2017-Jan/Feb - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2017

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MEDICINE 2 3

2017 Education Series PRESIDENT’S MESSAGE Don’t Wait, Communicate

The Ascent of Goalball

Michael Schermer, MD

The Impossible Naturalist

John Loofbourow, MD

Ruenell Adams Jacobs, MD

EXECUTIVE DIRECTOR’S MESSAGE Announcing the New Joy of Medicine Program

How to Talk to Eating Disorder Patients

Ann Gerhardt, MD

Aileen Wetzel, Executive Director

SSVMS Election Results

GUEST EDITORIAL Proposal for Supervised Needle Injection Facilities

A Posit on Expensive Medications

Fecal Microbiota Transplants

George Meyer, MD

BOOK REVIEW Dr. Mütter’s Marvels

Reviewed by Gerald Rogan, MD

Welcome New Members

Board Briefs

SPIRIT Program

Myel Jenkins, Program Director

Advisement Incomplete

Caroline Giroux, MD

12 How JAMA Led Me to Sorolla

Jack Ostrich, MD

2016 – A New Kind of House of Delegates

Richard Gray, MD

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 is by Sacramento otolaryngologist Dr. David Evans. “This image was created to celebrate my Welsh heritage, as both of my parents immigrated from Wales in the 1950s. St. David was the patron Saint of Wales and is said to have died on March 1 in either 569 or 601 A.D. Thus, St. David’s Day is celebrated March 1 each year and symbols are the daffodil and the leek. The other item is a Welsh “Love Spoon,” which is a traditional craft that dates back to the seventeenth century and was designed to be given to a young woman by her suitor in order to prove that he had valuable wood carving skills. The image was made in my garage using a strobe through a ‘snoot’ with selective coloring and a texture layer from a piece of slate added in post processing.” −devans@sacent.com

January/February 2017

Volume 68/Number 1 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

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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. 2017 Officers & Board of Directors Ruenell Adams Jacobs, MD, President Rajiv Misquitta, MD, President-Elect Tom Ormiston, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Vijay Khatri, MD Christian Serdahl, MD Vacancy District 3 Thomas Valdez, MD District 4 Alexis Lieser, MD

District 5 Sean Deane, MD Paul Reynolds, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Carol Kimball, MD

2017 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 Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Don Wreden, MD

District 1 Anissa Slifer, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Megan Anzar Babb, DO Natasha Bir, MD Helen Biren, MD Arlene Burton, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Sandra Mendez, MD Robert Peabody, MD Armine Sarchisian, MD Eric Williams, MD Vacant Vacant

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA President Ruth Haskins, MD

CMA Speaker Lee Snook, MD

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Editorial Committee John Paul Aboubechara, Sean Deane, MD Adam Doughtery, MD Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Albert Kahane, MD

MS III Robert LaPerriere, MD George Meyer, MD Steven Nemcek, MS II John Ostrich, MD Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD

Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2017 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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PRESIDENT’S MESSAGE

Don’t Wait, Communicate By Ruenell Adams Jacobs, MD I GREW UP IN A FAMILY that liked to talk, to communicate their thoughts, concerns and wishes to minimize any misunderstandings. Politics, history and current events were favorite topics for my father, and my mother loved talking about work, family news, and friends. I learned the oral history of our family roots from my grandparents. My sister and I spent countless hours talking together about things that mattered to us. We became skilled at listening to each other and comfortable speaking to relative strangers on many subjects. I listened with interest when my parents and/or their friends discussed their families, concerns and political views. As a result of these experiences, listening and talking about difficult or sensitive concerns to patients came fairly easy for me. Beginning in 1990, I listened with sadness and then acceptance, first to my grandfather and then, after five years, to my grandmother when they were making their end-of-life decisions. By that time, I had been a practicing physician for a few years. I had returned to California for postgraduate training and work, and fortunately lived in close proximity to most of my extended family. Walking with these two beloved people through their last years was an eye opener into the complexities of medical decision-making from the point of view of a patient. My grandparents were literate, but with limited educational experiences. My grandfather was somewhat suspicious of the medical profession, and questioned everything. My grandmother had a lot of faith in her personal physician, and questioned nothing. End-of-life discussions were not initiated by either of their primary care physicians during routine office visits, but fortunately they had their daughters and me to help. The lessons we learned from my grand-

father’s experience definitely helped us to do a better job with my grandmother and, by extension, to my husband, kids and many of my patients. So, when the issue of end-of-life care recently emerged in the case of his younger brother, my husband was surprised at how ill-prepared he was for this moment. My brother-in-law had had a “cancer scare” a few years ago, when he was diagnosed with stage 0 prostate cancer. He went through treatment and seemed to be fine. Then in late September 2016, my husband received a telephone call from Ohio, where his brother resides. His brother informed him that he would be having surgery to remove a tumor in his lung (the procedure was actually only a biopsy). My husband flew to Ohio to be with him. Unfortunately, the procedure resulted in a collapsed lung and the need for ventilation support and progressive deterioration of his condition. This also precluded any further input from my brother-in-law regarding his care. What has transpired since has been sad and stressful for all concerned. It seems that end-of-life options were not discussed in full before this latest crisis. The possibility that this procedure might end in disaster did not occur to anyone. No one, including my sister-in-law really knows what his wishes might be at this stage. And so he lingers in a state of existing, but not existing, phone calls go back and forth between the family in Ohio and California. There are calls between the family and the new treating physicians who were not initially involved in his care, but are left to bridge the communication gap that now exists. There’s a lesson here for us all, patient, provider and family members. Don’t wait. Communicate. adamsr78@comcast.net

January/February 2017

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.

EXECUTIVE DIRECTOR’S MESSAGE

Announcing the New Joy of Medicine Program By Aileen Wetzel, Executive Director

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

BURNOUT IS A BUZZWORD that physicians are hearing about from colleagues, medical groups, health systems, CMA, AMA, specialty societies and from the media. It is no wonder – physician burnout is at near-epidemic levels. According to the Mayo Clinic Proceedings, in 2015 over 54 percent of physicians reported suffering symptoms of burnout. Burnout is complex, and has many causes and symptoms. With the unprecedented change in the health care delivery system in the United States, many physicians feel that their role as healers, comforters, and listeners is diminished. As your colleagues, the physician leadership at SSVMS understands the struggles physicians face on a daily basis. As your professional organization, SSVMS is determined to help physicians in the Sacramento region find happiness and fulfillment in your profession. Our goal is to engage physicians in the Sacramento region in a long-term conversation that will help them recognize the signs of burnout, build meaningful resiliency and help physicians thrive. In early 2017, SSVMS will be introducing our SSVMS Joy of Medicine Program that will relieve physician pain and help to reclaim the joy of the practicing medicine through education, advocacy and program services designed to nurture individual wellbeing, collegiality and systemic change. Be on the lookout for information on our life coaching sessions, group coaching sessions, interest groups, resiliency workshops and educational events, social opportunities, and our first annual Joy

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of Medicine Summit that will be dedicated to providing physicians with the tools needed to cope with the stressors that are part of practicing medicine. Please join the conversation through social media (@ssvms is our twitter handle), attending upcoming events, and being open to exploring the issue of physician wellness and resilience. If you have any ideas or suggestions on ways SSVMS can help members build resilience and thrive, I invite you to contact me personally. Your voice matters. awetzel@ssvms.org

GUEST EDITORIAL

Proposal for Supervised Needle Injection Facilities By George Meyer, MD Guest Editorials are welcome, as are comments regarding the editorials themselves. I DID NOT VOTE TO “legalize” recreational marijuana this year for a couple of reasons. First, we are trying to get people to stop smoking, and most people get their marijuana from smoking. The other reason is that I agree with the CMA’s position that the U.S. Government (the FDA) should remove marijuana from the Schedule 1 Narcotics List to allow legal clinical investigation of this agent so we can better understand its benefits and risks. The City of Sacramento has officially allowed needle exchanges recently, but unofficially, this practice has been in effect for 30 years. The hepatitis/HIV infection rate among injection drug users in Sacramento is less than 4 percent. A recent epidemic in a small town in Indiana was seeing 10 new cases of HIV weekly (160 new cases in the first six months of 2016) because people were sharing needles to inject Opana (oxymorphone). It was illegal in Indiana to have needle exchanges until April 2016. So, where am I going? I propose a program that will decrease transmission of hepatitis and HIV from needles; decrease the murder rate and drug-related gang warfare in the U.S and other countries; help prevent drug overdosing; decrease the number of persons in prison; and save money. There is precedent for this, not only in Europe, but in North America. If the government approved facilities where those addicted to medications, whether prescription medications to which they have become addicted, or drugs like heroin, methamphetamine, and cocaine, could get their

drugs in a clean, safe area with sterile, singleuse needles, many of the above goals could be achieved. According to the Drug Policy Alliance, there are now more than 100 supervised injecting facilities (SIFs) operating in nine countries (Switzerland, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia and Canada). SIFs provide sterile injection equipment and health care, as well as information about reducing the risks of drug use. Some offer counseling. Public disorder has been reduced. The first SIF in North America was established in 2003 in Vancouver, Canada, called InSite, paid for by taxpayers. InSite reports that four dollars are saved for every one dollar spent, based on the anticipated cost of future health care. In 2014, the Danes published data acquired in their first stand-alone SIF. They reported a 76 percent reduction in injection risk behaviors, including injecting in a less rushed manner (63 percent), fewer outdoor injections (56.1 percent), no longer syringe sharing (54 percent) and cleaning injection sites more often (44 percent). Some 59 percent changed their syringe disposal practices, all but one reporting disposing their used syringes in a safe location, providing safety to the neighborhood, which previously had used syringes lying around. In 2015, the Harm Reduction Coalition convened a meeting of representatives from countries where SIFs were located (Frankfurt, Germany, Sydney, Australia, and Vancouver, British Columbia). They arrived at the following five conclusions: 1) “People who use SIFs take better care

January/February 2017

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.

VALUE OF

MEMBERSHIP

Sierra Sacramento Valley Medical Society

Representing over 3,400 physicians in Sacramento, El Dorado and Yolo Counties

A COMPONENT OF:

Alexis Lieser, MD Emergency Physician El Dorado County Member Since 2008

WE ARE MEMBERS OF SSVMS & CMA TO:

Speak with a UNITED VOICE to influence the political process 1 on issues such as Scope of Practice and public and private

of themselves, reduce or eliminate their needle sharing, use their drugs more safely, and ultimately reduce their drug use; “SIF participants gain access to other medical and social services and entry into drug treatment; “There has not been a single overdose death in any of these programs over many years of operation and many thousands of supervised injections; “SIFs do not increase drug use in the area, nor do they encourage young people to initiate drug use; “Crime and public nuisance decrease in the areas around these programs.”

I propose that a SIF be introduced to the Sacramento area; I think it will save money and lives as well as decrease crime. geowmeyer@icloud.com

payor reimbursement rates.

MICRA, saving physicians practicing in the Sacramento 2 Protect Region an average of $93,000 annually on malpractice premiums.

Improve the PHYSICAL AND MENTAL HEALTH OF OUR COMMUNITY by spearheading initiatives to address our region’s mental health crisis, the opioid epidemic, and to give access to specialty care for the uninsured.

the JOY OF PRACTICING MEDICINE by enhancing 4 Reclaim health and wellness for ourselves and our colleagues.

It is Easy to Join!

ssvms.org/membership/join-now or 916-452-2671 or membership@ssvms.org

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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.

SPIRIT Program Warmth. Generosity. Gratitude.

By Myel Jenkins, Program Director, Community Service, Education and Research Fund BEHIND EVERY NUMBER, a life is changed. Since the Sacramento Physician’s Initiative to Reach out, Innovate and Teach (SPIRIT Program) was established in 1995, SPIRIT volunteer physicians have donated over 40,000 hours and have served close to 50,000 patients. That’s over $10 million dollars donated in care in the Sacramento Region in 21 years! SPIRIT, a program of the Sierra Sacramento Valley Medical Society (SSVMS), partners with physicians to donate their time and services to provide medical care to uninsured patients in the Sacramento region. SPIRIT is able to provide this care due to the volunteer physicians and our partners − SSVMS, the four local hospital systems (Dignity Health, Kaiser Permanente, Sutter Health and UC Davis Health System) and the County of Sacramento. In 2016 alone, volunteers donated over 3,000 hours to serve more than 3,800 patients. That equals more than $535,000 in donated care in one year! Also, in 2016 the SPIRIT Program launched the Collaborative Clinic, in partnership with the County of Sacramento. SPIRIT volunteers provided medical care at quarterly clinics hosted at the County of Sacramento Primary Care Clinic. The Collaborative Clinics are open to undocumented residents enrolled in the County of Sacramento’s Healthy Partners Program. Three clinics were held between April and October 2016 that provided patients access to much needed Dermatology, GYN, GI and Ophthalmology services. SPIRIT is pleased to continue this partnership into the 2017 year with the next clinic scheduled for the end of January. As we start the new year, we are excited to

continue to expand the availability of SPIRIT services in multiple ways. One is the addition of Mercy San Juan Hospital as a SPIRIT surgical site. With this addition, Dignity Health will jump from donating four surgeries a month at Mercy General Hospital, to providing a total of six SPIRIT surgeries a month. Kaiser is also expanding the array of available SPIRIT services in 2017. Starting in January, Kaiser will provide up to 20 eye exams and free eye glasses monthly to SPIRIT patients. These expansions will help the SPIRIT Program to continue to provide critical care to those most in need. SPIRIT will continue to spread its reach by participating for the first time in the Big Day of Giving on May 4, 2017. The Sacramento Regional Foundation facilitates the local Big Day of Giving event which encourages community members to make online donations to local non-profits. SPIRIT hopes to increase the number of donors who contribute to the SPIRIT Program by being a Big Day of Giving participant. We know that behind every number in the SPIRIT Program, a life is changed. When asked about his experience with the SPIRIT Program, one patient shared, “I am grateful to all the people who made this surgery happen. Thanks to the doctor, his staff, partners and the hospital, I am feeling better, and I have been able to return to work without pain.” You can help change a life. You can become a SPIRIT volunteer and provide much needed care. Learn more about volunteering at www. ssvms.org. We also invite you to save May 4, the Big Day of Giving, and to donate to the SPIRIT Program at www.ssvms.org. As long-term SPIRIT volunteer, Dr. Robert Bellinoff, states, “I

January/February 2017

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.

have been part of SPIRIT’s volunteers for as long as I can remember, probably over 20 years. What an easy way to help do something for those close by to us. You never know who you are going to touch.” mjenkins@ssvms.org

SPIRIT Program staff member, Diana Landeros, speaks with a Healthy Partners’ patient at a Collaborative Clinic.

Be a Source of Hope

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

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

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Advisement Incomplete By Caroline Giroux, 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.

AS I WALK TO MY OFFICE every day and notice to the left, in awe, the work from our art therapy group (their recent project is a beautifullypainted version of Van Gogh’s Starry Night), I shake my head as I notice to the right the rows of unused seats turned against the wall of what was meant to be the second waiting room when our county clinic was remodeled. Like the annoying seats in most airports that have armrests to prevent people from sleeping. Then I see that the notice, “No unattended minors” is no longer hanging, but fell on the floor. I observed this strange occurrence a couple of mornings already, as if the pointless sign had decided to retire, expressing its futility in companionship with the passive aggressive seating area. But on a Saturday (and on its twin, Sunday), twice a year, here I am, in this other, more terrible place without windows, where all cues to sane life and nature have been removed, where people found walking barefoot or with incomprehensible monologues are brought in, wrapped in this odious form that expires even before their crippling symptoms. Here I sit, in front of this sheet of paper, which contains too many words in small font, too few lines with not enough space in between to put my own voice, inviting a micrographia that couldn’t contain enough of my silent flame. A form that is supposed to magically stretch this untouchable promise that never materializes and that we call time, by detaining a 9-year-old patient against her parents’ plan or assent, so Child Protective Services (CPS) could buy time as they send an investigator rushing to the emergency department to make their assessment. My intern and I heard this highly disturbing disclosure from this young girl, Naomi. Mandated reporters, we became. And now my mission is reduced to the absurd

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task of filling out a 5150. But this child is not a danger to herself. She doesn’t want to hurt anyone. She is not a gravely disabled adult. And, despite the overwhelming combination of all her past diagnoses (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, etc.), she is not a disabled minor either. In fact, removing her from what we sensed must have been a chaotic life for a few days, and giving her only one medication instead of the stunning regimen consisting of four she was on before admission (two atypical anti-psychotics, one stimulant, one sleep aid), but were abruptly discontinued due to no linkage with mental health after relocating, seems to have done her some good. She is no longer the “agitated, uncooperative” girl the social worker described her to be earlier that day during rounds. And even if she still were, she would have all the right in the world to be. Something terrible happened to her, like I guess it can happen when there is a lot of family dysfunction (the caretaking figures had a troubling past), or when minors are left unattended. No words were whispered to her that morning. As part of my intern’s gentle questioning, she disclosed candidly what we believe she believes happened to her. An older sibling was mentioned during her narration. This child was apparently investigated three times, according to the parents. But in another area. And the case was dismissed, dropped. Here we have no proof of that. Therefore, it has to be treated like a fresh case, according to the child psychiatrist on call I had to consult with since I am an adult psychiatrist. And the social worker wondered if the alleged abuse “could have occurred within the last 72 hours, because that means we also

need to call law enforcement.” How could I determine that with certainty? One year, one month, or one day. How would the exact amount of elapsed time matter to a child who is experiencing nightmares, who is detached and casual upon mentioning what one did to her “bad part” (adjective taught by the parents), who now has a poor sense of boundaries… When it comes to trauma, the sense of time is altered. The continuity of normalcy and predictability is gone. Life isn’t flowing like a nice thread, but rather saccadic, repeatedly disrupted by triggers and flashbacks. The re-experiencing (or re-enactment through play, especially in children) fragments time or makes it spiral into this infernal cycle of victimization. Some time ago, an agency had decided on her truth. But whether this happened to this child or not, something clearly happened. Her perception of a particular experience obviously still affects her. So I stare at the form. I want to laugh. And cry. My heart is sinking. All I feel like doing is taking this little girl home with me because her situation doesn’t fit in any of the four little boxes. Bureaucracy has a gift in making the docs feel so incredibly powerless. So, I deliberately forget and ignore this in the hope that some administrator will wake up, after having been confronted too many times by inflammatory spirits like mine, and decide to change this ineffective process. The next day, at least 22 hours later, despite what they qualified as requiring an “immediate response,” CPS still hadn’t put their nose in this stinky story. Meanwhile, I had to tell the parents that we had gone through this “administrative process.” I hated that part of the job. In an outpatient clinic, I would have sat down with Naomi, examined her drawings or observed her playing with a dollhouse. I wish I had done something meaningful for her. But maybe the meaningful lied in the “not doing.” Not labeling her “disabled” because I refused to see all these heavy acronyms that have nothing to do with her amazing energy, her profound nature, her life potential. I couldn’t “complete the advisement”

because how would this nonsense do her any good? My priority was her sense of safety. Real and perceived. And, at that point, we were not convinced that she would be discharged to a safe situation. That meant scribbling my reasoning on the dreaded 5150, calling back CPS to inquire about the status of their investigation, and clearly documenting our concerns for the team to read the following day. And the shift was over. It was no more in our hands. I would go on to work at the clinic Monday morning, but so many elements of this child’s story stayed with me. Among other things, the color of her bright eyes, her boisterousness, her cute generosity at sharing popcorn. But also the parents’ clumsy way to deal with naming certain parts of the body, which immediately reactivated some unpleasant, guilt-inducing Catholic remnants of my own past. I am glad I took the liberty to convey to the parents that the choice of words can have an impact, and I firmly recommended that they choose more neutral or even technical terms to describe anatomical parts instead of demonizing the body. I wish all the parents on earth would mindfully choose their vocabulary upon referring to boys’ and girls’ specific apparatus. The shame-instilling words can be almost as damaging to the sense of self as the reported abuse. The experience must resemble the one of the pariah, or being sentenced to stare at a wall on a ghost waiting room. P.S. After I left the ghost waiting room the night I crafted this article, the intern who was on my team during that call emailed me saying she had received a letter from CPS mentioning they had dropped the case, two weeks after our initial report. The ironic “no unattended minors” sign and our role as protectors of the vulnerable of this world had suddenly a feature in common. cgiroux@ucdavis.edu

January/February 2017

To protect the patient’s privacy, her name and some other characteristics have been modified.

How JAMA Led Me to Sorolla “The cover art made JAMA a beacon for humanism…in a sea of technological advancement, and reminded us that medicine is closely intertwined with people and culture. In marketing terms, the revised cover represents rebranding, not only of JAMA, but perhaps of the medical profession itself. It is no wonder that the artist…is no longer an appropriate symbol for the cover of a prestigious medical journal.” −Jeffrey M. Levine, MD, July 3, 2013

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.

BEGINNING IN 1964, the Journal of the American Medical Association (JAMA) featured a “work of art” on the cover of every issue. Most of the covers were graced by paintings, but there was an occasional photograph of a sculpture or an “objet d’art” of some sort. JAMA distinguished itself by this maneuver, as almost all other medical and scientific journals had elected the same industrial, “gray lady” look for their covers – name and date of the journal at the top, lists of articles, commentaries, letters, etc., in the center and space at the bottom for the recipient’s name and address, and perhaps the journal’s origins. In 2013, the staff at JAMA decided to create their own similarly drab cover, so the cover art was moved to an inside page and could be found in the table of contents under “The Art of JAMA” More recently, the “Art of JAMA” has been replaced by “The Arts and Medicine,” under which heading one finds essays or commentaries on poetry, plays, books and movies. When the February 17, 2010 issue of JAMA arrived at my home, I was at once struck by the cover, a painting by the Spanish artist Joaquin Sorolla. Depicted is the interior of a railway passenger car with spare wooden benches as seats. Only three people inhabit the space, two are armed men, both in military attire, who appear bored and are looking vacantly into the foreground. The central figure, sitting alone on her bench in front of the armed men, is an

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obviously dejected young woman whose hands are manacled and whose meager possessions, bound up in a cloth, lie next to her. The scene is dimly lit by a few rays of sunlight that have managed to pierce the small windows of the rail carriage. The scene is appropriately somber and sad. Sorolla originally sketched the scene from life. The woman had killed her child, had been tried, and was on her way to prison. Sorolla finally titled his subsequent painting, “Otra Margarita.” It is not clear why he chose that title. The painting won a prestigious art competition in Madrid, helping to make Sorolla famous in European art circles, and was chosen to be exhibited at the Columbian Exposition in Chicago in 1893. There it was bought by an American named Charles Nagel who immediately donated it to the Washington University Art Gallery in St. Louis where it is still on display. Nagel later became Secretary of Commerce and Labor under President William Taft and in 1909 helped Sorolla come to the United States where the artist created a portrait of Taft in the White House. That portrait now hangs in the Taft Museum in Cincinnati. In spite of a couple of History of Art courses in college, one titled, as I recall, something like “A Survey of Modern American and European Art,” I knew essentially nothing about Sorolla. The JAMA essay that accompanied the painting,

written by Janet Torpy, MD, included a mention of the Sorolla Museum in Madrid, the artist’s former family house and studio, which is now the home to many of his paintings. The building and its contents were gifted to the Spanish nation in 1932, nine years after Sorolla’s death and immediately after the death of his wife, Clotilde. My wife, Mary, and I were already booked for a trip to Europe a few months later, and that trip included a few days in Madrid, so a visit to Museo Sorolla was now definitely on our agenda. It was an easy Metro ride on Line 1, from the busy “Gran Via” station near our hotel, to the quiet “Iglesia” stop in a residential area of the city, and then a 10-minute walk down Paseo del General Martinez Campos to the museum, at number 37. The ochre and white three-story house, built in 1911, is set back about 30 yards from the street behind a brick wall with a large cast iron gate. Behind the wall is a leafy garden with a fountain and decorative pool – what an American real estate agent would probably call a “water feature.” There are a few benches in the garden where visitors can sit, rest and enjoy the ambiance. A few stairs lead up to the front door, behind which is a small antechamber with a ticket booth. A multilingual sign announced a discount for people over 65 years of age, but I soon discovered that it applied only to residents of the European Union. From the antechamber, one turns left and enters an immense two-story room, Sorolla’s studio and occasional bedroom. It is bathed in natural light due to an array of clerestory windows. The artist’s canopied bed is tucked in a far corner, and his easel is in place that still holds the unfinished painting he was working on when he was disabled by a stroke in 1920. He never painted again, and he died three years later. The walls of the studio are covered, floor to ceiling, with furniture, ceramics, small sculptures and over 20 paintings. At the far end of the room is a large (6’9” x 6’7”) luminous painting of two women, dressed in white flowing dresses, walking on a sun-drenched beach. It is hung in

the center of the wall, about eight feet off the floor, and it dominates the room. Sorolla called it “Paseo a orillas del mar” and the English language catalog has it as, “Women Walking on the Beach.” Elsewhere on the first floor is the family dining room with original furniture and table settings, and parlors that contain original furniture, lamps, and decorative ceramics. A beautiful wooden staircase takes you to the second floor where many more of Sorolla’s works are displayed, as well as space for special exhibitions. Visitors exit through the basement where there is a small gift shop. Mary and I returned to Madrid in 2015 and again visited Museo Sorolla. This time we stopped for lunch at a nearby restaurant, then walked for about 20 minutes to another museum that we had not before visited, Museo Lazaro Galdiano. Lazaro Galdiano was a wealthy financier, publisher and avid art collector. His four-story home, built in 1903, is palatial compared to Sorolla’s. It, and Galdiano’s huge collection, also were willed to the Spanish nation. The collection includes paintings, sculptures, bronzes, jewelry, silverware, ceramics, manuscripts and ancient weapons and firearms. The home’s original richly-decorated interiors are preserved, and the building sits in a park-like setting on Calle de Serrano, a few blocks from the American Embassy in the swanky Salamanca district of

January/February 2017

Sorolla’s 1892 painting, “Otra Margarita.”

Madrid. A leisurely walk south on Calle de Serrano will bring you to a seemingly endless array of shops, bars and restaurants. Go slow. Have fun. Go to bed late and get out of bed late. You have my permission. And thus did JAMA entice me to visit Joaquin Sorolla’s old home and introduce myself to his life story and his most enjoyable art. So if you go to Madrid, be sure to visit the place and take a look at Museo Galdiano as well, if you have the time. Then, when you get home, send an e-mail to the editors at JAMA and ask them to restore the cover art. It probably will do no good, but do it anyway, In memoriam of Joaquin Sorolla. jmost119@aol.com

Sorolla called this painting, “Paseo a orillas del mar.”

Expertise you can rely on. As a trusted partner to businesses and families across generations since 1919, Baird has seen investors through many market cycles. And the insight we’ve gained from this experience informs all we do today as we strive to create great outcomes for our clients throughout their financial lives. Put Baird’s time-tested expertise to work toward your long-term goals. Patty M. Estopinal, CIMA®, CDFA Director Private Wealth Management 916-783-6554 . 877-792-3667 pestopinal@rwbaird.com pattyestopinal.com Investment Management Consultants Association is the owner of the certification mark “CIMA®” and the service marks “Certified Investment Management AnalystSM,” “Investment Management Consultants AssociationSM” and “IMCA®.” Use of CIMA® or Certified Investment Management AnalystSM signifies that the 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.

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THE SIERRA SACRAMENTO VALLEY MEDICAL SOCIETY SERVING THE COUNTIES OF EL DORADO, SACRAMENTO AND YOLO

PROUDLY CONGRATULATES SSVMS MEMBER

Ruth E. Haskins, MD 2017 PRESIDENT OF THE CALIFORNIA MEDICAL ASSOCIATION

2016 − A New Kind of House of Delegates By Richard Gray, MD, Chair, 11th District Delegation 2016 BROUGHT TO FRUITION a change in CMA governance that had been anticipated for the past three years, as we morphed from a three-day to a two-day House of Delegates meeting. Significant benefits are realized with the shorter HOD, including delegates taking off less time from work and decreased costs to the organization, with less expense incurred for delegates’ food and housing and one day’s fewer costs for convention space, etc. Much of the business of the HOD was moved to an online venue, with a quarterly resolution process. Our District XI had quarterly conference calls to review resolutions and reports. This has been very different and, hopefully, we are using our time more efficiently and effectively, staying more closely involved with the CMA through

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

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this year-round process. Yet, there is a down side to the new governance structure: The HOD, formerly the ultimate decision-making body for the CMA, in voting for the new structure, abdicated its control to the Board of Trustees (BOT). The BOT now makes not only all the business decisions, but also rules on all submitted resolutions, to the extent of ratifying or modifying decisions of the HOD as it sees fit. The written plan for this change was so lengthy that many people did not read it through, and many did not understand the ramifications of what they were agreeing to in voting for these changes. We are already seeing some backlash as people are asking the BOT to inform them before taking positions on

legislation, as was required previously. We have yet to see how this all turns out. In the meantime, the HOD at its October meeting dealt with only six major items and related resolutions. We received educational presentations on each item and had an opportunity to ask questions before debating and voting on the resolutions and their amendments. The six major items were MACRA (the greatest change in reimbursement since the introduction of Medicare), recommendations for improving the Affordable Care Act, dealing with the opioid epidemic, how to deal with physician burnout, concerns about the current Maintenance of Certification situation, and developing a five-year public health plan. Some of the educational presentations were outstanding. All issues were hotly debated, and delegates took their various positions. As always, the democratic nature of the discussion was outstanding, and the decision-making process was a beauty to behold, regardless of whether an issue went the way one wanted to see it, or not. As we move forward, we will see a maturation of this process. We look forward to the coming year under the A leadership of our new CMA President, Ruth Haskins, MD, of Folsom, and our Speaker of the House, Lee Snook,

MD, of Sacramento. The District XI Delegation has openings for new delegates, and we would encourage those of you who are interested in learning and serving to make your interest known.

Dr. Richard Gray, above, addresses the HOD attendees. Below left, is Dr. Ruth Haskins, the 2017 President of the CMA.

rgraymd@comcast.net

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January/February 2017

The Ascent of Goalball This Paralympic Event has No Losers

By Michael Schermer, MD I HAD AN OPPORTUNITY to attend the Rio Paralympic games because I have worked with the United States Association of Blind Athletes (USABA). Our Sacramento Marathon is the national championship for blind and visually-impaired athletes. This was my first Paralympics, and I hope it is not my last. Unlike typical sporting events, this one pulls at the heartstrings. There are really no losers, just some who do not receive medals. The focus of USABA at the Paralympics was Goalball. That’s right, Goalball. I remember the first time I ever heard the word, “Goalball.”

It was December 2010. I was driving Joe Hamilton to the USABA banquet that precedes the Sacramento Marathon. Joe, who is totally blind, was running in the marathon. He was also a member of the U.S.A Team that had just won a silver medal in the 2010 International Goalball competition. So I asked him, “What is Goalball?” That was a few years ago. Now, after attending the Paralympics in Rio, I am well versed in this sport created for blind and visually-impaired athletes. Think of Goalball as reverse dodge ball. The players use their bodies to prevent a ball

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containing a bell from entering a goal. It is played on a hard court about the size of a volleyball court. The goals are one meter high and run the entire width of the court. There is no net between the teams. The floor has a few tactile markings to help the players get positioned. Each team has six players. Three are on the court at any one time, a center and two wings. There are liberal substitutions. All of the players have a significant level of visual impairment. During the game their eyes are taped shut and they wear opaque, rubberized masks similar to sleep masks. This makes for an equal playing field. The ball with the bell inside is made of hard rubber. It is the size of a basketball, but twice as heavy. The team has 10 seconds to hurl the ball across the court in an attempt to get it into the opposition goal. The ball must hit the ground in designated areas. Line drives are illegal. The defending team dives and stretches to block the throw. It is about throwing hard and being

crafty. The thrower often does a spin move like a discus thrower. Sometimes the throw is more like bowling, and some players prefer to hurl the ball between the legs with their back facing the opponent.

Fans must be very quiet during the play because the players rely on hearing. Goalball is a fast game of two 12-minute halves. The clock stops when the ball goes out of bounds. The average game lasts 45 minutes. Fans must be very quiet during the play because the players rely on hearing. Generally, each side makes about 80 throws, and a typical score is in single digits, so most throws are blocked. If there is a penalty, then just one player from each side takes the court. Now, one sightless person has to defend the entire goal against another sightless person who fires the ball across the

Image 1: American woman throwing. Image 2: Brazil wins Bronze. Image 3: Lithuania, the world’s best men’s Goalball team. Image 4: USA moves on. That’s Joe Hamilton with the towel. Matt Simpson is on his left. Image 5: Israeli women protect their goal. Image 6: USA got Silver in Rugby. Image 7: They blew the lead.

January/February 2017

Image 8: The Germans at half time. Image 9: Turkey gets Gold. Sevda is third from the left.

8 court. Almost all penalty shots result in a goal, although I did see one blocked. The crowd cheers for each goal and gasps when the ball takes a bounce toward the goal. Many times the defenders make thrilling, lastsecond saves. It is an exciting game to watch. In Europe where Goalball is better known, they even have divisions like our minor and major leagues. The United States has a Goalball training facility in Fort Wayne, Indiana. The men’s team resides there. The women also use the facility, but they are primarily in Portland, Oregon, because three team members and the coach live in Portland. I was with a group of four representatives from USABA. The first day we started at 7:30 am so we could make the 9:00 am woman’s match against Israel. U.S.A. won, but the memorable aspect for me was the chanting of the Israeli fans, “Chi Chi Yisrael.” The special thing about Paralympics is that it creates deep emotions. The fans want everyone to win. This really came through when I first saw Wheelchair Rugby. France was playing the U.S.A. All of the players poured their hearts and souls into the game. These guys rolled fast and turned on a dime. They blocked and crashed into each other. Every goal brought a cheer from the entire crowd. None of the players could use their legs, some had no legs and many of them were missing part of their upper limbs. Somehow these men with big hearts, big shoulders and strong upper arms were able to maneuver, catch the ball and place

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it on their lap, then fight on down to the goal or pass the ball to a teammate. There is a lot of scoring in Wheelchair Rugby. Although the U.S.A. beat France 51 to 42, all of the players were winners and the crowd acknowledged that with a rousing standing ovation. The Germans have a young, handsome Goalball team. They took the court in very stylish white and black uniforms with matching black and white sneakers. Our team looked a bit scruffy compared to the Germans. With two minutes to go, the Germans were ahead by one goal, but in the next 30 seconds, they gave up two goals losing the game 7 to 6. Joe Hamilton scored the winning goal. After the loss, one of the German players was inconsolable because they had blown a lead, and this was a must win game for a medal. His teammates gathered around him for comfort. His emotion distracted from the expected post-match, mutual team recognition. I do not think this omission by the Germans was an intentional slight. It was a product of the moment, recognizing the great effort and great expectations of the German team. The Germans were too despondent to appreciate the cheering they received. People in the know believe that this young German team has a lot of medals in its future, but not this year in Rio.

…sportsmanship prevailed so that both teams got rousing, standing ovations.

We saw the U.S. women defeat Brazil for the Bronze Medal, and the U.S. men lose to Lithuania in the Gold Medal match to take the Silver. Although the Brazilian fans were disappointed in the loss by their women, sportsmanship prevailed so that both teams got rousing, standing ovations. The women’s gold medal match was China versus Turkey. Turkey has a 22-year-old superstar named Sevda Alunoluk (not yet a household name in America), who is an extremely hard thrower. Turkey was undefeated in all of its women’s matches. They beat us by 10 goals. It was painful. China, although they lost, did much better with a score of 4 to 1. Sevda scored 3 of the 4 goals. Turkey got the gold. Lithuania has a dynamite men’s Goalball team. Don’t bet against them. They, too, like the Turkish women, won all of their matches. Our team was down by five goals at the half. Then the U.S. coach put in a sub who, on his first throw, scored a goal. This sub was Matt Simpson from Atlanta. He, subsequently, scored three more goals, but it was not enough. We were all pulling for Matt because we got to know his family. His mom, dad, sister and two aunts were in Rio to cheer him on. Lithuania got the gold with a final score of 14 to 8. When these matches are over, there is a celebration. The winning team hugs and jumps for joy. The fans make a lot of noise and often the players march around the arena with an outstretched arm on the shoulder of the teammate in front. When near the fans, they give high-fives and pose for selfies. Even the losing team gets this kind of treatment. It is a heartwarming sight. The Lithuanian men formed a shoulderto-shoulder chorus line. The line moved to face on each side of the arena, then they did a coordinated right leg lunge and jumped for joy. The crowd loved it. The Paralympics is a huge event. With 4,350 athletes from 150 countries, it is impossible to see everything. The vital theme is that these people are athletes to be admired for their ability. They compete with all of their heart and soul to make the experience moving and

unforgettable for the spectator. They show us how to achieve more with less. I’m ready to go to Tokyo in 2020. 20/20 is most appropriate for an ophthalmologist. Google “Yes I Can Rio” for an excellent 3-minute video introduction to the Paralympics. mjsmd1943@gmail.com

The Impossible Naturalist “We privileged few, who won the lottery of birth against all odds, how dare we whine at our inevitable return to that prior state from which the vast majority have never stirred?” −Richard Dawkins

By John Loofbourow, MD As soon as he could count it was clear he was the mathematically impossible winner of a life in this galaxy, star, earth, in this time, here at a center of this civilization. So soon as he could read and reason it was clear he was the impossible winner of other lotteries: culture, language, technology, and history; he would demarcate the borders of infinity. In puberty, at the rising of the numinous, fearless, fevered and foolish as youth can be, emboldened by Darwinian science, and Learning, he planned to steal candy from the bloody jaws of God. But this miracle child of blind Chance stole only the lone eye of the three blind Fates. Now, cherishing it like his own newborn child, he sings joyously, while chained to the walls of Time. He recalls that for science nothing is certain; to doubt is the only law and commandment. He chants and sings and looks through his stolen eye, and only fears to see The Eye look back. john@loofbourow.com

January/February 2017

How to Talk to Eating Disorder Patients By Ann Gerhardt, MD

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

RAISING A DIFFICULT CHILD can be one of the most exasperating things to do in life, but when the child turns out OK, it’s a tremendously gratifying, extraordinary accomplishment. That’s exactly how it feels to treat eating disorders (ED) patients, who are some of the most frustrating patients in medicine. How one talks to them, even more than what is prescribed, can dictate success or failure. Knowing what to say takes understanding, sensitivity and a lot of intuition. The intuition comes from learning a lot about EDs, listening carefully to patients and putting oneself in their mindset. These intelligent people may eventually make good use of their lives, and need and appreciate someone who cares enough to make the effort to treat them. When the treatment process works, and an ED patient achieves some degree of psychological peace and gives up her/his maladaptive weight control behavior, it is tremendously rewarding for the entire treatment team. Eating disorders are psychiatric diagnoses, often with physical manifestations. Most ED patients also have additional psychiatric diagnoses, like depression, addiction (to relationships, substances, gambling, shopping, whatever) and obsessive-compulsive, bipolar, personality or schizoaffective disorders. Sure, a patient can die of starvation or electrolyte imbalance, and those should be prevented. But focusing only on the starvation, bingeing, vomiting, laxatives or diet, rather than the underlying psychological problems, gives the patient a lousy chance of recovery. Eating disorders are not appetite problems. “Anorexia” means absence of appetite, but most

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anorexia nervosa patients are not anorexic, at least initially. They have up-regulated appetitestimulating hormones, are hungry and rigidly avoid eating. After prolonged starvation, true anorexia may intervene, due to ketosis and nutrient deficiencies. Bulimia means “ox appetite,” but bulimics aren’t especially physically hungry. They binge in response to psychological urges, much like an alcoholic uses alcohol as a coping mechanism. They only have an ox appetite if they purge excessively or severely restrict food intake between binges. Aberrant food behavior, whether starving or bingeing, is a coping mechanism for psychological problems. Their conscious brain detours to food, weight and calories, rather than face unpleasant feelings and conflicts. These are actual quotes from patients: “I’m worthless and don’t deserve to eat,” “I must be punished by purging and cutting,” “Anorexia is the only thing I do well,” or “Binge eating keeps me sane.” This thinking is delusional and, like any delusion, can’t be argued with and I don’t. But it helps over time to acknowledge the thoughts and counter them with something like, “I think you’re a great person who deserves to nourish and take good care of yourself.” It’s hard to treat ED patients for many reasons, the most important of which is the patient, who doesn’t want to get better. The disorder is their coping mechanism. They deny they even have a problem. They may feel physically well, often energized by counterintuitively high catecholamines. Even if they don’t feel well, they deny it, and may continue

to function at a high level. It can take upwards of two years just to break through denial. Even then, change is hard because they need the eating disorder to protect them from intolerable feelings. For chronic patients, the eating disorder is their identity, and contemplating the void created by giving it up is terrifying. Obtaining a history at each visit may be difficult, since the patient often doesn’t want to complain or admit to symptoms. They often avoid full disclosure or they outright lie. They use skin lotion to hide dehydration and sew weights into their clothing to falsify their weight. They may be totally accustomed to denying their bodies’ signals to the point of being unaware of physical symptoms. Asking, “Any problems?” is usually a waste of breath. It takes reading their body language to tell if “No, I’m fine” is the truth. Only by asking specific questions does one garner useful information. Their insight into underlying trauma, family dynamics and emotions is often totally repressed. They are delusional about their own weight, appearance, nutritional adequacy and how others view them. They often have a history of abuse, a dysfunctional family and/or a lack of an effective support system. They will walk out your door with no recollection of what you said, wondering how you tricked them into briefly seeing things in a different way. They are almost all hyper-vigilant, meaning overly sensitive to words, body language and perceived slights. They ascribe negative connotations to innocuous words and take them personally. There are also doctor factors that impede recovery. Doctors assume patients want to get better. We are trained to negotiate treatment approach with patients, not to cajole a delusional patient into wanting to nurture her/ himself. Doctors give orders and expect them to be followed to some degree, but should give up any notion that they are in control of these patients. It’s like the inability to “airplane” some food into a stubborn one-year-old’s mouth – No one can make people change behavior or ED patients get better. Here are some Do’s and Don’ts for

interacting with ED patients that I’ve gleaned over 30+ years of treating them. In some ways my approach differs from published literature, but my success rate has been better than what’s published also.

Demanding totally healthful eating and behavior right off the bat is way too overwhelming… • Do be kind. ED patients don’t need another control freak in their lives to abuse them. Suggest the minimum behavior necessary to stay out of the hospital. This motivates most patients, since hospitals take control of their behavior away from them. The “minimum” may consist of adequate non-caffeinated fluid, some salt, 600 kcal per day with portions from all the food groups and an agreement for no suicide attempts. Or a limit to the daily laxative dose. Or eating breakfast, no matter how big the binge was the night before. Demanding totally healthful eating and behavior right off the bat is way too overwhelming, impossible to achieve even for “normal” people and defeating. Having a patronizing authority figure threaten them with hospitalization only sets up a confrontational digging in of heels. Instead, reassure them that they should do all they can to stay compensated, but if they become medically unstable, we’ll do what it takes to stabilize them again. • Do demonstrate by your questions that you understand EDs and that everyone is different. They want to be understood. The stereotypical psychological pattern is one in which the patient has low self-esteem, often because of an emotionally “absent” parent (alcoholic, workaholic, abusive, narcissistic) or abusive environment. There may be a sense of loss of control, typically due to an overly controlling parent, inability to cope with conflicting demands, terror over pubertal body changes, or physical, emotional or sexual abuse. The family may overemphasize physical appearance or being seen as a “perfect” family, stifling emotional expression. Bulimics often have subverted anger, which they

January/February 2017

are unable to express in healthy ways. These are stereotypes, not absolutes. Stereotyping patients and taking our assumptions for granted, without checking it out with them, demeans them and compromises the doctor/patient connection. Each patient has a unique history, family situation and pattern of mental, behavioral and physical responses. • Do an exam because it shows you are not blowing them off, but do it with a minimum of skin-to-skin contact. Many of these patients have been abused, and all of them hate their bodies. Your touch may cause anxiety and/or revulsion. • Do make compliments to show you accept them, even if they aren’t doing well. Say, “It’s good to see you” or “That’s great that you were able to change X” (even if it is the tiniest baby step). Or compliment some new insight, ability to set boundaries, or self-nurturing behavior. • Don’t make comments about appearance except those related to affect or color, such as “You look much better when you smile.” “You look really tired – what’s going on?” “You look really good in orange.” But make no comments that could be distorted into a comment about body size or shape. Even “You look good” is interpreted as “You are fat” or “You are a failure at being an anorexic.” • Do see patients of all ages without family and friends in the room. They just don’t give the same answers when their abuser, parent or judgmental friend is present. Talk to those people later. • Don’t lie, exaggerate or bend the truth to make a point. Someone consuming adequate fluids and 600 kcal a day with a stable BMI of 16 may feel fine and have normal basic lab results, proof of the amazing capacity of the human body to conserve and adapt. If you panic, and tell them they are going to die if they aren’t admitted to the hospital now, you’ve lied as a result of your own fear and lost connection with the patient. • Do focus on life goals and making continual mental and behavioral and changes, no matter how small. Otherwise, we are sucked into their obsession with weight, food and calories and get nowhere.

• Don’t emphasize weight. It reinforces their obsession. Focus instead on ability to function and mental peace, while using the exam, vitals (especially orthostatics) and labs to assess physical status. What’s important is working towards self-nurturing behavior, achievable within a wide weight range. Use weigh-ins judiciously as a reality check, though edema and full pockets may complicate its interpretation. If you weigh patients regularly, don’t reveal the weight, and don’t stop when they’ve reached “normal” weight because they’ll assume they’re fat. • Don’t back off from a patient who has achieved a goal weight, particularly in a residential or in-patient program which grants privileges (like phone calls, walking outside or going to the bathroom without being watched) in exchange for gaining weight. Psychological progress is always much slower than forced feeding. These patients aren’t stupid and know that compliance will get them discharged so they can resume their eating disorder – Or they panic and commit suicide. After discharge back to the environment that begat the ED, they need a lot of support. • Do individualize treatment. Refer to a good psychotherapist, not necessarily an ED specialist, to focus on the patient’s selfesteem, individuation, ability to express feelings, co-dependency, sexuality, and boundaries. It helps if the doctor coaches the patient about what’s normal nutrition, exercise, self-care and physical health, so the therapist can focus on the real problem. • Do focus on progress, even if it’s just baby steps, and be patient. It often takes years to recover from the disorder. The patient’s readiness to change rarely matches the clinician’s time-table, but expressing your frustration is unproductive and leads the patient to think she’s even more hopeless and “bad” than she thought. The course of improvement is rarely linear, and transient set-backs are the norm, especially when therapy touches on sensitive subjects. Show a wary teen (who was dragged to you by Mom) that you understand and care, and you just might have a really grateful patient when you ask if they need a hug. algerhardt@sbcglobal.net

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 2017 Board of Directors President: Ruenell Adams Jacobs, MD President-Elect: Rajiv Misquitta, MD Immediate Past President: Tom Ormiston, MD District 1, North: Seth Thomas, MD District 2, Central: Vijay Khatri, MD, Christian Serdahl, MD, (1) Vacancy District 3, South: Thomas Valdez, MD District 4, El Dorado County: Alexis Lieser, MD District 5, The Permanente Medical Group: Paul Reynolds, MD, Sean Deane, MD Sadha Tivakaran, MD, John Wiesenfarth, MD, Eric Williams, MD District 6, Yolo County: Carol Kimball, MD

2017 CMA Delegation District 1, North: Reinhardt Hilzinger, MD, Delegate; Aniss Slifer, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Ann Gerhardt, MD, Alternate District 3, South: Katherine Gillogley, MD, Delegate; Thomas Valdez, MD, Alternate District 4, El Dorado County: Russell Jacoby, MD, Delegate; Alternate Office Vacant District 5, The Permanente Medical Group: Sean Deane, MD, Delegate; Jason Bynum, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Rajan Merchant, MD, Alternate At-Large Office 7: Rajiv Misquitta, MD, Delegate; Sandra Mendez, MD, Alternate At-Large Office 8: Ruenell Adams Jacobs, MD, Delegate; Armine Sarchisian, MD, Alternate At-Large Office 9: Don Wreden, MD, Delegate; Eric Williams, MD, Alternate At-Large Office 10: Alicia Abels, MD, Delegate; Megan Frost Babb, MD, Alternate At-Large Office 11: Alan Ertle, MD, Delegate; Helen Biren, MD, Alternate At-Large Office 12: Kuldip Sandhu, MD, Delegate; Carol Kimball, MD, Alternate At-Large Office 13: Charles McDonnell, MD, Delegate; Natasha Bir, MD, Alternate At-Large Office 14: Richard Jones, MD, Delegate; Alternate Office Vacant At-Large Office 15: Richard Gray, MD, Delegate; Derek Marsee, MD, Alternate At-Large Office 16: Janet O’Brien, MD, Delegate; Robert Peabody, MD, Alternate At-Large Office 17: Tom Ormiston, MD, Delegate; Arlene Burton, MD, Alternate At-Large Office 18: Barbara Arnold, MD, Delegate; Ernesto Rivera, MD, Alternate At-Large Office 19: James Sehr, MD, Delegate; Alternate Mark Drabkin, MD At-Large Office 20: Senator Richard Pan, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office 21: Jose Arevalo, MD, Delegate; Amber Chatwin, MD, Alternate At-Large Office 22: Kevin Jones, DO, Delegate; Alternate Office Vacant

January/February 2017

A Posit on Expensive Medications “Medicare should cover an anti-cancer drug that improves 6-month, progression-free survival, even if there is no evidence of an overall survival benefit.”

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.

Background: Medicare covers anti-cancer drugs for their labeled indications when approved by the FDA as “safe and effective.” Medicare assumes the drug is “reasonable and necessary” when it is safe and effective. But the concepts are different. Anti-cancer drugs may (1) cure the patient, or (2) delay the return of the cancer, or (3) temporarily reduce the cancer. When cancer treatment is fruitless, the patient may benefit from palliation. Most FDA approvals of anti-cancer drugs require evidence of an overall survival benefit (OS), which means the average patient will live longer with the treatment compared to treatment with placebo. However, the FDA may also approve a drug when the only benefit is a progression-free interval (PFI) or a partial response (PR) compared to placebo. A PFI or PR means that the tumor may respond to treatment, but the average patient may not live longer. When the tumor returns, it may grow fast enough that the patient has no OS benefit. Is there a medical value of providing anticancer treatment in order to reduce the tumor on imaging, or only when there is clear evidence that it will extend life? What do you think? 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. Depends on the age and condition of the patient and potential benefit. –Douglas Young, MD I disagree. Medications that offer limited

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survival benefit or no survival benefit should not be covered by Medicare. Individuals are free to pay for treatments that they feel they want to try, or assume the risks where long-term benefit is not determined. 80 percent of health care dollars are spent in the last six months to the last year of life. To better manage our costs and resources, we need to apply some justification for society, as a whole, to pay for treatment. − Rajan Merchant, MD

80 percent of health care dollars are spent in the last six months to the last year of life. Prolonging the patient’s life, especially if it affords quality time with loved ones, would be worth the cost of the expensive drug. −Rosalind Kirnon, MD Anyone who is familiar with the way drug trials are crafted, or who has dealt with the FDA Pharma Cabal, realizes that words matter — “improves six-month survival” is pharmeze for Show Me the Money. Busy physicians and sick patients are no match for this sort of true lie. −John Loofbourow, MD The challenge really is that even though overall there might not be a survival benefit (OS) in patients with Progression Free Interval (PFI); however, in an individual patient, it might lead to OS, and even if there is no OS, it might lead to better quality of life/symptom relief. Don’t we all wish there were “unlimited” funds

to take care of patients?! −Kuldip Sandhu, MD We must reduce end-of-life costs. −Julita Fong, MD This will require some cost constraint. Do we wish to spend $200,000 for six months of palliation for every patient with a common cancer? That would threaten all other patients. −James Foerster, MD Personally, quality of life is more important than survival time. −Richard Park, MD It should be an available option for patients. −Gerardo Lamiel, MD I fully understand that the disclaimer, “Posits are one sided statements intended to promote discussion among members,” is intended to stimulate comments and at times controversy. However, the current posed data under the heading BACKGROUND, does not mention or take into consideration the issue of “quality of life” during the proposed six-month period of a PFI or PR. Having practiced clinical medicine since graduating medical school in 1966, I have been involved with many patients and their families who agreed to protocols to avoid “removing any hope of survival” and in retrospect, came to the realization it was an exercise of futility, associated with significant stress for all.

The “mask of cancer” on their faces, their slumped position and general demeanor clearly sends a message that a dignified death would have been, or maybe is, the better choice. Watching a family member wither away during treatment with a drug that has been approved after completing all the required clinical phases, but has marginal outcomes using Evidence I data, seems unfair to all involved. On a daily basis I observe the ambulatory, and more often, the wheelchair-bound patients, entering our building enroute to their chemotherapy appointment on the third floor. The “mask of

cancer” on their faces, their slumped position and general demeanor clearly sends a message that a dignified death would have been, or maybe is, the better choice. This focus on payment by Medicare is not the prima facie issue. It is the absence of asking the patient to be the final decision maker after a very thorough and honest discussion with their oncologist and family members. This discussion and decision needs to take place long prior to a patient becoming nauseated, frail, unable to eat, confused and relegates a family member to answer posed questions. −Michael Klein, Jr., MD Treatment may cause toxicity. Drugs that show only a progression-free survival compared with placebo may be more toxic than the effects of the cancer itself, combined with palliative care. A friend recently suffered irreversible brain damage from the toxic effect of Kyprolis® (carfilzomib). She cannot walk, her speech is slurred, and her vision impaired. She lived seven years with first- and second-line treatment, survived a bone marrow transplant, and tolerated significant neuro and vascular toxicity. For her last year, she enjoyed four good days out of each seven, three weeks a month, then a good seven-day week. Another friend lived six extra months with Yervoy® (ipilimumab) for treatment of metastatic malignant melanoma, with significant toxicities before entering hospice. Six months were productive for both friends. Both drugs provided a survival benefit. Once the FDA clears a drug for marketing, physicians may prescribe, and Medicare may pay for, additional indications which are called off-label uses. Medicare coverage policy is posted at https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/bp102c15.pdf. Off-label approval is based on a few studies with a relatively few patients, compared with the eligible patient population. The studies constitute either insufficient evidence for FDA approval for that indication, or the FDA is still thinking about it. The studies may show only a PFI or PR. When Medicare pays for an off-label continued on Page 31

January/February 2017

Fecal Microbiota Transplants By George Meyer, MD (Editor’s Note: This article was adapted from information provided by BloodSource.)

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.

WHILE MOST 15-YEAR-OLDS are focused on school, hobbies, and/or sports − not to mention navigating their way through their often-complicated social lives − Amy (not her real name) spent most of each day trapped between her bed and the bathroom as the result of a chronic gastrointestinal (GI) infection that most of us would not wish on our worst enemies. Her illness prevented her from participating in the activities enjoyed by so many of her peers, all because the risk of a flare-up required that she be near a toilet constantly. The pain, and the embarrassment that accompanies it, would be too much to bear for many adults; for an adolescent girl, the impact is that much more devastating. Even if you’re not one of the 350,000 individuals in our country who are diagnosed each year with Clostridium difficile infections (CDIs), it’s highly likely that you have a family member, co-worker, friend, or patient who has dealt with this debilitating, and potentially lifethreatening, disease. So, what would you do if you were Amy’s parent? Most of us probably would agree, with little or no hesitation, that when it comes to our children, no treatment is too unconventional, so long as it’s been proven to be safe, and it promises an acceptable likelihood for recovery. The name of this treatment is fecal microbiota transplantation or FMT. The data are strong that patients with C difficile, recurrent infection and/ or those whose diarrhea has not responded to antibiotic treatment, may get complete resolution of their disorder in from 80 to 90 percent of cases. The method of introduction has varied from capsule to nasogastric tube to colonoscopic

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introduction of the transplanted material. The data on the proper makeup of the donor feces are not clear, so there seem to be no data about the ideal donor stool composition. A recent paper published in the Annals of Internal Medicine suggests that healthy donor stool is safe and more effective for CDI than autologous FMT. There are few side effects of the procedure, and the concern for transplanting material that could cause illness seems to be avoided by choosing stool from healthy individuals.

Growing Challenge of Clostridium Difficile Infections The management of CDIs remains, to the dismay of so many of us, an often vexing challenge. Far too many people contract CDIs, and a sizable number fail to respond to, or tolerate, traditional treatment regimens. FMT, which entails the infusion of a healthy donor’s fecal matter suspension into the GI tract of a recipient, offers a new hope for many of those patients who are most severely affected by CDIs. First recorded in China in the 4th Century AD, FMT has been used for more than 100 years in veterinary medicine. In some countries, babies have been given oral maternal fecal matter to attempt to jumpstart the child’s immune system. According to the website Wikipedia, in the 1600s, Li Shizhen used “yellow soup” (aka “golden syrup”) which contained fresh, dry or fermented stool to treat abdominal diseases. Yellow soup was made of fecal matter and water, which was drunk by the patient. The website goes on to state that the consumption of “fresh, warm camel feces has been recommended by Bedouins as a remedy for bacterial dysentery; its efficacy, probably attributable to the antimicrobial subtilisin produced by Bacillus subtilis, was anecdotally confirmed by German soldiers of the Afrika

Korps during World War II.” The first U.S. description of FMT was published in 1958 by Eiseman et al., from Colorado, who treated four critically-ill patients with fulminant pseudomembranous colitis (before C. difficile was the known cause) using fecal enemas, which resulted in a rapid return to health. “Stool transplants are about 90 percent effective in those with severe cases of Clostridium difficile colonization, in whom antibiotics have not worked.” Over 1,000 species of harmless bacteria exist in the gut with many synthesizing vitamins influencing the immune system, metabolizing a range of biological compounds, and preventing harmful bacteria from taking residence in the intestines. In CDI and other GI-related diseases, this protective intestinal microbiome is altered by antibiotics and/or other environmental or iatrogenic factors. By reintroducing a healthy diversity of bacteria, FMTs can re-establish these protective properties, thereby suppressing harmful microorganisms such as C. difficile. Evidence strongly suggests that this technique is highly effective at eradicating CDIs. The best, long-term follow-up study to date, which took place at five medical centers and involved 77 patients, demonstrated a 91 percent primary cure rate and an astonishing 98 percent secondary cure rate (the latter defined as cure enabled either by use of antibiotics to which the patient had not responded before the FMT, or by a second FMT). Patients in this study had been experiencing symptoms for an average of 11 months before FMT, and most (74 percent) reported resolution of diarrhea within three days. There are some data that suggest fecal transplants can be successful in reversing such neurological disorders as Parkinson’s disease. A recent study from Australia, presented at the European Crohn’s and Colitis Organization 2016 Congress, described steroid-free remission in ulcerative colitis patients previously resistant to treatment, but frequent FMT applications were required.

FDA Guidelines Guidelines for FMT were written and published in July 2013. In March 2014, the

FDA issued a proposed update (called “draft guidance”) that, when finalized, was intended to supersede the July 2013 enforcement policy for FMT to treat C. difficile infections unresponsive to standard therapies. It proposed an interim discretionary enforcement period, if: 1) informed consent is used, mentioning investigational aspect and risks; 2) stool donor is known to either patient or physician, and 3) if stool donor and stool are screened and tested under the direction of the physician (79 FR 10814, 26 February 2014).1 Some doctors and patients have been worried that the proposal, if finalized, would shutter the handful of stool banks which have sprung up using anonymous donors, and that ship to providers hundreds of miles away. As of 2015, FMT for recurrent C. difficile infections can be done without mandatory donor and stool screening, whereas FMT for other indications cannot be performed without an FDA Investigational New Drug application (IND). Unlike OpenBiome (see below), the stool bank in Massachusetts that offers $40 per stool sample, AdvancingBio does not offer any financial incentive to donors, instead relying on their willingness to help those in need, much like a blood bank. (Read more at: www.sacbee. com/news/local/health-and-medicine/healthychoices/article14072969.html#storylink=cpy) In March 2016, the FDA submitted a new draft proposal for professional comment. The newest IND proposal states, “A stool bank sponsor may identify as the investigator on the IND an individual who is within, or affiliated with, the stool bank. Health care providers who receive FMT product from the stool bank may be sub-investigators. Sponsors may request waiver of certain IND regulations applicable to investigators. IND sponsors requesting a waiver of certain investigator responsibilities may also include a request for waiver of those regulations related to sub-investigators.” (See 312.10 - Code of Federal Regulations Title 21)2 In 2012, a group in the Boston area, after watching a friend with resistant CDI achieve remission following a fecal transplant, founded a 501(c)(3) nonprofit organization to make and January/February 2017

provide FMT to physicians for their patients. This organization, called OpenBiome, has expanded throughout the United States. They are currently sponsoring several research teams looking at the effects of FMT on such illnesses as irritable bowel syndrome and ulcerative colitis. They are working with several Sacramento-based medical centers. In March 2015, Sacramento-based BloodSource developed an organization, AdvancingBio, that provides FMT materials. Headquartered in Mather, California, this FDA-registered, not-for-profit stool bank provides comprehensively-tested fecal products collected from screened, volunteer donors. With the mission of making FMT safe for patients suffering from CDIs, as well as more convenient for clinicians committed to offering this lifesaving treatment, AdvancingBio also supports ongoing research surrounding future FMT applications to treat other GI diseases including inflammatory bowel disease, irritable bowel syndrome, and non-GI diseases such as multiple sclerosis.

Donor Screening and Product Preparation at AdvancingBio AdvancingBio carefully screens volunteer donors at the time of each stool collection. This is a change from the most frequent existing practice, where a family member serves as the stool donor. With the emergence of stool banks, a strong infrastructure and set of good manufacturing practices have been put into place to provide frozen products from a screened donor pool. This supports improved safety plus speed of delivery to the practitioner, as well as Photo Credits: Jeff McIntosh, Associated Press, left, and Boston University News Service, far right.

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overall cost effectiveness. As recommended by the American Gastroenterology Association (AGA) and other national organizations, AdvancingBio utilizes an extensive donor history questionnaire (similar to the approach BloodSource applies when screening blood donors), and other exclusion criteria to determine fecal donor eligibility. In light of evidence supporting the role of the intestinal microbiota in preventing or ameliorating systemic diseases, AdvancingBio defers donors with a variety of exclusion criteria including, but not limited to, a history of: antibiotic treatment during the three months preceding donation, travel within the last six months to areas where enteric pathogens are endemic, and intrinsic GI illnesses (e.g., inflammatory bowel disease, irritable bowel syndrome, GI malignancies). The most widely-feared, potential risk remaining is the transmission of infectious agents acquired from the donor. For this reason, AdvancingBioâ&#x20AC;&#x2122;s testing strategy is to screen each donor carefully at the time of every donation (unlike other stool banks that test only at periodic donation intervals) for numerous infectious agents, including viruses, bacteria and other potentially infectious agents. The fecal material is collected from the donor onsite, filtered to remove the particulate matter (e.g., undigested fibers, etc.), and diluted with saline solution and a small quantity of glycerol. A final volume of 50 mL or 250 mL is obtained for administration via the upper and lower GI tract, respectively. The solution is then placed in a -20Â°C freezer for storage of up to six months.

On the day of transplant, the frozen product is thawed carefully, and then transplanted within two hours (deglycerolization is not required). FMT is most commonly performed via colonoscopy; however, it also has been administered via nasogastric or nasoenteric tubes, gastroduodenoscopy, and even enemas. The monthly magazine, Wired, reports on the latest research into making fecal microbiota transplants (FMT) available in a tablet form, thereby making it easier for patients suffering from C. Difficile infections to undergo an FMT. Meanwhile, this past August, “the National Institutes of Health announced that it would fund a fecal transplant registry, maintained by the American Gastroenterological Association.” The fecal transplant registry would allow, “for the first time, thousands of transplant patients” to “have their microbiomes sequenced before and after treatment so doctors can have a better shot at identifying not only the bugs that fight C. diff, but also what’s causing all those side effects.”3

Patient Indications The ideal recipient candidate is a patient age 18 years or older who has experienced recurrent

CDIs and failure to respond to at least one cycle of appropriate antibiotic therapy. The scientific literature consistently shows effective cure rates of greater than 90 percent, making FMT an increasingly viable and appropriate option for patients who have failed to improve following traditional therapy. FMT is generally considered to be relatively contraindicated in patients with severe comorbid conditions, those taking immunosuppressants, and pregnant women. Additionally, most of the published literature highlighting FMT interventions is limited to the adult population, with only a few successful case reports involving pediatric patients.

Follow-Up Amy recovered after her FMT, as did a friend of mine who had failed four episodes of antibiotic treatment including two months of a tapering Vancomycin regimen. geowmeyer@icloud.com REFERENCES 1 https://www.federalregister.gov/citation/79-FR-10814 2 www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/ CFRSearch. cfm?CFRPart=312 3 https://www.wired.com/2016/11/microbiome-therapy-makingfecal-transplants-better/

Posit continued from page 27 use, it does not require data to show whether or not the drug helped a particular beneficiary, the stage of the cancer treated, or its toxicity. With coverage assured, additional studies necessary to prove a toxicity adjusted benefit for an off-label use may be delayed. ICD-10-CM claims data is not sufficiently granular to show the stage of the cancer treated, the benefit, if any, or the toxicity experienced by the patients. Several years ago, the CMA decided that CMS (Centers for Medicare and Medicaid Services) should require robust data collection of benefit and toxicity as a condition of coverage for any off-label use of an anti-cancer drug. Since then, ASCO (American Society of Clinical Oncology) has taken the lead and begun a

process to collect data on a voluntary basis via CancerLinQ. Medicare does not require it. https://www.youtube.com/watch?v=SJr97W-6pus The FDA may approve a drug and/or Medicare may cover a drug with evidence of only a PRI or PR. Is an anti-cancer drug that offers no evidence of a survival benefit medically reasonable, given the toxicity risk? On the other hand, the absence of evidence of a survival benefit is not evidence of the lack of a survival benefit. Moreover, some patients may benefit for a long time when many others do not. For most cancers there is no test to predict who will benefit and who will not, or who will suffer avoidable toxicity. −Gerald Rogan, MD January/February 2017

BOOK REVIEW

Dr. Mütter’s Marvels A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine, By Cristin O’Keefe Aptowicz; Avery Publisher; ISBN-13: 978-1592409259

Reviewed By Gerald Rogan, MD (Editor’s Note: Dr. Jim Hamill wrote an article on visiting the actual Mütter Museum in Philadelphia, PA, for our Jan-Feb 2015 issue, but it did not include a review of the book.)

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.

THOMAS DENT MÜTTER, surgeon and physician, died at age 47 in 1859, probably from TB, just before the beginning of our Civil War. He left his collection of surgical and other teaching specimens, together with a financial endowment, to the College of Physicians of Philadelphia for a museum, now named in his honor. The museum holds many marvels, including a Hirschsprung’s colon from “balloon man,” who died at age 27. The book, Dr. Mütter’s Marvels by Cristin O’Keefe Aptowicz, is about much more than Mütter’s collection of bizarre human specimens and drawings. Her story is about the evolution of the art and practice of the beginnings of modern surgery. Dr. Mütter, taught surgery between 1841-1859. He was one of the leading surgeons two generations before the Mayo Brothers and before, for example, the recognition that an acute abdomen caused by an inflamed appendix can be cured with an appendectomy (described by Dr. Charles McBurney in 1889). Dr. Mütter was born in 1811 in Richmond, Virginia, orphaned at age 7, and raised by a wealthy, distant relative. Partially trained in Paris, then the center of the medical and surgical arts, he became a professor at the second medical school in the U.S., Jefferson Medical College in Philadelphia. When he began his surgical professorship in 1841, surgery was a last resort for patients.

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A superb technician, he pioneered methods to repair clubfoot, cleft lip and palate, congenital anomalies, and mutilating injuries. He is best known for the cervical flap that bears his name to treat anterior neck adhesions from burns which drew the chin down to the clavicle. Aptowicz’ book escorts us through a dramatic change in surgery which we now take for granted. Mütter operated before and after the discovery of general anesthesia in 1847. Anesthesia was a disruptive technology because before it, the most important surgical skill was speed. After it, precision and empathy became more valuable to patients. The best surgeons no longer needed to be the fastest. Mütter rejected the prevalent concept that doctors were “all-knowing gods with whom you should never disagree.” Mütter’s bedside manner and patient orientation was nurturing and compassionate as opposed to distant and clinical. Mütter lectured his students about the need for compassion by practitioners of the healing arts, as well as the importance of detailed attention to scientific principles and new discoveries. He pioneered pre-operative care and a post-operative recovery unit instead of sending patients home from the operating suite in a horse-drawn wagon on bumpy roads. During his time, the leading causes of premature death in Philadelphia were infectious diseases: cholera, smallpox, yellow fever, typhus, dysentery, malaria, tuberculosis, puerperal fever, and scarlet fever. Mütter quickly embraced the discovery of the epidemiology and prevention of puerperal fever, published by Oliver Wendell Holmes, Sr.

in 1843. This was 11 years before Dr. John Snow documented the epidemiology of cholera in London (1854), 20 years before “germs” were discovered by Louis Pasteur (1860-1864), and 37 years before Dr. Robert Heinrich Herman Koch (b1843-d1910) explained how germs work (1880). Mütter attracted students and patients from all over the U.S. His medical students included E.R. Squibb, who standardized ether and developed an ether mask, yet eschewed his rights to its patents. Then Squibb founded Squibb pharmaceuticals, which today is part of Bristol Meyers Squibb. Squibb advocated for transparency between the patient and practitioner, and between the doctor and supplier, resulting in the 1906 federal Pure Food and Drug act that required drugs to be labeled with their active ingredients and purity levels. Eventually, the FDA was born. The ripple effect of Mütter’s teaching is also documented by the accomplishments of many of his other students. Francis West Lewis helped develop the first Children’s Hospital in Philadelphia in 1855. Juan Carlos Finlay discovered the cause of Yellow Fever in 1881 (bites from the Aedes aegypti mosquito), widely acclaimed to be the second most important medical discovery since the discovery of vaccination. Jonathan Letterman (b1824–d1872) became the medical director of the Army of the Potomac. He organized an ambulance service and a triage system. The Letterman Army Hospital (Presidio SF) was named for him in 1911. Robert T. Coleman became the surgeonin-chief of the Stonewall Jackson Brigade. John H. Britton became the personal physician of General Ulysses S. Grant. Andrew Jackson Foard became assistant U.S. Surgeon general, resigning to serve for General Braxton Bragg at the Battle of Shiloh. Daniel Leisure embraced Mütter’s philosophy of cleanliness and successfully applied it to his military command for sanitation and hygiene. William Forbes worked with Florence Nightingale during the Crimean War. In 1866, he successfully had enacted a legal method to provide cadavers for the teaching of

This is a cast of conjoined twins, Chang and Eng Bunker, who were born in 1811 in what is now Thailand. They came to the United States in 1829.

gross anatomy to medical professionals. Today, we promote hand washing outside each patient’s hospital room. Others debate the relative benefit vs. harm of immunizations. Surgeons consider a pre-operative “check list” as a clinically beneficial innovation. Are these innovations, or did we forget our inheritance? George Santayana is quoted: Those who cannot remember the past, are condemned to repeat it.” Thoughtfully, Cristin Aptowicz rekindles for us the life and times of Dr. Thomas Mütter so we may discover that our inheritance was cultivated decades before our grandparents were born. We can also appreciate how innovation can be disruptive to some, beneficial to others, and requires courage to promulgate. The knowledge we apply today was painfully wrought through tedious, tenacious discovery and implementation during times that must not be forgotten. jerryroganmd@sbcglobal.net REFERENCE http://Müttermuseum.org/

This display of skeletons includes the notable Mütter American Giant. At 7’6” tall, this is the tallest skeleton on exhibit in North America.

January/February 2017

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: Rodney Acuna, MD, Family Practice, Davao Medical School Foundation – 1999, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670 Vladislav Afanasevich, MD, Psychiatry, Saba University School of Medicine - 2011, The Permanente Medical Group, North Valley

Robert Gordon, MD, Ob/Gyn, University of Tennessee Center for Health Sciences – 1986, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815 Christopher Horne, MD, Psychiatry, George Washington University School of Medicine and Health Sciences – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Michael Ajakaiye, MD, Family Practice, University of Ibadan, Nigeria – 2005, Mercy Medical Group, 3000 Q St, Sacramento, CA 95816

Susan Huang, MD, Ophthalmology, University of California San Francisco School of Medicine – 2010, The Permanente Medical Group, 1001 Riverside Ave, Roseville, CA 95678

Ketan Ajudia, MD, Hospitalist, M P Shah Medical College Saurashtra University – 1994, Marshall Medical Center, 1100 Marshall Wy., Placerville, CA 95667

Julie Hylton, MD, Psychiatry, George Wasington University School of Medicine – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Enass A. Arahman, MD, Occupational Medicine, University of Khartoum, Khartoum, Sudan – 1994, Mercy Medical Group, 3000 Q Street, Sacramento, CA 95816

Anne Kern, MD, Internal Medicine, University of California, San Francisco – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Melissa Capule, MD, Hospital Medicine, University of California, San Francisco – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Paul Koenig, MD, Family Practice, University of California College of Medical – Irvine – 1998, Sutter Medical Group, 125 N. Lincoln # G, Dixon, CA 95620

John Champlin, MD, Family Practice, University of Florida – 1983, Med Center Medical Clinic, 6651 Madison Ave., Carmichael, CA 95608 Amber Chatwin, MD, Hahnemann University School of Medicine – 1994, Surgical Affiliates Management Group, Inc. Allen Dang, MD, Internal Medicine, Wayne State University School of Medicine - 2013, The Permanente Medical Group, North Valley Adnan Din, MD, General Surgery, University of California School of Medical – Davis – 1997, Sutter Medical Group, 2030 Sutter Place #1100, Davis, CA 95616 Jason Epstein, MD, Emergency Medicine, Wayne State University – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Caroline Esguerra, MD, Family Practice, The Chicago Medical School at Rosalind Franklin University of Medicine and Science – 2013, Mercy Medical Group, 7601 Hospital Dr. # 103, Sacramento, CA 95826 George Gallardo, MD, Hospital Medicine, Medical College of Wisconsin – 2012, The Permanente Medical Group, 1600 Eureka Rd, Roseville, CA 95661

Rachel Kornrich, MD, Family Medicine, Oregon Health & Science University – 2006, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670 Devna Mangrola, MD, Internal Medicine, Albert Einstein College of Medicine -Yeshiva Univ – 2013, The Permanente Medical Group, 2345 Fair Oaks Blvd, Sacramento, CA 95825 Melissa Mariano, MD, Internal Medicine, University of California, Davis, School of Medicine - 2013, The Permanente Medical Group, North Valley Purvi Y. Parikh, MD, General Surgery, Drexel University College of Medicine - 2001, The Permanente Medical Group, North Valley Neha Prakash, MD, Dermatology, University of Wisconsin Medical School – 2012, The Permanente Medical Group, 2120 Professional Dr #135, Roseville, CA 95661 Danilo C. Ramos, MD, Anesthesiology, University of California, Davis, School of Medicine - 2006, The Permanente Medical Group, North Valley Jack Russo, MD, Otolaryngology, University of California School of Medical – Davis – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

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Ragini Sastry, DO, OBGYN, Lake Erie College of Osteopathic Medicine - 2012, The Permanente Medical Group, North Valley Kapil Sharma, MD, Cardiology, McGill University, Montreal, Canada - 2000, Mercy Medical Group, 3941 J Street, Suite 270, Sacramento, CA 95819 Sarah Takekawa, MD, Ob/Gyn, University of Hawaii School of Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Jessie Albert Tan, MD, Emergency Medicine, Wayne State University School of Medicine - 2013, The Permanente Medical Group, North Valley Jared Taylor, DO, Family Medicine, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific – 2009, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815 Mary “Cathy” Tran, DO, Internal Medicine, Lake Erie College of Osteopathic Medicine - 2013, The Permanente Medical Group, North Valley Felipe Villena, DO, Anesthesiology, Kirksville College of Osteopathic Medicine – 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Anna Vinter, MD, Psychiatry, University of California School of Medical – Davis – 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Julie A. Wood, MD, Psychiatry, Ross University School of Medicine - 2006, The Permanente Medical Group, North Valley Xiaojing Ye, MD, Internal Medicine, Tongji Medical University, Wuhan, China – 1998, The Permanente Medical Group, North Valley APPLICANTS FOR RESIDENT/FELLOWSHIP MEMBERSHIP: John McClain, MD, Internal Medicine, UCD Medical Center (Resident/Fellow Programs) – 2017 Arkady Yusupov, MD, MBA, Neurology, UCD Medical Center (Resident/Fellow Programs) – 2018

Board Briefs November 14, 2016 The Board: Approved the 2017 Proposed budgets for the General Fund, Building Fund and the Community Service, Education and Research Fund (CSERF). Approved the 3rd Quarter 2016 Financial Statements, Investment Reports and Recommendations. Approved the following Scholarship and Awards Committee recommendations for the 2016 annual awards: Gordon A, Wong, MD, Golden Stethoscope Award; Tim W. Grennan, MD, Medical Honor Award; La Familia Counseling Center, Medical Community Service Award; and a Special Recognition Award to Retinal Consultants Medical Group. Approved a letter to the Sacramento County Board of Supervisors requesting that the county sanction Syringe Exchange Program Centers. Approved the following appointments to the SSVMS Delegation to the California Medical Assoication: Ernesto S. Rivera, MD, Alternate-Delegate At-Large Office 18 and Mark E. Drabkin, Alternate-Delegate At-Large Office 19. Approved the selection of Vavrinek, Trine, Day & Company as the SSVMS auditor. Approved the SSVMS Final Election Results. Approved the Membership Reports: October 15, 2016 Membership Report For Active Membership — Rodney Acuna, MD; Michael A. Ajakaiye, MD; Jason Epstein, MD; Christopher B. Horne, JD, MD; Susan Huang, MD; Julie Hylton, MD; Anne Kern, MD; Neha Prakash, MD; Jack E. Russo, MD; Felipe Villena, MD. For Reinstatement to Active Membership — Ketan P. Ajudia, MD.

For Resident Active Membership — George Gallado, MD; Devna Mangrola, MD. For Retired Membership — Monice Kwok, MD; Craig Yamada, MD. For Resignation — Dominique Lan Rash, MD; Elaine Miller, MD. November 14, 2016 Membership Report For Active Membership — Melissa Capule, MD; John Champlin, MD; Amber Chatwin, MD; Adnan Din, MD; Caroline Esguerra, MD; Robert Gordon, MD; Paul Koenig, MD; Rachel Kornrich, MD; Sarah Takekawa, MD; Jared Taylor, DO. For Reinstatement to Active Membership — Anna Vinter, MD For Resident Active Membership — John T. McClain, MD; Freshta Obaidi, MD;; Arkady Yusupov, MD. For Retired Membership — Henry Mok, MD For Resignation — Myla Canales, MD; Erica Heiman, MD; Janice Santos, MD; Ganesan Venkatapathy, MD. For Transfer of Membership — Rashmi Narayana, MD; Anthony Russell, MD.

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 of Special Consultant. Physicians will be paid on an hourly basis for their time and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if you may be interested.

January/February 2017

Contact SSVMS TODAY to Access These

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

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement

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

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

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

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

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

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

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

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

Avis or Hertz www.cmanet.org/groupdiscounts

CME Certification Services Discounted CME Certification for members

CMA’s Institute for Medical Quality (IMQ)

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DocBookMD www.docbookmd.com/physicians/

HIPAA Compliance Toolkit Various discounts; see website for details

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PUBLICATIONS CMA Publications

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

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

SSVMS Publications

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

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

Retinal Consultants Medical Group Members of the American Society of Retinal Specialists

Macular Degeneration • Diabetic Eye Care Flashes & Floaters • Retina & Vitreous Disorders • Clinical Trial Research LOCATIONS: Chico • Elk Grove • Fairfield • Folsom • Grass Valley • Modesto

Roseville • Sacramento - J Street & Greenback • Stockton

We accept Medicare, Medi-Cal, Covered California Plans, TriCare and most other insurance plans

New Physician! We warmly welcome our newest physician, Dr. Carlos A. Medina Dr. Medina joined Retinal Consultants after completing a retina fellowship at Bascom Palmer Eye Institute, ranked #1 by US News & World Report for twelve consecutive years. Dr. Medina is an accomplished clinician, researcher, author, and lecturer, and has received numerous awards such as the prestigious Pearl Goldberg fellowship award and the ASCRS Foundation Resident Excellence Award. He is fluent in both English and Spanish, and enjoys road cycling and spending time with his family.

New Location!

2330 E Bidwell St. Suite 200 Folsom, CA 95630 (916) 293-9381 www.retinalmd.com

2330 E Bidwell Street, Suite 200 Folsom, CA 95630

www.retinalmd.com

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