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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2016

Success. It’s what Sierra Sacramento Valley’s finest physicians strive for...and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice these days, and are committed to supporting you with a range of programs and services that no other professional liability company offers. These include a 24-hour early intervention program, HR support, EHR consultation, and a robust group purchasing program, to name a few.

Free Risk Management Dinner Presentations! CAP is proud to join the Sierra Sacramento Valley Medical

To reserve your spot, please call 800-361-5569

Society (SSVMS) and Placer-Nevada County Medical

or email RSVP@CAPphysicians.com. Space is limited and

Society (PNCMS) in hosting a series of free, no-obligation

reservations are required.

risk management presentations designed to help physicians run safer, more successful medical practices.

September 22 - 6:00 p.m. The Firehouse Restaurant, Sacramento CyberRisk: Is Your Practice at Risk? Presented by Deidri Hoppe Vice President, CAP Physicians Insurance Agency November 9 - 6:00 p.m. Sienna Restaurant, El Dorado Hills Every Chart Tells a Story:

For Your Protection. For Your Success.

Reducing Risk with Appropriate Documentation Presented by Susan Jones, CPHRM Senior Risk Management & Patient Safety Specialist,

800-252-7706 | www.CAPphysicians.com

Cooperative of American Physicians

Sierra Sacramento Valley


2016 Education Series


SSVMS Railroad Museum Social


PRESIDENT’S MESSAGE The Direction of Our Profession



Thomas W. Ormiston, MD

Reviewed by Jack Ostrich, MD




Pixel People

John Loofbourow, MD


Closing the Gap – A Brief History of Suturing

Kent Perryman, Ph.D.

Nathan Hitzeman, MD


Letter to the Editor


Firearms and Mental Illness

Amy Barnhorst, MD


BOOK REVIEW Almost a Psychopath

Reviewed by Lee Welter, MD

10 Trilogy


Back the PAC

Nicholas Birtcil, Associate VP, Political Operations, CMA


A 90-Hour Fast

John Loofbourow, MD

Eric Williams, MD


A Posit on a Little Nip and Tuck


New MACRA Rules Make Pay Cuts Less Likely


Board Briefs

Barbara Arnold, MD


The Zika Scare

33 Scriptures

Caroline Giroux, MD

Glennah Trochet, MD


Welcome New Members


California Legislative Updates


Thank You Letter

Richard Pan, MD, MPH, State Senator

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our cover image by Dr. Eric Williams, a member of the SSVMS Board of Directors and a vascular surgeon with The Permanente Medical Group, is that of a display of dried calabash taken on the streets of Grenada, West Indies. It was taken with a Cannon 70D with an 18-55mm macro lens. A calabash is a product of a tropical evergreen tree which produces these gourds of many shapes and sizes. When dried, they can be cut and shaped for a variety of purposes including carrying water, purses or as pipes. In America they are most often used as decorative pieces. Even as a hobby, I have learned two important lessons about photography: 1) The exact event never occurs twice, so you should always be prepared to shoot. 2) Objects, like life, never look the same going toward as leaving it behind, so develop a habit of looking back, or in life, by reflection. A trilogy of poems written by Dr. Williams is on pages 10 and 11. — eric.s.williams@kp.org

November/December 2016

Volume 67/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org


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 Kevin Jones, DO 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 Ann Gerhardt, MD Sandra Mendez, MD Robert Rabody, MD Armine Sarchisian, MD John Tiedeken, MD Eric Williams, MD Vacant Vacant Vacant Vacant Vacant Vacant Vacant Vacant

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President Ruth Haskins, MD

CMA Vice Speaker Lee Snook, MD

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising.

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS III Sean Deane, MD George Meyer, MD Adam Doughtery, MD Jillian Millsop, MD Ann Gerhardt, MD Steven Nemcek, MS I Caroline Giroux, MD John Ostrich, MD Sandra Hand, MD Mary Pauly, MD Albert Kahane, MD Gerald Rogan, 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


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.

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The Direction of Our Profession By Thomas W. Ormiston, MD I RECENTLY HAD THE HONOR of participating in my daughter’s White Coat Ceremony. For those, who like me, did not have such an event when they started medical school, it is the ceremony where beginning medical students receive their first white coat and stethoscope. We took the Hippocratic Oath together. Most of the students consider it a bigger event than medical school graduation. Despite the prospect of years of hard work and sacrifice ahead, their excitement and enthusiasm were overwhelming In my view, it is our responsibility to justify the excitement of all those entering medicine. We need to assure that physicians are doing work for which we are trained, and not busy work that can be done by those who have not invested years in training. For example when my patient gets sucked into a jet engine, should I use code V97.33XA? With a problemfocused history, a detailed physical exam, and a moderate complexity decision-making visit, do I code 99213 or 99214? We also need to assure that physician work continues to be done only by those with the training and experience to safely and effectively practice medicine. Naturopaths want to prescribe medication, optometrists want to treat diabetes, nurse practitioners want to practice independently as physicians. With far greater training than any of these groups, most of us realize that only after years of medical school and residency are we able to practice independently, and even then, most of us still consult regularly with our colleagues. We need to realize that we are (or should be) leaders of an industry generating over two trillion dollars annually, now more than 16

percent of the U.S. economy. We can do this through specialty societies, hospital associations, or group practice organizations. Each of these speaks for a segment of our profession, but not for the profession as a whole. But the only voices speaking for all physicians are our local, state, and national medical societies. When physicians ask, “What has the medical society done for me?” Please remind them that the direction of our profession, public health, and health care delivery needs to be led by physicians. And, only our medical societies can speak for our profession as a whole.

The years ahead offer much excitement as the art and science of medicine continue to advance. For those who avoid membership because they disagree with CMA or AMA policy, encourage them to join and help set the direction for our profession. If we fail to take a leadership role, there will be plenty of naturopaths, pharmaceutical companies, insurance companies, lawyers, or countless others who would be happy to determine the future of medicine and public health for us. The years ahead offer much excitement as the art and science of medicine continue to advance. Only through continued physician leadership can our colleagues who follow us enjoy the fulfillment our profession has to offer.

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


November/December 2016



Moving On 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.

IT’S BEEN A FUN RIDE these last five years as your SSV Medicine Editor. I admit, I haven’t always kept my arms and legs inside the vehicle, but under Aileen Wetzel’s thoughtful leadership and ample supply of TUMs, and with a solid Editorial Board and miracle worker Managing Editor, Nan Crussell, we’ve covered a lot of ground in our magazine. We’ve inhaled the topic of medical marijuana, traveled to far-off lands with our members, watched the pot of stem cell research in hopes it may someday boil, applied ancient lotions and potions, gawked at medical gadgets/ gizmos, reviewed some books you might want to read, and opened peepholes to the history of medicine. We’ve put out some controversial posit pieces and calls for stories to get our members on the pages, too. We thank you for your responses. What does an editor learn from perusing through five years of essays and letters? Physicians are interesting. Physicians are opinionated. Physicians are humble. Physicians are proud. Physicians do a lot of good in the community. Physicians care, feel, and experience the world through a unique, shared lens. Being privy to the stories of my patients is a privilege. Reading the stories of fellow physicians is a gift. Thank you for that gift. Stories are what make our profession beautiful. Like boils, they need to be lanced and spewn onto paper from time to time. It’s not just a gallbladder in room one, or an aneurysm in room two. It’s the lady with Prader-Willie syndrome and a funky tattoo who can’t control her eating, or the alcoholic attorney with the comb-over and bulbous nose who can’t now move his leg and demands answers. Indeed, one of my favorite JAMA essays was written by pediatrician, Elizabeth Toll, of Brown University in 2013, entitled “Obesity

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NOS.” Her mother-in-law saw a physician who wrote in his note: “The patient is a 77-year-old obese female.” Dr. Toll offers how much richer the encounter could have been had it read: “The patient is a 77-year-old adoring mother of four and grandmother of eight, retired third grade teacher, committed walker, talented bird-watcher, avid reader, and accomplished watercolorist who remains engaged in all these activities even as she and her husband are soldiering through Parkinson disease.” Even as a child, I learned from the fantasy movie, The NeverEnding Story, that the absence of stories and imagination is “The Nothing,” a darkness which threatens to consume us all. That darkness might be different things to different readers: rote EHR checkbox clicking, prior authorization “mother-may-I” games, big box cookie-cutter medicine, hamster-wheel work, or fighting the endless bureaucracy of recertification, maintaining license/privileging, and watching a mandated two-hour sexual harassment course every two years. We will overcome! We are physicians. Our stories are valuable. Our patients’ stories are valuable. Please continue to share your stories and read the stories of others. I will keep reading as well. hitzemn@sutterhealth.org

Letter to SSV Medicine Re: Stem Cell Program at UC Davis

had to be peri- or para-spinal, Doctor T would do it, but peripheral joints or trigger points were the purview of the PA, it seemed. The stem cells would be harvested from one’s own blood, so there was no need for compatibility testing or bothersome FDA interference. After all, you were just going to get your own blood re-injected after the stem cells had been isolated and “concentrated.” I had the impression that the vast majority of patients needed only one shot. And if, say, after six months there was no improvement? “Just give us a call.” −Jack Ostrich, MD, Member, Editorial Committee, SSV Medicine

Dr. Jim Rybka’s informative article in the September-October issue of this magazine, “Stem Cell Program at UC Davis,” reminded me that I had attended a so-called “seminar” Comments regarding stem cell therapies at a local hotel or letters, a few months ago. I went there attracted by which may be expansive ads in The Sacramento Bee, thinking published in a that whatever I might learn at such a meeting future issue, should be sent might blossom into a full-blown article about to the author’s this increasingly popular subject. The title of the email or to “seminar” might as well have been, “Stem Cells e.LetterSSV Can Cure Almost Anything.” Medicine@gmail. The presentation was done jointly by a com. Physician’s Assistant who identified herself as such, and by a middleaged man who was a very good speaker. I had to ask him directly for his credentials, as he did not reveal them prior to his talk, and he told me he was a chiropractor. The supervising MD was not As a trusted partner to businesses and families across generations since 1919, Baird has seen investors through many market cycles. present and was referred to And the insight we’ve gained from this experience informs all we do only as “Doctor T.” We were today as we strive to create great outcomes for our clients throughout told that he was a board their financial lives. certified neurosurgeon. If we wanted to Put Baird’s time-tested expertise to work toward your long-term goals. proceed, the cost might vary between about $5,000 Patty M. Estopinal, CIMA®, CDFA Director to $10,000, depending Private Wealth Management on the number and sites 916-783-6554 . 877-792-3667 of the injections. We also pestopinal@rwbaird.com would have to obtain pattyestopinal.com appropriate X-rays or scans on our own and bring Investment Management Consultants Association is the owner of the certification mark “CIMA®” and the in the originals, not just service marks “Certified Investment Management AnalystSM,” “Investment Management Consultants AssociationSM” and “IMCA®.” Use of CIMA® or Certified Investment Management AnalystSM signifies that the reports. If the injections

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user has successfully completed IMCA’s initial and ongoing credentialing requirements for investment management consultants. ©2016 Robert W. Baird & Co. Incorporated. Member SIPC. MC-48079. Robert W. Baird & Co. does not provide tax or legal advice.

November/December 2016


Firearms and Mental Illness By Amy Barnhorst, MD

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

I AM A PSYCHIATRIST, but originally I went to medical school to become an epidemiologist. I read the Coming Plague by Laurie Garrett in my twenties, and I wanted to tromp through the villages and forests of sub-Saharan Africa in my cargo pants and jungle boots, hunting down hemorrhagic fevers. Eight years of training, a pile of student loans, and two children later, that didn’t seem like such a good plan. Instead, I happily settled into my 9-to-5 job with UC Davis, running the county psychiatric crisis unit. When Ebola broke out in West Africa, I was secretly relieved to be reading about it from the comfort of my sofa. But in 2012, the Sandy Hook Elementary School shooting drew me in again, this time to an epidemic that was much closer to home. Like every parent who drops their children off at school each day, I take that leap of faith that they will be there to pick up. Sandy Hook changed that forever. As a mom, I felt scared and powerless. As a psychiatrist, I felt frustrated by the media and the public blaming the mental health system for failing to prevent mass shootings. As a gatekeeper to involuntary psychiatric treatment, I know that the mental health system cannot be responsible for preventing this kind of violence. Focusing efforts there and not on firearms themselves is misdirected if not counterproductive. Although we understand many of the population risk factors for violence, psychiatrists are notoriously bad at predicting it in individuals. This is especially true in a sizeable population whose background risk of violence is fairly low – e.g. socially-isolated adolescent white males who play violent video games. While this description fits many mass shooters, most of them do not have a history of mental illness. And the majority of people with mental illness

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are not more violent than comparable members of their communities. Most violence is driven by other factors; only about four percent of community violence is attributable exclusively to mental illness. But sometimes the signs of impending violence are undeniable and specific: social media postings promising imminent revenge, methodical acquisition of semi-automatic weapons and ammunition, pilgrimages to pay homage to Columbine or other sites of mass violence. Can’t these people be identified by the mental health system and stopped? Potentially, they can be put on an involuntary hold for dangerousness and psychiatrically hospitalized, but only if the psychiatrist believes and (can prove in court) that their dangerousness is due to an actual mental illness. This system exists for treating, for example, a man plotting to kill his co-workers because he delusionally believes they are part of a cult that is poisoning and brainwashing his family. A bullied teenager who wants revenge on his aggressors would not likely qualify, and even if admitted to the hospital by the psychiatrist, would likely be released by a judge at his certification hearing a few days later. Even if his involuntary hold were certified at his hearing, the inpatient psychiatric team would have 17 days maximum to treat him for dangerousness under standard procedures. That may be enough time to mitigate someone’s delusions about a brainwashing cult, or turn down the volume on the voices in their head telling them to kill their neighbor. But it is almost certainly not enough time to undue decades of neglect, belittling, bullying, resentment, and unfulfilled needs that drive many of these young men. And at the end of that 17 days, he goes back home to his same environments, and

maybe to his cache of weapons. Of course, there are laws against presumably dangerous people owning guns – and a disproportionate number of those are aimed at people with mental illness. Federal law prohibits anyone “adjudicated as a mental defective” or “committed to a mental institution” from purchasing or owning a firearm. So, a patient whose hold was certified in court would be reported to a federal database and prohibited from future gun purchases from a licensed dealer. But, in most states, he could still buy a gun at a gun show or from a private party without a background check. And, reporting does nothing about the cache of weapons he may already have squirreled away in his closet. California has taken unique steps to close some of these gaps. Our Armed Prohibited Persons Program is the first of its kind, aimed at removing guns that are owned illegally. Because all firearm sales in California are registered, even private ones, the Department of Justice has a list of all legally-owned firearms in the state. Many of those owners may later become prohibited, because of a psychiatric hospitalization, a restraining order or a felony offense. The APPS program cross-checks that list of prohibited persons with the list of registered firearm owners. When they get a match, they send agents out to recover the illegally-owned guns. California also passed a Gun Violence Restraining Order, which went into effect earlier this year. It allows family members or police officers to petition a court for an order to remove someone’s gun if they believe that person is at risk of hurting themselves or someone else. Indiana and Connecticut both have similar laws, and though both were passed in response to acts of violence, they have been used most often to intervene in cases where people were suicidal. One benefit of these laws is that they focus on getting guns out of the hands of potentially

dangerous people, and steer the focus away from horrifying but rare mass shootings, and from people with mental illness. Though media coverage may lead us to believe otherwise, the real epidemic of firearm mortality is from neither of these. It is from the steady toll of gun deaths that takes place every day in poorer neighborhoods, domestic disputes, and suicides. Firearms claim over 30,000 lives per year; mass shooting deaths represent less than 0.01 percent of these. Nearly two-thirds of these deaths are suicides. Despite their dangers, firearms are a part of our national and cultural identity, thus we have much higher gun ownership rates than other countries. Americans see them as essential to safeguarding their freedoms, protecting their families and defending their property. Evidence to the contrary does little to sway public opinion. Because of our collective psychological affinity for firearms and the strength of the Second Amendment, attempts to universally restrict firearms on a national level have been rejected by the courts. This climate provides fertile ground for an epidemic of gun deaths, just as the unique conditions in central Africa allow Ebola to survive and recur. Economic, cultural, social and political forces contribute nearly as much to these epidemics as the firearms or viruses themselves. There are limits on what can be done with the tools available, whether those tools be educational, pharmaceutical or legislative. And, there are limits to what will be done, by the affected people who are asked to compromise their traditions and values for the sake of public health. As with most epidemics, firearm mortality will not be resolved by the discipline of medicine alone; it will require working to change legislation, industry, and culture. barnhorsta@saccounty.net

November/December 2016



Almost a Psychopath By Ronald Schouten, MD, JD, and James Silver, JD; Hazelden Publisher; ISBN-13: 978-1616491024

Reviewed By Lee Welter, MD CONSIDERING SACRAMENTO’S regional challenges with mental health, this book is very timely. Authors Ronald Schouten, MD, JD, and James Silver, JD, offer an overview of personality disorders, focused upon “almost psychopaths,” how to identify them, and what differentiates them from similar psychopathology. The difference between psychopaths (found in 1-2 percent  of our population, and recognized in the Hare Psychopathy Checklist www.sociopathicstyle.com/psychopathic-traits), and “almost psychopaths” is well explained.

Included are examples of unethical behavior by psychotherapists, attorneys, and physicians, among others. Dealing with conflict between “significant others” is an important topic. The success of almost psychopaths in business (and apparently in politics) is covered as are reminders about keeping affection for patients within ethical (and legal) boundaries. The puzzling Munchausen Syndrome is well depicted, along with the more dangerous Munchausen by Proxy. A New York Times reviewer states, “The almost psychopaths are inherently fascinating; they may rise high and fall low…or simply cause smaller miseries in their roles as controlling spouses, manipulative colleagues or uncontrollable teenINC. agers. At work, they may be compeA REGISTRY & PLACEMENT FIRM tent, self-disciplined and highachieving. At home they may be charming and lots of fun. And on the inside they may be just as morally empty as any true psychopath, but Nurse Practitioners ~ Physician Assistants the almost-psychopaths are grounded enough to keep some of their worst instincts in check, staying employed and out of major legal trouble.” Protecting ourselves and others from hazards of these abnormal personalities, and from our own worst potential behaviors, is outlined. Locum Tenens ~ Permanent Placement Recognizing and dealing with the need for therapy is a key topic. Written for a general audience, this 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 book is especially meaningful for us FA X : 8 0 5 - 6 4 1 - 9 1 4 3 in the healing professions.

Tracy Zweig Associates Physicians

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m


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CMA/Sierra Sacramento Valley Medical Society sponsored Health Insurance Program

Is your health insurance open enrollment soon? Are your rates going up? Want to shop? Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2017. The open enrollment period for individual and family plans starts on November 1, 2016. Many practices have open enrollment periods for small groups on December 1 or January 1. Did you know that you can get the right insurance though the CMA/Sierra Sacramento Valley Medical Society sponsored Health Insurance program with Mercer? If you are covering yourself, or if you’re responsible for providing coverage for your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. Working with the largest insurers in California, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.

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74510 (11/16) • Copyright 2016 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

Trilogy By Eric Williams, MD

Resilience Calabash rounded and dried Shining and brown Filled with precious possessions She carried her burden Balanced upon her head by day Through the dust laden wind blown streets Pitted trails and rooted roads Obstacles in the path of the tired and inattentive pilgrim We travel this road our parents walked Though the rocks, roots and trails appear different We balance our bowls upon our heads Though we may stumble we dare not fall For we have a history and a legacy and a tradition To walk upright chest out and proud by day

Balancing our possessions and our legacy and our tradition in our bowls upon our heads While In the privacy of our hearts and in the dead of night When no one else is there to share We remove our possessions And bow to our calabash and cry our bowl to overflowing with our tears To quench our thirst and to wash our dusty feet and prepare for the next day’s obstacle-filled journey For that is our pride and our struggle and our strength We will bow but will not break, strong and tenacious and resilient by day and privately human by night.

Without A Place Called Home What does the refugee see As she travels the dusty ragged pathway of human suffering She knows not where she goes and what awaits She suffers the arrows of the rejected, the unwanted, the maligned. Words of hate and anger and venom and of fear are slung as from a hand filled with rocks Harsh words do hurt They are rough and strike a blow as hard as any stone


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They wound as deeply as any knife plunged into the gut of an old man or an innocent sleeping child They are as deadly as a gun held to the head of a woman willing to carry all her possessions and her pride To a place she knows not where To a people who do not care To a collection of drafty rotting tents which she and her family will call home She sleeps, she dreams.

Time Past, Time to Come I dream vivid dreams of time past And of childhood gone I walked past the fallen old hut Which was once a house, Past branches of the short mango tree bare except for a single ripening fruit Past the bush of thorns also with fruit, Past the slippery rocks at the river’s edge glistening with moss and threatening to toss me into the raging waters if I should slip

I smell the smells of childhood of home, of parents and of meals shared I hear the sound of laughter past those thorns and slippery rocks where care is needed to reach the other side To home, to safety, to family I awaken to life To its struggles and to its rewards To the noises of human joy And to the cries of human suffering To the rewards of careful dedicated work I dream vivid dreams and live what I remember. −eric.s.williams@kp.org

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November/December 2016


New MACRA Rules Make Pay Cuts Less Likely Asking for what we need – a proof that communication works

By Dr. Barbara Arnold, District XI Alternate-Delegate, CMA Delegation to the AMA

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

ON SEPTEMBER 8, 2016, most welcome news came from acting CMA administrator, Andy Slavitt, on his CMA blog. As long as physicians do some reporting in 2017, they can steer clear of a penalty in 2019. Organized medicine, led by the AMA and other major specialty physician organizations, has asked the government to delay the new payment system kick-off until July 2017. But, instead of a delay, comes a promise of physicians picking their “own pace“ in implementing the Quality Payment Program (QPP), allowing all those who submit some data to the QPP to avoid a negative payment adjustment. The options and other supporting details will be described fully in the final rule expected by November 1, 2016. First Option: Test the Quality Payment Program. As long as some data are submitted, the negative adjustment is avoided. This is designed to ensure that the system of submitting data is working, and that practices can prepare for broader participation in 2018 and 2019. For those practices on paper charts, submitting data through a registry can get one into the reporting system. Most specialties have registries, and now can be the time to begin the process for 2017 submissions. Second Option: Participate for part of the calendar year. This means that your first performance period could begin later than January 1, 2017, and your practice could still qualify for a small positive payment adjustment. One can select from the list of quality measures and improvement activities available under the


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QPP program. Third Option: Participate for the full calendar year, beginning January 1, 2017. This could qualify a practice for a modest positive adjustment. Fourth Option: Participate in an Advanced Alternative Payment Model in 2017. It is unlikely that most specialists will be participating in Advanced APM, but CMS is holding up a 5 percent incentive payment for those who may get such a program off the ground. Penalty avoidance can be a real relief to the medical community at large, and looks to be worth the effort. Considering that many practices have totally avoided reporting, this leaves a pool of physicians who would be subject to negative payment penalties and, thus, increase the modest dollar amount available for positive adjustments for those who do report. Now is the time to consider affiliating with a registry for data collection. When Andy Slavitt presented to the AMA House of Delegates in June of 2016, he invited and encouraged physicians to give input into helping make the new system work. Concerns were expressed for small and rural practices. These modifications come as a sign that Slavitt is listening. For more information, go to https://blog. cms.gov/2016/09/08/qualitypaymentprogrampickyourpace/. bjarnold@ucdavis.edu

The Zika Scare By Glennah Trochet, MD LAST YEAR, WE WERE ALL discussing Ebola and how it arrived at our shores. Public Health Departments throughout California developed elaborate plans, as did hospitals, to deal with this disease. This year, the infectious disease of greatest concern is Zika virus, which has arrived at our shores, first with people who had traveled to regions where it is now endemic, and now with reports of infected mosquitoes and disease acquired in the continental United States. There is much that is not known about Zika virus. Recommendations for diagnosis and follow-up (to date there is no known treatment) change frequently. Because Zika virus could become endemic in the United States, it is important for clinicians to stay informed of the most recent recommendations for patient care.

General Information Zika virus was first identified in the Zika Forest of Uganda in 1947, in the blood of a sentinel Rhesus monkey. Like dengue and Chikungunya, it is a flavivirus that is spread by the bite of Aedes species mosquitoes. Although it was known to be widespread in Africa, and about 14 cases of human disease were described since it was first discovered, Zika virus remained of interest mostly to researchers until 2007 when it caused an outbreak of disease in the Yap state of Micronesia. Initially, that outbreak was

misidentified as dengue fever, but local clinicians noted that the symptoms were different. Eventually, PCR (Polymerase Chain Reaction) studies identified Zika virus. This was the first time that the virus was found outside of Africa. After that, the virus was identified in specimens of people who were ill in or had traveled to Cambodia, Philippines, Thailand and Malaysia. By 2013, the virus had spread to French Polynesia, with an outbreak in the Easter Islands reported in 2014. In March of 2015, the virus was identified in Brazil, in an outbreak in Bahia state. Since then, there have been anywhere from 440,000 to 1,300,000 cases of Zika illness in Brazil. The outbreak now extends to most countries in South America, Central America and Mexico, as well as island nations of the Caribbean. Along with the spread of the virus, the clinical picture of Zika virus illness has changed. Initially, in Africa, the disease was described as being self-limited, with mild symptoms including fever and a maculopapular rash. During the outbreak in Yap State, the illness continued to be described as mild, but including arthralgia and conjunctivitis. No hospitalizations occurred. The outbreak in French Polynesia included an increase in Guillain-Barre syndrome, not previously described, and other outbreaks have described meningoencephalitis and myelitis. The outbreak in Brazil has been associated with an increase in Guillain-BarrĂŠ and microcephaly in infants of women infected with the virus. As of September 28, 2016, 59 cases of locally-acquired Zika infection have been reported in Florida, and infected mosquitoes have been detected there. The vectors of the disease in the Americas are mostly mosquitoes of the species Aedes Aegypti and Aedes albopictus. These mosquitoes November/December 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.


are aggressively day-biting, and lay their eggs in small, artificial water containers. They fly short distances. The eggs can remain viable for months after desiccation, which makes control of the population very difficult. The current clinical presentation of Zika virus infection continues to have mostly mild symptoms of fever, rash, arthralgias and conjunctivitis. More severe cases may have myalgias and headache. The symptoms last about a week and severe disease, requiring hospitalization, is uncommon. Fatalities from Zika virus are rare, but Guillain-Barre syndrome following a case of Zika has been reported. There is no known treatment for Zika virus illness, and no current immunization against it. Zika virus infection in pregnant women has been strongly associated with microcephaly and other brain abnormalities in the fetus. In addition to mosquito bites, Zika virus can also be spread through sexual contact with a man or woman who is actively infected, even if the person has no symptoms. It appears that Zika virus persists in semen longer than in other body fluids, but currently it is unknown how long.

Zika Disease in California California has a strong mosquito-vector control system that is locally funded, giving us more protection from mosquito borne diseases than many states have. Both Aedes Aegypti and Aedes albopictus have been detected in California, and there is active surveillance for them throughout the state, which is regularly updated. (See www.cdph.ca.gov/HealthInfo/ discond/Documents/AedesDistributionMap.pdf) Zika disease is reportable to your local health department. In order to control the spread, it is important to report suspected illness early, even before laboratory confirmation is available. Once a case of Zika infection is identified, the mosquito/vector control district can set traps for mosquitoes close to where the patient lives to check for both the species and for infected mosquitoes. In addition, steps can be taken to destroy mosquito larvae and eggs, as well as adult mosquitoes. These steps are proven to


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help control the spread of these diseases, and even eliminate them. Sacramento County had endemic malaria until the mid-20th century. Once the Sacramento-Yolo Mosquito Vector Control district was created, locally-acquired malaria was eliminated. But even now, when there is a case of malaria reported in either county, the vector control district takes steps to ensure that no mosquitoes are infected in the vicinity of the case’s home. As of September 30, no Zika infected mosquitoes have been detected in California and there is no evidence for locally-acquired disease. As of September 30, 2016, 305 travelrelated Zika infections had been reported in California. Sacramento County has reported five cases and Yolo County has reported four cases, while El Dorado County has had none so far. As of that date, 38 pregnant women in California had tested positive for Zika virus and two infants have been born with Zika related abnormalities. California participates in the National Zika Pregnancy and Infant Outcomes Registry with data collected during and after pregnancy. Professionals caring for pregnant women who have been infected by Zika, can participate. Your local health department can help, or you can go to www.cdph.ca.gov/HealthInfo/discond/ Pages/USZikaPregnancyRegistryforHealthcareProvi ders-HowtoParticipate.aspx. Physicians who suspect that they have a patient with Zika virus should contact their local health department for information and help. Although recently, commercial labs have started offering Zika testing, results still need to be confirmed in a public health laboratory where dengue and Chikungunya infections can also be ruled out. For more information on testing for patients who may have been exposed to Zika virus, see www.cdph.ca.gov/programs/vrdl/Documents/ CDPHZikaVirusTestingFAQsforHCPs.pdf. In summary, although Zika virus has been known for 60 years, the virus has gained clinical significance in the past 10 years, with widespread infections in the Americas since

2015. Knowledge about the virus and its effects is constantly changing, as are recommendations for testing and treatment. Clinicians who encounter patients with suspected or confirmed Zika virus infection, should report it to the local health department in order to receive help with testing and follow-up as well as to protect the rest of our community from the spread of the disease. It is possible to prevent this virus from becoming established in California, if we all work hard to control it. If we do not succeed in controlling the spread of Zika virus in our state, we will need to begin large-scale planning for the lifetime treatment of children who are disabled because of this disease. trochetg@gmail.com Reference The Lancet: Zika virus: history of a newly emerging arbovirus, Nitwara Wikan, PhD, Prof Duncan R Smith, PhD, Published Online: 06 June 2016 http://thelancet.com/journals/laninf/article/ PIIS1473-3099(16)30010-X/fulltext

CLASSIFIED ADVERTISING 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. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: managers@willowclinic.org. 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.

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November/December 2016


California Legislative Updates By Richard Pan, MD, MPH, State Senator

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.

THIS IS A REMARKABLE TIME for California and Sacramento. California is now the 6th largest economy in the world. Our state is among the top states in job growth, and growth in our state’s gross domestic product is more than twice the national rate. In Sacramento, household incomes grew last year at the fastest pace in at least a decade, and poverty in our region fell by 1.4 percent, although median income is still below its peak in 2007. The number of uninsured Californians fell by half to 3.3 million, with an uninsured rate of 8.6 percent, well below the national rate of 9.4 percent. We continue to face many challenges, but our state government has been able to avoid the gridlock paralyzing the federal government. California passed an on-time budget which increased per-pupil funding for public schools, expanded slots for students to attend our California State University and University of California campuses, and created financing for building affordable housing for people with mental illness and chronic homelessness, while building the state’s budget reserves to increase fiscal stability. This year’s budget included $33 million for primary care residency programs including clinic-based training sites. For the Sacramento region, the budget included $1.3 billion for state building construction. Our region also received $40 million in transportation funds for the Sacramento streetcar project and to increase Capitol Corridor service to Roseville. The state renewed the Managed Care Organization tax to avoid an over $1 billion reduction in the Medi-Cal program and increased


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funding for services for the developmentally disabled. Unfortunately, efforts to increase Medi-Cal rates were not supported by the Administration. As I write this article, many bills that were heard during our two-year legislative session await the Governor’s signature, and voters have yet to decide on the 17 propositions on the ballot. But this legislative session is particularly notable for public health and environmental legislation. Last year, California abolished personal belief exemptions to required school vaccines, and school districts are now implementing this law. The California Department of Public Health will be releasing this school year’s immunization rates in the beginning of 2017, which we hope will show further gains in restoring our community immunity to vaccine-preventable diseases. The legislature also set new goals for use of renewable energy, and this year, SB32 mandated an additional 40 percent cut in greenhouse gas emissions by 2030. California took several major steps in the fight against tobacco. The state will regulate vaping products as tobacco products; the legal age to purchase tobacco products or smoke was raised to 21 years, and additional locations, including school offices and owner-operated businesses, are now tobacco free. I authored a bill to increase the tobacco tax to $2 per pack. The bill was heavily opposed by tobacco companies and was unable to obtain the 2/3 vote needed, so a coalition of health advocates, including the California Medical Association, put forth Proposition 56. The proposition will reduce youth smoking and increase funding for Medi-Cal, thus reducing the need for

taxpayers to subsidize the $3.5 billion annual cost of tobacco-related diseases to the program. In addition, 8th grade students in Elk Grove sponsored SB977, a bill I authored to ban tobacco use near organized youth sports events. California also passed several laws in response to the chronic tragedy of gun violence limiting magazine capacity to 10 bullets, requiring a background check to purchase ammunition, and restricting the lending of firearms or purchasing firearms with the intent of giving or selling the weapon to someone else.

California is on the path to becoming the nation’s leader in firearm research… I partnered with Senator Lois Wolk to take a public health approach with funding a gun violence research center at UC Davis in the budget and authoring SB877 for the state to compile data on violent deaths and participate in the National Violent Death Reporting System. Between these legislative efforts, California is on the path to becoming the nation’s leader in firearm research, filling the gap left by a lack of research activity at the federal level. Since first coming to the legislature, I have also authored bills to add Severe Combined Immunodeficiency and Adrenoleukodystrophy to the California newborn screening program. However, it was clear that having to pass a bill for each condition can delay implementation of life-saving screenings. This year I authored SB1095 requiring California to add to the state newborn screen all conditions within two years of being included in the federal Recommended Uniform Screening Panel after rigorous scientific review. The Governor signed the bill, and the new law will prevent disability and premature death by expanding screening for rare metabolic diseases at birth. Health care delivery and costs were the focus of many bills. I authored bills to eliminate inappropriate incentives to physicians performing independent medical reviews for

worker’s compensation to deny claims. Working with medical examiners, I and Senator HannahBeth Jackson authored SB1189 requiring autopsies to be performed by physicians and to protect public confidence in the objectiveness and quality of autopsy reports. California Children’s Services, a program to assure access to pediatric subspecialty care for children with special needs, was originally proposed by the Medi-Cal agency to be rolled into Medi-Cal managed care plans in several counties, but I worked with families, pediatricians, and advocates on a bill to include protections for the child and families. Bills on “surprise billing,” sought to prevent patients from receiving bills by out-ofnetwork physicians, received strong support from consumer and labor groups. The final legislation still does not adequately address the fundamental cause of “surprise bills,” which is the need for health plans to have adequate networks of hospital-based physicians under contract. However, it is a significant improvement from the original legislation. A few bills that did not pass should be noted. A bill that requires physicians who are on probation to disclose to patients the allegations by the medical board, not the actual findings leading to probation after due process, was defeated on the Senate floor. Unsafe scope-of-practice expansions for naturopaths, optometrists, and nurse practitioners were also held in committee and prevented from becoming law. It is an honor to represent the 6th Senate District and to bring my knowledge and experience as a practicing physician to the state legislature. I appreciate working with my colleagues at the Sierra Sacramento Valley Medical Society and the California Medical Association to bring that important perspective to public policy and law making. Through our collaboration, we have strengthened public health policy for the benefit of our community and all of California. I look forward to further achievements in the upcoming 2017-18 legislative session. senator.pan@senate.ca.gov

November/December 2016


SSVMS Railroad Museum Soci THE SSVMS FALL SOCIAL EVENT was held September 10 at the California State Railroad Museum. It was a free, private gathering for physicians and their families, and was a great time to visit with colleagues while enjoying this Sacramento treasure. Photos by David Flatter, (flickr.com/davidflatter)


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November/December 2016



Cure A Journey Into the Science of Mind Over Body, by Jo Marchant; Crown Publisher; ISBN-13: 978-0385348157

Reviewed 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.

MY FIRST DUTY STATION as an Army physician was at the Lyster Army Health Clinic at Fort Rucker, Alabama. I worked in the adult medicine walk-in section a couple of half days per week while I attended the Army Aviation Medicine course. And it was there where I first purposely prescribed placebos. The pharmacy had available small, brightly-colored capsules, bright red on one end, brilliant blue on the other, which was labeled “Sule.” One could write a prescription for Sule if you were sure that there was nothing seriously wrong with the patient, and you were dealing with a self-limited, minor affliction. Most of the patients were training to become helicopter pilots or flight crew members. If they were given pills containing codeine or muscle relaxants that might have an adverse CNS effect, it was our duty to report that to the patient’s commander, and then the fight crew member might not be able to fly for several days or even a few weeks. They were all eager to fly, so prescribing Sule for a lumbar strain or a nagging cough was a perfect choice, and I could reassure the patient that the drug would not affect his flight status. It was common for patients to return for refills. In her book published this year, British science writer, Jo Marchant, delivers a detailed and very readable overview of the placebo effect and its importance, not only to a neuroradiologist at the Mayo Clinic, but to the Chinese herbalist in Cambridge, MA, and to the homeopath in London. In 2005, a Minnesota resident named Bonnie Anderson, a 75-year-old retiree and avid golfer, fell at home and immediately had


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disabling, low back pain. She was found to have an osteoporotic compression fracture. Her pain was unremitting, and she lost her ability to play golf or even to perform minimal domestic activities. She heard about a relatively new and increasingly popular procedure called vertebroplasty, which had first been done in France in 1984, and now was in common use in Europe and the USA. Cost was an issue, so she signed up for a subsidized single-blind study at the Mayo Clinic under the direction of interventional neuroradiologist David Kallmes. Anderson knew that she might be placed in the sham procedure group, but the price was right and she reckoned that she had little to lose. She was in the sham procedure group and walked out of the hospital free of pain, and so she remains now nine years later. Her sham procedure cohort did just as well as their properly injected opposites. Kallmes and his team published their results in the NEJM in 2009. A few years before Bonnie Anderson was treated for her back pain, Victoria Beck took her 3-year-old autistic son, Parker, to see Karoly Horvath, a gastroenterologist at the University of Maryland. Parker was beset by a panoply of abdominal complaints, and Horvath performed an upper GI endoscopy as part of the workup. Soon after the procedure, Mr. and Mrs. Beck noticed a spectacular improvement in Parker’s autistic symptoms. Victoria Beck became convinced that her son’s dramatic improvement was due to an injection of secretin that he had received as part of Horvath’s exam. She begged Horvath to give Parker another dose of secretin, but he refused

on the grounds that it was not approved for such use. So Victoria Beck endeavored to contact autism researchers and specialists throughout the country to ascertain whether anyone had noticed similar phenomena, or perhaps one or more of them would be willing to give Parker some more secretin shots. She soon heard from Kenneth Sokolski, a psychiatrist at UC Irvine, whose own son was autistic. Sokolski gave his own son a shot of secretin and observed an obvious improvement. When Horvath found out about Sokolski’s result, he himself found a third autistic child, administered secretin to him, and again apparent benefit was observed. Victoria Beck finally found another doctor willing to re-inject Parker, and he again improved for a while. In 1998, Parker’s story was featured on the NBC show “Dateline,” and soon parents of autistic children were clamoring for secretin injections and petitioning the FDA to approve its use for autism. The uproar prompted Horvath and Adrian Sandler, a pediatrician in Asheville, NC, to perform a single-blind study using intravenous secretin or saline solution in 60 autistic children. The study failed to prove any benefit for secretin. Horvath protested that multiple doses might be necessary to promote improvement and 15 subsequent studies were done, some involving multiple injections. The results were the same. The Henry Spink Foundation in the UK now sells homeopathic secretin pills and transdermal powder that parents can use without medical supervision. The pills cost about $10 each and the powder about $25 per dose. At Harvard, Ken Kaptchuk is Professor of Global Health and Social Medicine. Not an MD, he has a Chinese doctorate in Oriental Medicine. He wrote a brief review titled “Placebo Effects in Medicine” in the NEJM in 2015, and his 2014 “TED” talk about placebos, about 17 minutes long, is worth watching. Kaptchuk made headlines a few years ago when he began to prescribe placebos for patients who had a variety of chronic, and apparently benign, complaints. He told many patients that he was giving them completely

inactive pills, and often the bottle was labeled “Placebo.” In one trial consisting of 80 people with long-term and occasionally-disabling irritable bowel syndrome, the placebo group, who were told that they were, indeed, taking a placebo, reported much more relief from pain and irregularity than those who received the usual counseling. Kaptchuk calls his pills “honest” placebos as opposed to the “dishonest”

Colored pills work better than white ones. Green is best for anxiety, blue for sleep, and red for pain. ones that I prescribed at Fort Rucker. From Kaptchuk’s and others’ work, some general truths have emerged. Big pills work better than small ones, and capsules work better than tablets. Colored pills work better than white ones. Green is best for anxiety, blue for sleep, and red for pain. Sham injections and sham acupuncture work better than pills and most effective of all is sham surgery. But, Kaptchuk reports, when he asks an audience of physicians if they were presented with irrefutable evidence that “honest” placebos worked well for a certain condition, would they then prescribe it? “Not a single hand goes up,” he says. Ms. Marchant’s book, however, is not just a string of stories about a placebo effect that is reliably elicited by brightly-colored capsules or sham injections and procedures. She delves into the “mind-body” relationship. Can our “mind” truly cause biochemical and physical changes? In 2009, Elizabeth Blackburn, now president of the Salk Institute and at that time a biochemist and cell biologist at UC Berkeley, won the Nobel Prize for her co-discovery and characterization of the enzyme telomerase, which helps maintain the health of our chromosomes. As part of her research, she and her colleagues discovered that women who reported physical abuse or continued on page 23

November/December 2016




To Join SSVMS and CMA

COMMITMENT TO THE PROFESSION: By joining SSVMS and CMA, physicians affirm their commitment to the profession of medicine and to preserving its honored place in modern society.

LEGISLATIVE ADVOCACY: Ensure physicians have a voice and remain in control of medicine this year and in years to come. By speaking as a united voice, SSVMS/CMA exert a powerful influence on health policy and public health issues at the local, state, and national levels.

IMPROVING COMMUNITY HEALTH: SSVMS is a leader in our local communities in providing care for the medically indigent and uninsured through our SPIRIT program and addressing local public health issues such as mental health, vaccines, and safe prescribing.

PROTECTING MICRA: SSVMS and CMA continue to work diligently to protect the Medical Injury Compensation Reform Act (MICRA). Prop 46 was soundly defeated, saving physicians practicing in the Sacramento region an average of $93,000 per year in liability insurance premiums.

PRACTICE MANAGEMENT ASSISTANCE Resolve contracting, billing, and payment problems with one-on-one assistance from CMA’s team of practice management experts.

“Working together, the Sierra Sacramento Valley Medical Society and the California Medical Association are strong advocates for physicians from all modes of practice and for the profession of medicine.”

PRESERVING MEDICARE: SSVMS/CMA successfully eliminated Medicare’s SGR and GPCI inequities. Beginning in 2017, physicians in the Sacramento region will see Medicare increases between 1.6 – 6.6%.

OPPORTUNITIES TO GET INVOLVED: Participate on a committee or council, volunteer through SPIRIT, serve on the Board or Delegation to the CMA House of Delegates.

FOSTERING COLLEGIALITY: SSVMS and CMA bring doctors from all parts of the medical community together – through leadership, cooperation, social gatherings, and service.

FOCUSING ON WHAT’S REALLY IMPORTANT TO YOU: SSVMS and CMA provide access to a powerful staff of experts to help protect the viability of your practice so you can focus on what’s really important: your patients.

COMMITMENT TO THE PROFESSION Your support of SSVMS and CMA through membership affirms your commitment to the medical profession and ensures physicians remain in control of medicine this year and in years to come.

PLEASE JOIN OR RENEW YOUR MEMBERSHIP TODAY JOIN ONLINE: www.ssvms.org/membership/join-now.aspx RENEW YOUR MEMBERSHIP ONLINE www.ssvms.org/Membership/RenewandPayDues.aspx

CONTACT SSVMS: 916-452-2671 or info@ssvms.org

who had dysfunctional domestic situations had much more visible chromosomal damage as well as lower blood levels of telomerase than age- and race-matched women who reported a “low” or “normal” domestic stress environment. Marchant writes, “The most frazzled women had telomeres that looked 10 years older than the women who were least stressed.” In the Nicoya region of Costa Rica, a 60-year-old man has a life expectancy of 22 years, the highest in the world. If he makes it to 90, he can expect another 4.4 years of life, also the world record. Nicoya is one of the “Blue Zones” in the world where life expectancy is very high in spite of typically hardscrabble lifestyles, monotonous diet and minimal, if any, modern health care. Are the Costa Rican Blue Zoners blessed with high levels of telomerase and longer and more robust telomeres on their chromosomes? It turns out that they are. Is it all genetically based? Apparently not, since Nicoyans, who moved out of their home region, lost their longevity advantage. And Dr. Luis Rosero-Bixby, an epidemiologist at the University of Costa Rica, who has carefully studied the Nicoyans, found that the healthiest Nicoyans had predictable and regular family and community social encounters, and the strongest predictor of geriatric health was regular contact with young children. Marchant ends her book with stories about her own experiences as a volunteer at Lourdes where, “cured or not, everyone feels that they have experienced a miracle.” She interviews a woman with breast cancer who chose to seek a cure through “German New Medicine” which teaches that breast cancer occurs in women “who are conflicted regarding their loved ones or their own role as a mother.” She met the lady, by that time riddled with metastatic disease, at Lourdes where the poor lady seemed to achieve some peace of mind. She, of course, died soon thereafter. Marchant’s book is worth reading. At least give Ken Kaptchuk’s TED talk a look to get the flavor of modern placebo research.

Pixel People By John Loofbourow, MD Images appear every day and night; I look but do not see the pixelated sight of flesh that vegetates in bombed out homes, and the calcined white of a million femur bones, under smoke-yellow skies where every tortured shade flees chaotic lands where Gods are all man-made; Silent pixel children whose huge sad eyes and thin dry husk of skin don’t feel the feet of flies; Resigned young women wait to be resold; shriveled brittle women empty things and old; Pixel justice dispensed to each sex, race and age according to the canons of fear and hate and rage; While talking pixel heads sell the same “Breaking News” and beer and cars and drugs and specious political views. Yet since images are unreal should I look but never see imagined pixel people Or smash my iPad and TV? john@loofbourow.com


November/December 2016


Closing the Gap – A Brief History of Suturing By Kent Perryman, Ph.D. THE PRIMARY PURPOSE OF sutures is to close open wounds and bind tissue together to prevent infection and promote healing. Over the course of hundreds of years, the medical community has seen suture applications expand with the development of new surgical techniques and materials. Biomedical research has contributed to improvements in tissue binding using developments in knot holding, suture patterns and thread materials. In this brief historical survey, the progression of suturing to mechanical and adhesive binding will be covered.


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.

In South America, ancient shamans used large black ants to bite the wound edges together. The insect’s mandibles would maintain the tissue closure acting as clips after the bodies were twisted off the head. In the Eastern hemisphere, the ancient Egyptians employed stitching to close tissue associated with the embalming process. Archeological dating of Egyptian mummies back to 1100 BC discovered that hemp thread was used to fulfill this procedure, as well as a means to close wounds. Honey was frequently applied over the sutured region to promote healing. Later, the Indian physician, Sushruta, described suturing as a method to seal wounds in the Susruta-samhita text during the Sushrut Samhita era (500 BC). Hippocrates developed his own preference of suturing techniques. Around 47 AD, the Roman encylopaedist, Aulus Cornelius Celsus, described suturing techniques in the tome De Medicina. A hundred years later, Galen would utilize suturing to repair internal gut injuries. Most of these early medical


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practitioners relied on the use of plant threads like hemp, flax and cotton for suturing that resulted in an increased risk for infection unless they were removed early on in the healing process. It wasn’t until the 10th century that Andalusian surgeon Abulcasis discovered that catgut sutures were absorbable by the body. Another millennia would transpire before new suturing materials would be developed. Many animal products such as hair and silk, as well as arterial, nerve and muscle fiber, became popular for stitching wounds, while needle materials such as silver, copper and bronze wire remained constant. During the Renaissance, ligation was also employed as a method to control bleeding during suturing. It was during this period that Ambroise Pare (1517–1590) made a number of wound care contributions to the field of surgery. Pare started his medical career as a barber’s apprentice and then later as a wound-dresser in Paris where he joined the army. Rather than treating gunshot wounds with boiling oil, a common practice at the time, he was instrumental in reducing the infection rates by merely cleansing the region and dressing them using ligatures and sutures instead of cauterization to close the injured region. Infections from nonsterile sutures were always of concern until the Scottish physician, Joseph Lister, in the 1860s routinely sterilized all his threads and needles with carbolic acid. Sterile catgut wasn’t introduced into surgical procedures until 1906. Today, even sterilized catgut has been banned in Europe and Japan due to concerns regarding bovine spongiform

encephalopathy. Later in the 19th century, the French surgeon, JulesEmile Pean, popularized the use of ligation using a hemostat and suturing to initially control bleeding. Another French surgeon, Alexis Carrel (1873– 1944), also contributed considerable knowledge to vascular surgical suturing techniques. Prior to Carrel, suturing would often injure the interior of blood vessels leading to clots. This surgical risk often discouraged physicians from performing vascular surgery. Dr. Carrel took sewing lessons and developed a method of folding back the cut ends of vessels into cuffs to minimize trauma. His needles and sutures were coated with Vaseline to further minimize damage to the vessel. Correl’s pioneering suturing techniques eventually led to successful organ transplants and bypass procedures, as well as landing him the Nobel Prize in Medicine in 1912. American surgeon, William Halsted (1852–1922), was also a pioneer in vascular suturing techniques, in addition to being the first physician to promote surgical residency training at Johns Hopkins Hospital. Halsted promoted the use of fine silk rather than catgut to minimize tissue damage and infection, as well as closing tissue layers one at a time. Silk, an ancient, non-absorbable thread, is still used in contemporary surgery, especially to secure drains. During the 1930s, the chemical industry introduced synthetic thread that resulted in the use of a number of absorbable and non-absorbable sutures. Polyvinal alcohol was used in the manufacture of the first synthetic absorbable thread in 1931. Polyesters were developed later in the 1950s with the process of radiation sterilization established for both catgut and polyester. Chromic gut was also introduced as tanned with chromium salts to increase its resistance to

absorption. Today, most absorbable sutures are made of synthetic polymer fibers, which may be braided or monofilament. Each manufacturer has their own-patented formulations of synthetic absorbable sutures guaranteed to be non-toxic to meet the physician’s demands.

The needle kit image and suture thread image, above, are both artifacts located in our SSVMS Museum of Medical History.

Mechanical Suturing Early suturing methods were not always successful in sealing tissue surfaces together, resulting in post-surgical mortality from leakage, especially with bowel anastomoses. The advantage intestinal staplers have over conventional sutures is the tissue edges of the wound are compressed tightly together, effectively closing blood vessels. Current suturing techniques and materials no longer pose this surgical problem, but mechanical suturing is still a more rapid procedure. Indeed, the development of laparoscopic surgery would not have been possible without mechanical staples. Up until the end of the 19th century, abdominal surgery was out of the question due to the common belief during those times that stomach wounds do not heal! In 1872, an Austrian surgeon, Theodor Billroth (1829– 1894), was the first to perform a successful stomach resection. This was the first serosato-serosa suture procedure performed on a human’s internal organs that would later be referred to as an intestinal suture. However, concerns at the time were main-

November/December 2016


William Halsted, above, was an American surgeon who pioneered vascular suturing techniques.


taining asepsis of the operating field by preventing bowel leakage. Iodine and carbolic acid could not be used in an open abdominal cavity. Some procedure or device was needed to eliminate the leaks of gastric and intestinal contents into the abdominal cavity. Voila!, along came Hungarian surgeon, Humor Hulti, who developed and pioneered the use of a mechanical stapler beginning in 1908. Dr. Hulti’s instrument was an eight-pound monstrosity and difficult to load as well as to maintain a consistent staple line. The device resembled an office stapler applying steel staples in a mucosa-tomucosa suture. After each surgical procedure, the devices were boiled and then cooled down with ether. Hulti discontinued production of his stapler after a medical student at the University of Budapest named Aladar von Petz introduced a device of his own design that could reduce the number of lines using silver staples. The “petzen” stapler became very popular in Germany. During the 1950s, the petzen staplers were further refined in the Soviet Union enabling Dr. Mark Ravitch to adapt their use for bowel anastomoses in the United States. Dr. Ravitch and Dr. Felicien M. Steichen, known as the “Fathers of Modern Stapling,” promoted and advanced modern stapling devices and techniques in the United States during the 1960s. Later, United Surgical Corporation began manufacturing their own stapler in 1964 under the brand name of “Auto Suture.” In 1977, Johnson and Johnson’s Ethicon division also began marketing surgical staplers. The first surgical staplers were made of stainless steel with titanium staples. Synthetic absorbable staples were later developed in the 1980s, based on polyglycolic acid. Modern staplers and

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cartridges are also made of disposable plastic.

Adhesive Suturing Medical-grade super glues, known chemically as cyanoacrylate adhesives, are becoming increasingly popular as intradermal sutures, especially in plastic surgery. Cyanoacrylates have been around since 1949, but until N-butyl2-cyanoacrylate was developed in 1970, they were not suitable for surgical purposes due to inflammatory reactions. A number of surgical adhesives marketed as Dermabond, Liquiband, Surgiseal and Floraseal have been used in cartilage and bone grafting, coating of corneal ulcers, repair of damaged ossicles, embolization of gastrointestinal varicies and neurovascular surgery. Generally, theses adhesives are employed with surgical procedures that require sutures smaller than 5-0 in diameters. Adhesive sutures are totally unsuited for oozing or potentially contaminated wounds. Occasionally, the patient may experience some heating effects during the application. The science of wound and tissue closure has made incredible inroads to prevent infection and promote healing in the last century. The medical profession has a number of wound close options at their disposal, depending on the surgical procedure, and the physician’s experience and comfort level. With that, I will close. kperryman@suddenlink.net References Pickover, CA. The Medical Book: From Which Doctors to Robot Surgeons, 20 Milestones in the History of medicine. 2012; Sterling Publishing. The History of the Suture. https://www. Medibank.com.au/bemagazine/post/wellbeing/the-history-of-the-suture. Scierski, A. From Ant to Stapler-100 Years of Mechanical Suturing in Surgery. http://www.termedia.pl/review-paper-from-ants-to -stapler8211-100-years-of-mechanical-suturing-in-surgery, 42,14929,1,0. html. Lons, AS. And Petrucelli,II, RJ. Medicine: An Illustrated History. 1978; Harry N. Abrams, Inc Pub. Bruns, TB. And Worthington, JM. Using Tissue Adhesives for Wound Repair: A Practical Guide to Dermabond. Am. Fam. Physician, 2000; Vol 61(5): 1383-1388. The author was unable to borrow a recommended copy of the following text - Steichen, MD. History of Mechanical Sutures in Surgery. 2008 ISBN 0-9788890-5-3.

Back the PAC By Nicholas Birtcil, Associate VP, Political Operations, CMA EACH YEAR, THE STATE legislature considers hundreds of pieces of legislation concerning the practice of medicine in California. Out of 120 legislators, only two are licensed physicians with experience delivering care in California. That’s a staggering statistic, given the legislature has the power to increase the cap on non-economic damages in the Medical Injury Compensation Reform Act (MICRA), change the scope of practice for non-physician providers, or lift the bar on the corporate practice of medicine. Simply put, we need more physicians in elected office. CALPAC, the political action committee of the California Medical Association (CMA), uses contributions from our physician members to support physician and physician-friendly candidates for elected office across California. With the support of our contributors, we’ve been able to build one of the most successful medical political action committees in the state. However, there is still work left to be done. Late last December, Assemblymember Henry Perea (D-Fresno) announced he would be leaving office early. Perea’s announcement set in motion one of the most contested special elections in recent memory between CMA member and emergency room physician Joaquin Arambula, MD, and Fresno City Council Member Clint Olivier. This race became even more important when Olivier made expanding the scope of practice for non-physicians one of his main campaign themes. With the support of our generous physician contributors, CALPAC was able to plan and execute an independent expenditure campaign in support of Dr. Arambula, which totaled in the hundreds of thousands of dollars. On

election night, Dr. Arambula secured 53.8 percent of the total vote and was sworn in as the assemblymember representing California’s 31st Assembly District. Fast forward six months: the State Assembly is in the final days of the legislative session. A piece of legislation to expand the scope of practice for “naturopathic doctors” is being debated on the Assembly floor. Dr. Arambula spent time meeting with each of his colleagues, explaining the difference between the training a physician receives in medical school and the training a “naturopathic doctor” receives at a naturopathic school. When the author of this particular bill called for a vote, it only received 18 ayes, less than half the total needed for passage.

...we’ve been able to build one of the most successful medical political action committees in the state. Your contributions help elect legislators who understand the importance of MICRA and the bar on the corporate practice of medicine, and why physicians should lead the health care team. With your support, CALPAC has set the stage for much of the success CMA has enjoyed in the state legislature. I hope you will join me this year in contributing to CALPAC by visiting www.calpac.org. NBirtcil@cmanet.org

November/December 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.


A 90-Hour Fast By John Loofbourow, MD

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

A FRIEND, WHO TENDS TO be overweight, went on a 40-day fast recently. His dad had done that several times during his life, and he, himself, had fasted for 40 days once before. He explained that he continued all of his ordinary activities as an interpreter during his fast, without any difficulty whatsoever. Maybe, I thought, that makes more sense for the average mortal person than fasting alone in the wilderness like Jesus, which might awaken devils. I had supervised students at UC Davis in a several-week, antiVietnam War fruit juice fast like those of Caesar Chavez. Yet, these were child’s play compared to my friend’s 40-day fast. Being in a mythic old age when one can be freely irresponsible, I was tempted to submit myself as subject in a primitive, uncontrolled experiment. I decided on a 90-hour fast because I wasn’t entirely convinced my friend was telling the whole story; and I don’t have enough fat to fast much longer without feeding on my frightened proteins; or worse — a fat little brain that might still be useful again someday. I’m generally healthy, given the over-burden of foolish years; my numbers and chemistries are ideal. (Whatever that means! Time suggests that today’s sacred truths are often tomorrow’s gross error.) Yet, I have type II diabetes, using the only sort of medication that seems to me both rational and effective — in this case, Lantus insulin — with an insulin pen for carb flings. My A1c is most always between 5 and 6, and I never have a very low blood sugar since I stopped the pills. Looking over some of the literature on fasting quite superficially, it appears there is some evidence that intermittent, brief fasting may be beneficial for humans. But wellconstructed human studies on longer fasts seem small, and over-controlled to the point of absurdity. Apparently, they are not profitable,


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and worse, are troublesome and costly. Not so in mice, where neither TV ads for victims nor informed consent are yet common. It appears that repeated cycles of 2-4 days with no food — over the course of 6 months — suggest that “…metabolic changes, as a result of prolonged fasting for 3 days or longer, drinking only water, reset some components of (the) immune system. Drop in white cell levels trigger(s) a stem-cell-based regeneration of new immune cells.” Well, of course, if you are a mouse! Yet, if mice and my friend could do long fasts, why not I? I decided to at least try. Day One begins at noon on Monday and ends the next noon. I cut the Lantus in half that morning and have a light lunch. The next 24 hours are inconsequential. Day Two begins at noon on Tuesday: I wake that morning, skip Lantus altogether, making breakfast of black coffee to avoid caffeine withdrawal headaches. I am building a fence and must dig post holes this afternoon. It is a hot day, but the work feels easy, and I experience no hunger at all. I wonder if it is only the activity itself that takes my mind off eating. The rest of the day, I read and write, my usual thing. In the evening, I ingest more water, some TV, and a dose of Netflix. Day Three begins at noon on Wednesday after a typical, glorious, cool sacred Sacramento Valley morning. I follow my usual 3x weekly schedule of light, upper body work: about 80 lbs.x18x6 — or 3500 ft. lb — and a modest halfhour on an elliptical trainer; just enough to sweat lightly and to roil the heart and lungs. I am still not hungry.1 Not at all. I retreat back to my books, and dig up an heirloom copy of Don Quixote; when one re-reads a good book during a later time in life, it can be a different book, a different voice. Cervantes has new meaning for me now; I relate better to his aging Don Quixote who,

again, sets off on his fanciful quest after years of reading too much, causing his relatives to fret. Day Four begins at noon on Thursday: It requires cementing in five fence posts, but I am still curiously animated and comfortable, despite triple-digit heat. Is it a harbinger of insanity? No, I see no windmills. In the afternoon, I read a book just published by a Peruvian friend, Milton P. My GI tract relaxes, having somehow produced faithfully until day four. Where did that come from? By 10 pm, the fast has lasted 82 hours; the next 8 hours are spent asleep. I am an easy sleeper, and the night passes quietly except for some vague dreaming. At the 90th hour: I awake. My only distinct memory of the night is being instructed, a bit tersely, to turn over and stop snoring. What were those dreams? I recall only the last one: I am, somehow, trapped on a tiny island no bigger than a mattress — until I dream that it’s a dream; to get off the island I must wake up. I am still not hungry, but dutifully restart Lantus; two hours later I breakfast on granola with milk and fruit. I suppose that makes my fast 92 hours, but, in the words of an eminent person, “At this point, what difference does it make?” There doesn’t seem to be any difference between the old and new me, except the old one has shed 9 lbs. During the next 10 days, 7 lbs. returns. Comment: I took no insulin during the entire fast; my blood sugars were always between 80 and 100. Is there any benefit to a several-day fast besides transient weight loss? You couldn’t prove it by me. I don’t recommend it, as in, “Don’t try this at home!” The little adventure did have its reward though; it got me back to Don Quixote for some insights consistent with my age and condition. Further, my fast reminds me of what a much-admired old friend, Skeets Railsback, said years ago when he reached an advanced stage of emphysema and stopped smoking. On the third day of withdrawal, I asked, “Do you think you’ll live longer now?” “(Cough, Cough Cough, Gasp) I don’t know. (Cough, Cough) But I sure as hell hope not!”

References 1 Possibly related to moderate gastroparesis; a diabetic, neurostunned stomach sleeps quietly.

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Tidbits from Lydia E. Pinkham’s Private Text-Book Upon Ailments Peculiar To Women, c1875 A sudden chill is most dangerous when one is in a menstrual condition, and every care must be exercised to guard against it. Intense mental excitement should be avoided. The extremes of merriment or anger, laborious study, or brain activity of any kind, are alike matters which may cause great injury.


November/December 2016


A Posit on a Little Nip and Tuck “My patients who have had cosmetic surgery are generally satisfied.”

Background: Of course plastic surgery is here to stay! We are fascinated by shows like “Extreme Makeover,” and, more recently, the show “Botched.” We marvel at how some celebrities don’t seem to age, and others become plasticized and weird. An article written in Time magazine last year by Joel Stein claims 15 million cosmetic procedures in the U.S. in 2014, more than twice as many as in 2000. Liposuction and breast augmentation are the top ticket items, but nonsurgical procedures, like botox and fillers, outnumber surgeries by 5 to 1. Salt Lake City has the most plastic surgeons per capita, and would you have ever guessed that Iran leads the world in rhinoplasty? http://time. com/3926042/nip-tuck-or-else/. As physicians, we’ve seen many of our patients go under the knife to try to roll back the years. Some of us may have done it ourselves or are considering it. Is less more, or is more more? Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows: 13 agree/1 disagree. 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 cannot recall any dissatisfaction among my plastically-surgerized patients, and I was a family practitioner in California from 1976 to 2011. –Jack Ostrich, MD Plastic reconstructive surgery creates satisfaction also. –John Young, MD They seem to be satisfied. Or, they are too embarrassed to admit they shouldn’t have done it. I’ve had a few undergo liposuction and wonder why their torsos look like lumpy


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pillows. I can’t believe women are happy when their breast augmentations years later look like balls hanging in a sock. And, no one knows how satisfied those who die from the procedure are (reportedly as few as 1 in 57,000 to as many as 1 in 2,340). –Ann Gerhardt, MD I disagree. Patients with prior histories of cosmetic surgery present with some frequency to allergists with complaints related to (or perceived by the patient to be related to) procedures such as rhinoplasties and implantation of synthetic materials. Granted, the nature of the specialty is such that the patient population may differ from the average pool of cosmetic surgery recipients. However, it has been my experience that patients, who underwent a surgery because they were dissatisfied about a personal attribute, sometimes experience a recurrence of dissatisfaction a few years down the road. –Sean Deane, MD You betcha!  Personally, I am a fan of public art. – Gerald Rogan, MD I agree, doing Ob/Gyn, a day does not go by that I don’t see several patients that have had something done (breast, tummy tucks, liposuction, eyes, etc.). The vast majority are extremely satisfied, although occasionally, I see one that is not satisfied, and these are the patients that many times are redone by another plastic surgeon and are still not satisfied. The surgical techniques have become so good that the external scarring is minimal and sometimes not even detectable. We also are fortunate in this area to have many excellent plastic surgeons, and some that specialize in certain areas of the body. It is also very special to see a patient,

after having mastectomies for breast cancer, end up very happy with her reconstructive breast surgery done by expert hands. –Jose Cueto, MD Well-done plastic surgery can enhance appearance for those who wish it. But repeated plastic surgery by people who are a bit crazy is often a disaster. Plastics surgeons need to be part psychiatrist to filter out the surgery junkies. −Joanne Berkowitz, MD I am so interested to see others’ comments. As a private practice plastic surgeon, I tend to see a majority of patients who are happy with their results. When someone is not satisfied, they tend to not return for follow-up care, see another plastic surgeon, or provide anonymous venomous feedback online. As a practitioner, motivated to improve, it is hard to get this feedback; however, it helps and allows for practice, and hopefully, better care. I am motivated to make patients happy; however, plastic surgery only changes the outside appearance, and on occasion, your assistance is required to facilitate a great outcome. Thank you all

for your comments and help in caring for our community! Another issue I have noticed more recently is that some patients are cared for by non-plastic surgeons practicing cosmetic surgery. Many of these are core specialties (ENT, Oculoplastics, Dermatology) and are well trained. However, on occasion, I have cared for patients who have been cared for by non-core trained physicians, and when the outcome is less than optimal, the patient’s trust in the medical community has been eroded. This might be another question for the future, as well as: Do results differ when the cosmetic surgery is done by a solo practitioner versus a chain such as Sono Bello or New Body MD? Another issue with this are the itinerant plastic surgeons or cosmetic surgeons coming in for the chain operating in the area, and then leaving the city and the patient to be cared for by those who live here. It is an interesting time in medicine. –Charles Perry, MD

November/December 2016


Board Briefs September 12, 2016 The Board: Approved the Second Quarter 2016 Financial Statements, Investment Reports and Recommendations. Approved a request for a NO Position on Proposition 61, the California Drug Price Relief Act Ballot Initiative. Approved the 2017 appointment of chairs to SSVMS Committees as follows: Peter Hull, MD, Chair, Emergency Care Committee; Bob LaPerriere, MD, Chair, Historical Committee; Glennah Trochet, MD, Public & Environmental Health Committee; Margaret Parsons, MD, Scholarship & Awards Committee. Approved the nomination of Richard Jones, MD, and the re-nomination of Ruth Haskins, MD, and Lee Snook, MD, to the CALPAC Board of Directors. Approved the Nominating Committee Report regarding nominations to vacancies on the Board of Directors and the Delegation to the California Medical Association for 2017. Approved a proposal to streamline the SSVMS membership credentialing process in an effort to promote broader membership among physicians in the Sacramento region. Approved a dues increase for GovernmentEmployed Active members in accordance with similar action taken by the CMA Board of Trustees in July. Approved the Membership Reports: For Active Membership — E. Taylor Abel, MD; Shanthi Aribindi, MD; Suleiman Assaf, DO; Samantha Elise Ellinwood Auman, MD; Alok Banga, MD; Braden W. Boice, MD; Carmen E. Carazo-Gonzalez, MD; Nisha Chakraborty, MD; Muhammad Ibrahim Choudry, MD; Bo I. Chung, MD; Kiah Connolly, MD; Michelle Corbier, MD; Martin DuFour, MD; Tara Dutta,


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MD; Cesar Augusto Estela, MD; Nathan Fairman, MD; Matt Frankovsky, MD; Christine Gisel Chu, MD; Deepika Srinivas Goshike, MD; Kaitlin Herald, DO; Lindy Hong, DO; Sonia R. Joseph, DO; Choo-Won Kim, MD; Joy Kim, MD; Alan Koike, MD; Max Kong, MD; Devinder Kumar, MD; Michael Sunoh Kwak, MD; Steven Lalliss, MD; Kathleen Lynn Larkin, MD; Amy Ledgerwood, MD; Paul Sung Lee, MD; Yauk K. Lee, MD; Christine F. Lin, MD; Wutt Yie Linn, MD; David Liu, MD; Eleanor A. Loomis, MD; Sonia Mahajan, MD; Laura L. Maselli, MD; Carlos Alonso Medina, MD; Antonio Merez, MD; Maud Morshedi, MD; Denise Nguyen, MD; Maiuyen T. Nguyen, MD; Minhchau Nguyen, MD; Murat Pakyurek, MD; Madison Pham, DO; Thomas Pashalides, MD; Abdul W. Raif Jawid, MD; April M. Ramelli, MD; Tooba Rehman Jahangir, MD; Jason Roof, MD; Karanpal Sandhu, MD; Ming-Jie Sharman, MD; David J. Sloss, MD; Pankaj Ranjit Ranka, MD; Kristen Jonelle Reid, MD; Frank E. Reyes, MD; Joseph Alan Rogers, MD; Patrick James Sanchez, MD; Justin L. Stimac, MD; Frederick Y. Su, MD; Shabnam Khashabi Taylor, MD; Hendry Ton, MD; Dominique A. Trappey, MD; Maria Tsiu, MD; Neal Abraham Varghis, MD; Polina Volodarskaya, MD; Megan J. Wolf, MD; Peter Wei-Ju Wu, MD; Peter Yellowlees, MD. For Reinstatement to Active Membership — Adel Agaiby, MD; Dale Cotton, MD. For Resident Membership — Florence ChauEtchepare, MD; Wei (Wendy) Diao, MD; Julie Carin Garchow, MD; Salla Inkeri Hennessey, MD; Joshua Lee, MD; Daniel Mabardy, MD; Elizabeth Schamber, MD; Geneva Ann White, MD; Melissa Wilcox, MD. For Resident to Active Membership — Anna Gertruida Carlson, MD; Dariush Garber, MD; Lydia Mendoza, MD; Warrik M. Staines, MD; David H. Sun, MD; For Retired Membership — Patrick Mullin,

School of Medicine; Ariel Lee, 4th year student MD; Ehsan Sultani, MD. For Transfer from Stanislaus Medical Society to at Nova Southeastern University College of SSVMS — Peter W. Broderick, MD. Osteopathic Medicine; Megan Massoud, 1st year student at California Northwestern University For Transfer of Membership — Steven Chan, College of Medicine; Yahanna Torres, 3rd year MD (Resident to San Francisco Medical Society student at the University of California, Davis for Fellowship); Rochelle Jagdeo, MD (Resident School of Medicine; Bathsheba Wariso, 1st year to Placer-Nevada Medical Society); Kieu-Loan student at Meharry Medical College. Luc, DO to Solano Medical Society. For Resignation — Joshua Brent Bigler, MD (moved to Washington); In the solid skeleton Scott David Bricker, MD (moved to Are written ruptures, shattered Los Angeles); Melanie Chang, MD Olympic dreams (former resident, moved to San But also re-growth, a pantheon By Caroline Giroux, MD Diego); Matthew Lopez, MD (former Support and resilience resident left state); Kristen Marie In the once noble arteries Marshall, MD (former resident moved On the surface of the strange, Are written all the excesses out of state); Caterina Palumbo, MD elastic planet And as many refusals of good (former resident, moved out of state). With a beautiful color of earth, remedies


Serving as the Board of Directors to the Community Service, Education and Research Fund (CSERF), the following actions were taken: Approved changing the name of the Scholarship Fund from the William E. Dochterman Medical Student Scholarship Fund to the Sierra Sacramento Valley Medical Society Student Scholarship Fund. Approved the establishment of the Paul J. Rosenberg, MD, Medical Student Scholar to honor Dr. Rosenberg and his family’s generous contribution to the Scholarship Fund in his memory. The scholarship will be given annually to the scholar or scholars who best embody the qualities of compassion, patientfocused and ethical care. Approved the Scholarship Committee’s recommendations to provide grants from the Medical Student Scholarship Fund to the following individuals for 2016: Evan Adams, 3rd year student at David Geffen School of Medicine/UCLA Medical Education Program; Meygan Lackey, 1st year student at Icahn

Or the internalization of the heart messes Within the warm throat Are noted all the trembling silences The sadness unable to go out Or so many missed chances Through the marbling of eyes Are projected our photos Along with selective blindness When stood our fear of the truth On the walls of teeth are engraved All the bliss and sins of those who eat Grind, crunch or bite As well as the rebellious NO to floss at night One finds in the abdomen The daunting explosions before an exam The basement of silent organs Or the loud void of dark tunnels At the bottom of gravity Hides discovery but also shame The vault of life, little and pretty And the time to give a name

from as white as snow, to beige to red sand or dark clay Mole mole mole, tattooed punctuations of the soul Cluster of happy freckles, trying to create an exclamation or make a point In the busy head Hide all the words That once refused to come out While out there, love was silencing swords Within memory, this living cemetery Are imprisoned the ideas of the revolutionary That ironically would have freed Those who forbade them, whose ignorance grew like weed Everywhere in my heart Passion emits the Morse code of my dreams The acceptance of its loads, territories and dark caves Knowing that kindness can still save. cgiroux@ucdavis.edu

November/December 2016


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. APPLICANTS FOR ACTIVE MEMBERSHIP: E. Taylor Abel, MD, Internal Medicine, The Permanente Medical Group Adel D. Agaiby, MD, Internal Medicine, The Permanente Medical Group Shanthi Aribindi, MD, Anesthesia, The Permanente Medical Group Suleiman Assaf, DO, Emergency Medicine, The Permanente Medical Grou Samantha Elise Ellinwood Auman, MD, Pediatrics, The Permanente Medical Group Alok Banga, MD, Psychiatry, Sierra Vista Hospital Braden W. Boice, MD, Radiology, The Permanente Medical Group Peter W. Broderick, MD, Family Medicine, Sutter Medical Group Carmen E. Carazo-Gonzalez, MD, Pediatrics, The Permanente Medical Group Anna Gertruida Carlson, MD, Pediatrics, The Permanente Medical Group Nisha Chakraborty, MD, Pediatrics, The Permanente Medical Group Muhammad Ibrahim Choudry, MD, Anesthesiology, Sacramento Anesthesia Medical Group Christine Gisel W. Chu, MD, Pediatrics, The Permanente Medical Group Bo I. Chung, MD, Family Medicine, The Permanente Medical Group Kiah Connolly, MD, Emergency Medicine, The Permanente Medical Group Michelle Corbier, MD, Pediatrics, The Permanente Medical Group Dale M. Cotton, MD, Emergency Medicine, The Permanente Medical Group Martin DuFour, MD, Family Medicine, The Permanente Medical Group Tara Dutta, MD, Neurology, The Permanente Medical Group Cesar Augusto Estela, MD, Physical Medicine and Rehabilitation, The Permanente Medical Group Nathan Fairman, MD, MPH, Psychiatry, UC Davis Department of Psychiatry

Dariush Garber, MD, Emergency Medicine, The Permanente Medical Group

Sonia Mahajan, DO, Emergency Medicine, The Permanente Medical Group

Deepika Srinivas Goshike, MD, Family Medicine, The Permanente Medical Group

Laura L. Maselli, MD, Pediatrics, The Permanente Medical Group

Kaitlin Herald, DO, Anesthesiology, Sacramento Anesthesia Medical Group

Michelle Maynard, MD, Internal Medicine, Mercy Medical Group

Laura Hoffman, MD, Endocrinology, CA Northstate Univ. College of Medicine

Lynn McLean, MD, Maternal and Fetal Medicine, Sacramento Maternal-Fetal Medicine

Lindy Hong, DO, OBGYN, The Permanente Medical Group

Carlos Alonso Medina, MD, Ophthalmology, Retinal Consultants Medical Group

Sonia R. Joseph, DO, OBGYN, The Permanente Medical Group

Lydia Mendoza, MD, Emergency Medicine, The Permanente Medical Group

Choo-Won Kim, MD, Radiology, The Permanente Medical Group

Antonio Merez, MD, Family Medicine, Woodland Clinic Medical Group

Joy Kim, MD, Family Medicine, The Permanente Medical Group

Maud Morshedi, MD, Radiology, The Permanente Medical Group

Alan K. Koike, MD, Psychiatry, UC Davis Department of Psychiatry

Denise Nguyen, MD, Family Medicine, The Permanente Medical Group

Max Kong, MD, Pathology, The Permanente Medical Group

Maiuyen T. Nguyen, MD, OBGYN, Camellia Women’s Health

Devinder Kumar, MD, Internal Medicine, The Permanente Medical Group

Minhchau Nguyen, MD, Rheumatology, The Permanente Medical Group

Michael Sunoh Kwak, MD, Pediatrics, The Permanente Medical Group

Thomas Pashalides, MD, Urology, The Permanente Medical Group

Steven J. Lalliss, MD, Orthopedic Surgeon, Woodland Clinic Medical Group

Murat Pakyurek, MD, Psychiatry, UC Davis Department of Psychiatry

Kathleen Lynn Larkin, MD, OBGYN, The Permanente Medical Group

Madison Pham, DO, Internal Medicine, The Permanente Medical Group

Amy Ledgerwood, MD, Psychiatry, Woodland Clinic Medical Group

Abdul W. Raif Jawid, MD, Internal Medicine, The Permanente Medical Group

Paul Sung Lee, MD, Neuroradiology, The Permanente Medical Group

April M. Ramelli, MD, Emergency Medicine, The Permanente Medical Group

Yauk K. Lee, MD, Radiology, Mercy Radiology Group

Pankaj Ranjit Ranka, MD, Anesthesiology, Sacramento Anesthesia Medical Group

Christine F. Lin, MD, Ophthalmology, The Permanente Medical Group Wutt Yie Linn, MD, Internal Medicine, Mercy Medical Group David Liu, MD, Psychiatry, UC Davis Department of Psychiatry Eleanor A. Loomis, MD, Physical Medicine and Rehabilitation, The Permanente Medical Group Nina Kaur Ludder, MD, Internal Medicine, Mercy Medical Group

Matt Frankovsky, MD, Emergency Medicine, The Permanente Medical Group


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Kristen Jonelle Reid, MD, Psychiatry, The Permanente Medical Group Tooba Rehman Jahangir, MD, Internal Medicine, The Permanente Medical Group Frank E. Reyes, MD, Psychiatry, The Permanente Medical Group Joseph Alan Rogers, MD, Emergency Medicine, The Permanente Medical Group Jason G. Roof, MD, Psychiatry, UC Davis Department of Psychiatry

Patrick James Sanchez, MD, Radiology, Mercy Radiology Group

Julie Carin Garchow, MD, UCD Family Practice Residency Program – 2017.

Daniel Mabardy, MD, Sutter Family Medicine Residency Program – 2019

Karanpal Sandhu, MD, Internal Medicine, Mercy Medical Group

Gary S. Garcia, MD, UCD Family Practice Residency Program – 2017

Christine Marie Marechal, DO, UCD Family Practice Residency Program – 2018

Ming-Jie Sharman, MD, OBGYN, The Permanente Medical Group

Brent Hanson, MD, UCD Family Practice Residency Program – 2017

Susan Fields Mead, MD, UCD Family Practice Residency Program – 2016

David J. Sloss, MD, Emergency Medicine, The Permanente Medical Group

Salla Inkeri Hennessey, MD, Sutter Family Medicine Residency Program – 2019

Elizabeth Schamber, MD, Sutter Family Medicine Residency Program – 2019.

Warrik M. Staines, MD, Emergency Medicine, The Permanente Medical Group

Joshua Lee, MD, UCD Anesthesia Residency Program – 2018

Geneva Ann White, MD, Sutter Family Medicine Residency Program – 2016

Justin L. Stimac, MD, Emergency Medicine, The Permanente Medical Group

Valerie Theresa Liu, DO, UCD Family Practice Residency Program – 2018

Melissa Wilcox, MD, Sutter Family Medicine Residency Program – 2019

Frederick Y. Su, MD, Psychiatry, The Permanente Medical Group David H. Sun, MD, Hematology/ Oncology, The Permanente Medical Group Shabnam Khashabi Taylor, MD, Ophthalmology, The Permanente Medical Group Hendry Ton, MD, Psychiatry, UC Davis Department of Psychiatry Dominique A. Trappey, MD, Anesthesiology, Sacramento Anesthesia Medical Group Maria Tsiu, MD, Emergency Medicine, The Permanente Medical Group Neal Abraham Varghis, MD, Physical Medicine and Rehabilitation, Mercy Medical Group Polina Volodarskaya, DO, Family Medicine, The Permanente Medical Group Robert William Watrous, MD, Addiction Medicine, The Permanente Medical Group Megan J. Wolf, MD, Emergency Medicine, The Permanente Medical Group Peter Wei-Ju Wu, MD, Ophthalmology, The Permanente Medical Group Peter Yellowlees, MD, Psychiatry, UC Davis Department of Psychiatry Rena Yuni Yu, MD, Pathology, The Permanente Medical Group APPLICANTS FOR RESIDENT/ FELLOWSHIP MEMBERSHIP: Joel Bonilla-Larsen, MD, UCD Family Practice Residency Program – 2018 Florence Chau-Etchepare, MD, UCD Pulmonary Critical Care Fellowship 2019 Wei (Wendy) Diao, MD, UCD Family Practice Residency Program – 2018

November/December 2016


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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

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

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

SAVE THE DATE! Thursday, January 19, 2017 SSVMS & Alliance Annual Installation and Awards Dinner Hyatt Regency Hotel 1209 L Street, Sacramento 6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program

Installations Ruenell D. Adams Jacobs, MD, President 2017 2017 SSVMS Officers and Board of Directors

Award Presentations Golden Stethoscope Award Medical Honor Award Medical Community Service Award Dorothy Dozier Helping Hands Award







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Profile for Sierra Sacramento Valley Medical Society

2016-Nov/Dec - SSV Medicine  

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

2016-Nov/Dec - SSV Medicine  

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