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PRESIDENT’S MESSAGE My Farewell Message
Jason Bynum, MD
EDITOR’S MESSAGE Stories Over Evidence
Nathan Hitzeman, MD
EXECUTIVE DIRECTOR’S MESSAGE Physician Volunteers Needed
Eat Your Medicine
Bob LaPerriere, MD
Summer SSVMS Social
Reflections on Physicians With Disabilities
Thank-You From Our Museum Visitors
Kent Perryman, Ph.D. A Posit on Right To Die
Aileen Wetzel, Executive Director
Science and Public Health Win the Day
Richard Pan, MD, State Senator 6th District
Hepatitis C Coverage − Is Rationing Inevitable?
Gerald Rogan, MD, and John Paul Aboubechara, MS III/Ph.D. Student
BOOK REVIEW Chasing the Scream: The First and Last Days of the War on Drugs
Things You Can Catch Going Barefooted
George Meyer, MD
Caroline Giroux, MD
Welcome New Members
We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.
Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.
SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Eat your medicine! Food lover or health advocate…olive oil is for you. That is, extra virgin olive oil. It has been food, balm for the sick, unguent, award for victors and a source of light since ancient times. Its important role in history is evident in its use in the Sacraments, during Hanukkah, and in the Koran where the olive tree is considered sacred. The olive tree has been cultivated for approximately 6,000 years in the Mediterranean and can live for centuries. Dr. Bob LaPerriere explores the history, various types and uses of this fruit on page 14.
Volume 66/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax firstname.lastname@example.org
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The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.
Thursday, January 21, 2016 SSVMS & Alliance Annual Installation and Awards Dinner
2015 Officers & Board of Directors Jason Bynum, MD, President Thomas Ormiston, MD, President-Elect José A. Arévalo, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Vijay Khatri, MD Darin Latimore, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD
District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Kieu-Loan Luc, DO
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 Maynard Johnston, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Adam Dougherty, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Thomas Ormiston, MD Richard Pan, MD, Senator Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD
District 1 Kevin Elliott, MD District 2 Don Wreden, MD District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Sean Deane, MD Kevin Jones, DO Thomas Kaniff, MD Vijay Khatri, MD Sandra Mendez, MD Armine Sarchisian, MD Vacant Vacant Vacant Vacant Vacant Vacant Vacant Vacant
CMA Trustees District XI Barbara Arnold, MD
Douglas Brosnan, MD
Richard Thorp, MD
Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS III George Meyer, MD Sean Deane, MD John Ostrich, MD Adam Doughtery, MD Gerald Rogan, MD Ann Gerhardt, MD Glennah Trochet, MD Sandra Hand, MD Lee Welter, MD Albert Kahane, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Executive Director Managing Editor Webmaster Graphic Design
Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly
Installations Thomas W. Ormiston, MD, President 2016 2016 SSVMS Officers and Board of Directors
Award Presentations Golden Stethoscope Award Medical Honor Award Medical Community Service Award Dorothy Dozier Helping Hands Award
Entertainment To Be Announced
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.
CMA Imm. Past President Richard Thorp, MD AMA Delegation Barbara Arnold, MD
Hyatt Regency Hotel 1209 L Street, Sacramento 6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program
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. ©2015 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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My Farewell Message An Avenue for Advocacy Moving Forward
By Jason Bynum, MD THIS WILL BE MY last President’s Message before we usher in a new year and a new president in 2016 at the Annual Awards and Installation Dinner in January. Looking over my year as president, I see some tremendous growth for the society as a whole, but also some missed opportunities for me, personally. Let me elaborate. Over the course of 2015, we have seen the collaboration of emergency physicians, psychiatrists, and the SSVMS Board of Directors leading to the development of the white paper, “Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment.” The paper has implications, not only of a standard of care for our area, but also for the care and triage of mental health patients across the nation. I, personally, hope it will be published by its authors for this consideration. Secondly, we are working with our health systems and county partners to expand SSVMS’ Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) program to provide expanded specialty services to undocumented residents of Sacramento County. I must say, however, I learned a few things. In my time here in Sacramento, I have moved from a “young career” psychiatrist to more of a “journeyman” level physician (in the jargon of woodworking apprenticeships). I have learned that change is not always quick, despite your own enthusiasm or conviction that you have the best idea. You must open your eyes to alternatives, some of which I was humbled to know were better than my own. Change often comes at a level beyond your own control, such as at a legislative level, and you must relinquish your passion and trust in the wisdom of those
whose job it is to legislate. I realize I am being vague and coy, but if I could summarize my thoughts on mental health crisis in general, it would be this: Somewhere along the way, we have relinquished the treatment of our patients by physician-led practices over to privatization. Long-term psychiatric, state-run hospitals dominated psychiatric care in to the early 60s. With the passing of the Community Mental Health Care Act under President John F. Kennedy, community assertive treatment was then the standard of practice which carried on into the late 90s. Due to budgetary cuts, clinics were closed, hospitals went under, and care continued to suffer. As a result, private companies, who had a business model to suit the relatively low compensation of mental health patient care, filled this void, and I leave the results up to your review. I’ve seen this pattern over and over in the five states in which I’ve practiced. I have always envisioned a blending of these two models of treatment. I do not believe we can treat every patient in the community, and I believe my psychiatric colleagues would agree. The vast majority can be handled, yet, many require innovative treatment models. Where have all the ACT (assertive community treatment) teams gone, the drop-in programs, skills and job building programs, state-run hospital beds, and supportive living programs? I remember in former academic institutions, cardiac care centers and cancer treatment centers looked like palatial retreats. Mental illness is consistently in the top three diagnoses of emergency rooms, primary care clinics, and general hospital diagnoses. Yet, every psychiatric hospital I’ve ever worked in has been less
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
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than palatial. I personally think it’s because psychiatric diagnoses are often a progressive and deteriorating mental prognosis. As a result, CMS reimbursement codes for our care are unsupported by major political advocacy groups when many of our patients are destitute. I believe there has been much done this year to take steps which, in the next year or so, will hopefully relieve the immense burden of our psychiatric patients defaulting to emergency room care. But the root of the problem remains, in that, in a free market, nobody competes for psychiatric patients. No hospital program develops new programs to attract mental health patients, builds new facilities, or advertises for them…mainly because they don’t pay well! The ACA is hopeful, from a mental health perspective, in that ACO’s performance measures have interfaced with mental health treatment (i.e., the drinking cardiac patient). I do see that as an avenue for advocacy moving forward. I also will be putting efforts, even beyond my tenure at SSVMS, into raising attention to my theories, above. I may be wrong, as I’ve often found I can be this year, but I think it’s worth it if I can just move things an inch further along. Thank you all for the letters, emails, and opinions I’ve received over the past year. It has been a pleasure to serve as your president, and I wish everyone well in 2016. firstname.lastname@example.org
Stories Over Evidence By Nathan Hitzeman, MD A LOT OF MY Evidence Based Medicine (EBM) teachers from medical school are getting gray and anxious, waiting for the transformation to EBM in their lifetimes. I don’t think it will happen the way they had hoped. Risk calculators, infographics, and numbers needed to treat fall on deaf ears with patients time and time again. What the media and the population respond to are stories, for better or for worse. I was reminded of this again by a recent JAMA reflection entitled “Story as Evidence, Evidence as Story” by geriatrician Louise Aronson at UCSF. Dr. Aronson describes how she was listening to a very articulate public health scientist on a radio talk show challenging the benefits of mammography. All seemed to make sense until a caller brought up the story of her 42-year-old sister whose cancer was detected by mammography. The DJ and further callers pretty much derailed the message of the expert that “less was more.” Dr. Aronson goes on to relate a counter story where a patient of hers went through the wringer for a false positive on a mammogram. But patients often don’t want to hear stories of over treatment. And so stories emerge over time to curtail or redirect our public health efforts. The Jenny McCarthys. The legislators who rally against undertreated pain – how many thousands of people have died from the liberal “war-on-pain” prescribing since the mid 1990s? The nursing home bedsore and epidemic of elder abuse. On a more subtle level, even within our own ranks, our beloved Dr. Oz said everyone needs a colonoscopy in his TIME magazine piece (OMG, he had a polyp!) even though occult blood screening has been found to be a reasonable alternative in average risk persons. There are important issues addressed in all of these examples, but when someone superimposes a black-or-white, either-or decision tree onto
our complex patient interactions, the result is usually not beneficial for our public health wellbeing. Still, a heart-wrenching story carries more weight than all the p-values of PubMed squared. In this issue, when you read the article on limited Medi-Cal coverage of Hepatitis C treatments, imagine how different the policy might be had there been a Ryan White who tragically succumbed to Hepatitis C. When you read the responses of the Right-to-Die posit, think of the story of Brittany Maynard and how fast this bill went through the legislature. When you read Dr. Lee Welter’s book review on the war on drugs, think of the stories that got us to where we are in this campaign. SSVMS President, Dr. Jason Bynum, and numerous community stakeholders have been amassing a ton of EBM on underfunded mental health care and its ongoing toll on our society. When will these efforts gain traction? What kind of story will fix this mess: another Jodie Foster stalker, Sandy Hook massacre, deranged Santa Barbara college student women-hater, or senator being attacked by his mentally-ill son? When you read of a dead Syrian refugee boy in Dr. Caroline Giroux’s poem, recall Josef Stalin’s quote: The death of one man is a tragedy. A million deaths is a statistic. In the end, I hope we can follow State Senator Dr. Richard Pan’s lead. He has balanced stories with evidence and evidence with stories very well through his testimonials with afflicted families of preventable illnesses and his public health acumen. Still, it is this same sane and balanced approach which has incited a nutty fervor to recall him. Sorry, my esteemed professors, may EBM RIP. Pass me the bread and olive oil, and more vino please! email@example.com November/December 2015
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
Executive Director’s Message
Physician Volunteers Needed New Health Care Program for Undocumented Immigrants
By Aileen Wetzel, Executive Director
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
THE LACK OF COVERAGE for the By providing access to care for our region’s undocumented caused by their exclusion from undocumented residents, we hope to create a expanded Medi-Cal and/or Covered California preventative public health strategy by allowing has resulted in these patients relying heavily all uninsured residents access to primary care in on local Emergency Departments for services, a more timely and cost effective manner than to including services that are not emergencies. wait for emergency care. While some undocumented patients have To be eligible for SPIRIT specialty care established themselves with local community or surgical services, an individual must be a clinics, these clinics are unable to provide them resident of Sacramento County, 19-64 years old, with specialty and surgical care. Local hospitals continue to be the default setting for caring for these patients in the least economical way possible. In June 2015, the Sacramento County Board of Supervisors approved a new program called Healthy Partners. This program will provide specified services for undocumented residents of Sacramento County who meet specific eligibility criteria. While community clinics will continue to provide primary care services for the undocumented, new primary care services will be provided at Providing your patients a safe and the County’s Primary Care Clinic. enriching place to spend the day, The four local health systems and Sierra Sacramento Valley Medical while giving family caregivers respite. Society have committed to expand the Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) Program to address the Locations in Midtown, North Sacramento significant needs for specialty care and and Greenhaven outpatient surgery to undocumented Licensed by the State of California, patients served at both community Dept. of Social Services OLDER ADULT SERVICES and county clinics.
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have no other medical insurance, fall under 200 percent of the federal poverty level, and have a medical home. We need your help! There are opportunities for physicians to donate their time and expertise in the following ways: • Specialty care consultations/visits in private physician offices, where your recommendations for follow-up treatment will be sent to a referring clinic where they will be implemented. • Specialty care clinics housed at the County Primary Care Center, where you can provide consultation during a subspecialty clinic for patients referred, with recommendations for follow-up treatment implemented by the patient’s medical home. These subspecialty clinics would typically be in 3-4 hour blocks of time, once a month. • Surgeries in local hospitals/surgery centers. • Telephone specialty consultations with primary care providers. SPIRIT’s case managers make it easy for volunteer physicians to participate with as little disruption to his/her schedule as possible. In addition to case management, SPIRIT staff take care of all case management and care coordination between the referring clinic, the patient and the physician volunteer. Referring clinics are medical homes and are responsible for implementing the care plan and follow-up care recommended. Volunteer physicians are never asked to assume on-going care for a patient. SPIRIT services are limited to either consultation and evaluation or one-time only outpatient surgical care. Currently we have a need for: Cardiology Dermatology Endocrinology ENT Gastroenterology General Surgery Neurology Rheumatology
Urology If you are interested in donating your expertise or if you have questions, please contact Kris Wallach at (916) 453-0254 or kwallach@ ssvms.org. firstname.lastname@example.org
Interested in Becoming More Involved in Organized Medicine? Join a Committee —The Sierra Sacramento Valley Medical Society (SSVMS) is looking for physicians interested in serving on the following 2016 committees: Emergency Care, Editorial, Historical, Public & Environmental Health, and Scholarship & Awards. Volunteer with our SPIRIT (Sacramento Physicians’ Initiative to Reach out, Innovate and Teach) Program, which pr ovides medical services to the uninsured and undocumented immigrants in our community. Become a Legislative Key Contact for CMA — CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue. You don't have to be a political expert or know a legislator directly to serve as a Legislative Key Contact. You just need the desire to make an impact, and CMA will give you the rest. For more information or to discover mor e ways to become involved, contact Aileen Wetzel, Executive Director, at (916) 452-2671 or email@example.com.
Interested in Shaping Health Policy? The Sierra Sacramento Valley Medical Society (SSVMS) has
vacancies on its delegation to the California Medical Association (CMA) House of Delegates. The CMA House of Delegates convenes annually to debate and act on resolutions and reports dealing with a myriad of issues concerning medical practice, public health and CMA governance. Policies adopted by the House of Delegates are implemented by the CMA Board of Trustees either at the state level or referred for national action or legislation. Delegates and Alternate-Delegates are responsible for representing their colleagues in the House of Delegates by attending and actively participating in delegation caucus meetings and all sessions of the House of Delegates. SSVMS reimburses all of its delegation members for transportation and hotel accommodations. A daily meal allowance is also provided. Delegation members must stay for the entire meeting (Friday – Sunday) in order to be eligible for reimbursement. In 2016, the House of Delegates will meet in Sacramento, October 14-16, 2016, at the Sacramento Convention Center. Interested in learning more? Contact: Chris Stincelli, Associate Director, (916) 452-2671 or firstname.lastname@example.org.
Science and Public Health Win the Day SB 277 Promises a Vaccinated Community
By Richard Pan, MD, State Senator 6th District
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.
ON JUNE 30, 2015, our nation saw that science and public health can win over a concerted campaign of misinformation and intimidation. The Governor’s signing of SB 277 into law is the latest in California’s long, uphill battle for a safe and healthy community that is protected against vaccine-preventable diseases. It could not have been done without you — physicians, scientists, and public health advocates. Last April, when lawmakers were hounded by anti-vaccination extremists denying the dangers of polio, measles, and other preventable contagions, I stood with polio survivors at the Sierra Sacramento Valley Medical Society’s Museum of Medical History. The polio survivors, many in wheelchairs, spoke about the tremendous difference immunizations made to our country. They were incredulous that any parent would deny their child safe and effective vaccines from diseases including polio which continues to afflict them. Thankfully, despite appearing in droves at the State Capitol, the position of the extremists that these diseases are “no big deal” was outrageous to most. A statewide poll by the Public Policy Institute of California showed that 65 percent of Californians agree that children should not be allowed to attend public schools unless they are vaccinated against diseases like measles, polio and pertussis. Through a broad coalition of parents, educators, business and labor organizations and many others, the voice of physicians and other health professionals was not drowned
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out like it was in other states, such as Oregon and Washington. In March, vaccine opponents touted their victory when bills in those states failed. California was different because you and so many others took action to convince the public that Californians did not want to be further exposed to serious, preventable contagions, and vulnerable people, including cancer, transplant, and other immunosuppressed patients, needed the protection of a vaccinated community. With passage of the law, vaccine opponents are attempting to recall me from the Senate. With your support, I was elected just last year to help keep our community safe and healthy. SB 277 is a shining example of me keeping my promise to the people of my district. Anti-vaccination extremists know that my leadership and our success will inspire other legislators across the country to pursue legislation similar to SB277. This recall effort is an attempt to intimidate other elected officials from supporting vaccination, but I will not be bullied. Please go to KeepDrPan.com to help me fight this misguided recall effort. As physicians, we devoted years of study and practice to master the science of medicine and to apply it to improve the health of our patients. And when challenged by willful misinformation that endangers them, we need the courage to stand our ground for our patients. With your support, I had the strength to pass SB277 into law and will be able to defeat this recall. Thanks to you, science and public health will win again! email@example.com
Hepatitis C Coverage – Is Rationing Inevitable? By Gerald N. Rogan, MD, former Medicare B Contractor, Medical Director, California, and John Paul Aboubechara, MS III/Ph.D. Student A LESS TOXIC CURE FOR hepatitis C virus (HCV) is finally upon us, but the treatment is pricey. With more people under governmentsponsored health plans, some sort of rationing seems inevitable. But, is it ethical and optimally beneficial tothe public health? Here is our look into how our state is covering treatment of HCV. On July 1, 2015, the California Department of Health Care Services (DHCS) issued a MediCal coverage policy governing the new low-toxicity drugs including SovaldiTM (sofosbuvir − a nucleotide analog NS5B polymerase inhibitor) and Harvoni® (ledipasvir 90 mg – a NS5A inhibitor − combined with sofosbuvir 400 mg).1 Prior to these drugs, interferon-based treatment was so toxic that its use was limited. Treatment of HCV genotype 1 in adults with Harvoni tablets is once daily for 12 weeks.2 Treatment-experienced patients with cirrhosis require 24 weeks. The retail price is $1,147 per pill3 which equals $96,348 for a 12-week course of therapy. Treatment of HCV genotype 2 in adults with Sovaldi 400 mg tablets is once daily and requires ribavirin 500-600 mg twice daily. Treatment lasts 12 weeks, or 24 weeks for a patient with compensated cirrhosis. The retail price for Soldavi is $1,020 per pill.4 Ribavirin costs $0.86 per 200 mg pill. The total cost of 12 weeks of treatment is as low as $85,680 plus $361, which equals $86,041 retail. The Medi-Cal cost of each course of therapy is probably less, perhaps as low as the cost of a new luxury BMW Z4 ($52,363).5 Lower prices may be available to 340b programs.6
Compared to HIV treatment, which cost about $23,000 per patient per year in 2010, HCV treatment is a single course and curative. Lifetime cost of HIV treatment is $379,668.7 Therefore, HCV treatment costs less than HIV treatment, so long as the cured HCV patient lives more than four years after treatment and does not become reinfected. Looking at it that way, is $1,000-a-pill a good deal? The DHCS policy rations HCV treatment. Treatment is provided for those individuals at highest priority, high priority, and individuals at elevated risk of HCV transmission. Rationing is based, in part, on the stage of liver inflammation. Medi-Cal recipients with HCV who have stages 2, 3, and 4 (the most severe scarring) are eligible. Those with stages 0-1 are not. Priority also is given to some stage 0-1 persons based upon a comorbidity or, for others, a behavior that is more likely to spread the infection. A noncovered recipient must wait until he/ she becomes sicker, finds a job which offers insurance, buys a personal policy, pays out-ofpocket, works with the doctor to document severe fatigue, develops a systemic disease such as cryoglobulinemia or diabetes, or attests to a covered behavior. During the wait period, stage 0 and 1 recipients may receive monitoring for increasing liver inflammation, fibrosis, and cancer. Such monitoring will offset a portion of the savings from withholding their treatment. Evidence shows that HCV infection may cause symptoms at stages 0 and 1, such as fatigue and increased all-cause mortality. HCV infection also increases the risk of liver cancer at any stage
As many as 5.2 million of the 318 million people living in the U.S. are infected with HCV (1.6 percent).
of disease.8 This is the first policy we have seen that denies a safe curative treatment to a recipient who has a curable infection. The denial is based on the patient not being “ill enough,” the limited severity of current disease, and the lack of apparent current complications. Healthier recipients who are likely to live longer are denied access in favor of those who are sicker.9 Recipients who are more likely to infect others receive priority treatment. Unfortunately, delay in treatment of infected recipients may increase the prevalence of stage 4 recipients who will require treatment that costs twice as much, and, in some cases, a liver transplant. On the other hand, many recipients do not stay on Medi-Cal indefinitely. One may reasonably conclude the policy restricts access to care for a pre-existing condition, HCV infection, which is contrary to the Patient Protection and Affordable Care Act (PPACA − a.k.a. “Obamacare”) and relevant federal guidelines. The policy may also become unenforceable because one can qualify as a treatment candidate without verifiable documentation of behavioral priorities or subjective symptoms (i.e. fatigue). This is not to say that HCV-infected Medicaid recipients in other states are provided with a BMW cost equivalent! Most other states ration HCV treatment according to degree of liver damage. Some do not cover stage 2 liver fibrosis, but California does. California provides coverage of an active user of IV illicit drugs, in contrast to some states that require a period of drug-free behavior. Barua, et. al. (2015) describes the current Medicaid coverage of other states (each state makes its own coverage policy under general federal guidelines).10 Seventy-four percent of [state] Medicaid programs limit sofosbuvir access to persons with advanced fibrosis (Meta-Analysis of Histologic Data in Viral Hepatitis [METAVIR] fibrosis stage F3) or cirrhosis (F4). …Eighty-eight percent include drug or alcohol use in their sofosbuvir eligibility criteria, with 50 percent requiring a period of abstinence and 64 percent requiring urine drug
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screening. Restrictions do not seem to conform with recommendations from professional organizations, such as the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases. Current restrictions seem to violate federal Medicaid law, which requires states to cover drugs consistent with their U.S. Food and Drug Administration labels. The DHCS policy refers to the American Association for the Study of Liver Diseases (AASLD) guidelines for recommended retreatment regimens.11 California’s policy does not follow the AASLD guidance in some respects, such as to “treat all patients.” In August 2015, the NY Times wrote that “…experts from the Public Health Service and President Obama’s Advisory Council on HIV/AIDS said restrictions on the drugs imposed by many states were inconsistent with sound medical practice, as reflected in treatment guidelines issued by health care professionals and the Department of Veterans Affairs.”12 Medicaid directors have written to Congress about the cost of HCV drugs.13 Recommendations include price controls. Not discussed is whether taxpayer dollars may have supported the research that led to the new life-saving drugs. If so, should our government receive royalties, in addition to the 23 percent valueadded tax that is collected for branded drugs pursuant to the PPACA and prior legislation? As many as 5.2 million14 of the 318 million people living in the U.S.15 are infected with HCV (1.6 percent). Medi-Cal serves 6.8 million people, of which 52 percent are children.16 So, there may be about 57,000 adult Medi-Cal recipients who are infected with HCV. In 2010, deaths in the U.S. from HCV (15,106) exceed those from HIV (12,734).17 In California prisons, only stage 3 and 4 HCV patients are treated.18 There are an estimated 136,311 adults in California prisons.19 One in three is infected with HCV.20 So, we estimate 45,437 prisoners have HCV in addition to those on Medi-Cal, for a total of 102,000 persons who are subject to State of California decisions about access to HCV treatment. Seventy-five percent of patients infected
with HCV will develop a chronic infection and approximately 65 percent of those are expected to develop chronic liver disease. Most of those infected were born between 1945-1965,21 before HCV was discovered and removed from the blood supply. The CDC recommends screening these patients.22 Currently, only nine percent of HCV patients are being treated.23 What is the best solution here? Is it time to budget to provide curative treatment to all, regardless of their medical or behavioral status? Should lawmakers consider cutting other health care programs in order to treat every Medi-Cal recipient who has HCV infection, or find the money from other budgets outside of health care (e.g. education, maintaining roads)? What is the point of screening recipients for HCV when treatment might be denied? Is $1,000-a-pill too much to pay? Should all stage 0-2 HCV infected inmates be treated before release from prison? Should DHCS track the outcomes of its rationing policy to verify it benefits the public health as intended? After the controversy settles, which MediCal recipient will be provided with the BMW equivalent and who will remain sick? firstname.lastname@example.org email@example.com REFERENCES 1 www.dhcs.ca.gov/Documents/Hepatitis%20C%20Policy.pdf 2 www.gilead.com/~/media/Files/pdfs/medicines/liver-disease/ harvoni/harvoni_pi.pdf 3 www.goodrx.com/harvoni/price 4 www.goodrx.com/sovaldi/price 5 http://bmw.niello.com/details.php?stock=13197&id=71556&info =New_2016_BMW_Z4_sDrive28i&EnforceDesktop=true 6 www.hrsa.gov/opa/ 7 www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/ 8 www.ncbi.nlm.nih.gov/pubmed/24899827 9 www.icer-review.org/california-technology-assessment-forumctaf-issues-final-report-and-action-guides-on-new-treatments-forhepatitis-c/ 10 Restrictions for Medicaid Reimbursement of Sofosbuvir for the Treatment of Hepatitis C Virus Infection in the United States. www.ncbi.nlm.nih.gov/pubmed/26120969 11 www.hcvguidelines.org/ 12 www.nytimes.com/2015/08/26/us/wider-reach-is-sought-for-newhepatitis-c-treatments.html?_r=0 13 http://medicaiddirectors.org/sites/medicaiddirectors.org/files/ public/namd_sovaldi_letter_to_congress_10-28-14.pdf 14 Chak E, et al. Liver Int. 2011;31(8):1090-1101. 15 https://www.google.com/webhp?sourceid=chrome-
instant&ion=1&espv=2&ie=UTF-8#q=us%20population%202014 16 California health care almanac, slide 36 17 Ly KN, et al. Ann Intern Med. 2012;156(4):271-278 18 Personal Communication 19 www.cdcr.ca.gov/Reports_Research/Offender_Information_ Services_Branch/Projections/F14Pub.pdf 20 www.cdc.gov/hepatitis/HCV/PDFs/HepCIncarcerationFactSheet. pdf 21 Centers for Disease Control and Prevention. MMWR. 2012;61(RR-4):1-32. 22 www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section3 23 Holmberg SD et al, New Engl J Med. 2013; 1859-1861, Gish Hepatology, 2015.
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Chasing the Scream: The First and Last Days of the War on Drugs, By Johann Hari, Publisher Bloomsbury USA, Jan. 2015. ISBN-13: 978-1620408902
Reviewed By Lee O. Welter, MD THIS BOOK ARTICULATELY addresses concerns of everyone who values human health and happiness: that should include all medical professionals. Based upon very thorough investigation and documentation, it presents surprising in-depth information about drug use and abuse. From its explanation of the Drug War’s shameful motivation and its predictable but gruesome consequences — or have we not learned the lessons of Alcohol Prohibition? — the tone becomes increasingly therapeutic and optimistic. Author Hari offers two factors motivating the War on Drugs: 1) Following the 1933 21st Amendment repeal of Alcohol Prohibition, its enforcement agency needed a justification for that agency’s continuing existence; and 2) The Mafia needed equally-profitable illegal products to replace its lucrative alcohol business. Shrewd propagandists helped gain public support. Public opinion and government agencies have been swayed by the Drug War’s propaganda for more than a century. Hari addresses its consequences and the real world evidence to counter that propaganda. More realistic and humane approaches to drug use and abuse are revealed, countering efforts to hide them from public view. Hari gathered a large body of evidence and offers some conclusions. He addresses many questions, often revealing current deception. What are the consequences of drug prohibition? What is the actual risk of drug addition? How have programs more humane than punishment succeeded? If narcotics are highly addictive, how can so many patients discontinue their pain medications as they recover from surgery? What
is the “Rat Park Experiment,” and what are its implications? One phase of psychologist Bruce Alexander’s Rat Park Experiment studied laboratory rats confined in a cage, isolated from natural activities, with access to either water or morphine: those isolated rats consumed morphine. Another phase used a second set of rats living in a more natural environment — cages with other rats and many entertainments, aka Rat Park. These rats could also choose between water and cocaine. The Rat Park rats drank the water and ignored the cocaine. “Addicted” rats which were later moved to Rat Park abandoned their drug habit. Author Hari raises many questions, providing some conclusions, but leaving others unanswered: Who bears responsibility for the Drug Wars’ tens of thousands of deaths in Mexico, some accomplished using weapons provided by America’s “Justice Department”? What will become of Mexico’s economy and governance if drug money is removed? Who are the heroes who brought sanity and humanity to drug treatment programs in Portugal, Vancouver, and elsewhere? Are drug users human beings? What tactics achieved marijuana decriminalization in the states of Colorado and Washington? Will this trend continue? Finally, will physicians learn enough about this topic to bring sanity to its management? If you have any interest in economics, mental health, or human values, read the book. email@example.com
Eat Your Medicine Extra Virgin Olive Oil – A ntioxidant and Delicious
By Bob LaPerriere, MD
FOOD LOVER OR HEALTH advocate…olive oil is for you. That is, extra virgin olive oil (EVOO). U.S. Consumers spend more than $700 million every year on extra-virgin olive oil…the third largest specialty food product after coffee and chocolate. EVOO has been shown to have beneficial effects on virtually every aspect of body function, development and maintenance. Recently there is even evidence that it may decrease the incidence of breast cancer. Olive oil has been food, balm for the sick, unguent, award for victors and a source of light since ancient times. Its important role in history is evident in its use in the Sacraments, during Hanukkah, and in the Koran where the olive tree is considered sacred. The olive tree has been cultivated for approximately 6,000 years in the Mediterranean and can live for centuries. The U.S. is the major market for European Union olive oil. However, recently, California has become a major producer of excellent quality extra virgin olive oil, and its Council has some of the most stringent requirements. Standards for EVOO vary, but generally it should be produced by the first “pressing” of the olive fruit without the use of heat or chemicals, fall within the guidelines noted below under quality chemistry, and pass a taste test by professional tasters. EVOO accounts for less than 10 percent of olive oil in many countries. Olive oil may be filtered or unfiltered. Unfiltered is tastier, but filtered is more stable with a longer shelf life. Multiple other grades of olive oil exist but are not comparable in quality, taste or health benefits to EVOO. These include: Virgin Olive Oil − It is made from olives that are slightly riper and is essentially defective
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extra virgin oil with a higher level of acidity. Pure (Commercial Grade) Olive Oil − Comes either from the second cold pressing or the chemical extraction of the olive mash left over after the first pressing. Pure refers to the fact that no non-olive oils are mixed in. Refined Olive Oil − Refined olive oil is obtained from virgin olive oils which have a high acidity level and/or other defects. Much of the oil produced in the Mediterranean area is of such poor quality that it must be refined to produce an edible product. No solvents are used to extract the oil, but it is refined with the use of charcoal and other chemical and physical filters. Pomace Oil − used at times especially for deep frying, though it is banned in some countries and controlled in others because of harmful by-products such as benzopyrenes which can be formed from improper solvent extraction of the oil. Historically this grade has been used as lamp oil. Light Olive Oil − Produced from a lower quality oil that must be refined with chemical processing. It is only light in nutrients and flavor. The major countries producing about 90 percent of the world’s olive oil are Spain, Italy, and Greece (in that order). The broad belt across Southern Spain produces between 30-44 percent of the world’s olive oil, primarily from Picual olives. The island of Crete produces 1/3 of Greece’s olive oil from its 30 million olive trees. Historically, many olive oils, especially from other countries, have been mixed with “seed” (non-olive) oils which have generally been refined. Various studies have shown that up to 70 percent of olive oils sold as EVOO do not meet the required standards. Australian
and California EVOO’s appear to be among the most reliable. Spain and Italy have had varied problems the past year that almost doubled the cost of their olive oil. Consequently, Costco has switched from Italy to Greece to source its EVOO…and of interest, Greece in the past has sold much of their bulk olive oil to Italy who can then package it and export it for an additional 50 percent premium. Since the popularity of EVOO, which has skyrocketed only in the past couple of decades, many other countries, including Australia, South Africa, some South American countries, and the United States, have joined the list of producers. In the U.S., California, followed by Texas, Oregon, Arizona and Georgia are the major producers. California has 30,000 acres of olive trees and is planning to add 5,000 more each year until 2020.
Geographical Guideline Agencies Protected Denomination of Origin − guarantees that all phases from growth to production are done in that area. It is like the appellation control in French Wines. Italy − DOP Spain − DO Greece − PDO France − AOC
Main Techniques For Producing Olive Oil 1. Cleaning the olives 2. Grinding or crushing the olives into a paste 3. Malaxing (mixing) the paste, which allows small oil droplets to combine into bigger ones. 4. Separating the oil, which is generally done by centrifugation, though in the past was done with presses. The terms “first press” and “cold press” reflect that method.
Quality Guideline Agencies • IOC − International Olive Council (previously known as the IOOC or International Olive Oil Council) • USDA − United States Department of Agriculture • NAOOA − North American Olive Oil
Association • EVA − Extra Virgin Alliance • COOC − California Olive Oil Council – requires mechanically extracted oil without chemicals or heat with free fatty acids <0.5 percent. It provides a seal to those producers meeting their requirements and has more stringent requirements than the IOC and USDA.
U.S. Consumers spend more than $700 million every year on extra virgin olive oil. Photo courtesy of The Olive Press in Sonoma, California.
Quality Chemistry Free Fatty Acids (FFA, sometimes expressed as free oleic acid which represents at least 55 percent olive oil’s fatty acids) − High levels signify poorer quality oil. Low FFAs relate both to higher quality and a higher smoke point, which ranges from 185-210 C (365-410 F), but the safe range is generally agreed to be up to 375-385 degrees.1 Most regulations require FFA <0.8 percent, though the California Olive Oil Council requires <0.5 percent and the finest olive oils may be <0.2 percent. Peroxide: Peroxide value in newly-pressed oil shows oxidation. Most guidelines require <20 milliequivalent/kilo, though many feel it should be <10, and producers of premium oils try to keep the level down to 5 or 6, much less than allowed by the IOC. 1,2 & 1,3-Diacylglycerols (DAGs) – The 1,2 and 1,3-Diacylglycerols are related to both the freshness of the oil and the quality of the fruit. The 1,2- Diacylglycerols should represent 85-90
Photo courtesy of the California Olive Oil Council.
percent of the total diacylglycerols (the 1,3 form signifies older oil and poorer quality of olives). Alkyl Esters − A somewhat inadequate compromise set the maximum level at 75 mg, but good oil ideally should have a level of not more than 10-15 mg/kilo. This is a relatively new parameter. Polyphenols − Polyphenols are anti-
inflammatory, antioxidant and anti-aging. They help to reduce and neutralize free radicals and repair damage caused to cell membranes. They generally range from 100 (low) to 500 (very high) with some as high as 800. The most important polyphenols in EVOO are hydroxytyrosol, oleocanthal and oleacein. Oleacein is a derivative of oleuropein which is found primarily in olive leaves and also has antioxidative and anti-inflammatory properties. Recent studies suggest that oleocanthal acts similar to ibuprofen. Polyphenols are responsible for EVOO’s bitter, pungent taste and may have antioxidant effects up to 10-15 times greater than green tea. Striking is the fact that the pungency or burning is evident in the back of the throat and can even cause coughing when the EVOO has a very high polyphenol content. Higher polyphenol content increases the shelf life, but does decrease with the aging of the olive oil. Additional compounds found in EVOO include Vitamin E, Vitamin A (Beta-Carotene), and chlorophyll, which is responsible for its green color. The color of fresh olive oil is not generally related to its quality or health benefits, and professional tasters use a blue glass to eliminate the color affecting their evaluation.
Buying Olive Oil Expiration date by law is 18 months from BOTTLING, not harvest. As EVOO, for greatest taste and health benefits, should be purchased and used within 12-18 months of harvest and production, the harvest and milling date should be on the bottle. There are a number of reliable sources for olive oil, both imported and Californian, that market fresh oil and note the levels discussed in quality chemistry above. They are noted in the PDF that is linked below. If you want really fresh EVOO, keep in mind that olives in California are usually harvested the last quarter of each year, whereas in other countries may be harvested at other times, often April-May. Look for the seal of the IOC or the USDA, or if a California produced oil the seal of the COOC which gives you the best assurance
Photo courtesy of Juliette Cayol of the International Olive Council. It is of an olive tree in her garden in Umbria, Italy.
continued on page 30
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Summer SSVMS Social The Sierra Sacramento Valley Medical Societyâ€™s Summer Social Event was held at the Aerospace Museum of California on Saturday August 22. This family-friendly event was open to all physicians and their families who were treated to a private gathering and tour. Hors dâ€™oeuvres and beverages were served. A special appreciation to our sponsors, BloodSource, Cooperative of American Physicians and NORCAL Mutual. Photos by Bob LaPerriere, MD
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Reflections on Physicians With Disabilities Background: The June 9, 2015 issue of JAMA celebrated the 25th anniversary of the American Disabilities Act, signed into law by President George H.W. Bush on July 26, 1990. Undoubtedly, this landmark legislation has touched you, your family or patients, in numerous ways. One-fifth of the U.S. population is thought to have one or more disabilities, either physical or mental. The following are stories from our members about how they or a colleague have practiced medicine despite the challenge of a disability. Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows:
I fell into a dark hole at 14, and years later I was diagnosed with Bipolar Disorder. Because of recurrent depression, I dropped out of Stanford at age 20 and finished my degree at Cal State at age 32. When I applied to medical school, I was explicit about my disability and felt privileged to be admitted to UCSF. Throughout my career, I have struggled with boundaries between the pain of my patients and my own inner world. As a young doctor, I was relatively fragile and selected a “generally happy” specialty of pediatrics. From my days receiving psychiatric care at Student Health, I have been privileged to rely on the following professionals to help me remain a healthy and productive physician: my PCP, psychiatrist and therapists. Later in my career, when I, myself, had more recovery, I returned to residency to become an adult psychiatrist. As a 53-year-old former pediatrician, being up all night in a Washington, DC, ER was a challenge. But these are “my people.” I do not have their illness, but I listen
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with a special ear. I am entirely open about my illness with my colleagues, and they provide the occasional well-intentioned feedback. I rarely reveal my illness to patients. In one of those rare instances when I did tell a patient, the patient announced to a group I was leading, “Did you know that Dr. Brown has bipolar too?” That was a distraction! When I leave clinical practice, I hope to be a poster child for the “Stop the Stigma” Mental Health campaign: Doctor… Grandmother… living with bipolar disorder. − Stephanie Brown, MD I was officially declared disabled by the VA following my discharge from the military during the Vietnam War. My service-connected injury involved two burst fractures of the lower lumbar vertebra (L4 and L5) which occurred when I tried to lift a really big guy who went into sepsis. The injury produced severe pain in both legs, bladder incontinence and bilateral leg weakness for about three weeks. Residual was a slight foot drop on the right, but I completed my tour of duty and also three additional years on active reserves. (There were insufficient specialists in infectious diseases back then.) I went onto a long career in academics at Michigan and the University of California at Davis. From 1975 until 1997, I managed my lifestyle so I could play the house staff in basketball annually, handball or racket ball every two to three weeks, and downhill and cross-country skiing. My back pain was usually intermittent with moderately-severe sciatica every two to three months following some prolonged physical event, usually on weekends. Then, until 2005, I had increasing right leg pain and weakness, and right leg spasms every two to three weeks lasting two to four minutes. Walking was now becoming arduous and stairs
scared me. Occasional falls due to a sudden leg collapse made me even more cautious about items on the ground which I tripped over, and ladders were verboten. With time, prolonged illnesses in my daughter, then her twin mate brother, and eventually my wife for several years, really stressed my endurance and greatly increased by sciatica. I did a lot of repetitive lifting, and caretaking, at times, was exhausting. With their deaths, my physical stresses have diminished, as have the pains and frequency of spasms. But with the good has come the bad...foot drop in the left with bilateral dysesthesias and loss of sensations in 50 percent of my plantar surfaces. More leg weakness and loss of limb musculature in both legs. My pace is slow and prodding, but I can walk without assisted devices. Thank heavens Stair-climbing for handicapped parking wheelchair spaces. My future as to this disability is obviously not good. But, I am reminded often how many people have more severe mental and physical disabilities, and I find solace in some of my patients who are far more incapacitated, but are jewels of optimism and happiness. Hope for the better is eternal, and a major driving force for accommodating and accepting a disability. −Joseph Silva, Jr., MD I have Facioscapulohumeral (FSHD) Muscular Dystrophy. I had wanted to be a cardiothoracic surgeon since Christiaan Barnard did the first heart transplant when I was in the 5th grade. I matched into a surgical program, but soon realized that my disease was progressing, and a career in surgery would be cut short. I decided to switch to internal medicine and then go into cardiology. The decision to give up surgery was the death of a lifetime ambition and was a very difficult decision, but the correct one. Cardiology has been good for me. I was originally in the Cath lab doing procedures, but as the disease has progressed, I have had to
change my practice. I now work predominately in the echocardiography lab where I can do short procedures, mostly while sitting. The biggest single improvement in my life was when I stopped trying to hide my disability and let it be known to others that I had limitations. While tough for my ego, the accommodations that my colleagues have made for me have allowed me to continue to practice cardiology. Life with a disability is not easy, but life can certainly be rewarding. −William Lewis, III, MD In the 70s, we had a pediatric resident in a wheelchair. And at old Folsom, I had a specialist in a chair. It was the first time I saw a chair that could climb stairs. −Sandra Hand, MD Hearing loss is a disability – the ability to communicate with patients and with care teams is essential to great care. Lack of that communication can be a significant risk to the patient. This is especially true in the operating room or other environments where the ability to hear and act on that information has temporal significance, not to mention the risk of not hearing accurately resulting in a bad decision due to lack of or misinterpretation of data. Technology provides a wonderful solution to many hearing-related issues, but lack of information by professionals about what physicians need to address this disability could be improved. Hearing aids, cochlear implants, blue tooth to both devices and stethoscopes are all available, but guidance on the best solution for a given disability and particular environment is difficult to find. Being able to clearly hear the heartbeat of a patient was one the most wondrous gifts of technology to me. I suspect there are better solutions than those I have been able to find so far. One can be a successful physician and be hearing impaired – but like most things, those physicians need help navigating the best solution based on experience and evidence. − Thomas Atkins, MD
…I find solace in some of my patients who are far more incapacitated…
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Magnetic Therapy The Controversial History of Magnetic Healing
By Kent Perryman, Ph.D. THE USE OF MAGNETS TO treat disease processes has a long and colorful history. Magnetic therapy can be operationally defined as the application of a magnetic field of permanent magnets or electromagnetic devices to the body for purported health benefits. Often, the patient performs the application of this therapy.
Permanent Magnetic Therapy
The word “magnet” comes from the ancient Greek word “lithos” meaning “stone from magnesia,” an area of Greece known for its volcanic rocks possessing magnetic attributes. Naturally occurring magnets are also referred to as “lodestones,” meaning “guiding stone” used in compasses by sailors in the Middle Ages. Humankind’s early fascination with lodestones was, in a large part, due to their magnetic attraction to iron. Some thought magnetism possessed a spiritual quality. The Greek philosopher Aristotle made the first mention of using lodestones as a healing therapy. Cleopatra was reported to sleep with a lodestone on her forehead to preserve her youthful appearance. The Chinese in, The Yellow Emperor’s Classic of Internal Medicine, also documented the use of magnetic therapy around 2000 BC. Lodestones were employed by the Chinese in conjunction with acupuncture to treat many ailments. During the Middle Ages, European physicians became interested in the healing properties of lodestones. They believed that lodestones might function as an aphrodisiac or serve to cure such ailments as gout, arthritis, and poisoning. The 16th century Swiss alchemist and physician, Philippus von Hohenheim
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(Paracelsus), became known for investigating the healing potential of lodestones to treat epilepsy, diarrhea and hemorrhages. Paracelsus believed lodestones could energize the “life force” for healing purposes. In the 17th century, William Gilbert, court physician to Elizabeth I of England, advocated the beneficial use of lodestones for curing many diseases. Some early surgeons used the magnetic properties of lodestones to help remove shattered blades or shrapnel from victims. During the 18th century, Franz Anton Mesmer conceptualized an elaborate theory of magnetic therapy referred to as “animal magnetism.” Following an earlier publicized treatment of a deranged patient with lodestones, he attempted cures for various diseases by simply rotating his hands around the patient’s body. Mesmer’s theory was further elaborated on by J. H. Bagg in the 19th century. In 1845, Bagg referred to the body as a composition of magnetic fluids. Practitioners (magnetists) of Bagg’s belief promoted cures by “laying on hands,” a practice that was commonly adopted by some spiritualists at the time. Brochures promoting magnetic healing often depicted large magnetic hands shooting out lightning bolts as illustrated in Figure 1 on page 25. Magnetists believed they could redirect or balance the patient’s energy and restore their vitality by laying on hands. Most mainstream 19th century physicians considered mesmerism and magnetists’ therapy as a form of quackery. Magnetic therapy gradually found its way into chiropractic service in the 19th century. The famed chiropractor, Daniel David Palmer, who founded “Palmer’s School of Magnetic Cure” in 1897 near Davenport, Iowa, promoted the theory that misalign-
ment of the body’s bones was responsible for all disease processes. Palmer employed magnets in his readjustment procedures. Marketing claims have been made on behalf of magnetic health benefits including cures for cancer and depression. Gradually, interest in the therapeutic benefits of permanent magnets began to wane after WWII until the 1990s, when major league baseball players started making outrageous claims. Players reported that wearing magnets improved their strength and overall performance. Today, small, powerful permanent magnets manufactured from ceramic and rare earth materials can be inserted into clothing, jewelry, elastic bands, shoe insoles, and pillows. With magnet devices costing a few dollars to manufacture and selling for $40-$80, this has become a billion dollar market.
“Wonders of Magnetic Healing,” a pamphlet cover from the turn of the 20th century.
Electromagnetic Therapy Not until Michael Faraday established the link between magnetism and electricity in the 1800s, did anyone appreciate the field properties of magnetism. Faraday demonstrated the creation of temporary magnetic flux by applying electrical current through wire wound around an iron core. With the onset of the industrial revolution and the electrification of urban manufacturing centers at the beginning of the 20th century, the stage was set for the miraculous healing powers of electromagnetism. This period of time, when so little was known about electricity and medicine, was also the staging for electromagnetic quackery. Many electrical devices were marketed at medicine shows, in brochures and in newsprint, claiming beneficial health cures. For example, electric belts were one of the few devices that relied on electromagnetism to promote health benefits. The electric belts were first introduced and marketed in 1875. The belt’s magnetic flux was generated by passing an electric current through spools of copper wire wrapped around metal rods. Power was supplied by small batteries, and later in the 1920s, by household current. These belts, resembling a horse collar, were slung over the head and, when activated, would produce a slight tingling sensation.
Sears, Roebuck and Company marketed magnetic belts manufactured by Thomas Edison’s son, Tom. The therapeutic benefits of these belts were promoted as a means of magnetically restoring one’s energy and sexual vitality. Eventually, these devices, as well as many other electrical quackery devices, were prohibited from being marketed as health cures in the 1930s by the Food and Drug Administration. One of the electric belts from our medical museum is depicted in Figure 2 on page 26. There have been a number of scientific explanations purported to explain what, if any, health benefits magnetic fields bestow. The “Magnetic Field Deficiency Syndrome” theory, postulated by Dr. Kyochi Nakagawa of Japan, suggests the earth’s failing magnetic field places us at a health risk that magnetic therapy compensates for. Another popular belief underlying magnetic healing focuses on the hemoglobin iron that could possibly be altered by magnetic fields. Finally, there is a theory that suggests blood ions can interact with magnetic fields to
Since then, TMS and rTMS have been approved by the FDA for use in migraines, treatment-resistant major depressive disorder and neuropathic pain, as well as for treating the negative symptoms of schizophrenia and loss of function caused by stroke. There has been some success using rTMS to treat aphasia, tinnitus, anxiety disorders, obsessive-compulsive disorder, amyotrophic lateral sclerosis, multiple sclerosis and Parkinson’s disease. Adverse side effects associated with this procedure include syncope occurrences, induced seizures, hypomania and transient cognitive changes with hearing impairment. The success with using TMS and rTMS as a form of magnetic therapy may lie with its field strength. TMS is achieved by quickly discharging current from a large capacitor into a coil to produce magnetic fields of 1-10mT; about the same strength as an MRI. “The Electric Belt,” also dubbed the “Magic Horse Collar,” can be viewed at the SSVMS Museum of Medical History.
improve circulation. However, there have been no creditable scientific reports to substantiate these claims.
Transcranial Magnetic Stimulation Recently, it has come to light that there may be some credible health benefits to magnetic therapy if the teslas (T) field is strong enough. Transcranial magnetic stimulation (TMS) is a noninvasive method used to stimulate small regions of the brain. During a TMS procedure, a magnetic field generator, or “coil,” is placed near the head of the patient. The magnetic flux produced by the coil excites neuronal activity beneath the cranium to a depth of no more than five centimeters. In some procedures, the coil is connected to a pulse generator for intermittent, repetitive excitation, which is referred to as repetitive TMS (rTMS). Professor Anthony Barker, Ph.D., and his colleagues at the Royal Hallamshire Hospital in Scheffield, England, first successfully demonstrated this procedure in 1985. Its earliest application demonstrated conduction of nerve impulses from the motor cortex to the spinal cord, stimulating muscle contractions in the hand.
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Conclusion Most of the purported beneficial health effects of magnetic therapy can be attributed to anecdotal reports or placebo effects. There are a very limited number of unbiased studies incorporating blinded controls in their research design. Many studies also lack a statistically large-enough sample size as well as adequate randomization. Consequently, with the exception of TMS, available scientific evidence does not support magnetic therapy for any disease process. firstname.lastname@example.org References History of magnets: A tale of discovery, fraud and achievement. www.learningtarget.com/magpulse/history.htm Philpott, WH, Kalita, DK and Goldberg, B. Magnetic Therapy, 2000; www.alternativemedicine.com McCoy, B. Quack! Tales of medical Fraud. 2000; Santa Monica Press DeLa Pena, CT, The Body Electric, 2003; New York University Press Marshall, G. Can brain stimulation aid memory and brain health?, Harvard Women’s Health Watch, 2015; Vol 23(1). Rossi, S. Safty, ethical considerations, and application guidelines for the use of Transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol.,2009; 120 (12): 2008-39. Transcranial magnetic stimulation https://en.wikipedia.org/wiki/transcranial_magnetic_stimulation
A Posit on Right-to-Die “The currently proposed Right-to-Die legislation in California is the right thing to do.”
Background: The case of Brittany Maynard, a 29-year-old California woman with brain cancer who moved to Oregon to legally take her life, brought this issue to bear in this year’s state legislature. After the State Assembly approved the measure, it was approved by the State Senate on Friday, September 11, 2015. At the time of this posit request, it awaits Governor Jerry Brown’s approval. An excerpt from the Associated Press dated September 11, 2015: “The revised measure includes requirements that the patient be physically capable of taking the medication themselves, that two doctors approve it, that the patient submit several written requests, and that there be two witnesses. Doctors in Oregon, Washington, Vermont and Montana already can prescribe life-ending drugs.” 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: 63/Agree – 17/Disagree. Commentary follows: I agree. I have gradually changed from opposing to favoring physicians-assisted death. The extensive experience in Oregon has shown that it is requested infrequently and actually used even less. The major value is giving terminally-ill patients a sense of control at a time in their lives when they have control over very little. There is no data to support the objections of those who fear the frail and/or elderly may be coerced into requesting assisted death, nor that it has been used on those who are disabled but not terminally ill. −Mark Blum, MD I agree, the governor should sign it. −
Michael Meek, MD I disagree. Physicians can already give prescriptions for pain medication and should adequately treat pain. −Katherine Gillogley, MD I agree with the right to die under certain conditions with a prognosis of less than six months. −Robert Adam, MD I agree. I retired to Oregon, and I am grateful for this option should I need it. −Julita Fong, MD I disagree. “First do no harm.” I am opposed to any legislation that permits or legalizes the facilitation of suicide, with or without the assistance of a physician. −David Unold, MD I disagree. Physicians, for the most part, had remained outside the core of this debate, and will likely face divisions and patient loss of confidence if organized medicine states a position. −Mohammad Kabbesh, MD I am very ambivalent on the subject and don’t feel that I know the legislation well enough to weigh in firmly, so I am going to abstain. −Thomas McIlraith, MD A full description is found here: www. leginfo.ca.gov/pub/15-16/bill/asm/ab_0001-0050/ abx2_15_bill_20150914_enrolled.pdf. The bill should define “undue influence” so that it defines what a physician may do without risking an allegation of “undue influence.” Relevant part: The bill would make it a felony to knowingly coerce or exert undue influence on an individual to request a drug for the purpose of ending his or her life. A valid written request for an aid-in-dying drug under subdivision (a) shall meet all of the following conditions: (1) The request shall be in the form described in Section 443.11. (2) The request shall be signed and dated, in the
The bill should define “undue influence…”
Everyone should have the right to die with dignity.
presence of two witnesses, by the individual seeking the aid-in-dying drug. (3) The request shall be witnessed by at least two other adult persons who, in the presence of the individual, shall attest that to the best of their knowledge and belief the individual is all of the following: (A) An individual who is personally known to them or has provided proof of identity. (B) An individual who voluntarily signed this request in their presence. (C) An individual whom they believe to be of sound mind and not under duress, fraud, or undue influence. (4) Confirm that the qualified individual’s request does not arise from coercion or undue influence by another person by discussing with the qualified individual, outside of the presence of any other persons, except for an interpreter as required pursuant to this part, whether or not the qualified individual is feeling coerced or unduly influenced by another person. “Aid-in-dying drug” means a drug determined and prescribed by a physician for a qualified individual, which the qualified individual may choose to self-administer to bring about his or her death due to a terminal disease. Self-administration may be a problem for ALS and other neurologically impaired patients. This situation should be addressed. − Gerald N. Rogan, MD I agree. It’s a long time coming. −E. Bingham, MD I agree. There is considerable published experience regarding the impact of this law in other states for patients with terminal illness. Cultural and religious views vary regarding “right-to-die,” but the ethical principle of patient autonomy is at the center of this legislature. With the change in patient demographics and the shift to an aging population, the timing of this bill is favorable. −Paul Akins, MD I agree. Everyone should have the right to die with dignity. −Richard Meister, MD I disagree. This turns medicine on its head. Although the intent is to end suffering, ending a life is doing ultimate and complete final harm to the physical body, and violates the Hippocratic Oath, “First of all do no harm.” − James Moorefield, MD
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I disagree. In caring for the terminallysuffering, when no cure is possible, and lifesustaining treatment has become futile, the role of the physician is to provide comfort through the palliation of symptoms. −Peter T. Skaff, MD I disagree. Asking the question suggests you wouldn’t understand the answer: Everybody has a right to die. The legislation is not conferring a right to die, but is suggesting physicians should be writing prescriptions for their patients to give them medication that will kill them. Doctors don’t kill patients (at least not on purpose…) −Richard Gray, Jr., MD I disagree. Not appropriate to put a doctor in the position of executioner. −Dennis Michel, MD I disagree. Physicians possess a generally positive public image as a result of perceived commitment to the safety, health, and wellbeing of others. Regardless of the motives and justifications, taking direct action to end a patient’s life undermines the principles that have led to this perception with the public. Development of policies that permit direct action leading to patient death will also undermine public perception that one’s physician is their advocate through hardship. Departure from Hippocratic principles is a slippery slope. In a system with access to hospice care, the death and dying process need not be agonizing or cause undue suffering. When the death and dying process can be managed with dignity and comfort, the request for willful physician actions to end a patient’s life based on their personal preference becomes essentially a request to be released from ANY suffering. I have learned in medical practice that suffering, to some extent, is part of the human experience, and the desire to avoid all suffering can often lead to greater negative outcomes for the patient and their loved ones. How often do we, as physicians, make pronouncements about conditions that are proven incorrect in time? If a diagnosis is made with ANY degree of uncertainty that then leads a patient to pursue physician-assisted suicide, then the system has embraced the possibility of actively contributing to the death
of a patient by medical error. How can we, then, call unintentional death from medical error a tragedy when it happens in a surgical setting for example, but advocate death by direct action with assisted suicide with any level of uncertainty about the motive and underlying diagnosis? As it stands, the legislation doesn’t appear to require demonstration of exhaustion of alternatives. “Multiple requests” is vague enough to be laughable. To assist a patient in direct action leading to their death is to accept civil liability for wrongful death. I choose to maintain the sanctity of the physician-patient relationship and commit to seek the best possible long-term benefit to my patients, even when that is in conflict with their immediate desire. −Ryan Nicholas, MD I search for words to convey my disappointment in the CMA for withdrawing from the physician-assisted suicide debate. It is disingenuous to claim that a “neutral” stance is anything other than the agreement to let physician-assisted suicide go forward without our input. We have much of importance to say on this topic, and that we have decided to say nothing is a tragedy of the first order. −Stephen A. McCurdy, MD, MPH I agree. This is long overdue. −Walton Brainerd, MD I agree. The right to assisted death/ suicide has been a regularly-discussed medical ethics topic in the Doctoring 2 class I have participated in, and I have noticed several interesting changes: 1) It seems well accepted by most medical students; 2) The access to this option has become easily available – the only administrative requirement to be eligible to get this care in Oregon is proof of residency, which can be as simple as having a contract to rent an apartment. So it is available for someone from California right now; and 3) In reviewing several papers about the Oregon experience with our students, I have not found inappropriate use, providing a suicide method for mentally ill patients or other ethical concerns. −James Margolis, MD I feel it is OK to prescribe high enough
doses of medication to alleviate pain which can possibly result in death; however, if the intent is to aid in one’s death, I disagree. I believe it comes down to intent not necessarily outcome. −Chiraag Patel, MD I agree. If implemented, much as Oregon’s law, patient safety will be assured as well as their own autonomy. −Alan Ertle, MD I disagree. When our patients request assistance in ending their lives, this represents a failure on our part and that of contemporary medicine to have successfully met complete palliative needs whether it be spiritual, physical or mental pain. We need to do a much better job in providing palliative care that meets all these needs. −Marion Leff, MD I am in favor of “Right to Die” legislation. I like Oregon’s law. −Irma West, MD I agree. I think this issue should be between patient and physician and not “legislated.” − Barbara Livermore, MD I agree. This is “just” an extension of DNRs and End of Life Directives, and is the right thing to do. −Maynard Johnston, MD
SSVMS Alliance Holiday Sharing Card Summer is over and the holidays are just around the corner. Be on the watch for the SSVMS Alliance Annual Holiday Sharing Card letter. Your dedicated support for the annual SSVMS and Alliance’s Holiday Sharing Card has enhanced Sierra Sacramento Valley health projects and the next generation of medical professionals. The 2014 Holiday Sharing Card raised $20,761 for the Alliance’s Community Endowment Fund and the SSVMS William E. Dochterman Medical School Scholarship Fund. Please be generous and give. Thank you. Debbie Wills and Paula Cameto are Co-Chairs. email@example.com
Olive Oil continued from page 16 of quality.
Storing Olive Oil Olive oil ideally should be stored, tightly capped in a dark bottle or can, in a dark place at a constant temperature, ideally 57 degrees F, although normal room temperature (70) is OK. A wine cellar is ideal. Refrigeration is not recommended due to condensation that affects flavor and the fact it may turn cloudy.
If you are really interested in comparing olive oils do not do the “cube of bread in the oil method.”
interval the better…hours are ideal…some have milling operations almost in the middle of the groves Technique − More kneading of the paste, necessary to pull the oil molecules together, produces a less bitter oil.
If you are really interested in comparing olive oils do not do the “cube of bread in the oil method.” Put a small amount in a shot Tasting Types glass sized container, cover it with your hand • Lightly fruity, soft and delicate, for a couple of seconds, smell it… mild hints of bitterness and then hold it below your lips and pungency pull air into your mouth…then sip • More flavorful oils, medium a bit and “slurp and swirl” it…much fruitiness, rounded mouth feel, like wine tasting. Great EVOO is balanced fruit, pungency and not cheap but well worth the cost, bitterness with a clean fresh and you may want to keep several aroma Scan for a list of varietals for accompanying different • Intensely fruity oils, strongly references foods or dipping bread at dinner. flavored, perceptible bitterness Collecting and enjoying different and pungency, well balanced but “forward.” EVOO’s can be as interesting as tasting wines. One of my favorite uses of olive oil is pouring a Causes of Variations in Olive Oil “moat” of it around a mound of Greek nonfat Variations in olive oil can be due to the yogurt, and sprinkling it with zatar that contains producer, the weather, the region (soil) and the sumac, then scooping it up with pita bread or quality of the fruit in addition to the following crackers…makes a healthy breakfast or lunch. factors. And I am now addicted to baked potatoes with Variety of olive – Over 100 types of olives EVOO instead of the traditional butter and are used to produce olive oil. The Hojiblanca sour cream. But it can also be used in baking variety from Spain produces a slightly citrus with a slight conversion of measurement, and delicate oil, whereas the Arbequina produces a do not forgot to use EVOO for frying. What softer and sweeter oil. Other types offer a further a wonderful way to make your meal not only variety of individual characteristics. tastier, but healthier. Season (Time of Harvest) − Picual olives are Further information on EVOO, especially too bitter if harvested too green and Grignano California Olive Oil, references, resources, local olives in Italy produce a refreshingly citrus or producers, stores, and updated information can tart apple flavor when picked in a three-week be found on a PDF that I created at: https://goo. period in October. Time to pick is determined gl/0lA6TL or by scanning the QR code above. by when the green and ripeness balance each other. Picking riper olives produces a more firstname.lastname@example.org mellow oil in a larger quantity but with lesser quality and fewer health benefits than from 1 Olive oil maintains its structure nutritional value better than other oils due to antioxidants and high oleic acid content. The formaolives picked earlier. tion of toxic substances when frying is decreased compared to Interval before pressing – The shorter the fats with lower smoke points, and food fried in olive oil has a lower fat content.
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Things You Can Catch Going Barefooted Travel Tip From George Meyer, MD MANY OF OUR SSVMS members enjoy world travels, and Editorial Committee member Dr. George Meyer is one. While traveling, he enjoys photographing images of health warnings and diseases that we don’t commonly see back home in California. On a recent visit to Costa Rica, he came across a poster warning of “podoconiosis.” Ever heard of it? Basically, it’s something you can catch going barefooted. The World Health Organization describes this illness as endemic non-filarial elephantiasis, a “neglected tropical disease” that is the result of an inflammatory reaction to mineral particles in irritant red clay soils derived from volcanic deposits. Podoconiosis, which is non-infectious, is found in highland areas of tropical Africa, Central America and northwest India among barefoot populations living on irritant soil. Farmers, who for cultural reasons or through sheer poverty do not wear shoes, are at high risk, but the risk extends to any occupation with prolonged contact with the soil. Primary prevention consists of avoiding or minimizing exposure to irritant soils by wearing shoes or boots and by covering floor surfaces inside traditional huts. email@example.com
Podoconiosis is basically something you can catch going barefooted.
The Revolutionaries By Caroline Giroux, MD
A stream of tears Wiped, on a child’s cheek, so dear Large hands clapping Above an eye-opening doodle, encouraging A nurse trying to obtain incessantly A wheelchair for her community facility So the frail and the wounded could be free And the caregivers move about their duty
Silence is strong As long as action speaks Boundaries are useful Only as a shield
But hierarchy is this pattern on the carpet No one can see, an invisible fence Until good faith stumbles on it When attempting to practice common sense
A defeated sorrow Simple joys everybody can borrow A no, or a yes Whispered, then loud, at last
How far should we comb the desert To say we travel, in thirst… How big is the heart Who truly helps ? Still horrible wars ravage many a country Ordinary people like you and me Desperately try to flee But too many hopes end up at the bottom of the sea A little boy, inert, on a cold beach, promised haven for a multitude Laying on his tummy, surrounded by an unbearable solitude Looking asleep, deeply But it is the viewer who hides in sleep, not wanting to see
Sweet songs in motion These are the true revolutions The most capable of shedding the light of truth The ones I want to partake, with the old or the youth The secret is to remind ourselves What really matters: the freedom of feelings, ideas and words, What makes a difference for the world. Is it not to spread the warmth of peace? It can start with one word, one silence, one shared meal In the basement of dreams lit by a candle, a flame that rose Like thoughts never grandiose, But, O! So pure, so real. Revolution starts incrementally A loud silence, a profound no in plea What a privilege to be ordinary! All this power we have, unnoticed by creeping envy Let’s reach out and smile at each other For we can march together We have to knock on all the doors, at least try Until the day we die.
This precious dark-haired boy Skin as glowing as the moon Has a name we have to remember For he is the true revolutionary The one who left his roots ashore To try to touch the hopes and dreams of his family The one who will never laugh anymore A silent sea star who will forever inspire society
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The true revolution Starts with a smile for the hopeless A poem engraved in prison A small window for the oppressed
Be a Source of Hope
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Board Briefs September 14, 2015 The Board: Approved the appointment of Darin Latimore, MD to the Board of Directors representing District 2 Office 7. Dr. Latimore fills the vacancy created by the resignation of Laurie Gregg, MD. Approved the 2015 Second Quarter Financial Statements and Investment Reports. Approved the 2015 Nominating Committee Report. The committee is charged with nominating members to vacancies on the Board of Directors and Delegation to the California Medical Association. The Nominating Committee Report will be sent to all Active members, and any Active member may submit additional nominations for any vacancy in any office. Approved to endorse the candidacy of Lee T. Snook, Jr., MD for CMA Speaker in 2016. Received a legislative update from Senator Richard Pan, MD and information regarding the recall petition by the opponents of SB 277 (vaccine bill) who vowed to recall the sponsors of the bill if the bill became law. Approved the following Membership Reports: September 14, 2015 Report For Active Membership — Syed D. Ali, MD; Arash Aryana, MD; Dave S. Auluck, MD; Mya Mon Aung, MD; Ali Azarm, MD; Rohit Bhaskar, MD; Mark R. Bowers, MD; Rances F. Canet, MD; Michael L. Chang, MD; Kyle P. Davis, MD; Aieska X. DeSouza, MD; Pooja P. Desa, MD; Amit Gupta, MD; Pantea Hashemi, MD; Kaushik Ivaturi, MD; Roy F. Kaku, MD; Joseph A. Kozina, MD; Mai Lee, MD; Nick Majetich, Jr., MD; Padraig G. O’Neill, MD; Rene A. Orona, MD; Shannon M. Poti, MD; Thomas W. Powers, MD; Nadir Y. Qazi, DO; Karanjit Singh, MD; Penelope C. Thomas, MD; Stephanie A. Wood, MD; Robert F. Zimmerman, MD. For Resident/Fellow Active Membership — Sarah J. Williams, MD. For Retired Membership — Randall Anderson, MD; Ronald Lee, MD.
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For Acceptance of Resignation — Oma N. Agbai, MD (moved to Detroit, MI); Ivan B. Anderson, MD (moved to Reno, NV); Arapana Gupta, MD (moved to Culver City, CA); Andrew J. Parker, MD. For Transfer of Membership — Shashi Shravana, MD (transferred to Santa Clara).
August 24, 2015 Report For Active Membership — Jeffrey L. Anderson, MD; Megan A. Babb, DO; Jesse D. Babbitz, MD; Christina Y. Bilyeu, MD; David C. Caretto, MD; Anjali A. Chanana, MD; Lisa Marii Cookingham, MD; Paul M. Dagenais, MD; Richard P. Detwiler, MD; Priyal P. Dholakiya, MD; Robert C. Freed, MD; Barry N. French, MD; Adam M. Griffith, MD; Ashraf S. Haddad, MD; Rabab E. Hanjar, MD; Devin A. Harper, MD; David C. Hsu, MD; Mary Ann N. Johnson, MD; Navjot Kaur, MD; Afsaneh Khalili, MD; Dennis J. Lee, MD; James J. Luz, MD; Palaniappan Manickam, MD; Murat D. Mardirossian, MD; Anand J. Mehta, MD; Leena Mehta, MD; Greg P. Naughton, MD; Andrew G. Norris, MD; Candice M. North, MD; Adrian M. P. Oribello, MD; Carlos G. Perez, MD; Ajay N. Ranade, MD; Gloria G. Rho, MD; Britta C. Salvetti, MD; Meryl A. Twarog, MD; Sa Vang, MD; Helen L. Vinogradova, MD; Trevor M. Williams, MD; Christopher J. Zegers, MD; Ning Zhong, MD. For Resident/Fellow Active Membership — Suzanne B. Dela Cuesta, MD; Christina Tran, DO. Serving as the Board to the Community Service, Education and Research Fund (CSERF), the following actions were taken: Approved the 2015 SPIRIT (Sacramento Physicians Initiative to Reach out, Innovate and Teach) Program Plan. In June 2015, the Sacramento County Board of Supervisors approved a new program for undocumented residents of Sacramento County meeting specific eligibility criteria. While community clinics provide some primary care services for the undocumented, these new primary continued on next page
Welcome New Members 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. — Rajiv Misquitta, MD, Secretary. Syed D. Ali, MD, Internal Medicine, Chicago Medical School – 1994, Mercy Medical Group, 3000 Q Street, Sacramento 95816
Michael L. Chang, MD, Cardiovascular Diseases, Brown University – 1981, Mercy Medical Group, 3941 J St, #260, Sacramento, 95819
Arash Aryana, MD, Cardiovascular Diseases, Ross University School of Medicine – 2000, Mercy Medical Group, 3941 J St., #350, Sacramento, 95819
Kyle P. Davis, MD, Emergency Medicine, University of California Davis School of Medicine – 2012, The Permanente Medical Group, 2025 Morse Avenue, Sacramento, 95825
Dave S. Auluck, MD, Psychiatry, Ross University School of Medicine – 2007, The Permanente Medical Group, 2155 Iron Point Road, Folsom, 95630 Mya Mon Aung, MD, IM/Hospitalist, Mandalay Institute of Medicine – 2005, Mercy Medical Group, 3000 Q St., Sacramento, 95816 Ali Azarm, MD, Gastroenterology, Shiraz University of Medical Sciences – 1994, The Permanente Medical Group, 2025 Morse Ave. Sacramento, 95825 Rohit Bhaskar, MD, Cardiovascular Diseases, Mount Sinai School of Medicine – 1986, Mercy Medical Group, 3941 J St, #260, Sacramento, 95819 Mark R. Bowers, MD, Cardiovascular Diseases, Medical College of Wisconsin – 2006, Mercy Medical Group, 3941 J St,#350, Sacramento, 95819 Frances F. Canet, MD, Cardiovascular Diseases, Virginia Commonwealth University School of Medicine – 2007, Mercy Medical Group, 1010 Hurley Wy,#500, Sacramento, 95825
Aieska X. De Souza, Dermatology, University of Sao Paulo Faculty of Medicine – 2001, Mercy Medical Group, 8820 Wymark Dr., Elk Grove, 95757 Pooja P. Desa, MD, Pulmonary Critical Care Medicine (IM), Terna Medical College – 2007, Mercy Medical Group, 3000 Q Street, Sacramento, 95816 Amit Gupta, MD, Critical Care Medicine, Maulana Azad Medical College, University of Delhi – 2001, The Permanente Medical Group, 2025 Morse Avenue, Sacramento, 95825 Pantea Hashemi, MD, Dermatology, Tehran University of Medical Sciences – 2005, The Permanente Medical Group, 10725 International Dr, Rancho Cordova, 95670 Kaushik Ivaturi, MD, Internal Medicine, Kamineni Institute of Medical Sciences – 2010, Mercy Medical Group, 3000 Q Street, Sacramento, 95816
Roy F. Kaku, MD, Cardiovascular Diseases, University of California San Francisco – 1974, Mercy Medical Group, 3941 J Street, #260, Sacramento, 95819 Joseph A. Kozina, MD, Cardiovascular Diseases, University of California San Diego – 1984, Mercy Medical Group, 3941 J Street, #260, Sacramento, 95819 Mai Lee, MD, Internal Medicine, Rosalind Franklin University of Medicine and Science – 2011, Mercy Medical Group, 4001 J Street, Sacramento, 95819 Nick Majetich, Jr., MD, Cardiovascular Diseases, The Ohio State University College of Medicine – 1981, Mercy Medical Group, 6401 Coyle Ave, #416, Carmichael, 95608 Padraig G. O’Neill, MD, Cardiovascular Diseases, University College Galway, Ireland – 1979, Mercy Medical Group, 3941 J Street, #350, Sacramento, 95819 Rene A. Orona, MD, Family Medicine, Universidad Autonoma De Guadalajara – 1987, The Permanente Medical Group, 2155 Iron Point Road, Sacramento, 95630 Shannon M. Poti, MD, Otolaryngology, Saint Louis University School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Avenue, Sacramento, 95825 Thomas W. Powers, MD, Orthopaedic Surgery/ Sports Medicine, University of Hawaii, John A. Burns School of Medicine – 2009, Mercy Medical Group, 8820 Wymark Dr., Elk Grove, 95757
Nadir Y. Qazi, DO, Internal Medicine, Chicago College of Osteopathic Medicine – 2015, Mercy Medical Group, 3000 Q Street, Sacramento, 95816
continued from previous page care services will be provided at the County’s Primary Care Clinic. The four local health systems and Sierra Sacramento Valley Medical Society will expand the SPIRIT Program to address the significant needs for specialty care and outpatient surgery to undocumented patients served at both community and county clinics. Approved providing grants from the William E. Dochterman Medical Student Scholarship Fund to the following individuals for 2015: Evan Adams, a 2nd year student at David Geffen School of Medicine/UCLA Medical Education Program; Bejan Alvandi, a 1st year student at Keck School of Medicine, USC; Kim Le, a 3rd year student at the UC Davis School of Medicine; David Lee, a 4th year student at the UC Irvine School of Medicine; Kristiana Lehn, a 2nd year student at the UC Davis School of Medicine; Olivia Nguyen, a 4th year student at the UC Davis School of Medicine; Charlotte ter Haar, a 1st year student at the University of Illinois College of Medicine.
Karanjit Singh, MD, Cardiovascular Diseases, Jawaharlal Nehru Medical College, University of Rajasthan – 1987, Mercy Medical Group, 3941 J Street, #260, Sacramento, 95819 Penelope C. Thomas, MD, Radiology, University of Florida College of Medicine – 2008, The Permanente Medical Group, 2025 Morse Avenue, Sacramento, 95825 Sarah J. Williams, MD, Family Medicine, Oregon Health and Science University – 2013, Sutter Family Medicine Residency Program, 1201 Alhambra Blvd., Sacramento, 95816 Stephanie A. Wood, MD, Family Medicine, University of California Irvine College of Medicine – 2012, Mercy Medical Group, 1264 Hawks Flight Ct., Ste. 100, El Dorado Hills, 95762 Robert F. Zimmerman, MD, Infectious Disease, University of Illinois at Chicago – 2010, Mercy Medical Group, 3000 Q Street, Sacramento, 95816
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Success. It’s what Sierra Sacramento Valley’s finest physicians strive for...and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice, and are committed to supporting you with a range of programs and services that no other medical professional liability company offers. These include a 24-hour early intervention program, HR support, EHR consultation, a HIPAA hotline, and a robust group purchasing program, to name a few.
Free Dinner Presentation for SSV Area Physicians! This fall, CAP in conjunction with the Sierra Sacramento Valley Medical Society, is hosting a series of informative dinner presentations designed to help you run a safer, more successful practice. Please join us for our final presentation in the series, Protecting Your Online Reputation. Enjoy an elegant sit-down dinner, while learning how to:
Protecting Your Online Reputation THURSDAY, DECEMBER 10, 2015 Please call for location
• Encourage patients to post positive reviews • Respond to negative reviews • Use social media to establish your credibility There is no cost to attend, but space is limited and reservations are required. To secure your spot, call 800-361-5569 or email RSVP@CAPphysicians.com by December 3.
800-252-7706 | www.CAPphysicians.com
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Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on Oct 27, 2015
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...