections, long length

of stay and increased odds of readmission for in-patients, and missed diagnoses, medication errors and inadequate response to abnormal test results for out-patients. Patients are frustrated when their test results aren’t explained, or they are told by an MA that “everything was normal,” without any further plan to diagnose their problem. Patients who don’t fit the complacent mold have even more trouble: An anxious psychiatric patient, whose every visit was an exercise in doctor patience, suddenly started to get MRSA abscesses. She was blamed for her abscesses for three years, until someone evaluated her immune system and diagnosed common variable immunodeficiency disorder.

In today’s

Hands-On Medicine vs. Technology


Has the standard changed from hands-on medicine to technology? The airline industry provides a useful metaphor. In 2012, a Continental airplane crashed and killed all aboard when the autopilot malfunctioned and the pilot responded incorrectly. A similar error caused an Air France Airbus to plunge to the ocean, killing all on board, when the air-speed sensors coated with ice gave faulty readings and the pilot didn’t take corrective action. The Atlantic Monthly article describing these facts makes the case that “Seeking convenience, speed and efficiency, we rush to off-load work to computers without reflecting on what we might be sacrificing as a result. In other words, we rely so much on technology that we forget (or never learn in the first place) how to do the task without technology.” Medicine has been heading in the same direction. We rely so much on technology that we forget how to diagnose without it. Patients continually complain that a doctor never touched them, in spite of specific, physical complaints. Because so many physicians don’t take the time to do examinations, has that become the standard of care? One woman relates her frustration in trying to get doctors to do a basic history and physical exam for her mother. Cared for in an out-ofstate teaching hospital, the daughter had the


January/February 2014

many offices miss doing these things because they have too many patients and too little time.


impression that the house staff were either afraid to touch her mother or didn’t know how. First- and second-year medical students are hungry to learn physical examination. By the third and fourth year, that urge wanes. Those students have learned by example from their mentors that the exam is incidental, perhaps a formality to avoid missing something blaringly obvious. They learn that the real answers come from scans and tests. Every laboratory and imaging study has its limits of detection and caveats. Most trainees don’t internalize that fact until they’ve been burned by a “normal” test, like the doctor who believed the normal hemoglobin, rather than the patient’s complaints of abdominal pain and acute lightheadedness. If he had done postural vital signs, he might not have later been surprised by the patient’s admission and hydrated hemoglobin of 6 g/dl. In the past, doctors did decent histories and physicals because it’s all they had to make

a diagnosis. Physical exams don’t make every diagnosis, but we should use symptoms and physical signs to guide tests and consults. Without an exam to define or limit the possibilities, inappropriate testing follows leading to a waste of money and prolonged patient misery. For example, an immuno-compromised patient’s fever necessitated three admissions to diagnose his sigmoid diverticulitis. The patient said the doctors had never touched his abdomen below the waistline, where he had tenderness, but of which he was unaware. Doing nothing to diagnose a physical complaint can have a horrible outcome. An elderly lady admitted with atrial fibrillation who suddenly couldn’t walk after a four-day hospitalization, never received a neurological exam, consultation or any scans. In the rehabilitation facility, she developed severe unilateral leg atrophy and never walked again. We don’t know if DRG-based hospital reimbursement or a hospitalist’s desire for a small census pushed this patient out of the hospital prematurely.

Case Definition

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The malpractice case definition of standard of care (Oh, no, the ideal again!): NorCal Mutual’s educational materials describe nuanced cases in which sometimes astoundingly strict standards of care are applied, particularly by the prosecution. While these standards may be ideal, are they truly achievable in the real world of a busy practice? Is it really our fault that a patient doesn’t see the consultant or fill a prescription or do the lab test because we didn’t sufficiently nag or scare the bejeezus out of her? Regardless of which standard is used, we are human and sometimes slip. The question is still how much slip is acceptable and how much slaps of negligence? Perhaps the best definition for standard of care is that which we would expect to be applied to ourselves. 1 Schiff GD, et al. JAMA Intern Med 2013; 173: 2063-2068 2 Litvak E, Fineberg HV. NEJM 2013; 369:1581-1583

The Sierra Sacramento Valley Medical Society and Alliance Invite Members and a Guest to Attend the

2014 Annual Awards and Installation Dinner Thursday, January 16, 2014, 6:00 pm Social, 6:45 pm Dinner, 7:30 pm Program Hyatt Regency Hotel, Regency Ballroom, 1209 L Street, Sacramento

Installations José Alberto Arévalo, MD, President 2014 • 2014 Officers and SSVMS Board of Directors

Award Presentations

Golden Stethoscope Award: Bradley E. Chipps, MD Medical Honor Award: John W. Young, MD Medical Community Service Award: Cordova Community Council for “Kid’s Day in the Park” Dorothy Dozier Helping Hands: Susan Brownridge CMA-Alliance Dedicated County Member: Celeste Chin

Music by Gardenia Azul Dinner Price $65.00 SSVMS Members, Alliance Members & Guests • $40.00 Medical Students & Residents Members are encouraged to consider hosting a medical student or resident. Reserved tables of 10 are available by request.

Reservation Deadline: January 13, 2014, 10:00 a.m. Call today! 916.452.2671 Special appreciation to NORCAL Mutual Insurance Company for their support of this event.

Saturday, June 21, 2014   Elk Grove Regional Park, Elk Grove 

Saturday, March 15, 2014   Valley Hi Community Park, Sacramento  

Saturday, July 19, 2014   George Sim Park, Sacramento  

Saturday, March 29, 2014   Phoenix Park, Fair Oaks 

Saturday, August 2, 2014   South Natomas Community Park,  Sacramento  

Saturday, April 5, 2014   Howe Park, Sacramento 

Saturday, September 20, 2014   Foothill Community Park, Sacramento   

Saturday, April 19, 2014   Eastern Oak Park, Sacramento 

Saturday, October 18, 2014   Shasta Park, Sacramento 

Saturday, May 3, 2014   Arcade Creek, Sacramento   

Saturday, November 1, 2014   Discovery Park, Sacramento 

Sponsored by: Saturday, May 17, 2014   Freedom Park, North Highlands   


We have set our   2014 Walk with a Doc   calendar!  We are looking for leaders   for all  2014   Walk with a Doc events.   


Saturday, February 8, 2014   Dry Creek Parkway, Rio Linda  

Walk with a Doc is  FREE to  anyone who is interested   in taking steps to   improve their heart health.  


To volunteer,   or for more info.,    contact Kris Wallach at   916 453‐0254 or 

Supported by:

January/February 2014


Should my Daughter go into Medicine? By Christian Serdahl, MD IT MAY COME AS A SURPRISE to many folks not in the medical field that most medical doctors these days are not recommending a career in medicine to their children. According to recent studies of career satisfaction published in 2012 by The Doctors Company, the nation’s largest malpractice insurer, nine out of ten physicians would not recommend medicine to their college kids. One question everyone should ask is, what does this mean for the future of medicine? On a more personal note, what does this mean for our daughter who is contemplating a career in medicine? My wife and I are both physicians in our early 50s, and we have one daughter who just started college. She has naturally expressed some interest in medicine, so we asked ourselves how we felt about medicine as a career for her. Together we compared notes and surprisingly agreed on the following list in favor of and against medicine as a career choice.

Top Reasons to Become a Physician

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.


1. Opportunity to help others. Although this is perhaps the most obvious, I think it is also the most important. In medicine, at the end of the day, you don’t have to think very hard about who you helped. This is not so easy in other professions where one is confined to a cubicle and a computer screen. Professions that directly help others, such as being a minister, a school teacher, a policeman, a nurse or a physician, offer a daily opportunity for kindness. The simple act of serving others is at the core of all medical care. The doctor-patient

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relationship is a sacred one, but no more sacred than a teacher-student relationship or the pastoral relationship a minister has with one of their congregation. The non-monetary benefit of directly helping others is a daily reward for the practicing physician. The ability to cure and treat with one’s own hands and diagnostic acumen is what sustains many of us as we plod along, wondering who our next patient will be. 2. Medicine will provide a stable financial career. There will always be sick people who will need doctors to care for them and, thus, no shortage of work. The ability of the patients to pay for physicians has been eroded by the huge escalation in pharmaceutical costs and insurance company profit margins, but in the end, there will still be a need for good physicians. 3. Opportunity to be self-employed. I am in private practice and truly enjoy running my own business and controlling my own schedule. I get to hire and fire my own employees and give other people meaningful jobs with full benefits. My wife, on the other hand, has spent 23 years at a large medical group functioning essentially like an employee. She has no control over her schedule and frequently gets told she needs to work harder to keep her present salary. Her staff is unionized and she has little control over their productivity and their patient care skills. It is getting harder to stay in private practice as many physicians jump to become employees of hospitals coupled with insurance groups. Even if there were a remote chance of being selfemployed, I would highly recommend medicine as a career choice. The ability to work harder

and make more money, rather than being paid a salary and being told to work harder to justify your salary, seems like a no-brainer to me. Running a medical practice is not rocket science, and there are always other professionals out there to help you stumble your way through the business side of medicine. 4. You can do other things besides medicine with an MD. Most of us practicing physicians fail to realize that we do have other choices besides actually seeing patients and doing surgery. Teaching in a medical school or university is also possible. There are positions with state and federal governments that favor those applicants with a medical degree. Opportunities arise as a medical expert in the legal world. It may be easier to get financing to start a new business in some health care related venture if one has an MD. With some additional training in business and management, many non-practicing physicians find employment with HMOs, insurance companies and medical groups in various roles as a medical director. In short, it would not be a waste of time and money if someone graduated from medical school but decided not to practice medicine!

Top Reasons not to Become a Physician On the flip side, why is it that so many physicians are not recommending medical school to their college-aged kids? 1. It takes a long time to get through medical school and residency, and it is expensive. To get a job as a physician, it takes four years of undergraduate training, four years of medical school and three to seven years of residency, depending on your specialty. About 50 percent of specialists decide to do a fellowship which can last from one to five years. That is a lot of time spent before beginning a medical practice! The American Medical Student Association predicts that by 2020, the average debt for graduating medical students will be $300,000. The increased cost of medical education has significantly outpaced the increases in income

for the average physician. These increases continue to shape specialty choices with higher indebted students usually choosing a more lucrative profession. Advice to our daughter: If you can finish residency with less than $150,000 in debt, choose whichever specialty you wish. If you owe $300,000, don’t choose family practice or pediatrics and expect to pay off your student loans in less than 10 years. 2. Doctors are increasingly viewed as “providers” and not “healers.” The delivery of health care in America has become a business, a big business. HMOs, insurance companies and hospitals now call physicians “providers” and consider us “cost centers.” Quality is no longer considered the most important attribute by the large-scale physician employers, but rather how many patients can one provider see in a single day. Hiring as few providers as absolutely necessary to get the work done seems to be the norm in large HMOs. Productivity standards can be harmful to the doctor-patient relationship if the “provider” has only minutes to discuss a patient’s medical condition. Physician “extenders” is a common term for physician assistants and nurses who are now charged with filling in the gaps that exist in our current health care systems. Many patients now do not get the luxury of even seeing a physician during their doctor appointments. Expect these gaps to widen as the population ages and more people enter the system through the Affordable Care Act. 3. Most new doctors will be employees of large health care systems and not private practitioners. These health care systems have to function as businesses and, as such, need to operate with a profit margin. This means paying physicians as little as possible for the services they provide while persuading them to work harder. These health care systems shift costs by paying primary care physicians above-market rates and various surgical specialists below-market rates. Employee physicians can be fired for failing to follow a set practice pattern. Most new physicians seem to want both

January/February 2014

It is getting harder to stay in private practice as many physicians jump to become employees of hospitals coupled with insurance groups.


the security of practicing in a large group and the lifestyle of working “9 to 5,” leaving time for family and recreation. The ideal of being your own boss as a physician is an ideal that will likely be much harder to attain for the next generation of physicians. 4. New regulations are making medicine less efficient. The current amount of waste in hospitalbased medical care is abominable. I estimate that nearly $500 of eye drops are wasted after each cataract surgery I do in the hospital-based ambulatory surgery center due to poorly written laws. The transition to electronic medical records (EMR) is another sensitive area for physicians. It is estimated that a practice that adopts EMR will suffer a productivity loss of 30 percent during the first year of implementation. These EMRs are costly and seem to have a short lifespan as the electronic medical highway tries to become

interconnected, a goal that seems to be several generations away and millions of dollars in the future. The Affordable Care Act places a premium on the patient experience with a physician and not on the actual quality of care they provide. Doctors now spend precious time looking at results of patient surveys rather than at the patient’s medical condition. Insurance billing complexity seems to increase exponentially, further reducing the amount of time your doctor has to spend with you. Witness the new ICD-10 (replacing the ICD-9) which has 68,000 billing codes in order to get paid. Using this data, insurance companies can get even more information about you, such as exactly how you fell and broke your leg. The bottom line for our daughter? I gave my daughter a cautious thumbs up about a career in medicine while my wife gave her a thumbs down! This is not so surprising, since my wife and I rarely agree on anything. In the end, our daughter will do what she chooses, and we won’t be disappointed in whichever path she follows, as long as she finds something she has a passion for and tries to graduate from college in four years. After all, what 18-year-old does what their parents tell them anyway?

Setting the Stage continued from page 3 between SSVMS’ physician volunteer program, SPIRIT, and community- and student-run clinics to address the needs of the underserved. I am committed in the coming 12 months to represent all of your interests. You have my pledge to be available to you to hear your concerns and opinions. I will gladly meet with you in your offices, homes, pubs, or hospitals. You can reach me by phone, snail mail or by email. Our medical society is here to advocate for you and for your practice. —William Nakashima, MD


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A Visit with Congresswoman Matsui Last November 7, SSVMS Executive Director Aileen Wetzel took a delegation of physicians to meet with Congresswoman Doris Matsui to thank her for her support of physicians, patients, and Medicare payment reform. She also took along three firstyear medical students for the experience, and they did a great job advocating for increased funding to Graduate Medical Education (GME). Left-right are Christina Lee, MS I; Lucy Ogbu, MS I; Congresswoman Doris Matsui, and John Paul Aboubechara, MS I.

When change moves you in a new direction, choose the right navigator. In health care, success requires diligence and foresight—two qualities that will prove important in the days to come. As reforms take effect over the next decade, will your organization be ready?

We’ve helped physician practices and medical groups nationwide strengthen their operations and position their business for success. Discover how can make a difference to yours.

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January/February 2014


The Voice of the Underworld By John Loofbourow, MD

When your senses sleep But your mind strays And brings back roses From long dead gardens Of time gone by And it’s 04:05;

When buried demons Of unspoken remorse, Malignant wrongs, Or thoughtless cruelty Walk your black night And it’s 04:29;

When the stale air’s dead You’re fighting the bed But lost every round, When a train whistle signals You’re all out of time And it’s 04:49;

When quintessential words Of a failing love poem Or a festering essay Step out of the dark of your night-numb mind And it’s 04:25;

When you’ve believed That sticks and stones Can break your bones Though words are harmless But you find that’s a lie And it’s 04:35;

Then steal a few moments From the underworld of night To write down some words From the wordless deeps Of your mindless mind, And go back to sleep.

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more informa�on or to register, visit or call CMA’s Member Help Center at (800) 786‐4262. January 15: Avoiding Embezzlement: A Physician’s Guide to Protec�ng Your Prac�ce 12:15 – 1:15 p.m. This webinar is open to physicians only. It has been esƟmated that one in six physicians will be the vicƟm of embezzlement at some Ɵme during their pracƟce years. Learn how to conduct employee reference checks, bonding, and how to implement accounƟng control procedures. January 22: Update on Medicare Physician Incen�ves: What’s New for 2014 12:15 – 1:45 p.m. Learn about parƟcipaƟng in the Physician Quality ReporƟng System (PQRS), the ePrescribing (eRx) IncenƟve Program, the Electronic Health Record (EHR) IncenƟve Program, and the new Value Modier (VM) program.


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February 19: Transi�oning your Prac�ce‐Re�ring, Selling or Buying a Prac�ce 12:15 – 1:15 p.m. Considering reƟrement? Selling or wanƟng to buy a pracƟce? Learn about opƟons for transiƟoning your pracƟce. February 26: Fraud and Abuse: Dangers and Defenses 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentaƟon, present suggesƟons for implemenƟng internal controls, and increase awareness of prevenƟve measures to protect your pracƟce from fraud or abuse.

YOU WORK TO PROTECT YOUR PATIENTS. We work to protect you.

AS A PHYSICIAN, you probably know better than anyone else how quickly a disability can strike and not only delay your dreams, but also leave you unable to provide for your family. Whether it is a heart attack, stroke, car accident or fall off a ladder, any of these things can affect your ability to perform your medical specialty. That’s why the SSVMS/CMA sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company: • Benefits not tied to a practice, giving you more flexibility with potential career changes


Call Mercer for free information, including features, costs, eligibility, renewability, limitations and exclusions at:

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• Protection in your medical specialty for the first 10 years of disability With this critical protection, you’ll have one less thing to worry about until your return. SPONSORED BY:


New York Life Insurance Company New York, NY 10010 on Policy Form GMR

66488 (1/14) Copyright 2014 Mercer LLC. All rights reserved.

CA Ins. Lic. #0G39709 Mercer Health & Benefits Insurance Services LLC 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 •


HOD 2013 – Delegates Set Policy at Annual Meeting

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.

MORE THAN 500 CALIFORNIA physicians convened in Anaheim October 11-13 for the 2013 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers. Over 90 resolutions were introduced and debated in reference committees on Friday, October 11. Over the next two days, the complete House met again to debate and vote on reference committee recommendations. A total of 63 resolutions were adopted. As a first step toward a “virtual” reference committee process that will enable a shorter, two-day meeting in future years, Reference Committee A (Science and Public Health) conducted all testimony online in advance of the meeting. All CMA members were invited to participate in the debate, and nearly 300 online comments were recorded. The committee members then met via web conference in advance of the meeting to develop their recommendations, which were presented to the House for floor debate on Saturday afternoon. The following are summaries of some of the resolutions that were adopted as policy. (The full actions of the HOD are available to members at, under the “documents” tab.) Increased reporting of immunizations Resolution 104-13 The delegates approved a resolution that encourages increased reporting of patient immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention. Nearly one in


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four children sees more than one immunization provider by age two. In fact, the chart in the child’s most recent medical home is accurate only 62 percent of the time. HIV and STDs: Consent requirements for testing Resolution 109-13 The delegates voted to support revision of HIV consent requirements to allow all health care providers to order a test for HIV when appropriate, and to encourage routine HIV testing for all patients that are evaluated for other sexually transmitted diseases. Graphic health warnings on tobacco products Resolution 115-13 Delegates called on CMA to support the use of graphic image labeling on cigarette and other tobacco packaging that warns of the health impact of smoking. CMA has been a tireless advocate for stronger restrictions on the tobacco industry for decades. In 1970, 1978 and 1980, CMA supported ballot initiatives that would have banned smoking in many public places. In 1987, CMA took on its biggest tobaccorelated challenge and won, with the passage of Proposition 99, which established a 25-centsper-pack tax on cigarettes and a tax hike for other tobacco-related products. Legal blood alcohol limit for drivers Resolution 118-13 Delegates endorsed the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower. Food insecurity screening Resolution 122-13 The delegates directed CMA to promote

that providers need to identify children and adults who are food insecure, as defined by the USDA,1 to avoid detrimental development and co-morbidities and to refer them to appropriate programs and services. Elimination of CMS outpatient observation status Resolution 211-13 The delegates directed CMA to request that the Centers for Medicare and Medicaid Services eliminate its “outpatient patient observation” status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Delegates noted that this practice places undue financial burden on patients and creates administrative hassles for physicians. Health exchange benefit designs and tax deductibility of out-of-pocket expenses Resolution 401-13 The delegates called on CMA to support efforts to develop benefit designs in the health benefit exchange that appeal to the young and healthy to boost the risk pool, and to support legislation allowing federal and state income tax deductibility of all out-of-pocket health care expenses. Reimbursement for telephone/electronic patient management Resolution 407-13 The delegates asked that CMA support legislation requiring health insurance companies to pay physicians for telephone or other electronic patient management services. The resolution received nearly universal support during testimony, with many speakers noting that patients are increasingly relying upon telephone calls and emails for consultations that previously were conducted during in-office appointments. Under the language adopted by the House, payment for these consultations would be similar to office visits that are similar in complexity or time required from the treating physicians. National health information exchange Resolution 518-13 The delegates called on CMA to support the development of a secure, interoperable, nationwide health information exchange network.

Health Exchange 90-day grace period Resolution 402-13 The delegates called for CMA to demand that the Department of Managed Health Care require that insurance companies involved in health insurance exchanges make it clear on the insurance cards which patients are federally subsidized, provide a user-friendly hotline or fax-back for authorization at the time of service, as well as guarantee payment for those claims with an authorization. That authorization would guarantee payment of the claim regardless of final coverage status. The resolution also requests that physicians be given the right to collect payment at time of service or refuse treatment to those patients whose guarantee of coverage cannot be verified at time of service. Richard Thorp, MD, FACP, was installed as the 146th president of the CMA at the close of the HOD meeting, while Humboldt surgeon Luther Cobb, MD, was tapped as president-elect. “I will not compromise the honor of this profession for the victory of the moment. I will not capitulate or surrender. I will fight to protect this profession you hold so dear,” Dr. Thorp said as he addressed the 500 physician delegates in attendance. “In this critical time, the house of medicine cannot afford to do business as usual. We cannot afford the status quo. We must come with the audacity to create a dream and a vision for the future of medicine and health care in California.” Dr. Thorp’s complete address to the delegates can be viewed on CMA’s YouTube channel, Also serving on CMA’s 2013-2014 Executive Committee are: • Immediate Past President, Paul R. Phinney, MD, a Sacramento pediatrician. • Speaker of the House, Theodore M. Mazer, MD, a San Diego ear, nose and throat specialist. • Vice Speaker of the House, Lee T. Snook, Jr., MD, a Sacramento pain medicine specialist. • Chair of the Board of Trustees, Steven E. Larson, MD, an internist infectious diseases consultant in Riverside County. • Vice Chair of the Board of Trustees, David H. Aizuss, MD, a Los Angeles ophthalmologist. January/February 2014

Over 90 resolutions were introduced and debated in reference committees…

1 publications/efanelectronic-publications-from-the-foodassistance-nutritionresearch-program/ efan02013.aspx


Book Review

Hygiene – Man Does not Live by Soap Alone By Jack Ostrich, MD

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

AMONG THE HUNDREDS OF BOOKS in the SSVMS Museum of Medical History, there are a few that are devoted to the teaching of what used to be quaintly called “hygiene.” For us, that word, hygiene, usually evokes images of personal cleanliness, proper hand washing and routine dental visits. It derives from the ancient Greek word for “health.” Hygiea was the goddess of health. She was the daughter of Aesculapius, who was the son of Apollo and a beautiful mortal named Coronis, with whom Apollo had a roaring affair. Aesculapius was slain by Zeus who became upset that Aesculapius had acquired the power to bring dead people back to life, and Zeus had long ago decreed that only full-fledged gods were licensed to do that. There was no adjudication or appeal. Just a lightning bolt to the head. In any case, the word hygiene had a much wider meaning in the 19th and early 20th centuries. It included all aspects of proper self care and care of one’s personal environment, as well as a basic knowledge of anatomy and physiology, germ theory, nutrition, wholesome exercise routines and avoidance of harmful substances, especially tobacco and alcohol. Three books in our collection are of special interest. The earliest, from 1894, is the “Pupil’s Edition” of a 107-page volume called Object Lessons on the Human Body, and it was used in the New York City public school system. The next, published in 1906, is titled Physiology and Hygiene, part of the “California State Series.” It is 279 pages long, and the inside front cover is stamped in purple ink with the name “Lorene Masterson.” Below that, in blue, is stamped


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“Department of Public Instruction, State of California, Glenn County.” The third is called Graded Lessons in Physiology and Hygiene by William Krohn, MD, PhD, printed in 1910 by D. Appleton and Co. of New York City. There is no evidence of prior ownership, but it is clearly a textbook and not meant for casual reading. It is 290 pages long and has a lovely dark green cover with fanciful oak leaf and acorn design embossed thereupon. Handwritten in pencil with a childish script on the inside of the back cover are titles of 10 books that presumably represent a reading list for whomever owned the book. Among them are Uncle Tom’s Cabin, Lorna Doone, Children of the Tenements (by muckraker and social critic Jacob

Riis) and Moni the Goat Boy (by the author of Heidi, Johanna Spyri). Well, you must be by now asking, what were the children of the late 19th and early 20th centuries being taught about their bodies and how best to care for themselves? A superficial review of the tables of contents of the three books reveals a general concentration on functional anatomy (with some significant exceptions, noted later), nutrition, infectious disease, and the nefarious dangers of alcohol and tobacco. Object Lessons on the Human Body opens with the “Author’s Note to the Pupil,” thus − This book has been prepared to help you in learning about “the house you live in,” and to teach you to take care of it, and keep it from being destroyed by two of its greatest enemies − Alcohol and Nicotine. Of its 107 pages, the last 35 are completely devoted to describing the noxious and even deadly effects of alcohol and tobacco. The very last page of the book briefly lists, as well, a few 19th-century patent medicine ingredients that should be assiduously avoided, including all opiates, chloral hydrate, cocaine and hashish. Near the end, there are several questions for

discussion and approved condensed answers are conveniently supplied − “What happens to children or young people who use tobacco in anyway?” Ans: They are not healthy; they are not strong; they do not grow fast; they look pale and sickly. And if that were not bad enough − “What other harm does the use of tobacco do to people?” Ans: It makes them waste time and money; it leads some to drink alcoholic liquors and to go with bad company. In the 60 or so pages in which human anatomy and physiology are discussed, there is no mention whatsoever of sexual anatomy or function, and one can assume that there was very probably no classroom activity relative to those items. Those were, indeed, the days when such topics were left for adult guardians to pursue with the kids. On page 32 of the book, there is a fullpage frontal illustration of “The Muscles of the Body,” and the body in the illustration is asexual. None of the muscles are labeled, but someone (a student probably, but maybe a teacher?) has taken it upon him or herself to pencil in a crudely-drawn and rather grandly-

“What other harm does the use of tobacco do to people?” Ans: It makes them waste time and money…

January/February 2014


The student is also taught that “reading before breakfast by (any) artificial light is

proportioned male member and to label the addendum, “pecker.” And, in case you missed it, there is a bold arrow pointing from “pecker” to the cartoon. It was probably a warm spring afternoon and the perpetrator surreptitiously passed the altered textbook to his girlfriend across the aisle, and she, then, erupted in raucous laughter. The teacher found her in possession of the X-rated illustration and she was sent home in disgrace, but not before she and her parents were scheduled to meet with the principal the following day. The young lady never revealed the source of the drawing. She married her beau after they graduated from high school, and they had three beautiful children and lived happily ever after. So much for sex education. Physiology and Hygiene, of the “California State Series,” is chock full of good advice. In a chapter titled “Care of the Eyes,” the student is advised to avoid “incandescent electric light” while reading or writing, as it provides “irregular illumination” and it is recommended that one should use “an Argand gas or kerosene burner” since “it throws a soft, uniform and agreeable light upon the work.” The student is also taught that “reading before breakfast by (any) artificial light is bad”



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as it “tires the eyes.” So tell dad not to read the morning newspaper at the kitchen table, but instead, to read it at work where he can use the Argand lamp that is on his desk at the office. After school, students are urged to pursue organized exercise, and in 1906, the state of California recommended tennis for girls and boys, as it creates “a constant interchange of play, active but not severe, with almost no danger of injury.” Bicycling was also mentioned as a splendid co-ed activity. Baseball and football were listed as appropriate only for boys as − ...these games call for great activity and develop manly qualities in boys and do much to make them active, fearless men, men who in times of danger have not only strength and endurance but also well-trained muscles, cool heads and brave hearts... Equally beneficial, it seems, is boxing since it teaches control of the temper more than any other form of exercise and it is indeed a “manly art” wholesome as can be given to boys to give them physical and moral health. Dr. Krohn’s Graded Lessons in Physiology and Hygiene is the most, for lack of a better term, technical, of the three books. But Dr. Krohn also worries in a paternal way about the slothful habits of the youth, especially the female youth, of his day, and so he writes −

Lack of exercise during school is much more common than excessive exercise. The general health of girls often becomes impaired, digestion is enfeebled, the circulation is not good and nervousness is manifest. The effect on bodily figure shows itself in flabby muscles, drooping shoulders, flat chest, stooping walk, and curvature of the spine. Girls should romp and play with the same freedom that boys do. So it seems that every generation has wrung its hands and bemoaned the fate of its progressively more mollycoddled and enervated youngsters. Where is Dr. Krohn now that we need him? And how about including Moni the Goat Boy and Lorna Doone in all high school reading lists ? Onward.

Girls should

(A special thank you goes to Dr. Bob LaPerriere, our museum curator, for scanning the books and sketches!)

romp and play with the same freedom that boys do.

January/February 2014


Health Benefit Exchange Resources for Physicians See CMA’s exchange resource page for information on exchange plan contracting, patient enrollment and eligibility, and more! Learn more at


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SSVMS Public Health Programs Receive Awards By Kris Wallach, SPIRIT Program Director SSVMS’ SACRAMENTO PHYSICIANS’ Initiative to Reach out, Innovate and Teach (SPIRIT) program was recently awarded the CMA Foundation’s Robert D. Sparks Leadership Award for 2013. SSVMS President José Arévalo, MD, accepted the award on behalf of the SPIRIT program at the CMA Foundation’s 2013 Annual President’s Reception and Awards Crystal Gala held on October 12 in Anaheim. The Robert D. Sparks, MD, Leadership Award is given annually to an individual or organization having demonstrated extraordinary interest and efforts in improving community health, consistent with the mission of the CMA Foundation to champion improved individual and community health through a partnership of leaders in medicine, related health professions and the community. The SPIRIT program is a collaborative of the medical society, Sutter Health, Dignity Health, Kaiser Permanente, and the UC Davis Health System. SPIRIT patients are working poor who do not receive benefits through their employers and who cannot afford to buy health insurance, or are without private medical insurance, yet ineligible for Medi-Cal. To date, SPIRIT volunteers have donated $8.4 million in care to nearly 40,000 patients. SSVMS’ Walk with a Doc program received the 2013 CMA President’s Award for outstanding public health project. Presented

by CMA Presidents’ Forum Gurang Pandya, MD, and CMA President Paul Phinney, MD, the award recognized SSVMS’ Walk with a Doc program for completing 16 events around Sacramento County in 2013. In 2014, SSVMS plans to have one walk per month, linking our Walk with a Doc program to the Sierra Health Foundation Healthy Communities Coalition’s Communities of Focus. The Healthy Sacramento Coalition (www. is a group effort that includes more than 40 organizations working to reduce chronic disease and to improve health for all Sacramento County residents. The Healthy Sacramento Coalition is funded by a Community Transformation Grant provided by the Centers for Disease Control

January/February 2014

Dr. José Arévalo, below right, accepts the Sparks award on behalf of SSVMS and the SPIRIT program. Presenting the award was David Holley, MD, Chair of the Board of Directors of the CMA Foundation.


Full time Physician needed for MED7 Urgent Care Center. We have urgent care clinics located in Carmichael, Roseville, Folsom and Sacramento. MED7 has been providing urgent care services in the greater Sacramento area since 1987. Visit our website for more information about MED7 at Attractive compensation package. Call Merl O’Brien, MD at 916-483-5400 ext. 111 or e-mail CV to

and Prevention to support state and local groups that are trying to reduce chronic disease. An analysis of both primary and secondary data revealed that there are 15 zip codes, or Communities of Focus, in Sacramento County that experience a high burden of disease and have had consistently high rates of poor health outcomes (above county, state and Healthy People 2020 benchmarks) related to chronic disease and mental health. SSVMS is working with parks and recreation departments in these zip codes to locate parks to host Walk with a Doc in 2014. Linking with the Communities of Focus offers the opportunity to collaborate with existing community coalitions and stakeholders to increase publicity and participation. If you are interested in learning more about the SSVMS Walk with a Doc program or volunteering for the SPIRIT program, contact Kris Wallach at (916) 453-0254 or kwallach@

“A man’s health can be judged by which he takes two at a time − pills or stairs.” − Fitness Author Joan Welsh


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A Posit on Bariatric Surgery Coverage “Bariatric surgery should be considered an essential and mandated health benefit under the new state health insurance exchanges.”

Background: As the different state health exchanges are setting up their plans, some states are designating bariatric surgery as a mandated benefit, while others are requiring patients to buy additional rider plans. While bariatric surgery has been shown to significantly reduce diabetes and hypertension with a modest mortality benefit, complications are not uncommon, and follow-up care and laboratory monitoring are intensive. A recent JAMA Surgery article, looking at almost 30,000 Blue Cross/ Blue Shield members who underwent surgery from 2002-08, did not show a long-term cost benefit for those undergoing bariatric surgery compared to a group who did not undergo the surgery. Note: Posits are aggressive statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 19/Agree – 55/Disagree. Commentary follows: I disagree. Personal behavior is a major determinant of health risk: improving nutrition and exercise is a better way to treat obesity. Surgery engenders increased cost and risk; and some patients have continued to gain weight despite such surgery. −Lee Welter, MD Current non-surgical weight loss programs are disappointing and not effective for most needing major weight loss for health issues. Although bariatric surgery is relatively costly, it is the most effective method now available. The identical twins studies, where only one is obese,

have identified the individual’s bowel bacteria type to be the difference. The understanding of the symbiotic importance of human biome bacteria (as well as our viral and prion human biomes) should provide effective non-surgical treatment, and will render surgical treatments obsolete. −Richard Park MD Everything can’t be covered, especially those things that are expensive and show little or no benefit. Like plastic surgery; if people want these things done, they need to pay for it themselves, if they can find someone to do it. I would think and hope that other procedures and treatments are re-evaluated in the same light. It’s amazing what people do if they, themselves, have to pay for it versus if someone else will have to pay for it. −Maynard Johnston, MD Yes. If medically indicated. Recent guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) define the role of bariatric surgery in patients with high risk for CAD. −Kuldip Sandhu, MD Patients should be able to choose what services they would like to purchase. A free society allows such flexibility. It is impossible for the government to mandate a “basic” level of service without “politics” being infused into the system. Political agendas and philosophical frameworks will play the dominant role in determining what is “basic.” “There is no worse tyranny than to force a man to pay for what he does not want merely because you think it would be good for him.” −John Gisla, Jr., MD Bariatric surgery is touted as a means to mitigate obesity-associated disease. Human

January/February 2014

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 evidence is mounting that this is an effective AND costeffective way of controlling Type 2 Diabetes…


nature always moves us to look for a quick fix to a complex problem, ignoring the underlying basis for the problem. Such surgical procedures are very major and far from risk-free. Recently, there has actually been some question of the benefit gained from performing these procedures. Truly intensive education and prevention of the problem have gotten short shrift. −Clifford Marr, MD After appropriate evaluation and Dx with comorbid conditions that is significantly affected by the weight. Should have criteria setup. −Kenneth Corbin, MD Only after appropriate counseling and attempts at other forms of weight loss fails. Current guidelines should be met. −Hui Cheong, MD The clinical benefits of bariatric surgery are clear when it is performed by skilled surgeons in the best centers. There is some good quality evidence to support its cost effectiveness. The NEJM study cited above is only one study. Please see UpToDate for a more thorough analysis. In summary, UTD says: “HEALTH CARE FINANCIAL IMPACT — financial impact of medical care is measured as cost-effectiveness and cost-savings. While bariatric surgery may be more efficacious than medical or lifestyle intervention for long-term weight loss and remission of diabetes, short-term cost-savings have been reported in some, but not all, studies, and long-term cost-saving and cost-effectiveness is strongly debated. Bariatric operations, in general, are expensive, and the cost of inpatient care and complications may not be offset long-term by the savings of improved health. Additionally, no one operation has been shown to be more cost effective than another. −Michael Patmas, MD I would support diet and monitored weight loss program vs. surgery. −Suzanne Montoya, MD If this surgery is medically necessary, it should be covered without riders, just like any other medically-necessary procedure. The determination of medical necessity should be made by physicians, not insurance companies. −Glennah Trochet, MD

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Obese patients should pay a higher premium, as should smokers. −Terry Zimmerman, MD Disagree. Growing mandates increase cost without clearly improving benefit. −Gerald Bishop, MD By doing it as health benefit means ok or encouraging to have obesity. Obesity is a completely avoidable/preventable situation if one has insight. Encouraging to take care at seed level is an intelligent choice. Encourage ways to do it. −Uma Kunda, MD I disagree! Long-term benefits are not proven in younger populations yet, and unfortunately, most lifestyles won’t change. Prevention is key. −Brett Christiansen, MD I’ve (somewhat reluctantly) come to realize that this is an effective treatment for a condition which has almost no other effective treatments. The evidence is mounting that this is an effective AND cost-effective way of controlling Type 2 Diabetes as well, when it is associated with obesity (of course, not all cases are). We should be guided by the evidence, not our biases, and this is what the evidence is showing. −Francisco Prieto, MD I agree. We have an epidemic of morbid obesity causing severe medical, orthopedic and psychological disability. There are no medical or psychiatric treatments that are effective. I have seen remarkable improvement in the patients I have worked with who have had bariatric surgery. Complications are significant but far less than the benefits. −James Margolis, MD This sort of thing should be covered only if you want the ACA to fail. −John Loofbourow, MD We physicians need to be part of the solution. Mandating benefits without good scientific basis diminishes our voice. −Kevin Keck, MD I think that this should be a benefit that patients who need it will and should, additionally, invest in. Evidence-based medicine shows that it has no advantage over regimented non-surgical treatment modalities for morbid obesity. It is medically labor intensive and expensive, and I personally feel that it is more expensive than the statement shows it to be

and, in turn, a heavy burden on “medical costs.” Unless there is a “healthy person” refund check on a six-month basis for all insurance payees for maintaining good health (as in safe drivers refunds), then this care entity should have a deductible to sustain fundamental health care funds and contain health care costs. −Elisabeth Mathew, MD Health care is a privilege, not a right, and elective lifestyle-type surgeries should not be covered. We will run out of money covering all the other elective surgeries. You could make the argument that if weight loss surgery is covered, why not cover “age” surgery. If this is covered, tummy tucks, breast lifts and facelifts should be covered for things such as post child birth, aging and the like. −Charles Perry, MD Under our current fragmented system, I sometimes see harm come to post-bariatric patients, as they can no longer see their original surgeon due to the vagaries of insurance. This leads to expensive, fragmented care, and patients bumping around between Emergency Departments when complications arise. Until care is less fragmented in this country, I vote “buyer beware” and let patients wanting this procedure invest in the financial pool to do so. −Nathan Hitzeman, MD Do not know why you again and again go against evidence. −Mohammad Kabbesh, MD I do NOT think bariatric surgery should be considered an essential and mandated health benefit under the new state health insurance exchanges. −Ann Richardson, MD Obesity can be self-managed without surgery. Were it a basic benefit under mandated coverage, the insurance premium will increase. Then more people will not afford insurance coverage for more problems that cannot be self-managed, such as appendicitis. Treatment of self-managable conditions must not be considered “basic” benefits. Coverage should remain a rider, not a mandate. Medicare should not consider obesity a disease. −Gerald N. Rogan, MD

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January/February 2014


Covered California FAQs For CliniCiAns And their stAFF WhAt is Covered CAliForniA? Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays. Through Covered California, individuals and small businesses can compare different health insurance companies and learn whether they qualify for federal subsidies and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal. hoW Will Covered CAliForniA impACt my prACtiCe? The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage. Small and medium sized physician practices with 50 employees or less are also eligible to participate in the Small Business Health options Program (SHoP) at WhiCh pAtients CAn buy CoverAge through Covered CAliForniA? legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California. if a patient has access to affordable health insurance through an employer or government program, he or she can purchase coverage through Covered California but may not qualify for financial assistance. WhiCh pAtients Are eligible For subsidies through Covered CAliForniA to purChAse CoverAge? Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers. eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance. income range

Up to $17,235 (+$6,030 per dependent)

Up to $22,980 (+$6,030 per dependent)

Up to $28,725 (+$10,050 per dependent)

Up to $45,960 (+$16,080 per dependent)

max % of income





max monthly premium share

up to $57

up to $121

up to $193

up to $364

hoW Will pAtients’ FederAl premium subsidies Work? federal premium assistance is only available when enrolled in a health plan through Covered California, and it is paid directly to the health plan in which the patient is enrolled. Premium assistance will be adjusted at the end of the benefit year based on the patient’s actual income. a patient may be held accountable for any excess subsidies received when filing that year’s taxes. for this reason, patients should immediately report any changes to Covered California that may impact their subsidies, such as changing jobs, losing a job or receiving a promotion.


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rev. 10.9.13

Will my Covered CAliForniA pAtient be Able to Continue to see me? You will have to be contracted with a Covered California plan and your patient will have to select that plan. each health insurance plan has a specific list of doctors and hospitals that are considered in-network providers for covered services. directories of doctors and hospitals will be available at Patients should be advised to verify with the individual plan that a particular doctor’s or hospital’s services will be covered under that plan. Covered California is providing a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital. hoW CAn A pAtient Apply For Covered CAliForniA CoverAge or medi-CAl? open enrollment will continue until March 31, 2014, but patients must enroll in a plan by december 15, 2013, for coverage to begin January 1, 2014. in subsequent years, open enrollment will run from october 15 through december 7. Patients can apply for a Covered California health insurance plan online at or by calling (800) 300-1506. in-person assistance is also available from certified enrollment assisters in many communities. Patients can be directed to their nearest certified enrollment assister by calling (800) 300-1506.

hoW muCh should pAtients expeCt to pAy out oF poCket For heAlth CAre serviCes? Patients’ co-pays and deductibles will vary based on the plan that is selected.






Covers 60% average annual cost

Covers 70% average annual cost

Covers 80% average annual cost

Covers 90% average annual cost

Preventive Care Copay*

No cost

No cost

No cost

No cost

Primary Care Visit Copay

$60 for 3 visits




Specialty Care Visit Copay





Urgent Care Visit Copay





Emergency Room Copay





Lab Testing Copay





X-Ray Copay





Generic Medicine Copay

$25 or less

$25 or less

$20 or less

$5 or less

Annual Out-of-Pocket Maximum Individual and Family

$6,350 individual and $12,700 family

$6,350 individual and $12,700 family

$6,350 individual and $12,700 family

$4,000 individual and $8,000 family

*In most situations, this is true for one visit per year.

WhAt iF i hAve Questions About hoW my business mAy be impACted by Covered CAliForniA or heAlth plAn ContrACting under Covered CAliForniA? if you have questions related to your business or contracts for providing services to Covered California patients, please refer to the California Medical association’s (CMa) resource page, “Health insurance exchange resources for Physicians,” at for further assistance, please contact CMa’s Physician Hotline at (800) 786-4262.

January/February 2014


rev. 10.9.13

Medical Eponyms A Fun Look at What’s in a Name!

By Nan Nichols Crussell, Managing Editor HAVING A DISEASE NAMED after you can be a decidedly mixed honor. On one hand, your scientific developments are forever remembered, but on the other hand, no patient will ever be happy upon hearing your name. Who are the scientists and doctors behind some of our most famous diseases and conditions? Here is a fun collection of a few of them and their eponymous ailments. CROHN’S DISEASE The inflammatory digestive disease could have easily ended up with the name Ginzburg’s disease or Oppenheimer’s disease. In 1932, three New York physicians named Burrill Bernard Crohn, Leon Ginzburg, and Gordon Oppenheimer published a paper describing a new sort of intestinal inflammation. Since Crohn’s name was listed first alphabetically, the condition ended up bearing his name. SALMONELLOSIS The salmonella menace that lurks in undercooked chicken is actually named after a person. Daniel Elmer Salmon was a veterinary pathologist who ran a USDA microorganism research program during the late 19th century. Although Salmon didn’t actually discover the type of bacterium that now bears his name — epidemiologist Theobald Smith isolated the bacteria in 1885 — he ran the research program in which the discovery occurred. Smith and his colleagues named the bacteria salmonella in honor of their boss. PARKINSON’S DISEASE While James Parkinson, an English apothecary, had a booming medical business, he also dabbled in geology, paleontology, and even politics. Following a late-18th-century foray into British politics where he found himself briefly


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ensnared in an alleged plot to assassinate King George III, Parkinson turned his attention to medicine. He did a bit of research on gout and peritonitis, but it was his landmark 1817 study, “An Essay on the Shaking Palsy,” that affixed his name to Parkinson’s disease. HUNTINGTON’S DISEASE George Huntington wasn’t the most prolific researcher, but he made his papers count. In 1872, a fresh-out-of-med-school Huntington published one of two research papers he would write in his life. In the paper, Huntington described the effects of the neurodegenerative disorder that now bears his name after examining several generations of family that all suffered from the genetic condition. ALZHEIMER’S DISEASE In 1901, German neuropathologist Alois Alzheimer began observing an odd patient at a Frankfurt asylum. The 51-year-old woman, Mrs. Auguste Deter, had no short-term memory and behaved strangely. When Mrs. Deter died in 1906, Alzheimer began to dissect the patient’s brain, and he presented his findings that year in what was the first formal description of presenile dementia. TOURETTE SYNDROME When the French neurologist George Gilles de la Tourette first described in 1884 the illness that now bears his name, he didn’t name it after himself. Instead, he referred to the condition as “maladie des tics.” It was Tourette’s mentor and contemporary, Jean-Martin Charcot, who renamed the illness after him. Tourette didn’t have such great luck with patients, though. In 1893, a deluded former patient shot the doctor in the head. The woman claimed that she lost her sanity after Tourette hypnotized her.

Tourette survived the attack. HODGKIN’S LYMPHOMA British pathologist Thomas Hodgkin first described the cancer that now bears his name while working at Guy’s Hospital in London in 1832. Hodgkin published the study, “On Some Morbid Appearances of the Absorbent Glands and Spleen,” that year, but the condition didn’t bear his name until a fellow physician, Samuel Wilks, rediscovered Hodgkin’s work. BRIGHT’S DISEASE This kidney disease bears the name of Richard Bright, an English physician and colleague of Hodgkin’s at Guy’s Hospital. Bright began looking into the causes of kidney trouble during the 1820s, and in 1827 he described an array of kidney ailments that eventually became known as Bright’s disease. Today, it is understood that many of the symptoms historically clumped together as Bright’s disease are in fact different ailments, so the term is rarely used. ADDISON’S DISEASE Thomas Addison, a colleague of Bright and Hodgkin at Guy’s Hospital, first described the adrenal disorder now called Addison’s disease in 1855. President John F. Kennedy suffered from this illness, though he did not wish it to be public knowledge. TAY-SACHS DISEASE Although both of their names are attached to this genetic disorder, Warren Tay and Bernard Sachs didn’t work together. In fact, they didn’t even work in the same country. Tay, a British ophthalmologist, first described the disease’s characteristic red spot on the retina in 1881. In 1887, Bernard Sachs, a colleague of Burrill Crohn at Mount Sinai Hospital, described the cellular effects of the disease and its prevalence among Ashkenazi Jews. KLINEFELTER’S SYNDROME The genetic condition in which males have an extra X chromosome bears the name of Harry Klinefelter, a young Boston endocrinologist who published a landmark study while working under the tutelage of endocrinologist Dr. Fuller Albright in 1942. Albright pushed his young protégé to be the lead author of the paper

that described the condition, so the young Klinefelter’s name is forever associated with the syndrome. ASPERGER’S SYNDROME Austrian pediatrician Hans Asperger first described the syndrome that now bears his name in 1944 after observing a group of children who suffered from what Asperger described as “autistic psychopathy.” The term “Asperger’s syndrome” didn’t come into widespread usage, however, until 1981, and today it is classified as an autism spectrum disorder. DOWN SYNDROME The 19th-century doctor John Langdon Down did not discover the famed genetic disorder, but he did assign it the name “mongolism.” In the 1960s, to purge medical journals of what was now considered a racist term (Down thought sufferers bore some resemblance to Mongols), researchers instead opted for an eponym — and falsely gave credit to Down. LOU GEHRIG’S DISEASE In this case, the disease, amyotrophic lateral sclerosis (ALS), a progressive neurodegenerative condition that affects nerve cells in the brain, was actually nicknamed after a patient, baseball player Lou Gehrig. FAME AND FORTUNE Doctors who have made positive contributions to health care don’t always get proper recognition. Dr. Jonas Salk (1914-1995) did have his name attached to a lifesaving vaccine defeating polio. He also had his face on the cover of Time magazine and on a U.S. postage stamp. Dr. Henry Heimlich had a lifesaving antichoking maneuver named after him. But others like Dr. Joseph Lister (1827-1912), an English surgeon and medical researcher who pioneered the radical new idea of using strict sterilization procedures and hand washing before surgical procedures, has had his name made famous only by … mouthwash.

Doctors who have made positive contributions to health care don’t always get proper recognition.

Compiled from these sources:

January/February 2014


 2014 Board of Directors          

2014 CMA Delegation                  


Sierra Sacramento Valley Medicine

In Memoriam

E.T. “Ted” Rulison, Jr., MD 1915–2013

AN AMAZING MAN! TED MADE THE most of his 98 years. He was born in Sacramento where his father was a local physician. Ted attended Sacramento High School, then Stanford University, and in 1939 he graduated from Harvard Medical School. After interning at Highland Hospital in Rochester, NY, he began an anesthesiology residency at the Mayo Clinic. During his residency, the attack on Pearl Harbor occurred, and in his second year he was drafted into the Army Medical Corp as an anesthesiologist. He was assigned to the 51st Evacuation Hospital, headed by Dr. Orrin Cook, Sr., and he practiced anesthesia with that unit throughout the war as it followed the battles in North Africa, Italy, southern France and finally Germany. Ted was resourceful as he had to fashion cuffs for his bare endotracheal tubes, and in the cold winters he used hot water bottles to keep his ether vaporized. All the while he had his trusty camera in play and he created a website of 51st Evacuation Hospital photos which can be viewed at VE_day.htm. In 1945 when the war was over, he returned to the Mayo Clinic and began a surgical residency which he completed in 1949. It was during those years he met and married Jean Bollman who was a physical therapist. They returned to Sacramento where he joined a former military surgeon, Dr. Dudley Saeltzer, in general surgery practice. The Sacramento hospital bed situation was extremely tight with the single Sutter hospital and with Mercy prior to its expansion. Surgical beds were hard to come by as was operating room time. Ted found that if he traveled to outlying communities he could work, so he operated in Stockton, Chico and Placerville and was very welcome in those communities.

With the eventual increase in hospital beds in Sacramento, Ted was able to create a Sacramento practice. He told the story that he once gave a talk on the surgical treatment of varicose veins and then, regrettably, became inundated with varicose vein referrals. But he maintained a general surgical practice and was the first in Sacramento to perform a subcutaneous mastectomy with implant replacement. In 1963, he and other Sacramento doctors established and staffed a medical and surgical clinic in Chichicastenango, Guatemala, all this while he did not neglect his other love: photography. After he retired from his Sacramento medical practice in 1976, E.T. “Ted” Rulison, Jr., MD he was able to explore diving and underwater photography. He fashioned his own waterproof camera and began a second career as an underwater photographer which took him from the California and Mexican coasts to the Philippines, Borneo and Saipan. Some of his photography has been featured on national TV programs. He combined this hobby with serving as a ship’s physician, as well as volunteering his Interested readers surgical skills in clinics in American Samoa may want to check and Saipan. Jean accompanied him on these the SSV Medicine adventures and she accumulated a marvelous July/August 2009 interview of Dr. shell and coral collection which graces their Rulison by Dr. F. home. James Rybka in In 1986, he made his last dive trip and then which Dr. Rulison relates his chance concentrated on community service in Cameron meeting with Park where he and Jean had moved in 1971. He Adolph Hitler in and Jean have two daughters, a physician son Berchtesgaden in 1937 and then who practices in Placerville, two grandchildren his return to and two great-grandchildren. Berchtesgaden at − James P. Hamill, MD war’s end.

January/February 2014


Board Briefs November 12, 2013 The Board: Received a legislative update from Assembly Member Richard Pan, MD, Chair, Assembly Health Committee. Approved the Sierra Sacramento Valley Medical Society (SSVMS) September and October 2013 Financial Statements and 2014 Budget. Serving as the Board of Directors for the Community Service, Education and Research Fund (CSERF), approved the September and October 2013 Financial Statements and the 2014 Budget. Approved the following Scholarship and Awards Committee recommendations for the 2013 annual awards: Bradley Chipps, MD, Golden Stethoscope Award; John Young, MD, Medical Honor Award; and the Medical Community Service Award to the Cordova Community Council for its “Kid’s Day in the Park.” The recipients will be honored at the January 16, 2014 SSVMS and Alliance Annual Awards and Installation Dinner at the Hyatt Regency Hotel. Approved the appointment of Helen Biren, MD to the CMA Delegation representing Alternate-Delegate Office 11. Serving as the BloodSource Member, approved a request to extend the term through 2014 for the BloodSource Immediate Past President. Approved the Membership Report: For Active Membership — Sanaz Abderrahmane, MD; Abigail M. Bewley, MD; Abraham Boskovitz, MD; Jason D. Brayley, MD; Christian S. Bromfield, MD; Monica B. Constantinescu, MD; Dale M. Cotton, MD; Rouzbeh Daylami, MD; Marc D. Ikeda, MD; Erica S. Kellenbeck, MD; Maria T. Koshy, MD; Courtney A. LaCaze-Adams, MD; John P. Lemos, MD; Gary A. Levin, MD; Brant J. Lutsi, MD; Rosanto A. Macam, MD; Nabil Majid, 34

Sierra Sacramento Valley Medicine

MD; Prasanna Malla, MD; Shahid Manzoor, MD; Vivek Mittal, MD; Keka A. Mostofa, MD; Yogesh Nandan, MD; Anne M. Neumann, DO; Gunjan Patangay, MD; Sarah J. Perez, MD; Yolanta V. Petrofsky, MD; Flora I. Rafii, MD; Natalie C. Rose, MD; Armine P. Sarchisian, MD; Paul M. Sasaura, MD; James M. Schipper, MD; Azad A. Sheikh, MD; Sonia Sonik-Spielvogel, MD; Shannon T. Suo, MD; Alice K. Tsao, MD; Richard K. Valicenti, MD; Biji Varughese, MD; Jennifer Villa, MD; Anna E. Vinter, MD; Neal R. Waechter, MD; Valerie M. Wang, MD; Matthew M. Watson, MD; Karen Win-Vroom, MD; Peggy S. Wu, MD; Po-Hui Michael Wu, MD. For Resident Membership — Robert B. Lurvey, MD. For Reinstatement to Active Membership — Robert E. Farrell, MD; Robert R. Peabody, Jr., MD; Shao-Ta Yeh, MD. For Retired Membership — Vincent A. Kiley, MD; Scarlet LaRue, MD; Gibbe H. Parsons, MD; G. Jeffrey Smith, MD; Earl Washburn, MD; Ned J. Whitcomb, MD. For Resignation — Enass A. Arahman, MD (transferred to Alameda-Contra Costa); Lori P. Burrey, MD (transferred to AlamedaContra Costa); Ashish Chawla, MD (moved to Pennsylvania); Emery L. Chen, MD (transferred to Los Angeles); Laura E. Hufford, MD (moved to Iowa); Francisco J. Garcia-Ferrer, MD (moved to Oregon); Victor M. Gellineau, III, MD (transferred to San Joaquin); Dennis Kumata, MD; James C. Kao, MD (transferred to Orange); Yelena Lapan, DO (transferred to Sonoma); Michael Luszczak, DO (transferred to PlacerNevada); Catherine A. Mazzei, MD (transferred to Alameda-Contra Costa); Christopher K. Mosley, MD (transferred to Ventura); Michael C. Okumura, MD (transferred to Placer-Nevada); Claire Pomeroy, MD (moved to New York); Peter E. Sokolove, MD (transferred to San Francisco); Ghalib M. Wahidi, MD (transferred to San Mateo); Jeanne Yu, 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. — Jason P. Bynum, MD, President-Elect.

Abderrahmane, Sanaz, Infectious Disease, Ross University 2007, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3401

Nguyen, Anh H., General Practice, University of Saigon, Vietnam 1972, 5026 Fruitridge Rd #1, Sacramento 95820 (916) 391-9497

Tsao, Alice K., Urology, University of South Florida 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2081

Constantinescu, Monica B., Dermatology, UC Los Angeles 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2045

Patangay, Gunjan, Internal Medicine, UC Irvine 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Valicenti, Richard K., Radiation Oncology, Drexel/ Hahnemann University 1990, UCDMC, 4501 X St #G140, Sacramento 95817 (916) 734-8295

Daylami, Rouzbeh, General Surgery, Pennsylvania State University 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014

Perez, Sarah J., Hematology/Oncology, University of Miami 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2086

Varughese, Biju, Family Medicine, American University of the Caribbean 2000, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Petrofsky, Yolanta V., Occupational Medicine, Loyola University 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2005

Villa, Jennifer, Internal Medicine, Temple University 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Ikeda, Marc D., Pediatrics/Allergy/Immunology, Ohio State University 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Lacaze-Adams, Courtney A., Pediatrics, UC Los Angeles 2007, Marshall Center for Pediatrics, 4341 Golden Center Dr #A, Placerville 95667 (530) 626-1144 Lemos, John P., Emergency Medicine, University of Washington 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Levin, Gary A., Anesthesiology, Michigan State University 1980, UCDMC, 4150 V St #1200, Sacramento 95817 (916) 734-5031 Levin, Harris DP, Otolaryngology, University of Michigan 1974, Sutter Medical Group, 2030 Sutter Place #1300, Davis 95616 (530) 750-5888

Sarchisian, Armine P., OB-GYN, Moscow Medical Academy, Russia 1997, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3350

Vinter, Anna E., Psychiatry, UC Davis 2003, Summit Eating Disorders & Outreach Program, 3610 American River Dr #140, Sacramento 95864 (916) 574-1000

Sasaura, Paul M., Orthopedic Surgery, UC Los Angeles 1996, Summit Orthopedic Specialists, 6403 Coyle Ave #170, Carmichael 95608 (916) 965-4000

Wang, Valerie M., OB-GYN, Tufts University 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Schipper, James M., Interventional Cardiology, Eastern Virginia 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Watson, Matthew M., Internal Medicine, Columbia University 2005, Sacramento Heart, 3105 Cedar Ravine Rd #103, Placerville 95667 (530) 295-1900

Sheikh, Azad A., Pediatric Critical Care Medicine, Karnataka Institute Medical Science, India 1978, Children’s Specialist Medical Group, 5301 F St #313, Sacramento 95819 (916) 733-8441

Lutsi, Brant J., Gastroenterology, Northeast Ohio 2001, Woodland Clinic Medical Group, 1321 Cottonwood St, Woodland 95695 (530) 668-2618

Stevens, William R., Anesthesiology, Wayne State University 1978, Metropolitan Anesthesia Consultants, 5530 Birdcage St #145, Citrus Heights 95610 (916) 769-0785

Macam, Rosanto A., Internal Medicine, St. Louis University, Philippines 2001, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 688-2106

Suo, Shannon T., Psychiatry/Family Medicine, University of Cincinnati 1998, UCDMC-Psychiatry, 2230 Stockton Blvd., Sacramento 95817 (916) 549-4290

Majid, Nabil, Internal Medicine/Hospitalist, University of Damascus, Syria 1997, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Malla, Prasanna, Internal Medicine, Tribhuyan University, Nepal 2002, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300 Mittal, Vivek, Gastroenterology, All India Institute of Medical Science, India 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2028 Mostofa, Keka A., Internal Medicine/Hospitalist, Jahural Islam Medical College, Bangladesh 1997, Mercy Medical Group/Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 983-7400

Win-Vroom, Karen, General Surgery, University of Pittsburgh 2007, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 Wu, Po-Hui Michael, Family Medicine, Medical College of Wisconsin 2008, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 Yeh, Shao-Ta, Emergency Medicine, Drexel University 2007, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5380

AD INDEX Page BloodSource................................................................................................................................................... 22 City of Sacramento........................................................................................................................................... 8 Hill Physicians........................................................................................................................Inside Front Cover J & L Teamworks........................................................................................................................................... 27 Mercer............................................................................................................................................................ 15 Med 7............................................................................................................................................................ 24 MICRA Savings Chart............................................................................................................ Inside Back Cover Moss Adams.................................................................................................................................................. 13 NORCAL Mutual Insurance Company................................................................................ Outside Back Cover The Doctors Center.......................................................................................................................................... 2 The Gordon Group.......................................................................................................................................... 27 Tracy Zweig Associates.................................................................................................................................. 24 Walk With a Doc............................................................................................................................................... 9

January/February 2014


Classified Advertising

Office Space

Doctor-Mentors Needed

Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494.

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

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

Membership Has Its Benefits!



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


Free and Discounted Programs for Medical Society/CMA Members

Auto/Homeowners Discounted Insurance

Mercury Insurance Group 1.888.637.2431 or

Car Rental / Avis or Hertz

Members-only coupon code is required Go to: or call 800.786.4262

Clinical Reference Guides

Epocrates discounted mobile/online products

Conference Room Rentals

Medical Society 916.452.2671

Healthcare Information Technology (HIT) information Resource Center technology HIPAA Compliance Toolkit

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Insurance Marsh Affinity Group Services Life, Disability, Long Term Care 1.800.842.3761 Medical/Dental, Workers’ Comp, more… Investment Planning Resources

Wells Fargo Advisors (855) 225-4369 or email

Legal Services & CMA On-Call

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Magazine Subscriptions 50% off subscriptions

Subscription Services, Inc. 1.800.289.6247 /

Medic Alert

1.800.253.7880 /

Medical School Debt Management Members-only coupon required: Practice Financing Reduced Loan Administration Fees

Members-only coupon code is required 1.800.786.4262 /

Office Supplies/Equipment-Staples, Inc. To access the members only discount link visit: Save up to 80% Reimbursement Helpline Assistance with contracting or reimbursement

Contact CMA at 888.401.5911 or email

Security Prescriptions Products

RX Security or call (800) 667-9723

Travel Accident Insurance/Free

All SSVMS Members $100,000 Automatic Policy BenefitsandServices.aspx



Kelly K elly Rackham Rackha m [916] 616 6270


Visit SSVMS online at

Sierra Sacramento Valley Medicine

savings of $ over 93,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s Trial Lawyers have launched an attack to undermine MICRA and its protections and we need your help. Membership has never been so valuable!

WAYS SSVMS/CMA IS WORKING FOR YOU! Physicians in El Dorado, Sacramento and Yolo Counties are saving an average of $93,748 this year.


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Sierra Sacramento Valley Medical Society 5380 Elvas Ave, STE 101 Sacramento, CA 95819 Phone: (916)452-2671 Email: Join online today * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

P R O u d tO b e e N d O R s e d b Y t h e s i e R R A s A C R A M e N tO VA L L e Y M e d i C A L s O C i e t Y.

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit, call 877-453-4486, or contact your broker.

A N o r c A l G r o u p c o m pA N y

January/February 2014  

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