2016-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2016

Success. It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

Prepare for Value-Based Compensation with CAP’s Free Guide As payers move toward a more value-focused model of reimbursement, your practice’s revenue stream may soon be tied entirely to clinical outcomes and patient experience. CAP’s Physician’s Action Guide to Value-Based Compensation is replete with valuable information and tips to help you stay ahead of the VBC curve and attain fair and prompt reimbursement from public and private payers.

Request your free electronic or hard copy today! 800-356-5672 | CAPphysicians.com/Value

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.

Sierra Sacramento Valley

MEDICINE 2 3

2016 Education Series PRESIDENT’S MESSAGE The Opioid Debate and Primary Care Physicians

Swine Milk

Jack Ostrich, MD

BOOK REVIEW Willpower

Thomas W. Ormiston, MD

Reviewed by Lee Welter, MD

Welcome New Members

EXECUTIVE DIRECTOR’S MESSAGE End of Life Decisions

Why do Butterflies Die and Cockroaches Live?

Ann Gerhardt, MD

Aileen Wetzel, Executive Director

We Are What We Are

EDITOR’S MESSAGE A World of Subcontractors

John Loofbourow, MD

A Posit on Hospitalists

Nathan Hitzeman, MD

Interested in Shaping Health Policy?

Electronic Health Records Part II – Legal Issues

How Colds Are Caught

Ann Gerhardt, MD

Creating a Pathway to Specialty Care

Liza Kirkland, Director, CSERF

BOOK REVIEW How to Get More Fun Out of Smoking

Why Are We Hooked on Drugs?

Glennah Trochet, MD

A Hopscotch Named Time

Caroline Giroux, MD

Reviewed by Donald M. Hopkins, MD

Call for Awards Nominations

IN MEMORIAM John White Harris, MD

Board Briefs

Primary Care: Medical School and Beyond

Cheng Nguyen-Xiong, MS IV Jennifer Estrada-Melgar, MS IV

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our cover photo was submitted by Dr. Eric Williams, a member of the SSVMS Board of Directors and a vascular surgeon with The Permanente Medical Group. He explains that, “On April 6th of each year we celebrate California Poppy Day. The flower was designated the State flower in 1903 and can be found throughout California. This image of the Golden Poppy or Copa de Oro (Eschscholtzia Californica) was taken in Folsom on Easter Sunday around 7 am using a Cannon EOS 70D with an 18-50mm macro lens.” −eric.s.williams@kp.org

July/August 2016

Volume 67/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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 Barbara Arnold, 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

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 John Tiedeken, MD Vacant Vacant Vacant Vacant Vacant Vacant Vacant

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

Richard Thorp, MD

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS III George Meyer, MD Sean Deane, MD Jillian Millsop, MD Adam Doughtery, MD Steven Nemcek, MS I Ann Gerhardt, MD John Ostrich, MD Caroline Giroux, MD Mary Pauly, MD Sandra Hand, MD Gerald Rogan, MD Albert Kahane, MD Robert LaPerriere, MD Glennah Trochet, MD John Loofbourow, MD Lee Welter, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

The following webinars are available on-demand at: CMA Resource Library http://www.cmanet.org/resource-library They are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more information call (800) 786-4262. •On Demand: Contract Renegotiations: How to Get Past “No” with a Payor. When submitting a request to renegotiate, many practices fail to present a business case, which often results in a quick reply from the payor indicating that they are not in a position to renegotiate at this time. This webinar will cover steps practices can take to build their best business case to prevent the “auto-reply” and present a thoughtful renegotiation request. •On Demand: CURES 2.0: Navigating the State’s New Prescription Drug Monitoring Database. The Controlled Substance Utilization Review and Evaluation System (CURES) is a database of Schedule II, III and IV controlled substance prescriptions dispensed in California. Effective July 1, 2016, physicians with an active medical license and a Drug Enforcement Agency certificate must be registered for access to CURES. This webinar gives physicians an overview of the registration process and key features of the newly upgraded system. •On Demand: The California End of Life Option Act: An Overview. This webinar reviews the requirements of the End of Life Option Act, who qualifies to participate, what is required if a physician opts-out, and what the documentation and reporting obligations are. It will also discuss palliative care services to help improve the quality of life of terminally ill patients, improve patient and family satisfaction and reduce lengths of stay and readmission rates. On Demand: MACRA and the Quality Payment Program: An Update on the Recent Proposed Rule. This webinar will cover the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the next steps in health system transformation including the Transforming Clinical Practice Initiative. (TCPI). Also discussed will be the key elements of the Merit Based Incentive Payment System pathways.

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. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©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 Opioid Debate and Primary Care Physicians By Thomas W. Ormiston, MD OPIOID OVERDOSE, abuse, and overprescribing are back in the news again. The pendulum swings back, as pendulums do. Back in the 1980s and early 1990s, the pendulum swung; and we had physicians convicted in court of undertreating pain, the appearance of the fifth vital sign, and mandatory pain treatment education for licensure. Opioids are not, by most accounts, our region’s most significant drug abuse problem. But they seem to have gathered the attention of the press and politicians yet again. As physicians, we know pain medicines are important for some people for short-term use in acute pain. Most patients take them briefly for post-operative pain, fracture pain, minor trauma and similar pain with much benefit and only occasional abuse (at least for those whose brains are not predisposed to develop substance use disorder). The dilemmas for me, as a family physician, come in two common circumstances: The first is patients using opioids for chronic pain. Which patients have chronic pain and which have opioid use disorder masquerading as chronic pain? Chronic pain is still poorly understood. We have no reliable way to measure pain − except, of course, the pain scale which, by its very nature, shows how little we understand pain. (How can you have frequent values of 11 on a 1-to-10 scale?) What roles do the peripheral nervous system and the central nervous system play in chronic pain in each patient, given that only a minute fraction of brain activity ever reaches conscious perception? What is the difference between the brains of chronic pain

sufferers whose brains respond to opioids, and those who don’t? How do I diagnose chronic pain versus substance use disorder (pejoratively known as addiction)? Unfortunately, our usual diagnostic methods are almost useless with substance use disorder. There are rarely physical findings, or diagnostic laboratory and imaging tests, and the disease itself makes the history unreliable. Those suffering substance use disorder often do not recognize their disease, and when they do, they choose to continue with their substance use disorder. It is part of the disease. They choose to avoid treatment. (And treatment is not very effective, with the notable exception of licensed health care professionals with appropriate treatment and monitoring, and where 87 percent fiveyear abstinence has been demonstrated.) Most physicians, and practically all lay persons, believe that substance use disorder is a character weakness and not a disease at all. The second dilemma for me is patients wanting relief from acute pain. Which opioidnaïve patients harbor brains predisposed to opioid use disorder – only to be readily activated by my prescription? Substance use disorder is a disease also much misunderstood by the lay and medical community. Abundant evidence indicates substance use disorder is a poorlyunderstood brain disease involving specific brain structures and functions. My understanding of current thinking is that some portion of the population harbor brain structural, functional, and/or genetic elements that are predisposed to substance use disorder. As long as a susceptible person is not ex-

July/August 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.

posed for too long to the substance, they are fine. Once sufficiently exposed, they develop substance use disorder. Currently, we have few ways to tell, before exposure to an opioid prescription, which individuals will develop opioid use disorder. Screening tools often take into account family history of substance abuse and comorbid psychiatric illness, but are far from 100 percent predictive. And do not susceptible patients, at times, have real and acute pain conditions that would warrant opioid treatment? Sprinkle on top of that patient satisfaction and share-decision making initiatives, and we find it hard not to give the patient the benefit of the doubt. As a family physician, I am left with patients requesting treatment where there is almost no

reliable science to guide me. Undertreating pain is clearly not good medicine. Nor is overtreating it. Nor is treating a nonpain condition with pain medication. As physicians, we do the best we can for our patients with the tools we have. I am quite sure that future physicians will look upon our current practice with opioids as primitive. But for now, that’s all we have for most people. We treat our patients as best we can within the limits of our knowledge. In my next President’s message, I will expand on the 2016 CDC guidelines for opioid use and will try to point out what still needs clarification. tom.ormistonmd@dignityhealth.org

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. — Chris Serdahl, MD, Secretary. Ryan Lewis Anderson, MD, Orthopedic Resident, UC Davis Medical Center – 2016, 2315 Stockton Blvd., Sacramento 95817

Ariana A. Hosseini, MD, Internal Medicine Resident, UC Davis Medical Center – 2016, 2315 Stockton Blvd., Sacramento 95817

Punit K. Sarna, MD, University of Southern California Keck School of Medicine – 2005, Mercy Medical Group, 9394 Big Horn Blvd, Elk Grove 95758

Linda H. Assaf, DO, Emergency Medicine, Michigan State University College of Osteopathic Medicine – 2008, Kaiser South Sacramento Medical Center, 6600 Bruceville Road, Sacramento 95823

Samira Kirmiz, MD, Endocrinology, University of California, San Diego School of Medicine – 2003, Mercy Medical Group, 1730 Prairie City Road, Ste 120, Folsom, CA 95630

Adrian Joseph Sauder, MD, University of Illinois College of Medicine – 2007, The Permanente Medical Group, 2025 Morse Avenue, Sacramento 95825

Vasuki Daram, MD, American University of the Caribbean – 1998, Kaiser South Sacramento Medical Center, 6600 Bruceville Road, Sacramento 95823

Nicole Knotts, MD, Ross University School of Medicine, Commonwealth of Dominica – 2008, The Permanente Medical Group, 10305 Promenade Parkway. Elk Grove 95757

Rebecca Pringle Smith, MD, Brown University Medical School – 1997, The Permanente Medical Group, 7300 Wyndham Drive, Sacramento 95823

Garth Davis, MD, Internal Medicine, Oregon Health Science University School of Medicine – 1998, The Permanente Medical Group, 1650 Response Road, Sacramento 95815 Ahmed Farrag, MD, Ain Shams University, Cairo – 2000, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 Reihaneh Forghany, MD, Anesthesia Resident, University of California, Davis – 2016, UC Davis Medical Center, 2315 Stockton Blvd., Sacramento 95817 Kusuma Hampapur, MD, University of Mysore, India – 1989, Kaiser South Sacramento Medical Center, 6600 Bruceville Road, Sacramento 95823 Kelly M. Hearney, MD, Pediatric Resident, University of California, Davis – 2015, UC Davis Medical Center, 2516 Stockton Blvd., Sacramento 95817

Sung Lee, MD, State University of New York, Upstate Medical University – 2004, The Permanente Medical Group, 7300 Wyndham Drive, Sacramento 95823 Fatima Masrur, MD, Allama Iqbal Medical College, Lahore Pakistan – 1997, Kaiser South Sacramento Medical Center, 6600 Bruceville Road, Sacramento 95823 Femi Philip, MD, University of Cape Town, South Africa – 2000, The Permanente Medical Group, 1600 Eureka Road, Roseville 95661 Gabriel Reina, MD, Family Medicine Resident, University of California, Davis – 2016, UC Davis Medical Center, 2315 Stockton Blvd., Sacramento 95817 Gayatri Sarkar, MD, Calcutta Medical College, India – 2000, Mercy Medical Group, 6620 Coyle Avenue, Carmichael 95608

Sierra Sacramento Valley Medicine

Debra Annette Thomas, MD, David Geffen School of Medicine at UCLA – 2006, The Permanente Medical Group, 1600 Eureka Road, Roseville 95661 Yan Wang, MD, China Medical University, Shenyang, China P – 1985, The Permanente Medical Group, 2025 Morse Avenue, Sacramento 95825 Morgan Elizabeth White, MD, Pediatric Fellow, University of Oklahoma – 2011, 2315 Stockton Blvd., Sacramento 95817 Asmaneh Soufi Yamagata, MD, University of Toledo College of Medicine – 2009, The Permanente Medical Group, 1650 Response Road, Sacramento 95815 Jocelyn Young, MD, Pediatric Resident, Jefferson School of Health Professions – 2015, UC Davis Medical Center, 2516 Stockton Blvd., Sacramento 95817

EDITOR’S MESSAGE

End of Life Decisions By Aileen Wetzel, Executive Director ON OCTOBER 5, 2015, California became the fifth state in the nation to allow physicians to prescribe terminally-ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” went into effect on June 9, 2016 and permits terminally-ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication, if certain conditions are met. CMA has published legal guidance to outline the requirements of the End of Life Option Act. CMA On-Call document #3459, “The California End of Life Option Act,” is in question-and-answer format, and is intended to help both physicians and patients navigate the law. This document discusses the requirements of the End of Life Option Act. To download a free copy, visit www. cmanet.org/endoflife, or call SSVMS at (916) 452-2671. SSVMS and CMA encourage all Californians to talk with loved ones about their wishes for end-oflife medical care before a serious illness or injury occurs. CMA has developed a number of guidelines, forms, and other resources to assist physicians, patients, and loved ones with making important end of life decisions. In California, advance directives are the legally-recognized format for “living wills.” An advance directive enables individuals to make sure that their health care wishes are known in advance and considered. Advance directives also allow patients to appoint a health care “agent” who will have legal authority to make health care decisions in the event that a patient is incapacitated, or immediately upon appointment if the patient expressly grants such authority.

In 2009, POLST (Physician Orders for Life-Sustaining Treatment) became a legally recognized document. The POLST form, used for patients with a serious illness or whose life expectancy is a year or less, outlines a plan of care reflecting the patient’s wishes concerning medical treatment and interventions at life’s end. The POLST form complements an advance directive by turning a patient’s treatment preferences into actionable medical orders. The Pre-Hospital Do Not Resuscitate (DNR) forms, and POLST Kit form, developed by the California Emergency Medical Services in conjunction with CMA, instructs EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. CMA’s Advance Health Care Directive Kit, DNR forms, and POLST Kit are available for purchase on the CMA website. These resources are offered in both English and Spanish.

CMA’s Health Law Library Updated annually, CMA’s online health law library contains nearly 5,000 pages of valuable information for physicians and their staff. The library includes comprehensive legal information, including current laws, regulations and court decisions related to the practice of medicine. Access to the library is FREE to SSVMS/ CMA members. Nonmembers can purchase documents for $2 per page, or the complete California Physician’s Legal Handbook (CPLH) in print or online format. awetzel@ssvms.org

July/August 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.

EDITOR’S MESSAGE

A World of Subcontractors By Nathan Hitzeman, MD

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

LAST FALL, MY WIFE and I decided to have some yard work done by a seemingly pleasant young man whom we met at a Sacramento Outdoor trade show at the Convention Center earlier that year. In years past, we negotiated services with a young man of Russian descent who worked hard and produced good results, despite some language barriers and the inevitable add-on expenses. He also stood by his work and took pride in it. Still, we thought this new guy came across as more polished and professional. Unfortunately, appearances can be deceiving. The new guy did none of the work himself, was often too busy to review details of the project with us, and subcontracted to folks who were focused on their specific task rather than the whole project. The project started with them ripping up the front yard lawn instead of the back because of a miscommunication. After that, we bought more Tums and had to be helicopter clients. When errors were discovered after the job was done, he never returned calls. As a family doctor, subcontracting is an especially sensitive topic to me. I trained doing most procedures and patient care myself, and have fought over the years to maintain those skills. I like doing home visits, drawing blood, doing office procedures, delivering babies, and caring for my patients in the hospital, as well as in the clinic. I doubt I am technically better than an obstetrician, dermatologist, or urologist (vasectomies), but I would guess that my patients appreciate the personalized care and one-stop service. I realize that all primary care docs may not want to have this breadth and that I, myself, may need to scale back as other life obligations arise.

Sierra Sacramento Valley Medicine

Fast forward to present day. I recently saw my PCP, who is a pleasant internist in his golden years. He does a full physical exam on me, chats with me about my family and current events, and just this past visit, reminisced about his days doing hospital rounds and teaching. “I miss it,” he said. But so much has changed. I doubt I could go back.” Indeed, health care has become more complex and there are many more players in the mix. We now have nurses and nurses’ aides, physicians and physician assistants, scribes, hospitalists, nocturnists, admissionists, even SNFists! Everyone is skilled at what they do. But at what point are there too many chefs in the kitchen, and how can we keep the patient and family from getting lost in the shuffle? With so many hand-offs, how do we keep ourselves emotionally invested in our patients’ wellbeing? How do we keep caring? I encourage you to Google “Jiffy Boob,” a 2011 article in Health Affairs by family physician Colleen Fogarty. She found herself dazed and confused by the number of handoffs she encountered when she went for her first mammogram and needed additional views and a biopsy done. She asks at the end of the article, “Isn’t it a core truth in health care that the process – the patient experience – is at least as important as the outcome?” There is lots of talk about the PCP being the quarterback, the team leader, and heading a patient-centered medical home. Will I become that, or the guy at the trade show with the flashy smile? hitzemn@sutterhealth.org

A ﬁnancial safety net for you—

AND THE ONES YOU LOVE 10- AND 20-YEAR LEVEL TERM LIFE No matter where you are in life, SSVMS Group Level Term Life Insurance benefits can be an affordable solution to help meet your family’s financial protection needs. Mercer and SSVMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the Voya® family of companies.

With quality life insurance beneﬁts extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plans.

As a member, you can conveniently help protect your family’s financial future with the Group 10-Year and 20-Year Level Term Life Plan. It features: • Benefits up to $1,000,000 • Rates that are designed to remain level for 10 or 20 full years* • Benefit amounts that never change during the level term period provided premiums are paid when due

See For Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plans, including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting www.CountyCMAMemberInsurance.com or by calling 800-842-3761. Sponsored by:

Administered by:

Mercer Health & Benefits Insurance Services LLC • CA Insurance License #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice. The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

Electronic Health Records Part II – Legal Issues 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.

ELECTRONIC HEALTH RECORDS (EHRs) are here to stay, but hopefully not in their present form. The first of this two-part series addressed the history of EHRs and how they adversely impact patient care, physicians’ efficiency and the doctor-patient relationship. This article addresses ways in which EHRs contribute to fraud and malpractice, and stymie efforts to adjudicate claims. The Doctors Company analyzed their EHR-related malpractice claims between 2007 and 2014. They closed only two such claims between 2007 and 2010, but saw a progressive rise as EHR use became more widespread. There were about 20 closed claims per year in 2011 and 2012, 28 in 2013 and 26 in just the first two quarters of 2014. They classified problems into EHR system factors and user errors. System factors included, in order of decreasing frequency, system design failure, technology failure, lack of alarm/decision support, electronic data routing failure, no space for documentation, and fragmentation. These accounted for 42 percent of EHR-related claims, making it clear that there is room for technical improvement. Many of the “system” examples entailed instances in which a doctor made a mistake and no nurse, pharmacy or EHR sounded the alarm. Example: A doctor didn’t notice that a dialysis patient admitted to a nursing facility was on Lovenox; there was no EHR alert and nursing didn’t report the fistula site bleeding prior to the day he bled to death. Rather than an alert failure, this may have resulted more from the EHR-related issue of accepting a computerized medication list rather than having to write out each order.

Sierra Sacramento Valley Medicine

Drop-down menus are truly an EHR liability. They create a problem when verbiage is ambiguous, auto-fill leads us astray, options are hard to distinguish from one another or none of the choices match the doctor’s. Some examples: Typing FLO (for Flonase) into a woman’s record leads to an auto-fill with Flomax; the doctor accepts it and no one connects her hypotension to the mistake. Or: A doctor clicks the wrong choice from a drop-down menu which lists morphine 15 mg right next to morphine 200 mg. (A doctor with an intention tremor would have horrible problems!) The company attributes to user error the EHR-related problems of incorrect information entered, mistaken entries resulting from hybrid health records or EHR conversion, passive importing/copy and paste, lack of EHR training, user error other than data entry, alert fatigue (clicking “accept” without reading the umpteenth irritating alert) and workarounds. One could argue some of these are system factors, as well. Importing data/copy and paste is a timesaving mechanism by which any or all of medical, family and social history, the medication list, nursing data and lab results from elsewhere are transferred into a note. Choosing to not update imported information potentially means missing a lot of pertinent information. Example: Finding out about a recent car accident, travel to an endemic TB area, unprotected sex with an HIV-positive partner and the six new supplements a patient is taking can be crucial to patient care. The EHR makes it easy to look like the work was done when it wasn’t, and EHR vendors enable this with ready-to-go templates.

Failure to update imported information can lead to diagnostic errors, which topped the Doctors Company claims allegations. This echoes the Institute of Medicine’s 2015 report which claims that missed, delayed and wrong diagnoses are a vast “blind-spot” in U.S. health care, mostly because they go unidentified. Ultimate blame often falls on the doctor for errors in diagnosis, but it is the EHR that steals our think-time, sequesters data from view and makes it easy to report an encounter without doing the work that might lead to better diagnoses. This is particularly true for physical examination. To compensate for the extra time that EHRs add to the day, any rational user develops work-arounds, like templates that eliminate repetitive typing. A template is OK if it is a format into which patient-specific information is typed. Most often, though, the “template” is a completely normal exam or an exam imported from someone else’s chart. Failing to modify it to match the current patient’s findings creates problems when something goes wrong. At times it’s humorous: A consult note from a cardiologist reports a full exam, with a completely normal HEENT exam, including the absence of cerumen. Not only do cardiologists rarely do HEENT exams, but that patient is edentulous. It is unlikely that the full exam was done. Reporting an exam that wasn’t done risks missing a diagnosis, with potentially disastrous consequences. Example: A sick patient has an acute hemoglobin drop to 5.6 g/dl. The intensivist “examines” the patient from the doorway and “documents” a normal abdominal exam in the chart. Nursing notes document a distended, firm abdomen. The patient dies 12 hours later from infarcted bowel. The EHR also makes it easy to “pull forward” someone else’s or your own entire progress note to the current note. It may help to remember yesterday’s findings, but is dangerous for patient care if not modified to reflect what was actually asked, examined and decided today. Example: A hospitalist pulls forward the admitting note for his daily progress notes. Only vitals and lab data

The doctor will see you now.

are updated, with automatic fill by the EHR. Piecing together exactly what happened to the patient, given an EHR’s fragmented data, is nearly impossible without daily notes telling the story. Fragmented data is really a problem. In my patients’ paper charts, I keep a graph page with the patient’s medications and doses listed in a column on the left, and I enter dates as necessary across the top. Arrows across date columns show continued treatment. Entries in a date column indicate a dose change, discontinuation or (for opiates) a refill. I enter the reason for stopping in the left margin. I can see someone’s entire medication list for today or any time in the past and be reminded of what didn’t work and why. In an EHR, other than for lab results, that kind of flowsheet is impossible. Currently in most EHRs, there is no documentation when a test result is reviewed unless a note is made. Staff messaging isn’t ever part of the chart. For all of the above reasons, it is very hard to reconstruct a record from an EHR. In addition, the record sent in response to a records’ release or subpoena doesn’t show all of the information contained in the system, particularly the metadata and submerged functionality. Metadata is digital information that provides information about or context for other data. In a medical chart, metadata tells information

July/August 2016

The EHR didn’t invent bloating; it just facilitated it.

about the author, date, time and conditions under which an entry was acquired, size and typeface of the file and method of compilation and processing. Most programs’ metadata records the dates and times of both an original note and any amendments to it. Some do not. Some allow turning off this function. Without visible metadata, it is hard to reconstruct what happened. Pulled-forward notes, at times, are easy to identify, especially when they contain unmodified data, vital signs, misspells, assessment and plan. There is a push to make pull-forward metadata visible, so that anyone can tell the source of the copied material and the date and time that it was done. Future EHR versions may automatically use a different typeface for copied entries. Submerged functionality is EHR programming that leads to actions that aren’t specified by orders. In other words, there is no visible trail that explains why they happened. Automatic defaults for medication timing are an example of this. Another is the computer’s assumption about the units for the medication you ordered. If you want milligrams, but the computer defaults to milliequivalents, the patient receives a

huge overdose. When EPIC modifies an order to a default, the originally-typed order never appears in the chart. The Center for Medicare and Medicaid Services (CMS) is aware that copy and paste, automatically changing the author of a pulledforward note (called clinical plagiarism), template and macro use, populating by default, up-coding and fabrication occur. Its official position is that EHRs are good for patients and the health care system, but dedicates over half the pages of its “EHR Toolkit” (www. cms.gov/Medicare-Medicaid-Coordination/ Fraud-Prevention/Medicaid-Integrity-Education/ Downloads/ehr-provider-booklet-overview.pdf) to “fraud, waste and abuse.” In some ways, CMS contributed to the problems by creating E & M coding criteria. CMS basically invited bloated notes to justify payment, which now they are calling fraud. The EHR didn’t invent bloating; it just facilitated it. Multiple laws make compromising the integrity of EHRs or using EHR systems to perpetrate federal health care fraud illegal. But those laws don’t detect, they only deter. CMS announced an objective to develop a plan to detect and reduce EHR fraud. Until it is implemented, however, they recommend policies discouraging turning off the internal audit mechanisms and safeguards. They expect the provider to “take advantage of and incorporate fraud prevention features in their EHR software and adopt appropriate policies that mitigate the risks of improper use.” If a fraud or malpractice claim is made, what is important is the integrity of the record, which reflects who the doctor is as a physician and person. We are more credible if our records are an honest reflection of what was seen, asked and done. To save our sanity, we can use short-cuts, but to preserve our credibility, we must still be honorable physicians – eliciting good histories, doing good exams, making intelligent diagnoses and being honest with our documentation. algerhardt@sbcglobal.net

—William Nakashima, MD

Sierra Sacramento Valley Medicine

WHEN IS A CHILD’S BRUISE FROM AN ACCIDENT OR SOMETHING MORE?

Do you know What, When and How to Report? Take this complimentary online course and: 

Learn essential signs that should be reported 

Earn continuing education credits 

Share with your colleagues. Pre-register for this free course at: http://www.imq.org/education/caprrc.aspx

Why Are We Hooked on Drugs? 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.

ACCORDING TO The Sacramento Bee edition of April 19, 2016, in a short time, the Sacramento region experienced 52 opioid overdoses, with 12 deaths due to illegally-obtained narcotic pills thought to contain hydrocodone, but actually having fentanyl. Fentanyl has 10-fold the potency of hydrocodone. Apparently most, if not all, of these overdoses were unintentional. The people who obtained this drug were from all walks of life and all ages. Some were drug addicts; some had legal prescriptions, but had run out of pills before their next prescription was due; some sought these drugs because their doctor had abruptly cancelled their long-time prescription without weaning them from the drug; some had chronic pain, could not afford to see a doctor and chose to spend their money getting the drugs; and some were seeking a “high,” but did not consider themselves addicted to drugs. The United States is the nation with the largest proportion of consumers of illegal drugs in the world. We are Number One for prescription opioid misuse, and a close second for marijuana, cocaine and heroin. We have the greatest number of opiate overdoses in the world. In 2014, more Americans than ever before reported use of illegal drugs in the past 30 days (10.2 percent in 2014 as opposed to 8.3 percent in 2002.) Americans are 5 percent of the world population, yet we consume 80 percent of opioid prescription drugs in the world. In the United States, our main approach to decrease drug misuse and illegal drug use in the past 40 years has been to attempt to control the supply. Doctors are repeatedly admonished not to over-prescribe, and new controls are

Sierra Sacramento Valley Medicine

periodically put in place to ensure this happens. At the same time, there is fear of litigation for “under-treating” pain. Countries that supply illegal drugs are sanctioned, and threatened by our government. We also incarcerate users of these drugs at a much higher rate than any other country in the world. And yet the American appetite for drugs continues to increase. Let’s stop blaming Mexico and Colombia for the steady stream of drugs that cross our borders, and contemplate why we might have such a huge drug addiction problem. One of the tenets of capitalism is that supply is driven by demand. So what drives the demand for narcotics and other drugs? According to the Substance Abuse and Mental Health Services Agency (SAMHSA), “Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of drug addiction. Protective factors are characteristics associated with a lower likelihood of drug addiction or that reduce a risk factor’s impact. Protective factors may be seen as positive countering events.”1 Regarding biological factors, do more Americans than other nationalities have a genetic predisposition to drug addiction? Is Americans’ experience of pain organically more intense than the experience of residents of other countries? Although these possibilities should be explored further, they are unlikely, because of the diversity of origins of Americans today. Living in an economically-depressed area with high unemployment, inadequate housing, high prevalence of crime and high prevalence of illegal drug use are all major community-related

risk factors for illegal drug use. In California, close to 25 percent of adults admit to using marijuana as a recreational drug. Although the high prevalence of illegal drug use is not restricted to low-income neighborhoods, the adverse effects of the growing economic inequality in our nation should not be minimized. Minority status involving racial discrimination, and a culture that is devalued in American society, are other risk factors, as are low educational levels and low achievement expectation from society. Parents with drug abuse problems are a risk factor for their children, as are frequent moves and inadequate supervision with little parent/child contact. The latter is not an unusual circumstance in a society where many parents must work two jobs in order to make ends meet. Listed as risk factors for drug addiction for young adults and adolescents are: lack of bonding to society (family, school, and community), rebelliousness and nonconformity, resistance to authority, strong need for independence, cultural alienation, present versus future orientation and vulnerability to peer pressure. Yet these are behaviors that we tend to encourage in our society as cultural norms. I am going to speculate here about other possible sources of our appetite for drugs. We may be one of the unhappiest developed countries in the world. Americans work longer hours, have fewer vacation days and are more stressed than the inhabitants of other developed countries. Our society conditions us to expect a life free of physical and psychological pain. No level of pain is acceptable. We are also conditioned to seek relief through pills. Can’t sleep? Take a pill. Can’t lose weight? Take a pill, or better still, have surgery. Feel anxious? Take a pill. Feel sad? Take a pill. The United States is unique among rich countries in that it allows direct-to-consumer advertising of prescription medications. And our regulating agency, the FDA, appears to be influenced to a great degree by pharmaceutical companies. This is evidenced by the revolving door of pharmaceutical company executives

who become FDA regulators and vice versa. As a result, dangerous narcotic medications are allowed to be marketed in ways that benefit the bottom line of the company, but not patients or physicians. A recent article in The Los Angeles Times about the marketing of Oxycontin underscores this problem. The very competitive society in which we live begins in childhood. Very few children I know have the experience of playing any sport or game just for the fun of it. Little league, soccer teams, volley ball, are all competitively played. Who plays games with no winners or losers? I can’t remember the last time I saw children on a playground playing tag or hide-and-seek, or any of the other games that got us moving when I was a child, which did not produce “champion” tag or hide-and-seek players. Perhaps, if we allowed enjoyment without “winning” or “losing,” fewer of our children would experience failure and seek relief in drugs. Instead of spending over a trillion dollars on trying to control the supply, we could spend some of those dollars on decreasing the demand. There are social policies that we could implement that would counteract some of our risk factors. Universal day care and pre-school, after-school programs and paid family leave would decrease the stress on families. Living wage initiatives would translate into parents being able to support their families with one job instead of two, and having time to supervise their children and interact with them. It is unlikely that the direct-to-consumer advertising from pharmaceutical companies will cease, but it could be counteracted by public service announcements funded with some of the trillion dollars spent over the past four decades on the unsuccessful “war on drugs.” The prohibition of alcohol in the early 20th century should have taught us that eliminating access to a recreational drug that is desired by a large proportion of our population only encourages law-breaking and disrespect for the law. In addition, massive amounts of money are illegally obtained by those who are willing to supply the population with that substance. I am not saying that legalizing currently

We may be one of the unhappiest developed countries in the world.

continued on page 16

July/August 2016

A Hopscotch Named Time Seeing Letters and Numbers in Color and Other Intriguing Traits of Synesthesia

By Caroline Giroux, MD Monday is yellow Friday is dark green January is always blood red February cold sky blue Vowels sharp and bright Consonants muffled and absorbent Words march on this parade This firework dance Months of the year Docilely aligned like encyclopedia volumes Their dozens of day children Stacked in twelve piles, waiting for their turn Certain words unbearable For they crack open the skull Music is a straightjacket with pins and needles in the brain Or snorkeling in my dreams

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

NOVEMBER, DARK BROWN like my mood. I am reluctant to open my eyes. I lay on number 30, the top of the pile. Another day has started, with all its promises of overwhelming influx of waves, energies, vibes, but also its unexpected awe-provoking displays, like the house that can look like a beagle or your perplexed expression sculpted on a boulder. Somewhere around midnight, like a bungee jump, the monthly descent will start the lunar cycle all over again. One will be white and luminous as snow in the dark of the winter. It will be Tuesday, therefore red. A magical hand wrote down the date in black ink on the calendar, but my brain is a rainbow-speaking translator, fluent in the whole palette. Although it is an unusual statistic, synesthesia (from the Greek “union of senses”)

Sierra Sacramento Valley Medicine

is not an anomaly. It is “an experience in which stimulation in one sensory or cognitive stream leads to associated experiences in a second, unstimulated stream” (Hubbard, 2007). Upon an incidental reading at age 17, from a book mentioning a musician who had been known to see notes in color for instance, I discovered I was among the less than 5 percent to experience the world through joined sensations. What a shame: most people with synesthesia live their entire lives without ever knowing they have it. Even though I perceive printed symbols in black ink, my automatic representations of letters and numbers have always been in a specific color (grapheme’color synesthesia), while being fully aware that the font is black on paper. Therefore, if I encounter 47 (in black), my brain automatically converts the digit in color so 4 appears pink while 7 is brown. It has been consistent across my lifespan, but I had attributed that to the magnetic letters I was forming words with as a kid (and maybe the designer of that Fisher-Price toy had synesthesia too!). But in my set, O is yellow while the one in my mind is definitely white. While different individuals usually do not report the same colors for all letters and numbers, studies with large samples find some commonalities across letters (A is likely to be red). Entire words that are part of a sequence, such as the days of the week or months, also have immutable colors. Numbers and years are also spatially organized in my head in a number form, which is apparently typical. A number form is a mental map of numbers that automatically appears whenever someone who experiences number forms thinks of numbers. Number forms were first documented in

1881 by Francis Galton in “the Visions of Sane Persons.” For me, as far as I can remember, from “birth” (zero) until 12 or so, numbers have always been on a vertical line, then suddenly puberty makes the timeline shift at 90 degrees up until 79. The next numbers start a new line. It is impossible to dislodge 80 for instance, which starts a parallel line right underneath 60, like a somewhat fractured hopscotch. Days, weeks and months of the year can also be arranged in a mental map and at any moment, I sense my whole being like a dot on a particular day in the space of time. I “see” the time by visualizing its orderly units horizontally (months are aligned like books on a shelf) or vertically (days of the months are stacked, from 1 at the bottom to 31 at the top); other people can see it on a ring or circle. People with spatial sequence synesthesia (SSS) may have superior memories. What is the underlying neurophysiological mechanism of such an intriguing ability? It might come from peculiar synaptic connections, allowing us to perceive time as a spatial construction. Another theory is that such connections are present in all at birth, but most people undergo a pruning process, losing these connections between cortico-sensorial areas. Those who do not lose such connections have the ability to experience a combination of senses. Third, another group thinks that it is due to a lack of inhibition, which occurs naturally in people who experience synesthesia, but artificially for people using certain drugs such as LSD. Lastly, some think that it is just a question of awareness, people being more aware of how senses connect in synesthesia. Congenital synesthesia runs strongly in families, possibly inherited as an X-Linked dominant trait. The F: M ratio is 6:1. An interesting form I don’t experience (and wish I would) is called ordinal-linguistic personification in which numbers or letters are associated with genders and/or personalities. For instance, 7 might be a rebellious boy, or the letter M some kind of fun ride. But it is probably quite distracting, too, to feel like letters can be escaping the page of a book at any moment!

Misophonia, a neurological disorder in which specific sounds trigger negative emotions (for instance, certain mastication sounds cause me great distress), could be a form of sound’emotion synesthesia. Mirror-touch synesthesia is a rarer form and consists of feeling the same sensation as another person feels (such as touch). Not surprising that people with this type have been shown to have higher empathy levels compared to the general population. Recently, I heard the word synesthete during a conference on memory. Another woman, grey-haired, dressed stunningly with fabulous patterned tights, a matching mustard yellow skirt and a velvety turquoise vest not far from me, raised her hand just like I did when the speaker asked who, among the audience, were “synesthetes.” Somehow, it struck me as his formulation, this noun emphasized me as “being” more than “having” something. And not just pathological stuff for once. It suddenly made me realize that it was part of my identity. My senses often seemed scattered Impossible to tame With time, I saw and felt that they were not lost For they had always known how to find each other It felt like a coming out, unexpectedly owning such an oddity legitimately rather than in secret. Like most synesthetes, when I was little, I thought the whole world was like me, and once I discovered with some shock that it was not the case, I kept this to myself. But with hindsight I see how this peculiar hidden sense has influenced how I selected the names of my children; the luminosity or vibrant combination of letters became more salient than the likelihood they will ever be pronounced perfectly in this country. At other times, synesthesia served me well: remembering numbers easily, identifying patterns in sequences, learning foreign languages, etc. Writing was (and still is) easier than the art of conversation, thanks to my inner

July/August 2016

Congenital synesthesia runs strongly in families, possibly inherited as an X-Linked dominant trait.

People with synesthesia related to music may also have perfect pitch…

template creating a frame for the thoughts. Overwhelmed with a mixture of awe and nostalgia, I like to reminisce over these intense months of studying for my specialty exams, when one word would suffice to make me visualize in my mind the unfolding of a parchment paper saturated with convenient knowledge or relevant associations, lowered like a blind over a window or unrolled like the endless white paper tongue tattooed by mathematical operations from an old, loud calculator. Even though it is a phenomenon that has been identified and documented for over a century, it has become the topic of renewed scientific investigations only for the past two decades. One reason for this might have been the overemphasis on behaviorist theories. Now that my interest − both personal and professional − in this idiosyncrasy has also accrued, I would like to know how I can use my synesthesia better. People with synesthesia related to music may also have perfect pitch because their ability to see/hear colors aids them in identifying notes or keys. Maybe I should start learning to play an instrument once and for all, or join one of the associations for synesthetes. I think the way each one of us is wired is so fascinating. The uniqueness of our minds is underutilized. There are probably so many

other peculiarities in people and ways to experience the world we are not yet aware of. And synesthesia might be more common than we think. In fact, some argue that we all have this ability. Kandinsky, Nabokov, Billy Joel and Nikola Tesla were reported to have synesthesia. The difference between those who report synesthetic experiences, and those who don’t, is the degree of awareness. If that is the case, then how can we safely enhance this amazing key to the secret vault of creativity or other possibilities? Through meditation, relaxation, visual imagery, or intense sensory stimulation? We are merely DNA and water, a biologist might say. We are hinges and currents, engineers could think. We are mostly a collection of impulses and defenses, would add a psychoanalyst. I think we are at least senses. We are also connectors. Establishing networks with the world and within ourselves. It is enlightening to pay attention to the intricacies of our minds, suddenly navigating or solving problems inside our representations arranged as a giant hopscotch, or bizarre jeu de marelle. Once we are in harmony with them and use them well, inner peace (and certainly a lot of other cool stuff) can happen. cgiroux@ucdavis.edu

Hooked on Drugs continued from page 13 illegal drugs is a panacea. Epidemiological studies show that the adverse health effects of alcohol and tobacco use in our population are much larger, proportionately, than those of illegally-obtained drugs. If we were to consider legalizing marijuana use, for example, we need to take into account this effect and prepare for a greater number of adverse health outcomes once the drug can be legally obtained. However, the societal benefits of no longer incarcerating drug users, improved regulation with consequent safety of drugs obtained, and the revenue created

Sierra Sacramento Valley Medicine

by taxing these drugs, may be a counterweight to these adverse effects. The war-on-drugs approach truly confirms that insanity is doing the same thing over and over again and hoping for different results. It’s time for a new approach. trochetg@gmail.com Reference 1 Risk and Protective Factors www.samhsa.gov/capt/practicingeffective-prevention/prevention-behavioral-health/risk-protectivefactors.

Call for Awards Nominations NOMINATIONS ARE BEING sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting January 19, 2017. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado-

Sacramento-Yolo region. The candidate must be an SSVMS member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship and Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, cstincelli@ssvms.org. Deadline: November 1, 2016.

Your patients get personal care. Shouldn’t your business? Every patient is different. So is every medical group. That’s why we provide you with customized solutions designed to help solve your unique business, financial, and operational challenges.

Find out what providers across the nation already know: that the right assurance, tax, and consulting firm is one that understands your industry. And offers candid insight to help you meet the needs of your patients. Put our expertise to work for you.

Certified Public Accountants | Business Consultants

W W W. M O S S A D A M S . C O M / M E D G R O U P S

July/August 2016

Primary Care: Medical School and Beyond By Cheng Nguyen-Xiong, MS IV, and Jennifer Estrada-Melgar, MS IV

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.

HOW LUCKY WE ARE to be students in Transforming Education And Community Health for Medical Students (TEACH-MS). Established in 2011, the UC Davis TEACH-MS program was designed to prepare medical students for primary care careers in urban underserved areas. As such, one of the highlights of our curriculum is our third year medical school experience. The third year of medical school marks a pivotal moment in our education. This exciting year of medical school allows us to do what we have dreamed of for so long − practice medicine! TEACH-MS students get an especially unique clinical experience. Our 2016 cohort of six students trains in clinical sites dedicated to working with Sacramento’s most vulnerable: the uninsured, underinsured and those receiving public assistance. We provide patient care in the hospital and clinics — we also visit patients in their homes. “Birth & Beyond” is the community-based organization that made this experience possible. Birth & Beyond is a multi-centered organization that provides resources to families of Sacramento County. We participated in their Home Visitation Program. Home visitors meet regularly with pregnant women and families to address concerns, and provide lessons. The lessons are designed to enhance confidence, develop empathy, gain new insight on how to discipline children with effective and nonviolent strategies, and ultimately become effective parents and role models. It was a privilege to be invited into family homes, as many of them shared intricacies of their personal lives and appreciated our

Sierra Sacramento Valley Medicine

presence. Participating in these home visits reminded us of our own families and communities prior to medical school, which motivated our pursuit of careers in primary care. One visit was to the home of a young, undocumented Mexican woman. She and her children were in temporary housing granted by her church. Isabel was a recent survivor of domestic violence and mother of three children, who would lose her health insurance in the next few weeks. During our visit, we reminded her to take advantage of any remaining postpartum visits. It was impossible not to feel overwhelmed with empathy for her. As students, many of us have had personal contacts with undocumented individuals and those who have been abused. We addressed her inquiries on the various birth control methods available, validating her strength in overcoming obstacles, and informed her of the various community resources.

Mental Health Care Services We visited Martha, whose two younger children received services through Birth & Beyond, but her older teenage son was out of the eligible age range. Unfortunately, he also suffered from psychological issues, which was an enormous struggle for his mother. She had no idea where to begin to look for mental health services, was wary of trying psychiatric medications, and did not know how to best support him, despite her best efforts. We took this opportunity to discuss mental health care and potential services available. Offering direct health education is a main objective during home visits. All health topics

discussed are selected by the clients, and the information provided is individualized during each visit to address specific patient concerns. Our goal as medical students and patient advocates was to meet people at their level of understanding. For instance, a session about Sexually Transmitted Infections for a female audience would start with the basic female anatomy before progressing to common types of infections, their treatment plans, and then how to prevent an initial or recurrent infection. We wanted to provide a safe setting where patients felt free to ask about anything. In addition to one-on-one home visits, we also had the opportunity to provide health information in a group setting, through Birth & Beyond’s Family Resources Center. This allowed us to reach a larger number of clients at one time, and also to lead group discussions in Spanish for non-English speaking women. We utilized handouts from the Centers for Disease Control and Prevention website, and discussed the topics of weight loss and women’s reproductive health. We were pleased by the level of participation from all of the women who joined the workshops.

Zumba Classes and Workshops We also enjoyed the interprofessional aspect of our experience. It was inspiring to see the team effort that goes into hosting community events, such as Zumba classes, parenting workshops, homework assistance for children, child care services during parent participation in the program, and the respite program. Such experiences are similarly modeled in outpatient clinics at UC Davis Medical Center and other health systems. As aspiring primary care physicians, we reflect on the value of working with other professionals for our patients. Our experience demonstrates that patient health can be addressed in other settings besides the physician’s office. We believe the medical community should take an active role in bringing health education from the clinic and hospital setting into the general community. For instance, addressing prevalent health

concerns in communities through home visits and classes in neighborhood settings may help eliminate long hours in waiting rooms, reduce transportation concerns, and provide a different forum for patients to receive information and answers to health questions. In addition, this approach may allow physicians and health care professionals to gain a better understanding of their patient’s home environment and support system. Ultimately, this may help improve patient health outcomes, as well as both the physician and patient satisfaction. As we near the end of our medical school journey, we are grateful for our experience with our beloved Sacramento County patients. Just as in medical school, our diverse cultural backgrounds and medical training will help us to better understand the communities we will serve as doctors. Yet, we realize that our work does not end here. We firmly believe that, as partners in the health care system − whether we are medical students, caseworkers, nurses, physicians, pharmacists, nutritionists, social workers, or other health participants, we all have a role in helping to shape the success of our patient’s and community’s health.

From left to right are students: Gerardo Hernandez, Cheng Nguyen-Xiong, Farah Shaheen, Vivian Vuong, Ariya Chau, Jennifer Estrada-Melgar and Angela Rodgers.

chenguyen@ucdavis.edu jrmelgar@ucdavis.edu

July/August 2016

Swine Milk 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 YEARS AGO, when I made nursing home rounds, I was called to see a newly-admitted female resident at a Carmichael facility. The charge nurse had phoned me to say that her new patient was “delightful,” that she seemed in no distress whatsoever, and was taking no oral medications. Sounded easy, so I made her my last stop late on that Friday afternoon. I sat at the nurses’ station and opened the chart and first reviewed the lady’s demographic data. She was almost 101 years old and, although she bore an Anglo name, her birthplace was “China.” She was a widow and no children were listed. She had an appointed conservator. Her only prescription was for eye drops to treat her glaucoma, and the nurse had already written that the patient’s eyesight was very poor. Her prior occupation was listed as “Physician.” I knocked on the open door of her room and called out, “Doctor Smith, I’m Doctor Ostrich, here to see you for your admission here.” “Oh, please come in,” she said immediately and clearly. She was lying in bed in her street clothes, gazing at the ceiling. “Have you been feeling well lately?” I asked. “Yes,” she answered. “I feel well, but I can’t stay where I was living because I’m having trouble with my ADLs (sic) these days.” She told me that her only child had died in adulthood, and she could not recall why. She said that she was, indeed, born in China to

Sierra Sacramento Valley Medicine

missionary parents and had lived in China until her early teens. “And you were a physician?” “Yes, I was a pediatrician.” “Where did you go to medical school?” “I must say I can’t recall.” Her vital signs recorded by the nurse were all right, and she looked a good deal younger than her stated age. I told her that I would visit her once a month on my routine rounds, or more frequently if she fell ill. She said that she did not ever want to be hospitalized. But before I left her room, I told her I had one last question, one that I was sure she had been asked many times in the past. “To what do you attribute your healthy, long life?” She turned towards me and replied, “You know, I think it was the swine milk that I drank all the time when I was a child.” “Really?” “Oh, yes. We only had swine, no cows or goats.” “Well, thank you. I will keep that in mind.” I saw her routinely for the next year or so, and she had no untoward episodes. She died quietly one day in her bed in her new home. I looked up pig’s milk and found that it is very similar to cow’s milk except for an 8.5 percent butterfat content. And perhaps some other mysterious components...? jmost119@aol.com

BOOK REVIEW

Willpower Rediscovering the Greatest Human Strength, by Roy F. Baumeister and John Tierney; Publisher Penguin Books; Reprint edition (2012); ISBN-13: 978-0143122234

Reviewed By Lee Welter, MD ROY BAUMEISTER IS a psychologist who has spent decades exploring how willpower works, and what exactly it is. Here, he teams up with journalist, John Tierney, to write a popular book surveying his and other folks’ research on the subject. The result is somewhere between a work of social science and a self-help book. Not only do you get insights on how willpower works, but you also get tips on how to make it work for yourself. I recall a psychiatry professor lecturing my med school class when he paused and said, “I see many worried faces out there. Relax: The seeds of mental illness reside within all of us… You will probably be all right.” However, some of us have varying moods and methods of dealing with the stresses of life. The stresses facing medical professionals seem to be greater than for most people. This is reflected in their relatively high suicide rate and burnout, as well as dependency on alcohol, caffeine and other substances. This guide to improving resilience offers great value. Of the many revealing examples presented in the book, my favorite is, “The Judge’s Dilemma (and the Prisoner’s Distress)” regarding the study of a parole board’s decisions. The prisoners who appeared early in the morning received parole about 65 percent of the time. Those who appeared late in the day won parole less than 10 percent of the time. This pattern applied to breakfast, the snack breaks in midmorning, and lunch of the judges. “Judging is hard mental work. As the judges made one decision after another, their brains and bodies used up glucose.” This phenomenon is probably one reason

my wife knows to feed me before any serious discussion or request. I also incorporate it in advice to my Paramedic and EMT students, along with emphasizing their need for adequate sleep and well-timed breaks from study sessions and exams. It might be partly responsible for one nearly failing student’s rejuvenation to become “the best student to ever walk through the door of the firehouse,” according to the captain. “Which Goals” is yet another instructive example in the book. Asked to sketch out how a fictional character might consider the future, one short-term, and the other a greater vision, a control group considered a week’s events for the prior, and an extended career or social plan such as marriage over a 4.5-year horizon for the latter. The “experimental group” of heroin addicts considered only the next hour for the former, and roughly 9 days for the latter. It’s akin to the classic “marshmallow experiment,” where young children were left alone in a room with the agonizing choice of eating one marshmallow now or two marshmallows 15 minutes from now. When the psychologist followed up decades later, he found that the 4-year-olds who waited for two marshmallows turned into adults who were better adjusted, were less likely to abuse drugs, had higher selfesteem, had better relationships, were better at handling stress, obtained higher degrees and earned more money. While pithy, this is an easy read. Try it, you’ll like it. welter@computer.org

July/August 2016

NOTE: The website of National Academies Press − www.nap.edu − offers free electronic versions of books. Those categorized as Health and Medicine are number 6032.

Sierra Sacramento Valley Medical Societyâ&#x20AC;&#x2122;s Fall Social Event California State Railroad Museum Saturday, September 10, 2016 6:00 pm - 8:30 pm This is a Free Family-Friendly Event All Physicians & Their Families Are Welcome to Attend You and your guest(s) are invited to join the SSVMS Board of Directors for a private gathering at the California State Railroad Museum. This is a great opportunity to bring your family and visit with colleagues while touring the museum. Hors d'oeuvres and beverages will be served.

RSVP to: (916) 452-2671 or mholland@ssvms.org RSVP Deadline: Tuesday, September 6, 2016 Special Appreciation to Our Sponsors Cooperative of American Physicians, BloodSource and NORCAL Mutual Insurance Company

Why do Butterflies Die and Cockroaches Live? By Ann Gerhardt, MD Why do butterflies die Helping flowers to live? Flitting and fluttering So much glory, wonder to give. While groveling below, Roaches feeding on feces, Cowering in crevices and cracks, Spread deadly diseases. What earthly balance could equate One or two months of colorful wings with year-long ugliness a roach’s existence brings?

Emma Willard, Nathan Hale, A leukemic child, Jeanne d’Arc, John Keats, Inez Milholland, Martin Luther King… Billy Joel knew it And proudly did sing, Only the Good Die Young Algerhardt@sbcglobal.net

We Are What We Are By John Loofbourow, MD Winter’s far peaks shine white in cold rain-scrubbed air. Still dark water sleeps covered in golden leaves. Bare branched tree limbs swell with dreams of Spring. Brittle marshlands rushes wake to geese, coots and cranes; golden hills begin to green and flights of magpies hide and chatter at dusk and sing up sunrise. It’s clearly impossible for the dust of dead stars to become you or me, living here and now despite blind galactic history. So be not ashamed, my friends,

that we pillage plant and flesh and earth sea, space, and air. In our brief human era, We Are What We Are: Querulous fleshy little gods made human for the while, here in illusory time, playing scripted roles like light and space and matter and numinous souls. Let’s try to love each other, like Buddha or J C try to keep the golden rules though imperfectly but always Keep on Dancing with Eros and Peggy Lee. john@loofbourow.com

July/August 2016

A Posit on Hospitalists “The evolution towards on-site hospitalists has led to better care.”

Background: Historically, internists, family physicians, and pediatricians cared for patients, both in the outpatient and inpatient settings. Their days often were a sandwich configuration of rounding before and after office hours with a smattering of midday calls and interruptions. Due to a variety of factors – lifestyle, convenience, reimbursement changes, increasing complexity and acuity of the hospitalized patient, and pressures to increase throughput – this model has largely been supplanted by that of the onsite hospitalist who stays in the hospital for a shift devoted to inpatient care. In 1996, Dr. Robert Wachter and Dr. Lee Goldman proposed the word “hospitalist” in their article in the New England Journal of Medicine. Fast forward to the present, several online sources project hospitalists’ numbers reaching 50,000 nationwide. 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: 40/Agree – 21/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. Patients in the hospital are sicker than ever and having a doctor on site makes way more sense than having someone who only rounds once or twice a day. −Joanne Berkowitz, MD I disagree. Unfortunately, hospitalists result in fragmented care with poor continuity and no captain of the ship. Basically, it reduces physicians to shift workers, which is also an issue with intensivists. −David Evans, MD I agree. Although there are advantages and disadvantages to both approaches, the hospitalist system is, in general, far superior (quality, efficiency, and cost) to having a busy PCP

Sierra Sacramento Valley Medicine

attempting to manage increasingly complex, high-acuity inpatients. In pediatrics the difference is so stark that inpatient and outpatient practices are quickly becoming separate specialties. A spinoff benefit has been to keep hurried, sometimes harried, primary care clinicians out of their cars. Who knew the evolution of medical care could lead to cleaner air and slower global warming? −Paul Phinney, MD I agree. Especially for NICU/nursery babies. −Sean Nealon, MD I disagree. My hospital experience − 20 hours after my admission, 2 hours after my appendix ruptured, in spite of my plea to obtain a consult soon after my admission; 17 days in ICU, 3 weeks in a nursing home, etc. No! In my days in primary care, I knew my patients and my surgeons. With an acute surgical abdomen, surgery would not have been delayed. Passing a patient from one hospitalist to another is not good patient care. −Wayne Matthews, MD I don’t know. If the Hospitalist specialty is coming up on 20 years, 1996-2016, what is the collective data that shows improvement or “better care”? What are we looking at that defines better care? Length of stay is certainly shorter. Is overall cost lower? Is patient safety in the hospital improved? Are we having fewer deaths in the hospital? And less medical errors? Are there more readmissions to the hospital than before? First, we have to define what better care is, then provide the data to support it before we can truly answer yes or no. −Rajan Merchant, MD I agree. My observation has been that the care of patients has improved in terms of safety and efficiency with hospitalists, as have internal medicine consultations for in-patient services. However, there has been a worsening of “care

coordination” with the post-hospital care venue. This is not unexpected given that hospitalists are not seeing the patient post-discharge. The introduction of the meaningful use “clinical summary” that is provided post discharge has helped address this, but gaps remain, as you would expect when there is a hand-off between hospital and follow-up, and this involves two physicians who have limited routinely-used communication channels available. −Michael Hogarth, MD I disagree. Communication, interaction, continuity of care, patient satisfaction. Definitely no! −Michael Parr, MD I agree. I saw this coming when I went to England for a two-month rotation my senior year in medical school. −Stephen Mandaro, MD I disagree. I think the hospitalist model can help with acute management and in hospital coverage. It does not, however, replace the primary care physician’s knowledge of the patient and family particulars and enduring relationship with the patient and family. It depends on excellent “hand offs,” and the quality and capability of the hospitalist to be successful, since they do not have a lasting and/or strong relationship with the patient or family. It makes things easier for the primary care or specialist physician, but supplants the real physician-patient relationship upon which the practice of medicine is based. Working a “shift” may be efficient, but it is not true caring or commitment. I feel it is akin to an industrialization (assembly line analogy) of medicine. −James Boggan, MD I disagree. This really depends on how you define care. From the patient perspective, the providers who replace their presence in the hospital setting with a hospitalist rather than using them as an adjunct are not providing a good experience. Similarly, the hospitalist who does not communicate with the patient and provider network to ensure a smooth transition back to the outpatient setting is doing the patient a disservice. −Kamran Sahrakar, MD Disagree. The evolution towards on-site hospitalists has led to better timeliness,

coordination, and digital documentation of care, but “continuity of care,” the highest “quality of care,” and “caring” itself are becoming extinct. Case in point: My elderly patient was discharged two days ago from a local hospital after ORIF of a comminuted fracture of the right humerus resulting from a trip and fall. At my house call yesterday, I found my patient resting fairly comfortably in a favorite chair in the front room and, upon review of post-operative X rays, was pleased to see a plate with nine well-placed screws which had promptly solved the problem. Upon review of the discharge summary and instructions, however, I was unsettled. In the summary, there was no mention made of alcoholism, an admitting alcohol level of 128 (12.8 times the upper limit of “normal”), no documentation of the source or sensitivities of a nosocomial UTI, and no mention made of in-hospital management of post-operative “agitation” with benzodiazepines. At no time during this hospital stay was I consulted, personally, about the medical background or care. − Scott M. Wigginton, MD I disagree. A hospitalist is not familiar with the patient and is frequently not a physician specifically trained for inpatient care. I have seen instances where the hospitalist ordered multiple investigative tests, whereas the patient’s primary internist had a simple solution once consulted. Perhaps best to develop a method to allow the patient’s internist to be reimbursed for telephone consultations with the hospitalist? −Sheila Braunstein, MD I agree. Hospitalists offer clear advantages in timely ER and in-patient evaluations; attending family conferences; more skilled, efficient use of lab, X-Rays, consultations, etc.; rapid assessments in hospital emergencies; knowledgeable referral for OP care; and skilled use of EMR. However, disadvantages can occur in communication with outpatient MDs, disruption in continuity of care with different hospitalists and handoffs to the next “team.” Overall, in-patient care is better for most patients, and other subspecialties − neurology, general surgery, ICUs − have developed programs. Oh, almost forgot, billing and reimbursements are more

July/August 2016

It does not, however, replace the primary care physician’s knowledge of the patient and family particulars…

comprehensive. −John Young, MD I agree. More rapid addressing of acute issues, although continuity of care can still be a problem. −Natasha Bir, MD I am not aware of any study addressing the issue of “Quality.” However, it has made care more efficient and created employment opportunities for PCP. It probably has added cost to patient care as more expensive/duplicate testing is done on hospitalized patients. − Kuldip Sandhu, MD I disagree. Perhaps more efficient, lower risk but “better” needs to be assessed from different viewpoints, i.e. the patient, the family, the hospital, the physician and care team, etc. −Jeanette Berrong, DO I disagree. In the years that I was last in practice, hospitalists did not lead to better care. We usually had to “board” them in the Emergency Department overnight and wait for the day crew to accept our patients. −Harold Renollet, MD

Overall better, but there are negatives. However, one thing is certain, there is no turning back, so our responsibility, as a profession, is to make it work. −Ralph Koldinger, MD I don’t necessarily think it is better care, only more efficient care. −William Junglas, MD I disagree. Continuity of patient care often suffers due to lack of collaboration. In addition, patient confidence about the care they receive from their primary care physicians is weakened. Patients feel abandoned and often rightly so. To create better patient care, there has to be better continuity and the feeling that the patient’s family physician is involved. −Gregory Joy, MD I agree. The system works even more efficiently if they are assigned to specialty care teams where members require more in-house, ongoing medical care. This system can better transfer to outpatient medical management to reduce readmission rates. −Eric Williams, MD

Be a Source of Hope

Jacqueline DeGracia, shown with her mother Leticia, needed plasma-based medicine to survive Kawasaki disease.

There’s more ways than ever to help patients in need – introducing source plasma. Source plasma donation, a type of blood donation dedicated for further development into lifesaving plasma-based medicines, is needed for patients with immune deficiencies, neurological diseases, blood disorders, and more. Learn more about donating source plasma by calling 866.822.5663 or visiting bloodsource.org/sourceplasma. Together, we do save lives. | bloodsource.org | not-for-profit since 1948

Sierra Sacramento Valley Medicine

Interested in Shaping Health Policy? THE SIERRA SACRAMENTO Valley Medical Society (SSVMS) has vacancies on its Delegation to the California Medical Association (CMA) House of Delegates. The CMA House of Delegates convenes annually to establish broad policy of the organization on current major issues affecting the practice of medicine and public health, as determined by the Speakers of the House and the Committee of Delegation Chairs. Policies adopted by the House of Delegates are implemented by the CMA Board of Trustees, either at the state level or referred for national action or legislation. Delegates and Alternate-Delegates are responsible for representing their colleagues in the House of Delegates by attending and actively participating in Delegation caucus meetings and all sessions of the House of

CLASSIFIED ADVERTISING Seeking Physician Mentors for Medical/PA Students Are you a physician willing to donate a few hours of your time to mentor medical, PA, and NP students? The Joan Viteri Memorial Clinic (JVMC), a UC Davis School of Medicine student-run clinic, is searching for physicians to serve as mentors and preceptors to teach future providers and help the community. The clinic serves IV drug users, sex workers, homeless, and undocumented patients of the Oak Park community, and is open every Saturday from 1pm to 5pm. We are also seeking physicians for the Womenâ&#x20AC;&#x2122;s Clinic on the first Saturday of every month from 10:30am to 2pm. Scheduling is flexible, volunteer physicians are welcome to come as often as they desire. For more information, please contact jvmclinic@gmail.com.

Delegates. In 2016, the House of Delegates will meet in Sacramento October 15-16, 2016 at the Sacramento Convention Center. SSVMS reimburses all of its Delegation members for transportation and hotel accommodations. A daily meal allowance is also provided. Delegation members must stay for the entire meeting (Saturday-Sunday) in order to be eligible for reimbursement. For more information contact: Chris Stincelli, Associate Director, (916) 452-2671 or cstincelli@ssvms.org.

Medical Consultants Needed Interested in moving away from direct patient contact? Prefer not to buy malpractice insurance, deal with overhead costs, and be on-call? Want your health benefits paid for, work flexible hours, either part or full time, and have your weekends free? Then join our team of professionals! The California Department of Social Services is seeking a few good psychiatrists and physicians who are interested in working with outside treating sources and other State professionals that evaluate medical evidence to determine its adequacy for making disability decisions as defined by Social Security Regulations. On-the-job training is provided. Interested applicants must have a current CA MD/DO License. Full-time Salary ranges can start at $9,152.00$13,547.00 per month, depending on experience and credentials. Job Locations: Covina, Fresno, Los Angeles, Oakland, Roseville, Sacramento, San Diego, Stockton, and Rancho Bernardo. If you are interested, please contact Ruby Chin at: (916) 285-7593 or Ruby.Chin@ssa.gov.

July/August 2016

How Colds Are Caught 1887 Health Suggestions and “Facts Worth Knowing”

FROM: The White House Cook Book − Cooking, toilet and household recipes, menus, dinner-giving, table etiquette, care of the sick, health suggestions, and facts worth knowing. A comprehensive cyclopedia of information for the home by Mrs. F.l. Gillette and Hugo Ziemann, Steward of the White House, 1887

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 great many cannot see why it is they do not take a cold when exposed to cold winds and rain. The fact is, and ought to be more generally understood, that nearly every cold is contracted indoors, and is not directly due to the cold outside, but to the heat inside. A man will go to bed at night feeling as well as usual and get up in the morning with a royal cold. He goes peeking around in search of cracks and keyholes and tiny drafts. Weather-strips are procured, and the house made as tight as a fruit can. In a few days more, the whole family have colds. Let a man go home, tired or exhausted, eat a full supper of starchy and vegetable food, occupy his mind intently for a while, go to bed in a warm, close room, and if he doesn’t have a cold in the morning, it will be a wonder. A drink of whisky or a glass or two of beer before supper will facilitate matters very much. People swallow more colds down their throats than they inhale or receive from contact with the air, no matter how cold or chilly it may be. Plain, light suppers are good to go to bed on, and are far more conducive to refreshing sleep than a glass of beer or a dose of chloral. In the estimation of a great many, this statement is rank heresy, but in the light of science, common

Sierra Sacramento Valley Medicine

sense and experience, it is gospel truth. Pure air is strictly essential to maintain perfect health. If a person is accustomed to sleeping with the windows open, there is but little danger of taking cold, winter or summer. Persons that shut up the windows to keep out the “night air” make a mistake, for at night the only air we breathe is “night air,” and we need good air while asleep as much or even more than at any other time of day. Ventilation can be accomplished by simply opening the window an inch at the bottom and also at the top, thus letting the pure air in, the bad air going outward at the top. Close, foul air poisons the blood, brings on disease which often results in death; this poisoning of the blood is only prevented by pure air, which enters the lungs, becomes charged with waste particles, then thrown out, and which are poisoning if taken back again. It is estimated that a grown person corrupts one gallon of pure air every minute, or twenty-five barrels full in a single night, in breathing alone. Clothes that have been worn through the day should be changed for fresh or dry ones to sleep in. Three pints of moisture, filled with the waste of the body, are given off every twenty-four hours, and this is mostly absorbed by the clothing. Sunlight and exposure to the air purifies the clothing of the poisons which nature is trying to dispose of, and which would otherwise be brought again into contact with the body. Colds are often taken by extreme cold and heat, and a sudden exposure to cold by passing from a heated room to the cold outside air. Old

and weak persons, especially, should avoid such body. The proper way to ‘cool off’ when overextreme change. In passing from warm crowded heated is to put on more clothing, especially if rooms to the cold air, the mouth should be you are in a cool place; but never remove a part kept closed, and all the breathing done through of the clothing you have already on. If possible the nostrils only, that the cold air may be get near a fire where there is no wind blowing, warmed before it reaches the lungs, or else the and dry off gradually, instead of cooling off sudden change will drive the blood from the suddenly, which is always dangerous.” surface of the internal organs, often producing Many colds are taken from the feet being congestions. damp or wet. To keep these extremities warm Dr. B. I. Kendall writes that “the temperature and dry is a great preventative against the of the body should be evenly and properly almost endless list of disorders which come maintained to secure perfect health; and to from a “slight cold.” Many imagine if their feet accomplish this purpose requires great care are not thoroughly wet, there will be no harm and caution at times. The human body is, arising from mere dampness, not knowing that so to speak, the most delicate and intricate the least dampness is absorbed into the sole, piece of machinery that could possibly be and is attracted nearer the foot itself by its heat, conceived of, and to keep this in perfect order and thus perspiration is dangerously checked. requires constant care. It is a fixed law of nature that every violation thereof shall be punished; Thanks to Dr. Bob LaPerriere, Curator, The Sierra and so we find that he who neglects to care Sacramento Valley Medical History Museum, for for his body by protecting it from sudden contributing this historical treatise. changes of weather, or draughts of cold air upon unprotected parts of the body, suffers the penalty by sickness, which may vary according to the exposure and the habits of the person, which affect the result materially; for what INC. would be an easy day’s work for A REGISTRY & PLACEMENT FIRM a man who is accustomed to hard labor, would be sufficient to excite the circulation to such an extent in a person unaccustomed to work, that Nurse Practitioners ~ Physician Assistants only slight exposure might cause the death of the latter when over-heated in this way; while the same exercise and exposure to the man accustomed to hard labor might not affect him. “So, we say, be careful of your bodies, for it is a duty you owe to yourselves, your friends, and particularly to Him who created you. Locum Tenens ~ Permanent Placement When your body is over-heated and you are perspiring, be very careful V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 about sitting down to ‘cool off,’ as FA X : 8 0 5 - 6 4 1 - 9 1 4 3 the custom of some is, by removing a part of the clothing and sitting in a tzweig@tracyzweig.com cool place, and perhaps where there w w w. t r a c y z w e i g . c o m is a draught of air passing over your

Tracy Zweig Associates Physicians

July/August 2016

Creating a Pathway to Specialty Care SPIRIT partners with Sacramento County to host specialty clinic for undocumented

By Liza Kirkland, Director, Community Service, Education and Research Fund

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 SIERRA SACRAMENTO Valley Medical Society’s (SSVMS) Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) program meets the health care needs of this community by recruiting and placing physician volunteers to provide free medical services to our region’s uninsured. By providing access to care for our region’s undocumented residents, SPIRIT creates a preventative public health strategy for uninsured residents in a timely and cost-effective manner, rather than these residents having to wait for expensive emergency care. As a collaborative partnership of SSVMS, Kaiser Permanente, Dignity Health, Sutter Health, UC Davis Health System and the Sacramento County Department of Health and Human Services, SPIRIT coordinates surgical and specialty services for uninsured individuals at local hospitals and ambulatory surgery centers. SPIRIT works with all of the region’s community clinics, including studentrun clinics, to assist with the coordination of care. In cases where the patient is self-referred, SPIRIT helps find a medical home which is necessary for continuity of care. Uninsured patients are often left with no viable options than to visit the emergency room, making local hospitals the default setting for caring for these patients in the least economical way possible. In June of 2015, the Sacramento County Board of Supervisors unanimously approved restoring primary care services to a limited number of undocumented residents of

Sierra Sacramento Valley Medicine

Sacramento County. This program is called Healthy Partners. SSVMS applauds the Sacramento County Board of Supervisors for their commitment to promoting access to medically necessary care for all of the county’s residents, regardless of immigration status. As a program providing free surgical services to uninsured, low-income patients since 1995, SPIRIT is excited to partner with Sacramento County Health and Human Services to expand this service and to address the need for surgical and specialty care within the undocumented community via the Healthy Partners program. Local hospital systems, SSVMS and the County joined forces to expand SPIRIT to Healthy Partners enrollees. The expansion includes an increased number of specialties and access to nonsurgical specialty consults. With the January 2016 start of Healthy Partners, SPIRIT has received more referrals in the first quarter of 2016 than it did all of 2015. This is due greatly, in part, to the roll out of the Healthy Partners program. SPIRIT participated in its first specialty clinic of 2016 on April 23. SPIRIT offered five specialties: GYN, Gastroenterology, Dermatology, Neurology and Urology. Four patients per specialty were scheduled and there was a 100 percent show rate. Thanks to a new partnership with Sacramento Covered, patients were able to receive free transportation via Uber. The volunteer physicians had a wonderful time and look forward to participating in the next specialty clinic. Patients were extremely

grateful. Many wrote “thank you” cards to the physicians, and some even brought baked goods as a way to express their gratitude. One patient shared, “I never thought in my wildest dreams I would have access to specialty care, let alone a neurologist, because I am undocumented. Thank you so much, SPIRIT. You are a miracle − you give me hope. I no longer have to live in the shadows and in pain.” SPIRIT would like to extend a very special thank you to its specialty clinic volunteers: Michael Lawson, MD, Gastroenterologist, Kaiser, retired; Ruth Haskins, MD, OB-GYN, private practice, California Medical Association (CMA) President-Elect; Mary Ann Johnson, MD, Dermatologist, Mercy Medical Group; Dennis Lee, MD, Urologist, Mercy Medical Group; and Yakaterina Axelrod, MD, Neurologist, Kaiser. Given the clinic’s success, the County has agreed to offer the specialty clinic on a quarterly basis. The next SPIRIT specialty clinic is tentatively scheduled for July 23, 2016. OB-GYN and CMA President-Elect, Ruth Haskins, MD, feels empowered by volunteering with SPIRIT. “Volunteerism is key. I feel empowered when I share with colleagues and patients that I am going to volunteer. You can’t just talk about it, you have to get out there and walk the walk. Everyone should give one day. The SPIRIT program is good for your spirit. It reminds me of why I went into medicine.” We need your help! There are opportunities for physicians to donate their time and expertise in the following ways: • Specialty care consultation visits in private physician offices, where your recommendations for follow-up treatment will be sent to a primary care referring clinic where they will be implemented. • Specialty care clinics housed at the County Primary Care Center, where you can provide consultation during a subspecialty clinic for patients referred with recommendations for follow-up treatment implemented by the patient’s medical home. • Surgeries in local hospitals/surgery centers.

• Telephone specialty consultations with primary care providers. SPIRIT’s case managers make it easy for volunteer physicians to participate with as little disruption to his/her schedule as possible. In addition to case management, SPIRIT staff takes care of all case management and care coordination between the referring clinic, the patient and the physician volunteer. Referring clinics are medical homes that are responsible for implementing the care plan and follow-up care recommended. Volunteer physicians are never asked to assume ongoing care for a patient. SPIRIT services are limited to either consultation and evaluation or one-time only outpatient surgical care. Currently we have a need for Cardiology, Endocrinology, ENT, General Surgery, GYN, Orthopedics and Rheumatology. Interested in volunteering or in making a donation? Please call (916) 453-0254 or email: spirit@ssvms.org.

Top photo, left to right are: Dennis Lee, MD; Mary Ann Johnson, MD; Ruth Haskins, MD; Yakaterina Axelrod, MD, and Michael Lawson, MD. The bottom photo is of Dr. Axelrod with a patient.

lkirkland@ssvms.org

July/August 2016

BOOK REVIEW

How to Get More Fun Out of Smoking A Guide and Handbook for Better Smoking; Author Sydney P. Ram; Publisher Muller Press; ASIN: B00D46B8JO

Reviewed By Donald M. Hopkins, 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.

INTERESTING READ − only 125 pages. If you are an inveterate pipe smoker, then this is the book for you. The book was donated to our Medical Society History Museum recently, and the Curator, Dr. Bob LaPerriere, asked me to check it out. The author was a “pipe maker” with a shop in downtown Chicago in the 1930s. As a disclaimer, being a retired thoracic surgeon, I am extremely biased and do not claim objectivity. This book was published in 1941 when I was only 10 years old, just a few months before our involvement in WWII. It has since been republished in 2004. Many interesting statistics are included, and there is a lot of information about pipe smoking. Briar Wood, described in detail, was top of the line in pipe construction. There is interesting information on cigar manufacturing, but not a lot of comments on cigarettes, though it was noted they were a penny each. Concern regarding the possible health hazards is mentioned, but not “proven” at the time. I do remember our coaches advising young athletes not to smoke, and smoking was not advised for growing children. It was an adventure for young boys to sneak out behind the barn or into an alley to take a drag on a cigarette and a “tough guy” would hold a cigar in the corner of his mouth. The contented, relaxed grandpa was pictured in a comfortable chair, sitting beside the fireplace with his pipe, reading the comics in the newspaper to his grandkids. The book ends with “Tobacco’s the one

Sierra Sacramento Valley Medicine

blessing that nature has left for all humans to enjoy. It can be consumed by both the ‘have’ and ‘have nots’ as a common leveler, one that brings all humans together from all walks of life regardless of class, race or creed.” The author states that the craving for tobacco is universal. Unfortunately, the severe addictive property of nicotine was not appreciated, or at least was “played down.” Now we know that many health, economic and social problems are related to the tobacco industry. There is proof that smoking is directly related to cancer of the lung, trachea, larynx, tongue and mouth as well as the bladder. It has a devastating effect on chronic respiratory disease and a significant deleterious effect on the cardiovascular system. These facts really take the “fun out of smoking.” Enough said − It is an interesting read. The author summarizes the attitude of the average smoker by quoting a little jingle by G. L. Hemminger: Tobacco is a dirty word, I like it. It satisfies no normal need, I like it. It makes you thin, it makes you lean, It takes the hair right off your bean; It’s the worst darn stuff I’ve ever seen, I like it. dmh95864@sbcglobal.net

IN MEMORIAM

John White Harris, MD 1924–2016

THE OTHER SHOE JUST dropped, and so unexpectedly. John White Harris, MD, internist brother of recently-deceased Dr. Bob Harris, died April 24th at age 91. Sons of Dr. Junius Harris, a Sacramento medical pioneer in surgery and medical politics, Bob and John, in addition to their own identities and skills, represented that connection to Sacramento’s early medical history. Growing up in the Arcade District of Sacramento County, John Harris graduated from Grant Union High School and began his pre-med studies at Stanford University in 1941. World War II started later that year, and John joined the Navy V12 program in order to stay in school. He began Stanford Medical School as a midshipman. Then the war ended, and being released by the Navy, John continued at Stanford, graduating with his MD in 1949. He interned at San Francisco General Hospital, and during his first year of internal medicine residency there, he met and married Alice Wood. Selective Service then notified him he was about to be drafted for Korean War duty, so John rejoined the Navy and was assigned to Oak Knoll Naval Hospital where he resumed his residency. Orders then arrived assigning him to the Fleet Marine Force as a combat surgeon. He soon found himself in Korea living in a tent for the next eight months, caring for wounded Marines and grateful for the experience gained at Mission Emergency at SFGH. The Navy Surgeon General, a 3-star Vice Admiral, visited Korea and chose to interview John in his tent concerning his views on medical conditions in the field. John was very frank in telling the admiral that having been assigned a dermatologist, a psychiatrist and a GP who had never seen trauma as colleagues, was a travesty as they were useless in handling trauma. Over a bottle of John’s medicinal brandy, he and

the admiral hit it off quite well. The admiral promised him any billet he wanted when his Korean tour was over. On returning stateside, John’s orders assigned him to a Navy weapons depot medical clinic in Hercules, CA. John contacted the admiral and was immediately reassigned to Oak Knoll to complete his internal medicine residency. In 1953, John and Alice returned to Sacramento where he opened his internal medicine practice. He practiced for 37 years. He truly enjoyed practice, unencumbered by today’s patient time quotas. He said the only reason he retired was he couldn’t tolerate arguing with some John White Harris, MD HMO secretary in Utah about a test his patient needed. In retirement, he volunteered at the County Indigent Medical Clinic for six years and regularly attended UCDMC medicine rounds. He and Alice raised five children, vacationed widely across Europe and toured the USA, often with a trailer, visiting all 50 states and every historical museum and art gallery, and fishing every stream and lake. In addition, he and Alice collected over 500 mineral specimens. Alice, besides being a mineralogist, was an accomplished artist in oils, watercolors and sculpture. Sadly, she passed away in January of last year. Like his brother Bob, John had that treasure trove of stories about his life and times that made his company so enjoyable. The Harris brothers were an institution in Sacramento, the dual legacy of their famous father. Sacramento seems a bit empty now without them. − Jim Hamill, MD July/August 2016

Board Briefs May 9, 2016 The Board: Approved the 2015 Consolidated Audit Review Report presented by auditor, James Marta, CPA. Approved the 2015 Tax Returns for the Sierra Sacramento Valley Medical Society and the Community Service, Education and Research Fund. Approved the 1st Quarter 2016 Financial Investment Review & Recommendations.

Quality adult day services since 1992

Providing your patients a safe and enriching place to spend the day, while giving family caregivers respite.

www.TripleR.org (916) 808-1591

Locations in Midtown, North Sacramento, and Greenhaven

Licensed by the State of California, Dept. of Social Services

Sierra Sacramento Valley Medicine

Approved the establishment of the 2016 Nominating Committee. The committee is charged with nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. The 2016 Nominating Committee members are: Chair, Tom Ormiston, MD, President; Ruth Haskins, MD, District 1; Margaret Parsons, MD, District 2; Barbara Arnold, MD, District 3; Russell Jacoby, MD, District 4; Rajiv Misquitta, MD, District 5; Marcia Gollober, MD, District 6; At-Large Members, Richard Jones, MD and Katherine Gillogley, MD. Approved the Membership Reports: For Active Membership — Linda H. Aasaf, DO; Vasuki Daram, MD; Ahmed Farrag, MD; Kusuma Hampapur, MD; Nicole Knotts, MD; Sung Lee, MD; Fatima Masrur, MD; Femi Philip, MD; Gayatri Sarkar, MD; Punit K. Sarna, MD; Adrian Jospeh Sauder, MD; Rebecca Pringle Smith, MD; Debra Annette Thomas, MD; Yan Wang, MD; Asmaneh Soufi Yamagata, MD. For a Change in Membership Status from Student to Resident — Ryan Lewis Anderson, MD; Reihaneh Forghany, MD; Kelly M. Hearney, MD; Ariana A. Hosseini, MD; Gabriel Reina, MD. For Resident/Fellow Membership — Morgan Elizabeth White, MD; Jocelyn Young, MD. For Reinstatement to Active Membership — Linda Copeland, MD; Derek Marsee, MD; Ronnie Sprinkle, MD; Andrew John Parker MD. For Reinstatement to Retired Membership — Patrick Saunders, MD. For Resignation — Charles Feng, MD (resident/moved to Sunnyvale).

www VISIT WWW.CALPAC.ORG

CLICK DONATE

CHOOSE OPT FOR MONTHLY COMPLETE CONTRIBUTION PAYMENTS FORM & SUBMIT

CALPAC, the California Medical Association Political Action Committee, supports candidates and legislators who understand and embrace our philosophy and vision of the future of health care.

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

Doctor-Mentors Needed Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. Weâ&#x20AC;&#x2122;re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramentoâ&#x20AC;&#x2122;s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: managers@willowclinic.org.

PLANET

E L LY

DESIGN / MARKETING

Kelly K elly Rackham Rackha m [916] 616 6270 planetkelly@me.com www.planetkelly.com

July/August 2016

Contact SSVMS TODAY to Access These

M EMBER O NLY B ENEFITS (916) 452-2671 BENEFIT

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement

CMA’s Center for Economic Services (CES) www.cmanet.org/ces | 800.401.5911 | economicservices@cmanet.org

Legal Services CMA On-Call, California Physician’s Legal Handbook (CPLH) and more...

CMA’s Center for Legal Affairs www.cmanet.org/resources/legal-assistance legalinfo@cmanet.org

Insurance Services Mercer Health & Benefits Insurance Services LLC Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, and Cmacounty/insurance.service@mercer.com more... www.countyCMAmemberinsurance.com Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.

Prudential Travel Accident Policy & AXA Travel Assistance Program http://tinyurl.com/SSVMS-travel-policy

ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD10 Code Set Boot Camps

AAPC www.cmanet.org/aapc

Mobile Physician Websites Save up to $1,000 on unique website packages

MAYACO Marketing & Internet www.mayaco.com/physicians

Auto/Homeowners Insurance Save up to 10% on insurance services

Mercury Insurance Group www.mercuryinsurance.com/cma

Car Rental Save up to 25% - Members-only coupon codes required

Avis or Hertz www.cmanet.org/groupdiscounts

CME Certification Services Discounted CME Certification for members

CMA’s Institute for Medical Quality (IMQ)

Health Information Technology Free secure messaging application

DocBookMD www.docbookmd.com/physicians/

HIPAA Compliance Toolkit Various discounts; see website for details

PrivaPlan Associates, Inc www.privaplan.com

Magazine Subscriptions 50% off all subscriptions

Subscription Services, Inc

Medical ID’s 24-hour emergency identification and family notification services

MedicAlert www.cmanet.org/groupdiscounts

Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services

EnviroMerica www.cmanet.org/groupdiscounts www.enviromerica.com

Office supplies, facility, technology, furniture, custom printing and more… Save up to 80%

StaplesAdvantage www.cmanet.org/groupdiscounts

Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required

COLA www.cmanet.org/groupdiscounts

Security Prescription Products 15% off tamper-resistant security subscription pads

RxSecurity www.rxsecurity.com/cma-order

PUBLICATIONS CMA Publications

www.cmanet.org/news-and-events/ publications CMA Alert e-newsletter CMA Practice Resources CMA Resource Library & Store www.cmanet.org/resource-library/list? category=publications

Advance Health Care Directive Kit California Physician's Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPAA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physician Orders for Life Sustaining Treatment Kit

SSVMS Publications

www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)

info@ssvms.org | (916) 452-2671

PrEP YOUR PATIENTS AGAINST HIV A DAILY PILL CAN PREVENT HIV INFECTION If your patients are HIV-negative and want to protect themselves from HIV, PrEP (pre-exposure prophylaxis) may be right for them: - If they donâ&#x20AC;&#x2122;t always use a condom. - If they have multiple sex partners. - If they have an HIV-positive partner. Take an important step to reduce their worry about HIV. Talk to your patients about PrEP.

Visit GetPrEPSac.org for Patient Information, Provider Information and to learn more about PrEP in Sacramento.

A CARES COMMUNITY HEALTH INITIATIVE

NO R C AL

G R O U P

O F

CO M PA N I E S

GUIDE GUARD ADVOCATE

MEDICAL PROFESSIONAL LIABILITY INSURANCE

PHYSICIANS DESERVE Offering top-tier educational resources essential to reducing risk, providing versatile coverage solutions to safeguard your practice and serving as a staunch advocate on behalf of the medical community.

NORCALMUTUAL.COM | 844.4NORCAL