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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2016

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Sierra Sacramento Valley

Medicine 2

Customs of Yesteryear

Sandra Hand, MD


PRESIDENT’S MESSAGE The Start of a New Year

Thomas W. Ormiston, MD


EDITOR’S MESSAGE From Sexual Revolution to Evolution



Reflections on Transgender Care


Back to Strunk and Fowler, or Mind Your Pees and Qs

Jack Ostrich, MD


Test Your Medical Vocabulary


Making Our Streets Healthy

Nathan Hitzeman, MD

Glennah Trochet, MD

EXECUTIVE DIRECTOR’S MESSAGE BloodSource Embarks on a New Chapter


A Time of Change

Richard N. Gray, Jr., MD


SSVMS Election Results


A Posit Addressing Dependency on Medicine


What Freedom is Left

Caroline Giroux, MD


Classified Advertising

Aileen Wetzel, Executive Director


Passing the Baton

Ann Gerhardt, MD


EMS: Guardians of the “Golden Hour”

Lee O. Welter, MD


The Death of Death Panels

Gerald Rogan, MD


A Compleat* Diary 1961-2015


“Don’t Rush to Flush”

John Loofbourow, MD

Donald Lyman, MD


Little Things


Board Briefs

John Loofbourow, MD


Welcome New Members


Transgender Care in Sacramento

Laura Brimberry, RN, BSN, MSN, NP

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 “Transgender Care Moves Into Mainstream” is the title of a perspective published recently in JAMA. The essay describes the expanding need for primary care, mental health, endocrine care, and surgical care for the approximately 700,000 transgender persons in the U.S. Many transgender patients have difficulty finding physicians comfortable in managing their needs. We asked our members to share their experiences and thoughts concerning the medical needs of transgender patients. Their replies begin on page 18.

January/February 2016

Volume 67/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax


Sierra Sacramento Valley

MEDICINE 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. 2016 Officers & Board of Directors Thomas Ormiston, MD, President Ruenell Adams Jacobs, MD, President-Elect Jason Bynum, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Vijay Khatri, MD Darin Latimore, MD Christian Serdahl, MD District 3 Thomas Valdez, MD District 4 Alexis Lieser, MD

District 5 Rajiv Misquitta, MD Paul Reynolds, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Anne Neumann, DO

2016 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Ruenell Adams Jacobs, MD José A. Arévalo, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD Vacant

Customs of Yesteryear From the collections of Sandra Hand, MD

To Take Away Freckles on the Face Wash your face in the wane of the moon with a sponge, mornings and evenings, with the distilled water of elder leaves letting the same dry into the skin. Your water must be distilled in May.

How to Color the Head or Beard Into a Chestnut Color in Half an Hour District 1 Anissa Slifer, MD District 2 Don Wreden, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Kevin Jones, DO Thomas Kaniff, MD Vijay Khatri, MD Sandra Mendez, MD Armine Sarchisian, MD Joseph Sison, MD John Tiedeken, MD Vacant Vacant Vacant Vacant Vacant Vacant

Take one part of lead calcined with sulphur, and one part of quick lime, temper them somewhat thin with water, lay it upon the hair, chasing it well in, and let it dry one quarter of an hour or thereabout, then wash the same off with fair water diverse times, and lastly, with soap and water and it will be a very natural hair color. The longer it lyeth upon the hair, the browner it groweth. This coloreth not the flesh at all, and yet it lasteth very long in the hair.

A Mineral Soak for the Face Incorporate with a wooden pestle and in a wooden mortar with great labor four ounces of sublimate, and one ounce of crude Mercury at the least six or eight hours (you cannot bestow too much labor herein), then with often change of cold water by ablution in a glass, take away the salts from the sublimate, change your water twice every day at the least, and in seven or eight days (the more the better) it will be dulcified and then it is prepared. Lay it on with the oil of white poppy.

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President-Elect Ruth Haskins, MD

CMA Vice Speaker Lee Snook, MD

AMA Delegation Barbara Arnold, MD

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.

Richard Thorp, MD

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.

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


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. ©2016 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.

Sierra Sacramento Valley Medicine

President’s Message

The Start of a New Year By Thomas W. Ormiston, MD THE START OF THE NEW YEAR is always a good time to look to the future for SSVMS and CMA. The changes that have been happening over the past few years make organized medical societies more important now and in the future. I am honored to serve as your President this year, and I would like to focus on six areas in particular for the upcoming year. First, as always, is membership. We need to continue to demonstrate the value of medical society membership to the individual and varied practices of all our physicians. We need to engage the future generations of physicians in training and early practice to be sure we are looking out for their future (and their future patients). We need to give them many good answers to the question of what SSVMS will do for them. Second, is legislative activity. We all should know by now that without CMA we would not have had MICRA for the past 40 years, much less defended it from its most recent attack. Proposition 46 started out winning in the polls, but, due to the expertise and long-term political savvy of our CMA leadership, was defeated by record margins. It showed that a sophisticated political team, along with the respected grass roots efforts of physicians across the state, can persuade voters to make the right choice in the face of self-serving dishonesty. That alone saved each physician more than the cost of our annual dues for the foreseeable future. But Prop 46, while high profile, was not an isolated event. CMA’s lobbying team has been doing this quietly and effectively for years. Last year we helped elect one of our members, Dr. Richard Pan, to the State Senate over an incumbent trial lawyer who had been consistently hostile to physicians. Of course, it helped that we were supporting Dr. Pan; you won’t find many more deserving and effective

legislators. And with the support of CMA and Dr. Pan’s remarkable personal courage, vaccination is now required for all school children without a medical contraindication. A victory for the public health of our citizens. The very last bill of the last legislative term, barely defeated due to CMA lobbying, was a sneak bill that would have over time reduced physician maximum compensation for all payers to Medicare allowable or lower rates. Let me emphasize that CMA is neither Democrat, nor Republican. CMA advocates policy set by its members through the House of Delegates. CMA advocates for the health of our patients and the strength of our profession. But as important as the voice of physicians has been in the past, the world is changing. Health care is now approaching 20 percent of GDP, which is larger than food, transportation, and national defense combined. Over 40 percent of all health care expense was paid by the government before the expansion of Medicaid under the Affordable Care Act. That number is growing and will continue to grow as the population ages into Medicare. Since the Gingrich era congressional staff reductions, most legislation is now written by lobbyists. And much of the law, especially health care law, is regulatory law written outside the legislative debate. Only through organized medicine can physicians be at the table representing our profession and our patients. Third, at the local level, our medical society is the only organization that can represent the interests of physicians and patients across the silos of medical groups, hospital systems, solo and small group practice, safety net providers, and academic medicine. Last year, members of the medical society spent countless hours working with the health systems, Sacramento continued on next page January/February 2016

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.


County, elected officials and other stakeholders to improve the fate of mental health patients housed for days in emergency rooms awaiting mental health treatment. The medical society can and will provide an inclusive, neutral forum for us all to discuss ways to improve care for our population. Fourth, SSVMS is poised to expand our efforts in health care for the undocumented. In the debate preceding the passage of Obamacare, it was widely stated that there were over 45 million uninsured in the U.S. There wasn’t much mention that 12 million of that 45 million were undocumented immigrants. Those 12 million are still uninsured. Many, of course, are members of our community, with health care needs but without access to insurance coverage. Our medical society, in partnership, with Dignity, Kaiser, Sutter, UC Davis and Sacramento County, through our SPIRIT program, will be expanding our efforts to provide specialty medical care for this population.

Fifth, SSVMS and CMA can support all forms of practice, including solo practice. Over the past few years, I have seen increasing predictions of the end of solo and small group medical practice. All leaders of medical groups know many excellent solo physicians who would not function as part of a large group practice, but excel as solo practitioners. As a medical society, we will continue our efforts to ensure that solo and small group practice remains a viable option for those physicians who thrive in their own practice. And finally, for the past two years SSVMS has sponsored social events for physicians and their families. These social events are an excellent opportunity for us to get to know our colleagues outside our usual practice settings. We are looking for suggestions for this year’s event, and I encourage you all to attend. Thank you for the opportunity to serve as your President in 2016.

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Sierra Sacramento Valley Medicine

Editor’s Message

From Sexual Revolution to Evolution By Nathan Hitzeman, MD I WOULD LIKE TO THINK that I grew up in a fairly progressive, culturally-accepting San Francisco metropolis in the 1970s and 80s. I skateboarded with hippie types on Haight Street, ran into cross-dressers on Polk Street, and got my feel-good messages from Saturday morning School House Rock. Or maybe that is just what I want to remember looking back now as a more seasoned product of a politicallycorrect generation. Scratching the surface, though, I also recall stand-up comedians like Eddie Murphy ripping into homosexuality in a way that would not be acceptable in today’s comedy circles, and rap music that was harshly anti-women and anti-gay. The language that my teammates and I used in Little League would also have been pretty deplorable to segments of the population with high BMIs or same-sex preferences. Later came the HIV scare and backlash against the homosexual population – “punishment from God” and all that vile rhetoric. My generation grew up a product of a society grappling with contradictions and hypocrisies – think Iran-Contra, Jim and Tammy Bakker, Bill Clinton, Enron – yet out of that has come cultural evolutions that I never would have predicted. An African-American president, gays in the military, same-sex marriage recognized by the Supreme Court, and transgender surgery starting to be covered by insurance as a medical necessity. I live and work among people with nontraditional sexualities, and it now seems the norm. My children have friends with same-sex parents and don’t think much of it. I haven’t eavesdropped on Little League players lately, but I doubt the same kind of slander exists. I’m sure

I am still far from fully culturally competent, but haven’t we come a long way? Transgender medical care and surgery is the next chapter in this sexual evolution. As a Gen Xer, why am I no longer surprised when a former Olympian macho man is now a woman named Caitlyn? It is all the stuff of social evolution that has happened during my lifetime, now more incremental and social media-driven than by large-scale Vietnam Era-style protests on the Capitol. In medicine, we cannot ignore sexuality and gender preferences. It permeates all of our lives, so why should it be any different for our patients? As physicians, we need to be more LGBT-friendly. (The stakes are high with depression and suicide in this population.) I am proud that we can openly talk about transgender medicine in this issue. I appreciate the baby boomers paving the way for open expression through free love and experimentation with psychoactive substances and funky music. That was a revolution. But revolution can be rough, and evolution more thoughtful and measured. I think we are evolving well here. The Millennials are a gregarious, altruistic bunch (even if they text more than speak). They will keep this conversation going. We have a long way to go before we “all get along” – and our society is certainly self-destructing in a lot of other ways. But when it comes to respect and tolerance for others, we are seeing a bright future in California for embracing and caring for those once ostracized and discriminated against. This is part of what makes our work meaningful. January/February 2016

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

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Sierra Sacramento Valley Medicine

Executive Director’s Message

BloodSource Embarks on a New Chapter Two of California’s leading nonprofit blood providers merge

By Aileen Wetzel, Executive Director I AM WRITING TO SHARE some very exciting news. BloodSource is merging operations with San Francisco-based Blood Centers of the Pacific (BCP). This merger will align two of California’s leading nonprofit blood providers and further provide exceptional service to patients, blood donors and the communities they collectively serve. Simultaneously, the newly-combined organization will be part of Blood Systems (based in Scottsdale, Arizona), one of the nation’s largest nonprofit transfusion medicine organizations, serving more than 700 hospitals across the nation. BCP has been an affiliate of Blood Systems for over 15 years. The joined organizations now form the largest blood supplier in Northern and Central California. Although operating as one organization, BloodSource and BCP will continue to conduct business under their brand names in their respective communities.

History of Excellence BloodSource and BCP have been neighbors and professional colleagues for nearly 70 years and share much in common, including a history of excellence, a commitment to quality, shared missions and compatible cultures. Both organizations offer highly-respected transfusion medicine expertise and blood management resources. Rob Van Tuyle, BloodSource CEO, will be the executive in charge of the combined BloodSource/BCP organization. BCP President

and CEO, Dr. Nora Hirschler, will retire in the spring of 2016, as she has planned. SSVMS founded BloodSource in 1948 (previously known as the Sacramento Medical Foundation) and has enjoyed a close and mutually-beneficial relationship. Looking ahead, BloodSource will continue to work closely with SSVMS in a variety of ways, including their support of our Community Service, Education and Research Fund (CSERF). CSERF programs include the Medical Student Scholarship Fund, Adopt-a-School program, the Sierra Sacramento Valley Museum of Medical History, and the Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) program. BloodSource physicians will continue to participate as members of the medical society.

Committed to the Community BloodSource remains committed to the needs of our community by collecting the much-needed blood and blood components from a very generous volunteer donor base, and will continue to provide transfusion medicine expertise, blood management and other consultative services to physicians in our community. We wish BloodSource the best as they embark on their new chapter and look forward to many more years of BloodSource saving lives.

January/February 2016

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.


Passing the Baton Ralph Koldinger and a History of Sutter Independent Physicians

By Ann Gerhardt, MD

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

RALPH KOLDINGER, MD, HAS resigned as President and Chairman of the Board of Sutter Independent Physicians. After 22 years on the Board, 20 as President and 10 as both President and Chairman of the Board, he feels it’s time for him to slow down and perhaps past the time for the organization to pass the baton. He hasn’t lost interest, he just recognizes that “people can stay too long and too entrenched in jobs like this.” Having been instrumental in SIP’s road from near bankruptcy to ongoing success, he certainly wasn’t pushed out. Ralph was kind enough to spend an afternoon with me, relating the history of managed care medicine in Sacramento and his role in it. He was supposed to be cleaning out his office, since the new chief, recent SSVMS President of the Board, David Herbert, MD, was moving in the next day. Ralph’s full of stories and, at 78 years old, has no problem with his memory, so our reminiscing cut seriously into his packing time. Ralph was one of a number of UCSF Internal Medicine trainees who settled in Sacramento in the 1970s. He joined William Fong, MD’s Internal Medicine group as its gastroenterologist. About the same time, William Bush, MD, was forming a group of Internal Medicine subspecialists to affiliate with him and fulfill his vision of a tertiary referral medical group. The concept of each group was great, except each doctor in the group had a different specialty, so they couldn’t cover each other in the hospital. As a result, in 1973 Ralph and Burton Goldfine, MD, from Bush’s group joined together and recruited Tommy Poirier, MD, to form Sacramento Gastroenterology (Sac Gas). By the 1980s, quite a few doctors with a variety of specialties had joined Dr. Bush. They formed

Sierra Sacramento Valley Medicine


Sacramento Sierra Medical Group (SSMG), adding some primary care doctors in order to compete with Sacramento Medical Group, a formally-joined group practice in one building. SSMG doctors formed one commercial entity, but retained their separate offices to create a “clinic without walls.” Managed care began in the 1980s, as physician affiliations with each other and hospitals were changing, and insurance companies attempted to cut costs. Kaiser Permanente was growing, and independent physicians needed to band together and affiliate with a hospital to maintain a referral base and to create bargaining power. “Forming tribes to increase strength has been going on for centuries – it’s human nature,” Ralph says. Some independent solo and small group practices aligned themselves as Capitol Medical Associates and affiliated with Sutter hospitals in 1982, while others created Sacramento Physicians Network (SPN), affiliated with the now-defunct American River Hospital, in 1984. In 1987, Capitol Medical Associates changed their name to Capitol Medical Group (CMG). Managed Care Systems, a business started by Karen Toronto, managed the business affairs and insurance billing for SPN’s doctors. Even with doctors in groups, things weren’t going well and doctors were struggling as HMO insurance companies grew in dominance. Foundation Health adopted capitation, a new iteration of the concept of prepaid medicine. Doctors had always thought of prepaid medicine as unethical, so much so that the Medical Society wouldn’t let Kaiser doctors join. Some doctors just packed up and left town. The independents who didn’t leave worried about retaining patients if they didn’t accept

capitation. Some SSMG Board members embraced it, figuring that there was a lot of inefficiency in medicine which they could eliminate and essentially get paid for doing nothing. The independents felt they had to accept capitation or the large groups were going to take all the business. Meanwhile, SSMG needed capital to grow. As affiliated but not corporately-joined doctors, they each would have had to sign loan documents, and most doctors are loathe to assume someone else’s risk. Hospitals were moving to create more integrated medical systems and they needed doctors. Catholic Healthcare West (now Dignity) beat Sutter to the punch by grabbing Sacramento Medical Group. Sutter Hospitals didn’t have such a neat integrated medical group to access. Around 1992, discussions began with SSMG. The CA Corporate Practice of Medicine forbids hospitals to employ doctors except as medical directors, so Sutter ensconced the group into the Sutter Foundation. This provided SSMG with access to capital, infrastructure and growth. Within a year, their leadership decided that they should emphasize primary care, moving away from Dr. Bush’s Internist focus. Family practice residencies were training primary care doctors with a broad skill set for which Internists weren’t trained, and subspecialty rather than generalist Internists were getting all the consults. Because the leadership and primary care doctors wanted obvious alignment with Sutter, SSMG changed its name to Sutter Medical Group (SMG). Some specialists opposed that name because only part of their referrals came from Sutter doctors. For that and a variety of financial reasons, many of them left SMG, including Ralph and his partners. Sac Gas and other small specialty practices again came to life. Though there was a lot of tension in the 1990s among doctors, there was more between doctors and HMOs. The independents needed a strong network, which eventually evolved because of Sutter’s help. In 1991, two significant events occurred: CMG merged with SPN to form an Independent Practice Association (IPA), retaining SPN’s name, and Sutter took

ownership of MCS. Thus, Sutter had acquired the business arm of SPN. In 1992, SPN started to contract directly with Health Plans, taking financial risk through capitation. The problem (the sinister part, according to Ralph) was that the HMOs had the data and business skills to out-negotiate SPN doctors. SPN accepted unrealistically-low cap rates for their historically-high utilization. “We talked about improving utilization without the tools or universal motivation to change. We provided quality care, but didn’t appreciate how expensive it was.” Within two years, SPN was going bankrupt. They hired the PACE Group to evaluate SPN’s financial situation, expecting to be told they were doing all the right things. Instead, they were several million dollars in debt to their own doctors, and indeed, doctors weren’t getting paid. Ralph joined the SPN Board, arriving right as they figured out that they were going bankrupt. He felt that SPN couldn’t survive without a strong relationship between the independents and Sutter, and Sutter’s CEO agreed. SPN changed its name to Sutter Independent Physicians (SIP) in 1995, and Ralph and Jack Benner, MD, were asked to replace the retiring leader. Since he and Jack still practiced medicine full-time, splitting leadership duties made it work with the support of SIP’s strong executive director. Ralph was president and Jack was chairman of the board. I asked Ralph what in his background might have made him a good leader. In his self-deprecating way, he avoided the question. Instead, he described a childhood that fostered success in negotiating and getting along with people. As a smart kid growing up in a small farming town in Stanislaus County, he could have been ostracized along with all the other smart kids. In addition, he was the only child of a teacher mother and dentist father who made enough money for them to be better off than the many poor kids. He was endowed with “a certain degree of athletic ability” in baseball, football, shot put and basketball and discovered that jocks, even smart ones, avoided ridicule. He January/February 2016

Ralph Koldinger, MD


“We need to preserve our small physician/group practices,” and that model of practice.


was good enough to be on all-star teams, which he says qualified him to be the team captain. (I suspect that his people skills had more to do with it.) SIP’s Board decided that doctors had to come together to make things better. Ralph suggested to the SMG leadership that, even though internal referrals were better for profitability, they must maintain a good relationship with outside doctors to be respected in the community. It’s better for both patients and doctors if they have a large referral base. Sutter’s leadership agreed, and in 1996, a legal relationship was established between the Sutter corporate group and the doctors of SIP, SMG, and Sutter West Medical Group. It required a complex legal process to form the new entity, named Sutter Physicians Alliance (SPA). SPA is governed by a steering committee made up of representatives from the four entities. It maintains open referral channels among the groups, allowing solo and small group physicians to be a part of a larger network. Sutter’s happy to have the independents be a part of it, but is not dependent on them. “The tricky part is that SPA’s an organization of a lot of little physician-owned businesses. One’s own business is personally more important than the organization, but the group has to be important or the small businesses won’t continue to exist. Not all docs want to be part of a big organization. And not all people like to see a doctor in a big organization. This is the reason for an IPA to exist, and every member has to be a shareholder. Independent doctors want a seat at the table, but there aren’t enough seats at the table. So we have to choose someone who will promote the agenda of the group, rather than themselves, to take that seat at the table.” In 2000, Dr. Benner left medical practice, and the SIP Board asked Ralph to take on both leadership titles. SIP offered a good way to taper his practice, but extend his career. That lasted until about 2008, when Robert Peabody, Jr., MD, came in as Chairman of the Board, and others like Oscar Mix, DPM, and later on José Arévalo, MD, as Senior Medical Director, provided essential service. Sierra Sacramento Valley Medicine

Since 2005, SIP management has actively worked to help their doctors improve from a service-excellence viewpoint. A quality committee reviews complaints. A comprehensive service team helps doctors to manage human resources and growth, improve staff interactions with patients and ensure clinical quality and financial stability, while reining in utilization. In order to survive, “you should provide even better service than a big organization does,” Ralph states. It’s been pretty smooth and financially profitable since the mid-1990s. Since 2002, SIP has distributed financial incentives of more than one million dollars per year to its physicians. Ralph’s views of the future: “We need to preserve our small physician/group practices,” and that model of practice. He knows that some doctors choose a different practice style, and he wishes them well, but the new docs coming in often want to be a part of an IPA, knowing that it’s necessary to succeed. The group wants to be able to contract with payors for all contracts, not just HMOs, without being accused of price-fixing. For this reason, SIP went through a restructuring process in 2014 to become a clinically-integrated organization, with standards of care and a common EHR. And they must figure out how they will participate in Accountable Care Organizations established by the Affordable Care Act, which are expected to narrow physician networks. Ralph is concerned about not having a fulltime job anymore. He has always had a job, taking no more than six weeks off his entire life. It will take two to three months to phase out of SIP as Dr. Dave Herbert takes over. He still has office hours two half-days per week, and interprets motility studies. He plans to play a little more golf, travel with his wife, Margie, and possibly find some other health care-related outlets. He feels that it’s a complex health care world, and “delivering our product requires coordinated team play.” With SIP, “we’ve gone from playing tennis to playing soccer.”

EMS: Guardians of the “Golden Hour” By Lee O. Welter, MD “BLOOD AND GUTS” SOUNDS gruesome, but those addressing it are vital to extending life rather than simply delaying death from serious illness or injury. A not uncommon scenario is a victim of a ruptured abdominal aortic aneurysm for whom rapid patient assessment, prompt life support, and timely surgery might have prolonged life. “The Golden Hour” connotes the need for speed in this process. Lacking timely treatment, compensated shock degrades to uncompensated shock. Oxygen starvation of vital organs causes damage leading to Multiple Organ Dysfunction Syndrome (MODS) over the ensuing hours. Failure of the gut to fend off bacterial invasion leads to sepsis and release of toxins, leading to Acute Respiratory Distress Syndrome, Acute Renal Failure, and Disseminated Intravascular Coagulation. It’s a death spiral, despite successful (but delayed) surgery and temporary restoration of cardiopulmonary function. Sierra Sacramento Valley Medical Society members, Hal Renollet, MD, and the late Ken Ozawa, MD, were key to the initiation and evolution of regional Emergency Medical Services (EMS). In much of the country, scoop, load, and speed to a hospital had been the only option. Now, California’s excellent EMS is under the jurisdiction and high standards of county EMS agencies — ours being Sacramento County Emergency Medical Services Agency (SCEMSA): aspx. Local EMSAs must certify EMS professionals — EMTs and Paramedics (EMT-Ps) − and establish their protocols and scope of practice under Basic Life Support (BLS) and Advanced

Life Support (ALS), respectively. Protocols are akin to the more familiar standing orders, and may require additional guidance from Medical Control. EMTs provide fundamental assessment and treatment, often calling upon EMT-Ps for more advanced care. As SCEMSA Medical Director, Dr. Hernando Garzon, once stated, paramedics are well suited for service in disaster or other austere scenarios. Their assessment and life-saving skills are vital in the Golden Hour following life-threatening trauma or disease. A pioneer in community college EMS Education, Grant Goold, EdD, and the American River College campus recently celebrated his program’s 20th anniversary. This model program has gained mutual benefit with regional EMS and acute care services. Our program, our partners in EMS and emergency care, and the community are among many stakeholders grateful for the competent, dedicated graduates resulting in high quality of emergency care. This education consists of three phases: preclinical, clinical internship, and field internship. Currently, a critical bottleneck is in securing more clinical skills — especially airway management: “Airway is king.” Ventilation and oxygenation is vital to survival, and teaching it is vital to student education. With extensive simulation experience and practice, students truly appreciate the kindness and support found in local clinical opportunities. However, with your help and encouragement, we can better prepare these future responders. During my anesthesiology practice at Enloe Hospital in Chico (1986-1999), I helped teach continued on page 13

January/February 2016

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 Death of Death Panels By Gerald Rogan, MD

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

OVER THE PAST SIX YEARS, Republican and Democrat Party candidates for national public office have argued about how best to help a patient make his/her choice regarding necessary medical care as the end of life looms. The Centers for Medicare and Medicaid Services (CMS), the AMA-CPT Committee, and the medical community have named these services “advanced care planning.” The CPT description is: • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. Plus the add-on code: • 99498 … each additional 30 minutes (List separately in addition to code for primary procedure). This planning service helps a patient make one or more professionally-informed decisions about what level of medical service he/she prefers now and in the future. The CMS coverage details are available in the final rule CMS-1631-FC for calendar year 2016 at https:// gov/2015-28005.pdf. Over the past six years, advanced care planning has been called something else in the press: “death panels.” One political party claimed that the other political party intended to establish a method within Medicare by which a government panel could make life and death decisions for a beneficiary, or perhaps a group of beneficiaries, or perhaps a group of treatments, deciding whether or not to withhold services to hasten death. According to Wikipedia, the death panel concept was first promoted by a spokesperson for Sarah Palin, Republican


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candidate for Vice President, in 2008: ”Palin’s spokesperson pointed to Section 1233 of bill HR 3200  which would have paid physicians for providing voluntary counseling to Medicare  patients about  living wills,  advance directives, and  end-of-life care  options. Palin’s claim of “death panels” was reported as false and criticized by the press,  fact-checkers, academics, physicians, Democrats, and some Republicans. Other prominent Republicans such as Newt Gingrich, and  conservative talk radio  hosts  Glenn Beck, Rush Limbaugh  and  Michelle Malkin,  backed Palin’s statement. One poll showed that after it spread, about 85 percent of respondents were familiar with the charge, and of those who were familiar with it, about 30 percent thought it was true. Due to public concern, the provision to pay physicians for providing voluntary counseling was removed from  the Senate bill  and was not included in the law that was enacted, the 2010  Patient Protection and Affordable Care Act. In a 2011 statement, the  American Society of Clinical Oncology  bemoaned the politicization of the issue and said that the proposal should be revisited.“ The rhetoric became so intense that, panicked, intimidated and fearful of the effect of propaganda, the Obama administration blocked CMS’ intent to implement the current rule until after the 2012 election. Now, for 2016, eight years after Ms. Palin’s disinformation, CMS has issued its final rule, after notice and comment, which will allow payment for care planning services. From the time of Asclepius, physicians have been providing end-of-life counseling services, and since 1965 under Medicare, have been paid for them by reporting evaluation and management (E&M) codes under their counseling option. In other words,

the effect of misleading propaganda was to delay this final rule. The new CMS rule allows advanced care planning to be a service separate from an E&M. The discussion and planning may be provided as a stand-alone service or during the same visit as an E&M service, an annual wellness visit, or a hospital visit. Planning may be provided in hospital inpatient, outpatient, and office settings.  In developing the final rule, CMS received comments, summarized them and responded. Several comments expressed were concerned that our government would be making health care decisions instead of patients, physicians, and families. This absurd comment also shows how effective the propaganda has been. CMS responded by stating that advance care planning is the responsibility of patients and physicians and their health care team under a physician’s direct supervision.  A decision by a “government panel” is not discussed by CMS in CMS-1631-FC. Government workers at CMS do not prescribe or deny treatment for Medicare beneficiaries. Physicians do that. CMS concerns itself with payment, quality, and access to care. CMS does not supersede a physician’s medical decisionmaking or patient counseling provided pursuant to the physician’s medical license. The concept of “death panels” was a complete fabrication by politicians and their consultants. The concept was designed to scare people, to play on a fear of large government aka “Big Brother.”

A “death panel” is completely incongruent to the Medicare Program. Promotion of the concept shows how degenerate the political process had become. Lies, innuendo and fear were created in hopes of gaining political office to serve a completely unrelated agenda. That 30 percent of respondents thought the “death panel” concept was actually a proposed policy is evidence that propaganda is effective. Even worse, the propaganda delayed for six years the implementation of advance care planning as a separate payable service. Evidently, our leadership has limited confidence in the ability of a portion of our people to understand the truth, which assessment appears appropriate given the comment written to CMS. Once again CMS has been permitted, albeit delayed, to rise above the political duplicity that pervades each election cycle. CMS has provided funding for services that Medicare beneficiaries need and physicians provide. CMS has improved the Medicare coverage to explicitly pay appropriately for compassionate professional counseling and interaction when death looms, as a separate service, in the best tradition of centuries of ethical medical practice. I am pleased to see the death of government “death panels,” a concept that was never proposed, but nonetheless was used for fear mongering by those who hope to manipulate our people for inappropriate reasons. “Death panels” are now officially dead. Good riddance. 

Government workers at CMS do not prescribe or deny treatment for Medicare beneficiaries. Physicians do that.

EMS continued from page 11 airway management, vascular access, and drug administration to Butte College paramedic students in the operating room. I also learned from those students: They were typically well prepared and motivated, working harmoniously within the surgical team. At least one later became a medical student. Developing greater skills and confidence requires more such

valuable opportunities for students. With thanks to those already helping us, we encourage more anesthesiologists and anesthetists to welcome a student into your tutelage: It’s a very satisfying experience. Please contact me if you wish to participate.

January/February 2016


A Compleat* Diary 1961-2015 By John Loofbourow, MD

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

MY ROWS OF RED OR GREEN books titled “Daily Reminder” start with 1961. Somewhere they begin to proclaim themselves, “Standard Diary,” but without any other change. One is partly empty because it went AWOL until captured on a train by a thoughtful young woman. There are two that escaped, but have never been caught. I still sometimes hope to find those two unrepentant deserters; I remember where one left me − when my attention was diverted at the Cattleman’s Restaurant near Dixon, CA. Maybe it was the lady with the bean bucket. I am reminded of this because today, 2015 is missing. It went AWOL on Thursday; this is Saturday so I have been without for three days; fortunately 2015 was apprehended and will be extradited on Monday. 1961 has a reservation card pasted at Jan. 2 for The Chancellor, then a comfortable but modest, nicely located, small, old San Francisco hotel – still there, I believe. It reads: Single – $8: 2 persons double bed – $10: two persons twin beds $12. That is the sort of thing that is a shock when one looks back so far. But I recall that in my small-group general practice, the cost of complete OB care from diagnosis to delivery, including PAP smear and all labs, was $75. On credit. 1968 reports a discussion and decision to raise that inclusive fee to $95. At Jan. 28, 1961 is brochure for a conference at UC San Francisco School of Medicine entitled, MAN AND CIVILIZATION: CONTROL OF THE MIND. It was one of several that Dr. Seymore Farber put together, arguably believing physicians


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were philosopher scientists; or scientific philosophers. This panel of speakers was loaded with non-physicians and writers. There is nothing written there to explain what induced me to drive alone to UCSF Medical Center for that particular weekend symposium. A mailing perhaps. I had been practicing in Woodland only two years. I was 29. A fourth child was eight months old. I knew no physician at UCSF School of Medicine, and to my surprise when I arrived there, a distant uncle and his wife appeared. They were quite beloved, cloistered intellectuals, and I had met them only once before; and once since. My uncle had been an intelligence officer in Turkey during WW I. Forever after he shaved his head, and taught English and Art at Menlo College. I have a little book of his Omar Kayaam-style poems. Maybe you can take the man out of Turkey, but not Turkey out of the man. The list of speakers suggests why they were there. It included: Holger Hayden Aldous Huxley Martin D’Arcy, S.J. Arthur Koestler Wilder Penfield I will never forget sitting in the front row of that old Medical Science Auditorium’s steep semicircle of seats while those remarkable speakers peered up from the place where dissections and demonstrations were formerly done. The tuition, including Saturday lunch with address by Huxley: $25. For more than a half-century, the diaries have saved the stuff of living for me: names, places, times, driving directions, children’s creations, ticket stubs, news cuttings, programs, notes, letters, addresses; and the almost-legible cursive

fast-scratch of this former med student. Today, an e.diary might be preferred by many: more easily searchable, linkable, and reproduction embeddable. But I relish the feel of paper, its simple, frank honesty, the substance of yellowing originals; and for searches, my standard business diary, “monthly cash account,” at the back of each book becomes an index of topics. The diaries are already as obsolete as cursive writing; they are destined to be recycled into corrugated cardboard boxes, paper cups, or toilet paper. But for now, I treasure them, refer to them often, and still hope to catch the two deserted years.

*COMPLEAT−archaic variant of complete, having all necessary or desired elements or skills. Also classic, quintessential.

Little Things By John Loofbourow, MD It’s not the Persian carpet, the house, car or jewels, but the little things that whisper or suggest even when they’re silent what I little know, of where, when, why, who or even what about her life gone by: Her medicine chest, kitchen and pantry, bedsheets and closets; eleven hard drives in a plastic ziplock meticulously destroyed,

A crochet hook, sewing kit, items for recycling, old photographs,

Pills, notions, lotions, purses, shoes, clothes, a hundred handwritten pages

TP and paper towels, bank statements, letters, perfume, and lotions,

from a lined spiral notebook filled with fear and voices speaking in silent audibles.

Detergents, linens, a dog dish and bird feeder half full. A mail box, still alive, when emptied, cries out for a little more, until rewarded with delicious junk mail and collection letters.

Dry plants, and flower beds, disconnected sprinklers, old hoses and garden tools. Cruel little things speak in their sharp edged forked foreign tongue,

Sad little things that hint of little pleasures, big plans, and hope of love. I follow the footpaths through the underbrush of her tangled troubled life. I walk there barefoot aware and wary of thorns, adders, asps, and broken glass, but the little things leave weeping little cuts that still wait and want to heal.

an unspent bullet in still stale air and cluttered dark.

January/February 2016


Transgender Care in Sacramento Where do Providers Begin?

By Laura Brimberry, RN, BSN, MSN, NP

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.

WE’VE COME UPON AN exciting and transformative chapter in transgender health. For a population that was once overlooked by the medical community, the spotlight has shifted. Mainstream television can take much of the credit for bringing transgender lives to the forefront, but behind the scenes, preceding the reality shows and drama series, have been countless hours dedicated to community service, lobbying, research and social justice. Providers now have an everexpanding pool of literature to draw from on care of the LGBT (lesbian, gay, bisexual or transgender) patient, such as the groundbreaking Institute of Medicine’s 2011 Report.1 This should be cause for celebration, except that there is a problem: the study results and practice recommendations are not reaching or registering with providers. For new graduates and residents, transgender or gender-nonconforming health and best practices may or may not have been incorporated into the curriculum or specialty rotations. But, for the majority of providers, this is a foreign topic, and for some, an intimidating one. For this reason, and for the reason that Sacramento is home to a substantial transgender/ gender non-conforming population, we need to have open discussions and ask the question: How would I care for a transgender patient? Would I be prepared? How can I prepare?


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On-line courses2 offered by organizations such as the Human Rights Campaign are helpful. Gaining a deeper understanding of the transgender experience and then allowing that understanding to translate into practice will make a significant impact on lives − or even save one. Here are my recommendations: 1) Become familiarized with transgender health practice standards3 and the impacts of gender dysphoria. Read about personal stories of transformation and the struggles faced by transgender individuals to gain insight and empathy. It is important to understand that transgender individuals have, historically, avoided health care because of provider lack of knowledge and outright discrimination or even violence.4,5 2) Register with the Gay and Lesbian Medical Association (GLMA).6 You do not have to be LGBT to become a member. Patients use the online database to find transgender health competent providers. They have an excellent newsletter sent by email, and their annual conferences are highly informative and provide continuing education credits. 3) Explore your community resources. For example, the Gender Health Center7 offers counseling services, a hormone clinic, networking, community outreach and assistance with insurance issues. Sutter Medical Center, Sacramento, has a Gender Identity Support

Group.8 Other campuses have LGBT support groups and resource centers. 4) Consider whether your clinic or waiting room nonverbally communicates to a transgender patient. Are your intake forms genderneutral or transgender inclusive? Do the receptionists have the appropriate competency training to ensure that transgender/gender non-conforming patients and families feel secure? 5) Consider the challenges that could be faced when admitting a transgender patient to the hospital. Consider billing issues and denials of claims. Electronic health records and billing are, for the most part, fixed in two genders: Male and Female. A pap smear performed on a patient who identifies as male but still has a cervix may not be recognized by the health record, and a claim may be denied outright. Transgender health is a fastevolving and fascinating field. Let’s have an open dialogue about the transgender experience with staff and colleagues. Silence can be as potent of a barrier as any. Resources and References 1 Institute of Medicine, The Health of Lesbian, Gay, Bisexual, ad Transgender People: Building a Foundation for Better Understanding, The National Academies Press (2011). 2 Hei Training on The CaL, 3 World Professional Association for Transgender Health 4 Lim. F, “Lesbian, Gay, Bisexual and Transgender Health: Disparities We Can Change,” Nurse Educator, 38;3: 92-93 (2013) 5 K. Rounds Et al, “Perspectives on Providers’ Behaviors: A Qualitative Study of Sexual and Gender Minorities Regarding Quality of Care,” Contemporary Nurse 44;1: 99-110 (2013) 6 Gay and Lesbian Medical Association (GLMA) 7 The Gender Health Center 8 Sutter Gender Identity Support Group www.

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January/February 2016


Reflections on Transgender Care Background: “Transgender Care Moves Into Mainstream” is the title of a perspective published in the October 14, 2015 issue of JAMA ( d=2463347&resultClick=3.) The essay describes the expanding need for primary care, mental health, endocrine care, and surgical care for the approximately 700,000 transgender persons in the U.S. Many transgender patients have difficulty finding physicians comfortable in managing their needs. The following are stories from our members about their experiences and thoughts concerning the medical needs of transgender patients. 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:

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

I have only one transgender patient who is transitioning from female to male currently, and his previous provider was insensitive to his transgender care. He was very relieved when I was happy to treat, and was accepting of, his gender identity, which can make all the difference to a patient in such a vulnerable position. After I spoke with the patient and started his hormone therapy, thanks to the help of the Gender Health Center in Sacramento, I gave a quick talk to our providers about transgender issues, including specifics on management, but also on how to be sensitive to the unique needs of this community. Overall, the experience was beneficial to all the providers, and I hope to continue to be a resource for any of my transgender patients in the future, as they are a particularly vulnerable group, both within medicine and in the greater community. −Christopher Swales, MD In a rapidly-changing world, it is difficult


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for large institutions to keep up. As we leave an era of “Don’t Ask, Don’t Tell” in medicine, welcoming LGBT people is a challenge. How can a medical school and its larger academic health system improve its education on transgender care? The answer, we believe, is in embracing transgender people at every level of our systems. When medical learners work with and befriend people of different racial and ethnic backgrounds, they become more comfortable, confident and competent in treating people of those backgrounds. The same is, undoubtedly, true for individuals with gender identities and expressions that differ from the cisgender malefemale binary. To serve the health needs of the transgender community and reduce health disparities, we must make our curricula, schools, and workplaces welcoming to transgender people. This includes teaching students and residents how to appropriately take a transgender patient’s medical history, and incorporating medical information about hormones into required courses – not just in optional LGBT Health electives. We must develop transfriendly policies in collaboration with our main campuses so that all transgender students (undergraduate, graduate, and medical) feel safe and valued. The same welcoming practices must be implemented for our employees, including benefits that support transition-related medical services. Only when we recognize transgender people as full members of our communities can we begin to improve care. −Julie Ann Freischlag, MD Transgender care should be limited to specialists who are comfortable managing and familiar with changing regulatory and scientific environments of practice, or risk bad outcomes

and reputation. −Mohammad Kabbesh, MD I have cared for transgender patients, providing breast surgery, both augmentation for females and mastectomy for males. The patients have been intelligent and thoughtful. I have been gratified by my interaction with them. − Debra Johnson, MD Before I transitioned into a teaching role, I had collected a small panel of transgender patients in midtown Sacramento. I discovered that patients discovered me by word-ofmouth and more, because I was viewed as non-judgmental rather than an expert. In fact, 30 years ago, I had a lot to learn, mostly from these individuals who had endured incredible obstacles to become outwardly the people they were inwardly. Some patients however, make a bigger impression than others. To this day, I still see the homeless transwoman who drives to Sacramento from Barstow and, due to psychiatric co-morbidity, remains at high risk unable to pass in mainstream society. She feels respected in our office despite her facial hair. I have since increased my education and do not hesitate to ask for help from local expert colleagues. I encourage a good read, should you have time: “Middlesex” by Jeffrey Eugenides, a Pulitzer Prize novel, 2002. −Marion Leff, MD Caring for transgender patients has been the most rewarding part of my career. Primary care physicians are uniquely poised to provide essential treatment that meets our patients’ most basic needs with regards to gender identity and the unique mental, physical, and preventive health care that goes with it. The American Academy of Family Physicians supports and encourages primary care management of transgender health. Medication management is now becoming an AAMC-required part of medical school curriculum, and the Affordable Care Act specifically prohibits discrimination based on gender identity. Treating gender dysphoria can be easier than managing uncontrolled hypertension – and the patient gratitude is unparalleled. As a new transgender patient recently emailed to me, “With one visit to your practice, Dr. Hauser, I have not felt better in my entire life. You have healed my entire

being.” When we provide transgender care, we go beyond physician, to healer. −Charlene Hauser, MD I have a close friend whose 23-year-old daughter moved to Toronto three years ago to have trans surgery done, with her dad at her side and hormonal support for her male appearance. He says, as a daughter of American expats raised from infancy in Japan, Gina was always very uncomfortable and clearly, from the beginning, wanted to be, and acted as, a boy though expressing it by presenting herself as manga or goth. As Jay, he is still loved by both parents and very happy. He is about to marry a Pakistani girl and come back to the U.S to continue postgraduate studies in Architecture. He is almost six feet tall and loves playing soccer and basketball. Probably a life saved. −Sandra Hand, MD I have been seeing and welcoming transgendered patients into my office for more than 30 years – since 1982. My reputation in this community escalated about 12 years ago when the medical assistant I was working with decided to make her transition. The news of her transition spread rapidly in the trans community, and the fact that my office is trans friendly was disseminated equally fast. My patients know that they have a safe place to come and discuss their concerns and questions with someone who has a depth of experience and who is committed to helping them discover their truest selves. I often work in collaboration with the Gender Center in midtown which is a wonderful asset; they provide care and support for patients who are often misunderstood and shunned by other providers. I have been told by patients, who have relocated to Sacramento from much larger cities, that those cities have nothing to compare to what our Gender Center offers. Sacramento is known for its incredible diversity and the Center is another expression of the diversity and acceptance that our city is known for. The Center has been the recipient of philanthropic support from my employer, Sutter Medical Group, for the last three years. That’s how much we value their services. −David Norene, MD

January/February 2016

Caring for transgender patients has been the most rewarding part of my career.


Back to Strunk and Fowler, or Mind Your Pees and Qs By Jack Ostrich, MD

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

A FEW WEEKS AGO, I sent a letter (electronically, of course) to the editors of The Sacramento Bee. I had not sent any message to any newspaper for many years, but this was a matter of such importance that I could not restrain myself. What stimulated me to write was an article in The Bee about the apparent epidemic of human public urination and defecation in San Francisco and Sacramento. The culprits seem almost always to be adult male vagrants. “Vagrant” derives from the Latin verb vagare that means to roam or to wander. The same Latin root gives us more words, among which are vagary, vagabond and vague, as well as the name of everybody’s favorite cranial nerve, the vagus, that wanders and roams from the base of the brain to well below the diaphragm. So, most of the public urination and defecation in San Francisco and Sacramento is performed by vagrants, and some, I suppose, by patrons of various athletic contests and musical concert events. I was not surprised by the facts within the story, but I was disturbed that The Bee chose to use the juvenile euphemisms “pee” and “poop” instead of the more formal terms for those excretory activities. So, it came to pass that I sent my brief e-mail to The Bee expressing my dismay. I expected no response and received none. The contemplation of this minor linguistic matter, however, led me to pull down two small volumes from my bookshelf, neither of which had been in my hands for many years. One was Fowler’s Modern English Usage, revised edition of 1965, and the other, The Elements of Style by William Strunk, revised and expanded in the late 1950s by Elwyn Brooks (“E.B.”) White,


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author of Charlotte’s Web and Stuart Little. Henry Fowler created his book in 1926 and it has been twice revised since then. It chiefly focuses on British English usage, with occasional references to “Americanisms” and some non-English phrases and words. William Strunk was a professor of English at Cornell who, in 1919, self-published a 50-page pamphlet which he gave to each of his students. E.B. White was one of Strunk’s students and he wrote a memorial piece about his mentor and his “little book” in The New Yorker in 1957. Two years later, he composed the revised edition. White recalls his teacher as quite obsessed and upset by the waning of clarity and the waxing of needless, and occasionally nonsensical, prolixity in the popular press, and even in “serious” literature. I am sure that Professor Strunk would never have directed his students to write a 2,000-word essay on “the inevitability of the 12th canto of Book 1 of Spenser’s The Faerie Queene,” as I had to do as a college freshman under the tutelage of one of my forever favorite teachers, Harold Bloom. As I recall, I actually enjoyed reading The Faerie Queene under Bloom’s enthusiastic guidance. Harold Bloom encouraged wordiness. In his class, a literary essay or “book report” was of little value unless it was at least 2,000 words long. I imagined him sitting up at night counting the words that I had produced on my Remington portable typewriter. Strunk, on the other hand, especially valued accurate and terse writing. White recalls him as “he delivered his oration on brevity to the class...leaned over his desk...and, in a husky and conspiratorial voice said, ‘Omit needless words! Omit needless

words! Omit needless words!’ “ For example, this first exposition is 51 words long and might have been written by Harold Bloom when a freshman in high school: “Macbeth was very ambitious. That led him to wish to become king of Scotland. The witches told him that this wish of his would come true. The king of Scotland at this time was Duncan. Encouraged by his wife, Macbeth murdered Duncan. He was thus enabled to succeed Duncan as king.” Strunk edits this for us and gets rid of 25 needless words: “Encouraged by his wife, Macbeth achieved his ambition and realized the prediction of the witches by murdering Duncan and becoming king of Scotland in his place.” But truth be told, clarity sometimes demands more words. This newspaper article needs expansion: “New York’s first commercial sperm bank opened Friday with semen samples from 18 men frozen in a stainless steel tank.” Copy editor Strunk clarifies the story: “New York’s first commercial human sperm bank opened Friday when semen samples were taken from 18 men. The samples were then frozen and stored in a stainless steel tank.” That’s better. And would the Gettysburg Address be more memorable if Lincoln had more economically begun: “Eighty-seven years ago...” or “In 1776...”? White muses about “literary style in the sense of what is distinguished and distinguishing.” He goes on: “Who can confidently say what ignites a certain combination of words, causing them to explode in the mind?” “These are the times that try men’s souls,” wrote Thomas Paine in 1776, and this little sentence has reverberated ever since. But what, White wonders, would be the case if Paine had written, “Times like these try men’s souls,” or “How trying it is to live in these times,” or “These are trying times for men’s souls,” or “Soulwise, these are trying times”? Stylewise, the

original seems clearly the best, but it is difficult to explain exactly why. And so, Strunk probably would not care if The Bee used “poop” or “pee,” as both words are concise and generally understood. But Henry Fowler would care. He devoted a good deal of his book to the proper use of words and was not much bothered by occasional prolixity. Plus, he disliked most euphemisms. He wrote: “In the present century, euphemism has been employed less in finding discreet terms for what is indelicate than as a protective device for government and as a token of a new approach to psychological and sociological problems. Its value is notorious in totalitarian countries where assassination and aggression can be made to look respectable by calling them ‘liquidation’ and ‘liberation.’ “ He continues: “We live in a scientific age and like to show, by the words we use, that we think in a scientific way.” So, the following arises from a treatise on family life: “The home, then, is the specific zone of functional potency that grows about a live parenthood; a zone at the periphery of which is an active interfacial membrane or surface furthering exchange − from within outward and from without inwards − a mutualising (sic) membrane between the family and the society in which it lives.” Whew. Even Harold Bloom might have marked down the author for that sentence, and Strunk would most definitely have done so. Well, enough of these curmudgeonly fuddyduddyisms.  There is not too much we can do about the changes in our language except to speak and write as clearly as we can. But, if The Bee next reports that “the homeless” (viz. vagrants) are increasingly “going Number One and Number Two” in public places, I shall have to send another letter.

‘Omit needless words! Omit needless words! Omit needless words!’

January/February 2016


Test Your Medical Vocabulary Puzzle Created by Nan Nichols Crussell, Managing Editor

ACROSS 2 A milky white fluid consisting of absorbed food materials from intestines after digestion 4 Hip joint 8 Excessive outward curvature of the spine 10 A tumor of a mixture of tissues 12 Any deformity of the foot involving the ankle 13 A gradual loss of moisture in the tissues 14 A membrane of granulated tissue covering a surface 15 Inability to walk 16 The part of an organ where the nerves and vessels enter and leave 17 Lying outside the axis of any body or part 18 A covering membrane 22

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21 A piece of dead bone or other tissue detached from the surrounding parts 24 Fat cell 27 Denoting nerve fibers lacking a myelin sheath 29 Pain in the ankle 31 A skin eruption occurring as a symptom of an acute viral disease as in measles 32 Relating to, causing or characterized by a rapid pulse 34 A term used to describe a stalk-like structure 37 Any yellow coloration of the skin 38 A disease involving destruction of the skeletal muscles 39 The bone that forms the heel 40 An amino acid occurring in many proteins

42 A turning or rolling out, especially of the margin of an eyelid 43 Dilation of a salivary duct 45 A slight hematoma following a bruise 48 Deposition of minerals like iron in the walls of small blood vessels 50 A chemical substance that causes dilatation of the blood vessels 51 Occurrence of bile pigments in the spinal fluid 52 The disintegration of a cell 54 A rare condition in which there is swelling of the joints 55 Excessive secretion of mucous in the stomach 56 Poisonous products of certain fungi that cause liver cancer in humans 57 Between the eyelids

DOWN 1 A benign tumor of mucous or gelatinous tissue 3 A bony projection that grows in response to inflammation or repeated trauma 5 Involuntary rhythmic movement of the eye balls 6 The appearance on otherwise normal skin of white patches of varied sizes, often symmetrically distributed and bordered by areas of increased pigmentation 7 A large mass of scar-like tissue occurring most commonly in the abdominal muscles of women who have borne children 9 A membranous layer or covering 11 Congenital absence of arms 14 A fever-inducing agent produced by bacteria, molds and viruses 19 A chronic infection involving the subcutaneous tissue, skin and bone 20 Any disease of the small blood vessels 22 A contraction or shortening of the muscles of the neck 23 A condition when the heart is on the right side of the chest rather than the left 25 Any of a group of skin diseases characterized by the shedding of bran-like scales 26 One of the primary divisions of a nerve or blood vessel 28 Blindness, especially that occurring due to reasons other than a change in the eye itself 30 A cup-shaped bone in the hip region where the thigh bone joins the hip bone

33 Extreme dryness of the nasal mucous membrane 35 Swelling of the eyelids 36 One of the three types of cells that together with the nerve cells compose the tissue of the central nervous system 41 An abnormal increase in the concentration of urea and other nitrogen-containing substances in the blood, commonly occurring in kidney diseases 44 A type of cell division that results in daughter cells with half the chromosome number of the parent cell 46 Irregular and involuntary movement of the limbs or facial muscles 47 Pain in the hands and feet 49 The basic structure of many natural products, drugs, dyes, antibiotics and pesticides 53 An irregular eruption and swelling on the skin, slightly red, spreading to adjacent areas and accompanied by intense itching Solution on page 31

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January/February 2016


Making Our Streets Healthy By Glennah Trochet, MD

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

PEOPLE WHO LIVE IN AREAS with good public transportation, such as San Francisco or New York City, tend to be leaner than those who live in areas where most people commute to work using private vehicles. In addition, those who have access to streets with sidewalks that lead to destinations such as restaurants, parks or businesses, are more likely to bicycle or to walk than those who do not. Streets are safer for pedestrians when more people are out and about than where there are occasional, solitary walkers. During the better part of the 20th century, U.S. development was built around the automobile. As a result, there are many cities with residential neighborhoods that are far away from commercial centers. Many streets lack pedestrian access to cross them, and in some neighborhoods there are no sidewalks or areas where people can walk or bicycle safely. As we have become more aware of how the built environment influences our exercise choices, there has been a movement in public health to modify the built environment to include active transportation choices, such as walking and biking. The movement for “active living” includes many actions: encouraging the use of public transportation, making sure that streets are “complete,” which means that in addition to the blacktop for cars, they have bike lanes, sidewalks, crosswalks and trees that provide shade and make the area more attractive. Not all existing streets can be modified to become “complete streets,” and even when they can be, current residents may resist change. In Sacramento, an advisory council called Design 4Active Sacramento (D4AS), of which I am a member, has taken the lead in advocating and working on ways to improve the built environment to support walking, biking and


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other ways of staying active. The council is the outcome of participation by a local team in the 2013 National Leadership Academy for the Public’s Health. This is a 12-month training program for teams from different disciplines, including medicine, to influence the policies and systems that impact public health. The team included the former CEO of WALKSacramento, (a local nonprofit that advocates walking), the current Sacramento County Health Officer, Dr. Olivia Kasirye; a practicing neurosurgeon, a county planner, a transportation engineer and a member of Sacramento Area Council of Governments (SACOG) among others. During the program, the team worked to increase awareness in the region of the importance of having walkable neighborhoods in order to improve health and the economy. During the course of the year, the group successfully added language into Sacramento County’s Housing Element to make the improvement of public health a goal of housing. At the end of the year, the group decided to become permanent and invited other members to join. Currently, D4AS operates under the auspices of WALKSacramento. Last year, D4AS reviewed Sacramento County’s Design Guidelines and identified the guidelines that promote physical activity and health, adding a section that describes active design and how to incorporate active design features into development projects. The Sacramento County Board of Supervisors recently approved these guidelines which can be found here: The icon of a walking human is placed next to guidelines that provide active living. On November 18, 2015, the American Planning Association announced that the

D4AS was one of 17 new coalitions that had received funding from their Plan4Health program to increase physical activity and access to nutritious food. The funding, which will come to WALKSacramento and partners, will increase education for elected officials and others working in government about the need to change the built environment to improve health, as well as other projects in Sacramento. Why is this team engaging in such work, that many might find boring? Because it is important. Having hundreds of bicyclists blocking streets one day a month is much more dramatic; holding “fun runs” in support of good causes increases the visibility of the good cause and underscores the importance of physical activity. These activities may increase awareness, but don’t change the built environment. If we are going to have communities that encourage and support walking and other forms of active transportation, we have to make sure that the policies support this concept and that the work is codified in zoning laws and design

guidelines. We have to ensure that elected officials understand the importance of active living to the health of their constituents and that developers build complete streets and make it safe and attractive to walk in newly-developed communities. This can only be done with the help of partners outside of medicine, who welcome the interest of the medical profession in non-medical measures that prevent obesity.

People who have access to streets with sidewalks that lead to destinations such as restaurants, parks or businesses, are more likely to bicycle or to walk than those who do not.

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References: Active Transportation: Making the Link from Transportation to Physical Activity and Obesity ActiveTransportation_0.pdf Analysis: Cities with More Walkers, Bike Commuters are Less Obese, Governing Magazine, June 14, 2012 Transit Use, Physical Activity, and Body Mass Index Changes: Objective Measures Associated With Complete Street Light-Rail Construction Brown, Werner et al. Am J Public Health. 2015 July; 105(7): 1468–1474. PMC4463394/ Environmental Barriers to Activity, Harvard T. Chan School of Public Health

January/February 2016


A Time of Change Report on the 2015 CMA House of Delegates

By Richard N. Gray, Jr., MD, Chair, 11th District Delegation

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.

NOTHING IS AS CONSTANT as change. This is true of the CMA: Transitioning from four days to a two-day California Medical Association (CMA) House of Delegates (HOD) has been an interesting process, fraught with the usual concerns and opportunities that come with change. Regardless, this is saving the CMA and its delegates significant expense, allowing funds to be redirected to our legislative interests and physician assistance, while shifting time requirements from a single, concentrated effort, to a year-round process with quarterly updates in policy, related to the quarterly Board of Trustees meetings, then a two-day HOD to work on some significant topics. Stay tuned for the results of this change! Another change is in leadership: Following the 2013 and 2014 presidencies of Paul Phinney, MD (Pediatrics, Sacramento), and Richard Thorp, MD (Internal Medicine, Paradise), respectively, this year we elected Ruth Haskins, MD (OB/GYN, Folsom) as the 2015 PresidentElect for CMA. She will serve as President following the 2016 HOD. Meanwhile, Lee Snook, MD (Pain Management, Sacramento) continues as the Vice Speaker of the HOD, also serving on CMA’s Executive Committee. This strong leadership in recent years surpasses that of any other delegation in the state. The HOD tackled a number of topics of varying importance to the individual delegates who, ultimately, rate the importance of each issue, leading to a prioritized list of concerns to direct policy and legislative efforts for the coming year. (The prioritized list was not available at the time this article was prepared.) Issues addressed included such things as:


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SCIENCE & PUBLIC HEALTH • Efforts to decrease homelessness, a known risk factor for poor health. • Efforts to decrease the use of tobacco. • Restoring California’s public health infrastructure. • Seatbelts in buses. • Restrictions and regulation of sugar-sweetened beverages.

GOVERNMENT HEALTH PROGRAMS & HEALTH SYSTEM REFORM • Physician-directed improvements to the Affordable Care Act in California. • Appropriate direction of public assistance. • Funding colon cancer screening for the indigent, and other improved access to medical care.

CMA MEMBERSHIP, FINANCE & GOVERNANCE • A CMA Health Policy Fellowship, and scope of practice compendium, to allow the public to understand the various roles of health care providers.

­­­INSURANCE & PHYSICIAN REIMBURSEMENT • Elimination of hospital affiliation for involvement in health plans. • Reducing hassle for benefit eligibility and pre-certification inquiries. • Prohibition of insurance company-authored health care pathways. • Support for health savings accounts.

QUALITY, ETHICS, & MEDICAL PRACTICE ISSUES • Liability protections for physicians participating, or refusing to participate in aid-indying. • Physician access to their own CURES database information. • Addressing EHR interface connectivity and interoperability issues. • Protecting parental involvement in treatment of minors with psychiatric conditions. • Discipline for physicians making false claims using mass media.

HEALTH PROFESSIONS & FACILITIES • Addressing physician shortages and misdistribution. • Physician re-entry into the workforce. • Addressing problems with maintenance of certification. • Patient mobility performance-improvement programs for hospitalized patients.

• Continuity of care for hospitalized patients. • Early-notification of non-physician supervision. A complete list of the final actions of the HOD is available to members at www.cmanet. org/hod under the “documents” tab. The above listing neither does justice to the passion of delegates urging adoption of policies to benefit patients and physicians in California, nor the amazing process by which the HOD comes to consensus on all its varied resolutions. You would simply need to see it for yourself. The next HOD is scheduled for Sacramento in October 15-16, 2016, and not only are you invited to observe the HOD in action, but all CMA members are invited to author resolutions for consideration. Be informed and involved!

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January/February 2016


 2016 Board of Directors President: Thomas Ormiston, MD President-Elect: Ruenell Adams Jacobs, MD Immediate Past President: Jason Bynum, MD District 1, North: Seth Thomas, MD District 2, Central: Vijay Khatri, MD; Darin Latimore, MD; Christian Serdahl, MD District 3, South: Thomas Valdez, MD District 4, El Dorado County: Alexis Lieser, MD District 5, The Permanente Medical Group: Rajiv Misquitta, MD; Paul Reynolds, MD; Sadha Tivakaran, MD; John Wiesenfarth, MD; Eric Williams, MD District 6, Yolo County: Anne Neumann, DO

2016 CMA Delegation District 1, North: Reinhardt Hilzinger, MD, Delegate; Anissa Slifer, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Don Wreden, MD, Alternate District 3, South: Katherine Gillogley, MD, Delegate; Thomas Valdez, MD, Alternate District 4, El Dorado County: Russell Jacoby, MD, Delegate; Alternate Office Vacant District 5, The Permanente Medical Group: Sean Deane, MD, Delegate; Jason Bynum, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Rajan Merchant, MD, Alternate At-Large Office 7: Ruenell Adams Jacobs, MD, Delegate; Sandra Mendez, MD, Alternate At-Large Office 8: Thomas Ormiston, MD, Delegate; Armine Sarchisian, MD, Alternate At-Large Office 9: Anthony Russell, MD, Delegate; Alternate Office Vacant At-Large Office 10: Alicia Abels, MD, Delegate; Thomas Kaniff, MD, Alternate At-Large Office 11: Alan Ertle, MD, Delegate; Helen Biren, MD, Alternate At-Large Office 12: Kuldip Sandhu, MD, Delegate; Vijay Khatri, MD, Alternate At-Large Office 13: Charles McDonnell, MD, Delegate; Natasha Bir, MD, Alternate At-Large Office 14: Richard Jones, MD, Delegate; John Tiedeken, MD, Alternate At-Large Office 15: Richard Gray, MD, Delegate; Alternate Office Vacant At-Large Office 16: Janet O’Brien, MD, Delegate; Joseph Sison, MD, Alternate At-Large Office 17: Karen Hopp, MD, Delegate; Alternate Office Vacant At-Large Office 18: Delegate Office Vacant; Kevin Jones, DO, Alternate At-Large Office 19: James Sehr, MD, Delegate; Alternate Office Vacant At-Large Office 20: Senator Richard Pan, MD, Delegate; Alternate Office Vacant At-Large Office 21: José Arévalo, MD, Delegate; Alternate Office Vacant


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A Posit Addressing Dependency on Medicine “Current trends in medical practice encourage patients to become dependent instead of self-reliant.”

Background: An article from NBCNEWS. com on November 3, 2015 announced “More Americans than Ever Use Prescription Drugs.” Close to 6 percent of U.S. adults take prescription medication and over 8 percent take five or more drugs at once. Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 17/Agree – 6/Disagree. Commentary follows:

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

I agree. I feel that the breakdown of family and community plays a key role in this, as much of the basic self health care knowledge that was taught amongst family members is lost. I see so many people in the ER for a cough, a cold or a blister, it is shocking. In addition, popular media works hard to create clients for health care with direct marketing of medications and sensationalization of risks for otherwise rare items. −Noel Hastings, MD I agree. More important than “dependency” is that many of those medications may be unnecessary, and the regimens are too complex leading to a higher complication rate and a lower compliance rate. More active involvement by clinical pharmacists to simplify medication regimens is what is needed. −Roy Schutzengel, MD, MBA I agree. I don’t know what the trend is, but I certainly feel that too many patients expect we can help them more than we actually can, and that they don’t do enough to help themselves. I wonder if this latter point is because the “frequent fliers” that so often seek help from


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us do so, in part, because they don’t have the ability to help themselves. It doesn’t help that it’s quicker to write a prescription than to spend time counseling on behavioral modification. There is no better example than patients who have chronic pain. I try to convince such patients that they can help themselves more than I can, as modern medicine, too often, does them more harm than good, such as when we allow for long-term opiate use or do some softcall indication surgeries. It’s a huge challenge to try to empower such patients with the knowhow and confidence to do activities that help them manage their chronic pain. −Michael Flaningam, MD I agree. The simple thing for a doctor to do is write an Rx. Counseling and listening may actually be the right thing to do, but this takes time (and actually more training, most likely.) −Maynard Johnston, MD Well, I think it is both. With the advent of Medicare, the government became increasingly involved in medical care with the natural consequence of entitlement and dependence. Increasingly, the consumer of the service (patient) was dislocated from the responsibility for paying for the service so their dependence increased, and input into the process became non-existent. This trend was accelerated massively by Obama care (I can’t call it “The Affordable Care Act” without becoming ill) to the point that consumers are coming to the realization that the result of dependence is poor or no care. There is no free lunch and you get what you (not the government) pay for. So, in one respect, consumers who pay attention

and care about the product that they have, are becoming more independent-minded by necessity. −Donald Hause, MD I agree. Part of the problem is all the TV advertising that tells people they may have a problem that may not exist for them. −Seung Kwon Lee, MD I disagree. I am not sure I agree with the premise that taking medications when prescribed makes you dependent on the medical system and that it takes away your self-reliance. Someone can pursue healthy lifestyles and still require medications. −Dennis Michel, MD In primary care, I see more people becoming “disabled,” more people trying to get a pill (Xanax or related) to deal with social or economic issues, and still an alarming number of aggressive procedures and cancer treatments in advanced age, end-of-life patients. The other day, a patient of mine with chronic pain asked me to sign a form for PG&E to give him a medical discount on his heating because “the cold weather makes my back hurt more.” The message from some patients has become clear:

Crossword Puzzle Solution

“save me” or “what can you do next” instead of “partner with me/empower me” or “help guide me” or “reassure me that this is just part of life [and death].” Reasons for this are numerous, I’m sure, but I’m afraid much of what we do in medicine is not helping people. −Nathan Hitzeman, MD I disagree. In my own group, we make every effort to partner with patients and get them to embrace self-directed lifestyle changes to improve their health. We need to do more, though, and get insurance carriers to cover preventative programs, including rewarding the patient for positive changes. −Amy Wandel, MD I agree. We should focus on the risks of addiction, and the treatment of substance abuse disorders as physicians. −Aimee Moulin, MD I agree. Patients believe that there is a pill or vitamin or health supplement for any ailment. Positive lifestyle changes are not well accepted by most patients. However, physicians, especially primary care physicians, have dwindling amount of time spent with patients. −Boone Seto, MD

Patients believe that there is a pill or vitamin or health supplement for any ailment.

Original puzzle is on page 22

January/February 2016


What Freedom is Left By Caroline Giroux, MD

North, South, East, West Why fight against a God of a different brand When the most destructive war of this fatherland Is tearing hope and life in its own breast.

The The The The

Bloody scenes assault our hearts, intoxicate our senses Fear has become our lens Why is the best of humanity Unable to prevent ongoing atrocity?

Fear makes us bypass our essence But don’t let it, rather, observe it, and remember: Barbarism is the byproduct of fear The fear of otherness.

My human rights have the blues What is left everywhere on cold concrete is warm red, spilled… Pure as children, only emotions should have colors Ideas should remain fluid, undivided, never spoiled. Defense only breeds more offense And both rhyme with violence Schools should teach Responsibility 101: each gesture, each word leaves a trace, Enlightens or shreds a face.

right right right right

to to to to

dream play laugh sing…

I say find your own freedom and dedicate your life to it Courage comes with it Maybe you’ll find yourself wondering What is left when peace is gone? The capacity to love The capacity to see And sometimes, to write. Such grand liberties…

What freedom is left When we remain fearful for our children What freedom is left When destruction of life attacks their utmost rights.


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“Don’t Rush to Flush” New Year’s Reminder About Safe Disposal of Unused Medications

By Donald Lyman, MD WHAT ADVICE SHOULD YOU give patients and their families on the safe disposal of unused medications? Recent events have highlighted this problem for: a) the environment into which these chemicals are often disposed and b) those affected by higher rates of overdoses from increased rates of prescribed opioids. The solutions to this issue for physicians and patients are rather simple: • Keep only as much medications as necessary. Excesses are at risk of theft or inappropriate discard. Theft of opioids is especially dangerous. • Prescribe only what you intend. Excess prescribed medications (especially opioids) are at risk of theft with sad outcomes by other users. Hormonal substances are known to present environmental risks. • Don’t flush any medications down the toilet. Hormonal and other chemicals cannot be removed at the sewage treatment plant and may be harmful to the environment. • Don’t trash any labelled medications. While landfill is less bad than sewage disposal, don’t tell others who you are and what’s in the bottle! • Return to the pharmacy if permissible. Ask your pharmacy whether they have a “Take Back” policy. • Use a pharmaceutical collection site. A number of these are now available in

the Sacramento region sponsored by the California Product Stewardship Council. Look for these at We have seen two problems develop from the issue of safe disposal of unused medications. One problem is environmental. Hormonal and other chemical substances deposited in wastewater or landfills may have adverse effects on fish and other living things. Sewage treatment plants do not remove such substances, and landfills leech groundwater which may turn up in our drinking water. The other problem is misuse of prescribed opioids. With public pressure for improved pain management by physicians, prescriptions for opioids have increased by some 400 percent in the past decade. Concurrently, hospitalizations for opioid abuse have also increased by some 400 percent. This is a national problem, but a 2012 L.A. Times series of articles blamed rogue physicians for prescription abuse as the cause. They prescribe too much; the excess is stolen and used illicitly. While CMA has addressed this matter constructively with the legislature, the legitimate generic issue is proper prescribing with good advice on safe storage and disposal of unused material. Let’s build this into our prescribing practice protocols.

January/February 2016

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.


Board Briefs November 9, 2015 The Board: Approved the appointment of Anne Neumann, DO, to the Board of Directors representing District 6, Office 6. Dr. Neumann fills the vacancy created by the resignation of Kieu Luc, DO who is moving out of the area. Approved the 2016 Third Quarter Financial Statements, Investment Reports and Recommendations. Approved the 2016 Budgets for the SSVMS General and Building Funds and the Community Service, Education and Service Fund. Approved the following Scholarship and Awards Committee recommendations for the 2015 annual awards: Robert A. Kahle, MD, Golden Stethoscope Award; George W. Meyer, MD, Medical Honor Award; and Special Recognition Award to Senator Richard J.D. Pan, MD. Approved the following Membership Reports: September 28, 2015 Membership Report For Active Membership — Maninderjit K. Atwal, MD; Carrie E. Black, MD; Cam Chau, MD; Rupinder K. Chima, MD; Mary E. Clegg, MD; Jeffrey J. Heffernon, MD; Terry J. Keifer, MD; Mohammad T. Khan, MD; Mohammad R. Khorasani, MD; Laura Y. Kurek, MD; Seth D. Lerner, MD; Ern Loh, MD; Joseph N. Marchesani, MD; Robert M. McCarron, DO; Stephen J. Morrisy, MD; Timothy R. Nolan, MD; Steven C. Pirog, MD; Alisa A. Roda, MD; Jennifer U. Spiegel, MD. For Resignation — Nina K. Hansra, MD (relocated to Sunnyvale); Michael V. Lasker, MD (transferred to Sonoma); Wen Lin, MD (relocated to Vallejo); Marie L. Truong, DO; Garth S. Watkins, MD (relocated to Vista, San Diego County). November 9, 2015 Membership Report For Active Membership — Ranjit S. Bajwa,


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MD; David S. Benjamin, MD; Allison M. Byrne, DO; Carmen A. Carneiro-Rojas, MD; Bettina Y. Chrysofakis-Baiduc, MD; John D. Coburn, MD; Annalyse A. Feldman, DO; Blaine M. Hannafin, MD; Erica M. Heiman, MD; Mehrdad Jafarzadeh, MD; Radhika M. Kadakia, MD; Seung Kwon Lee, MD; James E. Littlejohn, MD; Howard H. Liu, MD; Hailey R. MacNear, MD; Tamara M. Musso, MD; Ali R. Naqvi, MD; Gabriel R. Pettersen, MD; Frederick E. L. Ramos, MD; Roy E. Schutzengel, MD; Neha R. Shah, MD; Edina S. Torlak, MD; Cara L. Torruellas, MD. For Resident/Fellow Active Membership — Kate Richards, MD For Retired Membership — William J. W. Au, MD; Barbara Livermore, MD; Delbert Meyer, MD; Mark Owens, MD; Boone Seto, MD; Joseph Zimmerman, MD. For Resignation — Ruby Chan, DO; Cristian L. Dinescu, MD (moved out of state); Rino H. Dizon, DO; David P. Foos, DO; Munish C. Gupta, MD (Moved to St. Louis, MO); Carl Haller, MD; Jerry C. L. Huang, DO; Alexandra Y. Hunt, MD (moved to Quincy, CA); Ben M. Hunt, MD (moved to Quincy, CA); Kuo Y. Hwang, DO; Yang A. Li, MD (moved to Fullerton, CA); Brant J. Lutsi, MD (moved to Illinois); Shiny Mandla, DO (moved to Los Angeles); Trung L. Nguyen, DO; John D. Owens, DO; Shalin U. Parikh, MD; Guadalupe Roldan, MD (moved to Texas); Saba Sajid, MD (moved to Florida); Kapil Sharma, MD (left area); James Silverthorn, DO; Robin Steinhorn, MD (moved to Washington, DC); Robert H. Talkington, MD (moved out of area); Mai B. Tran, DO; Virgil L. Williams, MD (moved to Oakland); Limin Yu, MD (moved out of state); Eric R. Zacharias, MD (moved to Utah). For Transfer of Membership — Ngoc-truc T. Duong, MD (to Placer-Nevada); Yen N. Truong, MD (to Alameda-Contra Costa).

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. Maninderjit K. Atwal, MD, Obstetrics and Gynecology, Dayanand Medical College, India – 2000, TPMG South, 10302 Promenade Parkway, Elk Grove, 95757

Mehrdad Jafarzadeh, MD, Cardiovascular Disease, Shaheed Beheshti University of Medical Sciences – 1990, Mercy Medical Group, 6401 Coyle Avenue, #416, Carmichael 95608

Ranjit S. Bajwa, MD, Internal Medicine, Punjab University – 1995, Marshall Medical Center, 1100 Marshall Way, Placerville 95667

Radhika M. Kadakia, MD, Internal Medicine, Jefferson Medical College – 2012, TPMG, 1650 Response Road, Sacramento 95815

Carrie E. Black, MD, Plastic Surgery, Ben-Gurion University (Isreal) – 2007, Mercy Medical Group, 2200 Sunrise Blvd., Unit 250, Gold River, 95670

Terry J. Keifer, MD, Diagnostic Radiology, Rush Medical College – 1999, Mercy Radiology Medical Group, 3400 Data Drive, Rancho Cordova, 95670

Ali R. Naqvi, MD, Emergency Medicine, University at Buffalo School of Medicine and Biomedical Sciences – 2012, TPMG, 6600 Bruceville Road, Sacramento 95823

David S. Benjamin, MD, Urology, Loma Linda University School of Medicine – 1991, Mercy Medical Group, 1561 Creekside Drive, Folsom 95630

Mohammad T. Khan, MD, Internal Medicine, University of California Davis School of Medicine – 2012, TPMG South, 6600 Bruceville Road, Sacramento, 95823

Timothy R. Nolan, MD, Interventional Radiology, Albert Einstein College of Medicine – 2008, Mercy Radiology Medical Group, 3400 Data Drive, Rancho Cordova, 95670

Mohammad R. Khorasani, MD, Diagnostic Radiology (Musculoskeletal), SUNY Upstate Medical University – 2008, Mercy Radiology Medical Group, 3400 Data Drive, Rancho Cordova, 95670

Gabriel R. Pettersen, MD, Internal Medicine, St. George’s University School of Medicine – 2001, TPMG, 6600 Bruceville Road, Sacramento 95823

Allison M. Byrne, DO, Family Medicine, Touro University College of Osteopathic Medicine – 2010, TPMG, 2155 Iron Point Road, Folsom 95630 Carmen A. Carneiro-Rojas, MD, Family Medicine, University of the Orient School of Medicine – 2001, TPMG, 1650 Response Road, Sacramento 95815 Cam Chau, MD, Neuroradiology, University of California Davis School of Medicine – 2009, Mercy Radiology Medical Group, 3400 Data Drive, Rancho Cordova, 95670 Rupinder K. Chima, MD, Emergency Medicine, University of California Davis School of Medicine – 2010, TPMG South, 6600 Bruceville Road, Sacramento, 95823 Bettina Y. Chrysofakis-Baiduc, MD, Geriatric Medicine, Hannover Medical School – 2006, Mercy Medical Group, 3000 Q Street, Sacramento 95816 Mary E. Clegg, MD, Family Medicine, Indiana University School of Medicine – 2012, TPMG, 1650 Response Road, Sacramento, 95815 John D. Coburn, MD, Emergency Medicine, Rush University Medical College – 2012, TPMG, 6600 Bruceville Road, Sacramento 95823 Annalyse A. Feldman, DO, Family Medicine, Andrew Taylor Still University – Kirksville College of Osteopathic Medicine – 2012, TPMG, 1650 Response Road, Sacramento 95815 Blaine M. Hannafin, MD, Emergency Medicine, University of Alabama at Birmingham School of Medicine – 2004, TPMG, 6600 Bruceville Road, Sacramento 95823 Jeffrey J. Heffernon, MD, Diagnostic Radiology, University of California at Irvine – 1976, Mercy Radiology Medical Group, 3400 Data Drive, Rancho Cordova, 95670 Erica M. Heiman, MD, Internal Medicine, University of California San Francisco School of Medicine – 2012, TPMG, 10305 Promenade Parkway, Elk Grove 95757

Laura Y. Kurek, MD, Pediatrics, University of California Davis School of Medicine – 2011, TPMG South, 6600 Bruceville Road, Sacramento, 95823 Seung Kwon Lee, MD, General Surgery (Wound Care), University of Pittsburgh School of Medicine – 1986, 9245 Laguna Springs Drive, Elk Grove 95758 Seth D. Lerner, MD, Anesthesiology, David Geffen School of Medicine – 2011, TPMG South, 6600 Bruceville Road, Sacramento, 95823 James E. Littlejohn, MD, Anesthesiology/Critical Care Medicine, Texas A&M University College of Medicine – 2010, UCD Medical Center 4150 V Street, Ste. 1200, Sacramento 95817 Howard H. Liu, MD, Family Medicine, University of California Davis School of Medicine – 2012, TPMG, 1650 Response Road, Sacramento 95815 Ern Loh, MD, Dermatology/Dermatopathology, University of Washington School of Medicine – 2008, TPMG South, 6600 Bruceville Road, Sacramento, 95823 Hailey R. MacNear, MD, Obstetrics & Gynecology, University of California Davis School of Medicine – 2011, Folsom OB-GYN, 1735 Creekside Drive, Folsom 95630 Joseph N. Marchesani, MD, Obstetrics and Gynecology, Tulane University School of Medicine – 2011, Camellia Women’s Health Medical Group, 5821 Jameson Court, Carmichael, 95608 Robert M. McCarron, DO, Associate Professor (Psychiatry, Internal Medicine and Pain Medicine/ Anesthesiology), Midwestern University – Chicago College of Osteopathic Medicine – 1998, UCD School of Medicine, 2230 Stockton Blvd., Sacramento, 95817

Stephen J. Morrissy, MD, Cardiology, University of Arizona – 2007, TPMG South, 6600 Bruceville Road, Sacramento, 95823 Tamara M. Musso, MD, Pediatrics, University of Alabama at Birminghan School of Medicine – 2004, TPMG, 1955 Cowell Blvd., Davis 95618

Steven C Pirog, MD, Hospitalist, Medical College of Wisconsin – 2012, TPMG, 2025 Morse Avenue, Sacramento, 95825 Frederick E. L. Ramos, MD, Critical Care Medicine, Cebu Institute of Medicine – 2004, TPMG, 6600 Bruceville Road, Sacramento 95823 Kate Richards, MD, Family Medicine, UCD Medical Center (Resident/Fellow Program), 2315 Stockton Blvd., Sacramento, 95817 Alisa A. Roda, MD, Pediatrics, Loma Linda University – 1992, TPMG South, 10302 Promenade Parkway, Elk Grove, 95757 Roy E. Schutzengel, MD, Pediatrics, University of Pennsylvania School of Medicine – 1984, Adventist Health, 1101 Creekside Ridge Drive, #150, Roseville 95678 Neha R. Shah, MD, Obstetrics & Gynecology (Oncology), University of California San Francisco School of Medicine – 2007, TPMG, 1650 Response Road, Sacramento 95815 Jennifer U. Spiegel, MD, Obstetrics and Gynecology, Thomas Jefferson University – 2003, TPMG South, 6600 Bruceville Road, Sacramento, 95823 Edina S. Torlak, MD, Internal Medicine, University of Sarajevo Faculty of Medicine – 1978, Mercy Medical Group, 6555 Coyle Avenue, Carmichael 95608 Carla L. Torruellas, MD, Gastroenterology, University of California San Francisco School of Medicine – 2009, TPMG, 6600 Bruceville Road, Sacramento 95823

January/February 2016


Confidence The feeling you have when you are affiliated with Hill Physicians. Marina Rasnow-Hill, M.D.

Hill Physicians provider since 2012. Uses Ascender preventive care reminders and Hill inSite to review eClaims and eligibility.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit

Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, Chinese Community Health Plan, CIGNA, Easy Choice, Health Net, Humana, SCAN, San Francisco Health Plan, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in. 36 Sierra Sacramento Valley Medicine

The Sierra Sacramento Valley Medical Society and Alliance Invite You and Your Guest to Attend the

2016 ANNUAL AWARDS and INSTALLATION DINNER Thursday, January 21, 2016

6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program Hyatt Regency Hotel, Regency Ballroom 1209 L Street, Sacramento

INSTALLATION Thomas W. Ormiston, MD—2016 President 2016 SSVMS Officers and Board of Directors


Golden Stethoscope Award Robert A. Kahle, MD

Medical Honor Award George W. Meyer, MD

Special Recognition Award The Honorable Senator Richard J.D. Pan, MD Dorothy Dozier Helping Hands Award Ingrid Niles


DINNER PRICE $68.00 per person

RSVP by returning the enclosed card with your dinner selection and payment. Members are encouraged to consider hosting a medical student or resident. Reserved tables of 10 are available by request. Reservation Deadline: January 15, 2016, 4:00 p.m. Special Appreciation to Our Sponsors PLATINUM LEVEL SPONSORS








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2016-Jan/Feb - SSV Medicine  

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

2016-Jan/Feb - SSV Medicine  

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