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MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
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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.
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2017 Education Series
PRESIDENT’S MESSAGE A Good Turnout at Legislative Advocacy Day
Love Your Poop
Ann Gerhardt, MD
In Front of Our Eyes
Ron Chambers, MD
A Personal Encounter
Sarah Chaffin, MD Tips on Recognizing Victims
Ruenell Adams Jacobs, MD
EXECUTIVE DIRECTOR’S MESSAGE SSVMS’ Joy of Medicine Program
Aileen Wetzel, Executive Director
Ultrasound Training for Medical Students
Tanmayee Yenumula, MS II
Call for Awards Nominations
GUEST EDITORIAL Syphilis Cases and Cost of Treatment are Rising
Glennah Trochet, MD
GUEST EDITORIAL Risk Factor Reduction
Word of the Year ... or “Surreal, Dude”
Jack Ostrich, MD
Lighting for Literacy
Gerald Rogan, MD
John Loofbourow, MD
The Pathologization Conspiracy
Caroline Giroux, MD
Civil War Medicine Part II – Surgical and Medical Treatments
Kent Perryman, PhD.
Education Outside the Medical School Box
Neeraj Ramakrishnan, MS I
IN MEMORIAM Albert J Kahane, MD
Inspire the Next Generation: Volunteer
Myel Jenkins, Program Director
White of Cotton
Welcome New Members
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 entitled, “The Deconstruction of Sutter Memorial,” is by Sacramento otolaryngologist Dr. David Evans. Sutter Memorial Hospital opened in 1937 as the first satellite hospital in California, and it played a big role in the lives of Sacramentans. It was the first air-conditioned hospital west of the Mississippi River, and nearly 350,000 babies were born there. For those who worked there on a daily basis, it was a sad day when it closed. The newer wing to the right of the image was added in 1969, and housed the operating rooms and ICUs. This image shows the status as of August 2016. If you go by there today, you will see the infrastructure for a new housing development being prepared. −firstname.lastname@example.org
Volume 68/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax email@example.com
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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 Tonya Fancher, MD J. Bianca Roberts, MD Christian Serdahl, MD District 3 Thomas Valdez, MD District 4 Ranjit Bajwa, MD
District 5 Sean Deane, MD Cynthia Ramos, MD Paul Reynolds, 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 Rajiv Misquitta, 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 Vacant
CMA Trustees District XI Douglas Brosnan, MD
Margaret Parsons, MD
CMA President Ruth Haskins, MD
CMA Speaker Lee Snook, MD
Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.
AMA Delegation Barbara Arnold, MD
Richard Thorp, MD
Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising.
Editorial Committee John Paul Aboubechara, Sean Deane, MD Adam Doughtery, MD Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD
MS III Steven Nemcek, MS II John Ostrich, MD Neeraj Ramakrishnan, MS I Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD Jon Yan Zhou, MD
Executive Director Managing Editor Webmaster Graphic Design
Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly
Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©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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A Good Turnout at Legislative Advocacy Day By Ruenell Adams Jacobs, MD ONE MISSION OF SSVMS, as part of the California Medical Association (CMA), is legislative advocacy. This may be accomplished through participation in local and state events, writing resolutions which are vetted through the CMA House of Delegates process, and contacting our representatives via telephone, email or in person, to name a few. Every year, physicians, physician leaders, physicians in training and medical students from around the state gather in Sacramento, typically in April, to participate in CMA’s Legislative Advocacy Day at the Capitol. The turnout is usually good, and this year was no exception. On April 18, 2017 over 500 physicians, medical students and stakeholders throughout California gathered in Sacramento to participate. SSVMS was represented by area stakeholders, several current and past board members, other community physicians, residents in training and medical students from the University of California, Davis School of Medicine, and California Northstate University College of Medicine. We met with our elected Assemblymembers and Senators and/or their staff to give voice to our concerns regarding the Governor’s proposed state budget, which would divert the tobacco tax funds (Proposition 56) from Graduate Medical Education and improve reimbursement to physicians who serve Medi-Cal patients, into the General Fund. We also voiced our support for two proposed bills. SB641 (Lara),
CURES Privacy. If passed, this bill will provide greater privacy protection to patients who have prescription information housed in the CURES database. CMA-sponsored AB1048 (Arambula), Reducing Pressure to Prescribe Opioids, will improve medical providers’ ability to practice safe prescribing of opioids by removing the requirement that pain be assessed at the same time as vital signs, and to allow for partial fill of a Schedule II controlled substance, if requested by the patient or provider. So, my thanks to all who participated in this long and productive day. The work that we all do to protect physicians’ and patients’ rights throughout the year is so important, and what you all do does make a difference. firstname.lastname@example.org
A large crowd of physicians and medical students squeezed into Senator Bill Dodd’s capital office to lobby on behalf of local doctors.
EXECUTIVE DIRECTOR’S MESSAGE
SSVMS’ Joy of Medicine Program By Aileen Wetzel, Executive Director THE SIERRA SACRAMENTO Valley Medical Society (SSVMS) is passionate about helping physicians in the Sacramento region to find happiness and fulfillment in their profession. This year we launched Joy of Medicine, a program bringing together all specialties and modes of practice. Our goal is to engage physicians in the Sacramento region in a long-term conversation that will help physicians recognize the signs of burnout, build meaningful resiliency and help physicians thrive. While many of the Sacramento region’s medical groups offer Employee Assistance Programs, and the health systems utilize Wellbeing Committees, many physicians have stated that they will not seek out assistance within their own group or facility. Access to wellness programs and services is vital to physician wellness and resiliency. SSVMS’ Joy of Medicine Program will relieve physician pain and will help to reclaim the joy of practicing medicine through education, advocacy and program services designed to nurture individual well-being and collegiality, and to promote systems-wide changes. 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.
Annual Summit The 1st Annual Joy of Medicine Summit will be held Saturday, September 23, 2017 at Arden Hills Country Club. The purpose of the annual summit is to give physicians tools and resources to cope with the stressors that are part of practicing medicine. This halfday summit features keynote speakers, several breakout sessions and opportunities for group interactions.
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Connect with Yourself • Resiliency Consultations SSVMS is providing a limited number of sessions for physicians to receive counseling from vetted psychologists who are experienced in working with physicians. Counseling through this program will be anonymous for the physician, insurance will not be billed, and medical records will not be kept. • Finding Meaning in Medicine Groups Working with facilitators, SSVMS will organize small groups of physicians that will gather in various locations for weekly group meetings. Finding Meaning in Medicine Groups will discuss topics such as grief, kindness, healing, courage, service and other subjects. • Education Free in-person CME seminars and/or webinars are offered to physicians with topics including: mindfulness, professional fulfillment and resiliency.
Connect with Fellow Physicians • Social Gatherings To promote a greater sense of community among physician peers, SSVMS hosts small, intimate social gatherings in physicians’ homes. There is also one larger event per year, such as a day at the movies, to connect physicians and their families. • Interest Groups Physicians are encouraged to access email listservs that serve a common purpose, such as a book club, activity groups like biking, hiking or running, or women in medicine group. Each group has a physician champion to promote activities for the group to participate in. continued on next page
Board Briefs May 8, 2017 The Board: Approved the appointment of J. Bianca Roberts, MD, to the Board of Directors representing District 2, Office 2. Approved the 2016 Audit Report and 2016 SSVMS tax returns prepared by the CPA auditing firm of Vavrinek, Trine, Day & Company. Received a presentation from the Sacramento County Public Health Officer, Olivia Kasirye, MD, regarding Sacramento County’s Public Health Priorities, Community Health Improvement Plan. Approved proposed Bylaws amendments for submission to the Regular Active Membership for approval. In accordance with the current Bylaws, only Regular Active Members are entitled to vote and will receive a copy of the proposed amendments at least 30 days in advance of the ballot. Approved the 1st Quarter 2017 Financial Statements. Approved the appointment of the following members to the 2017 Nominating Committee: Tom Ormiston, MD, Immediate Past President, Chair; District Representatives: Ruth Haskins, MD, District 1; Margaret Parsons, MD, District 2; Barbara Arnold, MD, District 3; Russell Jacoby, MD, District 4; Rajiv Misquitta, MD, District
5; Marcia Gollober, MD, District 6; At-Large Members: Rick Jones, MD and Katherine Gillogley, MD. Approved the nomination of Andrea Bates, MD, to the CMA Subcommittee on Workers’ Compensation. Approved the April 24, 2017 and May 8, 2017 Membership Reports as follows: For Active Membership — Sherrill Brown, MD (transferring from Los Angeles), Raminder Gill, MD, Stephanie Hawkins, DO, Brian Jones, MD, Keith Jones, MD, Ajay Singh, MD, Marsha Snyder, MD. For Reinstatement to Regular Active Membership — John Canio, MD. For Resident Active Membership — Jeffrey Barrett, MD; Leigha Winters, MD. For Retired Membership — James Holcroft, MD; Michael Sims, MD; Silvana Volpe, MD.
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DESIGN / MARKETING
Kelly Rackham  616 6270 email@example.com www.planetkelly.com
Joy of Medicine continued from page 4 • Physician Gratitude Pop Ups These “Gratitude Pop Ups” are a way to show physicians that they are appreciated by the medical society, their medical groups, hospital administration, and by their patients. The pop ups are hosted in physician lounges or other designated areas of the region’s hospitals or office sites. Each physician who visits the pop
up is thanked for the work they do and receives a wellness themed goody bag. Thank you, each and every one of you, for your contributions to the profession of medicine. Now is the time to let SSVMS take care of you. firstname.lastname@example.org
Syphilis Cases and Cost of Treatment are Rising By Glennah Trochet, MD Guest Editorials are welcome, as are comments regarding the editorials themselves.
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
THE UNITED STATES IS experiencing an upswing of syphilis cases. Long-acting benzathine penicillin is the recommended drug for the treatment of the disease, particularly in pregnant women and in newborns with congenital syphilis. In 1999, the Centers for Disease Control (CDC) issued a “National Plan to Eliminate Syphilis from the United States.”1 Elimination of syphilis seemed like a reasonable goal in 1999, as reported cases were declining, reaching the lowest point in 2001. The number of cases started rising again in 2002. The groups most at risk at that time were men who have sex with men. In 2006, a new national plan for syphilis elimination was issued, recognizing changes in the epidemiology, groups at risk and social environment. However, the epidemic continued to grow, and now has spread to the usual risk groups, including pregnant women and their infants. The effort to eliminate syphilis in the United States was abandoned in 2013. Now, we are just trying to address the growing epidemic. I will use our region as an example of the epidemic, but the findings are reflected throughout the country. In Sacramento and Yolo Counties, the number of reported cases of primary and secondary syphilis has been trending upward since 2002. The most recent figures show that in 2011 the rate of primary and secondary cases of syphilis in Sacramento County, was 8.2 per 100,000 while by 2015, the rate had grown to 15 cases per 100,000.
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In Yolo County, the rate was 2.5 per 100,000 in 2011, growing to 10.3 per 100,000 in 2015. The number of syphilis cases reported in El Dorado County is so small that trends cannot be detected.2 After almost a decade of having no cases of congenital syphilis in the three counties, Sacramento County saw a spike in cases in 2011, and continues to see babies born with syphilis. An ominous note is that a case of congenital syphilis was reported in 2015 in El Dorado County, and another in Yolo County; both counties had no congenital syphilis cases for years.3 The drug of choice for the treatment of this disease has not changed in decades. It continues to be one dose of 2.4 million units of longacting benzathine penicillin for primary and secondary syphilis. Although other antibiotics may be effective in non-pregnant adult women, injectable penicillin is the only drug recommended for the treatment of pregnant women and for infants with congenital syphilis.4 The formulation of this drug for IM injection progressively became more convenient, going from single ampoules that had to be placed in solution before injecting, to pre-filled syringes that are single dose and have the medication in suspension. I remember in the 1990s, the manufacturers of LA Bicillin decided to stop selling individual pre-filled syringes of the medication and required that physicians, who wished to use the drug, buy it in packages of 10 or not at all. Many physicians in private practice, who saw a patient with primary or secondary syphilis maybe once a year, would not buy 10 doses when they planned to use only one.
Because Sacramento County did not have an STD clinic, the Sacramento County Division of Public Health began buying the medication and delivering it to physicians’ offices in order to encourage prompt treatment of the disease. However, since April of 2016, there has been a “shortage” of this drug in the United States due to a “manufacturing delay.”5 Only one manufacturer, Pfizer, is authorized to sell
injectable benzathine penicillin in this country. There is no generic producer of the drug in the United States. The nature of the manufacturing delay is obscure. The cost of this medicine, which was less than a dollar a dose in the 1970s, is currently $300 a dose to the Sacramento County Public Health Division. In the rest of the world, there are several manufacturers of benzathine penicillin, and there appear to be no manufacturing delays. The World Health Organization lists this drug as an essential medication, and it is freely available in the developing world for $0.50 to $10 a dose. In the United Kingdom, the drug’s price was between one and two British Pounds a dose in 2015.6 Why is this happening? Maybe because in this country, access to health care is considered a commodity to be sold at the highest price the market will bear; while in the rest of the world, access to health care is recognized as a human right, with access to medication considered a public good. The FDA, which is supposed to regulate medications to ensure their safety, appears to use its regulating power to allow for monopolies in manufacturing, which then lead to price gouging. This is not the first time, nor will it be the last where, in the U.S., company profits are considered more important than public health and the future of children.
The image on the upper left is from a large folio, circa 1898, in the collection of the SSVMS Museum of Medical History containing multiple images of dermatologic conditions. It is entitled, “Atlas of Skin Diseases Pringle - Rebman Co. New York Imp- Lemercier.” The images in this folio are photochromes likely from models in the St. Louis Hospital, Paris. The two photos, below, show syphilis in a baby.
email@example.com REFERENCES 1 https://www.cdc.gov/stopsyphilis/ seeexec2006.htm 2 https://archive.cdph.ca.gov/data/statistics/ Pages/STDData.aspx 3 https://archive.cdph.ca.gov/data/statistics/ Documents/STD-Data-Syphilis-CongenitalTables.pdf 4 https://www.cdc.gov/std/tg2015/syphilis. htm#Treatment 5 https://www.fda.gov/downloads/Drugs/ DrugSafety/DrugShortages/UCM557868.pdf 6 https://en.wikipedia.org/wiki/Benzathine_ benzylpenicillin
Risk Factor Reduction Soliciting Government Help to Improve Quality of Care
By Gerald Rogan, MD Guest Editorials are welcome, as are comments regarding the editorials themselves.
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
ON APRIL 20, 2017, I spoke at the CMS public meeting called to develop the 12th SOW for the QIOs for the five-year plan beginning August 2019. CMS is the Centers for Medicare and Medicaid Services. The QIOs are the Quality Improvement Organization Contractors. The SOW is the Statement of Work that CMS asks them to perform. About 60 people attended at the CMS auditorium in Baltimore, MD, and about 150 listened via the internet, followed the slide deck that CMS promulgated, and listened, then responded with votes and written comments. For several years, I have known that the QIO was not as effective as it could be to help assure quality of medical care and patient safety within hospitals. So, when I read about this opportunity via the CMS E-mail list-serve, I jumped at the chance to provide input. At the meeting, I discovered most of the discussion was about high-level goals without details of specific tasks. Few physicians attended, so I realized that speaking out for physicians about specific unmet tasks would be meaningful. Many of you may recall the disaster at the Redding Medical Center that hit the news in 2002. Over 700 patients received unnecessary coronary artery procedures, including bypass surgery. Two physicians lost their licenses, the hospital was kicked out of the Medicare Program and sold, and its owner, Tenant Corporation, paid about $500 million in fines and penalties. The negligence was discovered via two Qui Tam (whistleblower) lawsuits, filed separately, one by a patient and one by a community physician. After the case was settled in 2006, I asked the
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QIO to perform a “disaster analysis” to discover the root cause that allowed the negligent care to continue for several years within an accredited hospital whose leaders were bragging about their top quality medical care. The QIO refused because a disaster analysis was not part of its SOW. So, with two other physicians, we provided a disaster analysis, which revealed a failure of peer review, physician intimidation, and failures of Government oversight, both Federal and State.1 I know of two other medical disasters like Redding. One occurred at St. Joseph Hospital in Towson, MD around 2009 in which over 400 patients received unnecessary intra-coronary stents. The Senate Finance Committee’s Subcommittee on Health provided a disaster analysis of the St. Joseph Hospital Case.2 That analysis discovered a failure of medical staff peer review. A Qui Tam case was settled with St. Helena Hospital in California around 2014 in which about $2.5 million was awarded to the government. No disaster analysis has been done of the St. Helena Case. Currently, no government agency or contractor provides analysis of medical disasters. A successful Qui Tam law suit against a health care provider is evidence of poor quality assurance, as well as an embarrassing failure of state government to enforce hospital licensure requirements. Ineffective quality assurance is a risk factor for patient damage and wasted medical care resources. Physicians need to know when the medical staff of the hospital in which they practice is unwilling or unable to effectively guarantee adequate patient safety. Therefore, I recommended the QIO SOW
include root cause analysis of medical disasters with public reporting. Disaster analysis will help us all to learn from our mistakes. If this QIO task is successful, it could lead to the creation of a National Patient Safety Board whose mission would be congruent with that of the National Transportation Safety Board. We have benefitted from analysis of disasters: Analysis of FEMA’s failure after Hurricane Katrina, NASA’s management failure that led to the explosion of the shuttle Challenger, and the Intelligence Community’s failure that might have prevented the 9/11 disaster. A similar routine analysis should apply to medical disasters. Over the years, several physicians have called me asking how to report poor quality of care within their hospitals without risking retaliation. Some hospital leaders retaliate against potential whistleblowers to keep them quiet. Excess testing and treatment often contribute to poor quality, but are profitable through fee-for-service payments. There is a law firm that teaches medical staff leaders how to misuse peer review to intimidate whistleblowers. This is called “sham peer review.” One current task of the QIO is to make its staff available to field calls from patients and family members who are concerned about premature discharge of their loved one from the hospital. Building on this task, I suggested the QIO reach out to physicians to learn about their quality concerns in the same manner: Create a “physician ombudsman” service. The QIO could create a poster to be placed in medical staff lounges of every hospital stating: “Concerned about quality within your hospital and threatened by retaliation − call your QIO and let our professionals investigate. All calls are confidential.” My third request was that the QIO report on the efficacy of off-label use of anti-cancer drugs in adults. Pediatric cancer treatment has advanced faster than treatment of cancer in adults. One reason is better collection of data about off-label uses of anti-cancer drugs prescribed to children. By contrast, Medicare permits off-label use for adults without any
requirements to report details about the stage of the cancer, prior treatment, toxicity, or the benefit. Off-label uses are those in which there is insufficient evidence for the FDA to conclude the drug is safe and effective for a specific condition. CMS proposed the QIO report on drug safety. I suggested the QIO also report on the efficacy of off-label use of anti-cancer treatments. The American Society of Clinical Oncology, (ASCO) has spearheaded this effort.3 The QIO should assist. I was thrilled that CMS provided me the opportunity to speak on behalf of many doctors who have contacted me over the years about these three concerns. CMS asks for input. If you want to become involved, write via email to Monique.Ndenecho@cms.hhs.gov. Reference “Quality Improvement Organization (QIO) 12th Scope of Work.”
REFERENCES 1 http://bit.ly/2rufMIX 2 http://bit.ly/2rJ1ZyX 3 https://cancerlinq. org/
The Pathologization Conspiracy 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.
I SHOULD HAVE EXPECTED that kind of “coding error” message. I chose to proceed with my common sense anyway. The consequence took a whole week to manifest itself. Subject line: “Intake Diagnosis.” Content of the message included: “Unfortunately I cannot code an encounter without a diagnosis. This is a 90792 procedure code, which is an expensive service.” Recently, I received a very polite email from a person, conscientiously performing her duties, and whose title is “Patient Records Abstractor III” (I have never heard of such a title before). Two emails in fact: for the same reason, for two patients referred to me. Two “undiagnosable,” mentally balanced human beings, assessed the same afternoon. The supposedly routine administrative task of our job intercepted and turned into an abstraction still perplexes me. No matter how at odds with our dystopian world our patients might feel (and legitimately so), it concerns me to realize that they are often referred for some quick “fix” of their selves. Yet, when we take time to practice a deep understanding, an archeological search through defense mechanisms (whether they be interpersonal or somatic), in a lot of cases we conclude that there is nothing wrong with them. They present normal reactions to the unimaginable (the tragic loss of a spouse, or the amputation of a limb). In other words, whether the symptom lies in one’s gut, distress or counterproductive behavior, whether or not there is a corresponding drug commercial full of promises on TV that patients have heard of before the docs did, it can be a normal response to an abnormal situation. There is a cultural shift taking place; putting
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pressure onto us to find abnormalities makes me extremely uneasy. I am frequently filled with skepticism upon hearing a resident affirm, “He meets criteria for ADD,” to staff a patient whose nonspecific chief complaint is, “I can’t focus.” We are supposed to treat patients, not checklists. In psychiatry, the complex narratives of people cannot be dismembered into criteria. Most symptoms are not pathognomonic of any illness; various disorders overlap and biomarkers are rare. Somehow, the profession is often at the mercy of drug companies who sell the very diseases for which they market drugs. But when the problem lies in the environment, with its insane pace and around-the-clock overstimulation, is there a billing code or entity to diagnose the sickness of society? What justifies the prescription of a stimulant to an obese 50-year-old who cannot perform at his highly demanding job? Instead, I prefer to challenge my patients by saying things like, “Sometimes we have symptoms because we made life choices that are not a good fit for us. Most people would end up being distracted if they were bored or too stressed at their work. It doesn’t mean you have a neurodevelopmental disorder that starts in childhood called ADHD.” Why is my job so different than a pediatrician who sees a baby during a well child visit and concludes, “healthy toddler,” or even a radiologist who has the luxury to comment without fear of not being reimbursed for his legitimate labor, “no signs of fracture, normal X-ray”? Why does the rewarding, empowering and liberating task of saying, “There is nothing wrong with your mind,” or “What you are experiencing gets better, in most cases, and
you do not need medications for that,” seem so unpopular? Is it because we have become enslaved to our EMRs, sacrificing our sanity and critical thinking, desperate to please these insatiable gods? Meanwhile, how can I solve issues like the “undiagnosable”? Imagine a man who lost his wife in a tragic car accident, and whose three young children sitting in the back seat, survived. Pressured to do overtime at his stressful job, he is stuck in a double-bind. This would entail heartbreakingly more time away from his children, who so need him, or to choose a default option. The latter seems as nonviable for anyone who wants to be “normal” – complete disability. This measure seemed to solve the employer’s semantics dilemma about accommodation (which a regular work schedule had become contingent upon). But it is rather a preposterous one because the denial of the accommodation had been based on the initial opinion that there was no justifiable disability... I hope my note conveyed how normal this person was, given the circumstances, and how a prescription of regular work (now considered abnormal in our unreasonable world) was indicated. In front of me, I had a very caring father, willing to work, considering himself functional, dealing the best way he could with his grief, willing to share his story very honestly, despite his not liking doctors too much, as he said with a smile. I was impressed at how articulate this man was, how resourceful. No college degree, recent hardship, daily life challenges, yet keeping it together, kind, bright, resilient. Anxiety state, which is so universal and non-pathological, was the only impression I felt comfortable putting in the EMR’s required box. But, apparently, it wouldn’t do. I had to settle for something even more vague and meaningless: “unspecified anxiety disorder.” Another case involved a person referred to me after a procedure that was anticipated to be uneventful went really wrong. So, there was nothing abnormal about the fear I was hearing, the palpable dysphoria over a situation that could affect anyone’s body image and life. Since “normal reaction” is not among the choice of
answers, I dared to resort to an obscure V code, certainly an expression of my sense of futility as a doctor trained to find mental anti-order. People walk around with various psychiatric diagnoses attached to them. And, sometimes, people themselves seem very attached to such diagnoses as they become embedded in their identities. Since its first edition in 1952, a highly controversial, political1 manual, “Diagnostic and Statistical Manual of Mental Disorders,” has evolved a little bit like the German language: as descriptive and seemingly logical as it is, its à la carte way of adding words or concepts makes it somewhat tedious and not very integrative.2 From one edition to the next, the DSM created new sub-categories whenever symptoms would co-occur (for instance, major depressive disorder with psychotic symptoms, recurrent, severe, catatonic, with postpartum onset), not knowing what to make of the juxtaposition of specifiers, not looking at the underlying issue. I am always baffled to see people coming to my office assertively proclaiming their “ADHD, bipolar, PTSD, OCD, panic attacks, agoraphobia, kleptomania, insomnia, borderline personality disorder.” The consequences of such compulsory naming and coding are described in the book, “Crazy Like Us: The Globalization of the American Psyche,” by Ethan Watters, who also gives compelling examples of the perverse effects of public awareness campaigns. He talks about symptoms that become a way to express distress and are integrated in a “symptom pool,” once the socio-historical context feeds the feedback loop. There is a cultural molding of the unconscious, a medical shaping of symptoms. The DSM is an illustration of the cultural and medical shaping of illnesses. The first edition had 128 diagnostic categories. When the 5th version was released in 2013, it had blossomed into almost 541. There are probably only five or six really useful clinical entities. All the other diagnoses are probably only variations on more common themes. But a lot of corporations thrive on dysfunctional behaviors crystallizing people’s insecurities. Hence, it is our role as professionals to see normality through DSM-induced disorders and continued on page 13 July/August 2017
Education Outside the Medical School Box By Neeraj Ramakrishnan, MS I THE JOURNEY OF TRANSITIONING from years of preparing my application to actually enrolling in classes at California Northstate University College of Medicine (CNUCOM) in the fall of 2016 has been exhilarating. So far, I have expanded my knowledge of diverse topics, ranging from pathophysiology of lymphoma to medical management of heart failure. I’m learning to apply medical skills to real-life situations by working with standardized patients. Having faculty share their life stories about practicing medicine has broadened my outlook. While heavily involved in all that learning, I became curious about the future. What is the life of a doctor outside the classroom like? How do I form interests and connections in the medical field even before my clerkships? I decided to find the answers by attending the American College of Physicians (ACP) Internal Medicine meeting in San Diego this past March. Upon arriving in San Diego, I was amazed by the size and diversity of the ACP conference which was held in the beautiful San Diego Convention Center, located in the heart of the Marina District. As I collected my convention badge, I explored the countless informational booths, lectures, and activity sessions that were taking place there. The lectures, given by clinicians who were part of the ACP, particularly caught my attention. Information that I had learned in the classroom directly translated to actual clinical cases that these clinicians encountered. For instance, an infectious disease specialist described the most accurate and efficient way to diagnose parasitic infections, such as Lyme
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Disease and Rocky Mountain Spotted Fever. Another clinician, an allergist, lectured about taking an accurate history in a patient with a suspected allergic reaction, and arriving at a viable treatment. I was thrilled to see the theoretical knowledge that I learned at CNUCOM applied to improving patient care and their overall outcomes. I was even able to participate in a suture clinic workshop and to learn proper suture techniques. Though it was difficult to suture a pig’s foot with no prior experience, I appreciated the functional knowledge that I gained from this experience. As a first-year medical student, I had little insight regarding how to effectively study for medical board examinations and to prepare a competitive application for residency. However, by attending multiple seminars, I was greatly able to increase my awareness in these topics. I learned how to make an efficient study schedule to prepare for the Step 1 board examination, and familiarized myself with the most highlyrecommended study resources. I was also able to attend presentations given by residency directors regarding qualities that they valued in competitive applicants for residencies. I learned of the importance residency directors place on board scores and letters of recommendations from clerkship directors when evaluating candidates. The candidate’s willingness to engage with his or her community, and one’s leadership skills, were also emphasized. These seminars concluded with tutorials on writing effective résumés and performing well on interviews. In addition to greatly expanding my medical knowledge at the ACP conference, I
was able to network with a diverse spectrum of internists. For example, I met face to face with internal medicine residency directors from programs, such as those offered at UC San Diego and University of Texas, at a medical student breakfast social. By interacting with these residency directors, I learned about the various types and structures of internal medicine residency programs. I became motivated by their words of encouragement in enjoying the process of medical school and becoming passionate about particular issues in medicine. At a separate dinner, I had the opportunity to meet successful practicing internists. I heard the experiences of internists ranging from one who worked for decades at Kaiser Permanente to a couple who started a successful private practice in Southern California. From these physicians, I learned in depth both the challenges and rewards associated with a career in internal medicine. Overall, my experience at the ACP conference has contributed significantly to my growth as a medical student. I feel well-rounded, not only learning the curriculum presented at my medical school, but also being able to appreci-
ate the inner workings of the medical profession. The topics and physicians that I encountered at the conference have excited me greatly, and pushed me to work towards this goal. Given the rigorous and difficult curriculum of medical school, medical conferences have the ability to stimulate students and allow them to develop passions that they can follow. They can also simplify the life of the medical student by providing him or her with information such as how to prepare for applications to residencies so that they can more efficiently plan for the future. Finally, they have the potential to link students with mentors and role-models from whom they can learn a great deal through networking. The ability to engage in an enriching medical education and to learn the skills required to become a competent physician are truly three-dimensional. It should not only include following a medical school curriculum, but also engaging in valuable extracurricular activities outsides of it such as attending conferences. firstname.lastname@example.org
The Pathologization Conspiracy continued from page 11 partake in a massive depathologization crusade.3 We are not powerless. We can reverse the process of overmedicalization, or distortion of our frameworks that describe human suffering. When addressing a “chief complaint” or symptom, I suggest the following: 1. Listen with curiosity to the person, to the story behind the story (and turn your back on your computer screen, if necessary). 2. Try to achieve a deep understanding of the person’s problem. 3. Provide normalization, reassurance or, at least, hope. 4. Then, what can occur is a natural evolution of said symptom without the feedback loop from malevolent, pathologizing interests
(because #1, 2 and 3 can be effective therapy, the bedside manners, or so-called common factors, in psychotherapy). 5. The absence of social reinforcement can lead to an extinction of the symptom, both in the individual and in the symptom pool. email@example.com NOTES 1 For instance, the category “gross stress reaction” disappeared from the DSM-II in 1968, which was right in the midst of the Vietnam war. It reappeared again in 1980, under the name “posttraumatic disorder.” 2 The longest German word is apparently: indfleischetikettierungsueberwachungsaufgabenuebertragungsgesetz and means “law delegating beef label monitoring.” 3 I am deliberately creating an idiosyncratic term in the hope that the expression will make its way into the “idea pool,” and increase awareness of the problem.
Inspire the Next Generation: Volunteer By Myel Jenkins, Program Director, Community Service, Education and Research Fund
Students from California Northstate University College of Medicine, at right, are researching buprenorphine prescribing with support from mentor, Dr. Michael Parr, as a project with the Sierra Sacramento Valley Medical Society.
THE REGION OF EL DORADO, Sacramento, and Yolo counties is home to approximately 6,000 physicians. It is also home to two medical schools in which there are over 500 students preparing for a career in medicine. These two factors combined bring a perfect opportunity for established physicians to reach out and encourage local medical students as they pursue their dream in medicine. The Sierra Sacramento Valley Medical Society (SSVMS) is excited to launch a new program which will support this regional physician pipeline. Called the Future of Medicine, it is a new endeavor to engage physicians to give back and inspire the next generation by mentoring students interested in a career in medicine. The Future of Medicine offers multiple pathways for those interested in volunteering with high school and medical school students. High School Class Mentor: Volunteer physicians are matched with high school classes engaged in medicine pathways curricula. Volunteers serve as mentors to a designated class and visit several times a year to educate students on health-related issues, empower them to make healthy lifestyle choices, and inspire them to pursue a career in medicine. Medical Student Mentor: Physician volunteers meet with medical students at Mentor Events which are sponsored by SSVMS. Volunteers mentor students and provide guidance and encouragement. In addition, physicians with a passion for research are invited to volunteer as research mentors to provide supervision to medical students as they implement research projects. Mentoring is a way to lead, inspire and give
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back to the future physicians of the region. Eric Williams, MD, is a Kaiser Permanente vascular surgeon and a veteran mentor to high school students. He states, â€œAt the end, both mentor and mentee are changed by the experience. Since then, the opportunity to provide young adults with the information needed to make a career decision, and to reduce the impact of college cost to students and parents, has proven to be a very satisfying passion, and one that I am very thankful to have become involved with.â€? SSVMS invites you to get involved and to be a Future of Medicine mentor. Learn more about how you can lead, inspire and share at www. ssvms.org/program.aspx, and complete and return a Future of Medicine Interest Form to me at firstname.lastname@example.org. #FutureofMedicine email@example.com
Love Your Poop By Ann Gerhardt, MD THE LARGE MASS OF bacteria in stool is called the gut microbiome. It contributes to a healthy immune system, makes essential vitamins and amino acids, influences body weight and disease states and helps to inactivate toxins. Stool is basically bacteria, water, undigested fiber and small amounts of other nutrients. Even if you don’t eat much, bacteria will multiply and make stool. The human microbiome may consist of a few or many hundreds of different bacterial species. The more bacterial diversity, the better. Surgical patients with a greater variety of gut bacterial types suffer from fewer infections and heal better. A healthy gut microbiome stimulates and regulates a healthy host immune system. Low diversity is associated with infections, autoimmune disease, in which a person’s immune system inflames one or more body parts, and possibly even cancer. Stool bacteria make vitamins B12, K and biotin, all essential for health, which we absorb through the gut. Vegans, consuming only plant foods which are devoid of B12, can maintain a reasonable vitamin B12 status as long as the gut microbiome is healthy. Killing off stool bacteria with antibiotics transiently eliminates this vitamin source. Frequent courses of antibiotics can completely change one’s bacterial population, bowel habits and health. Stool bacteria exist in a symbiotic relationship with their human home. We use each other to stay healthy. Bacteria multiply by feeding off undigested food for energy and old intestinal cells that slough off, using them to make new amino acids (the building blocks of protein) and reproduce. Then bacteria die and their amino acids may be absorbed to nourish their human. Some bacteria break down toxins to use
for food. In this way, they help to detoxify the human host. Eliminating stool bacteria with laxative abuse and colonic “cleanses” doesn’t detoxify the body, it hobbles the body’s own mechanism of detoxifying. Our gut bacteria may also help to control our weight. A variety of experiments in mice show that transplanting stool bacteria from obese individuals into non-obese individuals causes the recipient to gain weight, while bacteria from lean donors does not. This has also occurred in humans who received a stool transplant for severe colitis. Indigestible vegetable fiber passes into the colon and is a preferred food for types of bacteria that do not promote obesity. There are two main families of bacteria in human stool, Firmicutes and Bacteroides. Firmicutes, in the course of their normal metabolism, produce more mass that can be absorbed into the human body than do Bacteroides. That absorbed mass is a source of energy, in addition to what calories are eaten, which might promote weight gain. Firmicutes also produce acetate, which stimulates the stomach to make an appetite-boosting hormone and makes the body less sensitive to insulin, increasing the risk of diabetes. It’s interesting that Lactobacillus species, the most commonly consumed probiotics, are Firmicutes bacteria. In recommending Lactobacillus, we may be promoting obesity and diabetes. Yes, poop smells and it’s yucky, but that doesn’t mean cleansing the body of it is a good thing. We should eat lots of vegetables to feed our bacteria and avoid laxatives and too many antibiotics to keep them healthy. firstname.lastname@example.org
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In Front of Our Eyes Human Trafficking is all around us in Sacramento … somehow medicine has just been blind to it.
By Ron Chambers, MD EMILY, AGE 13, SOLD for sex from age 5, was the first human trafficking victim I encountered. She was first sold for sex by her parents in a basement, later by numerous foster families, and finally by a trafficker in hotel rooms around Sacramento. A typical day of her life was servicing 10 or more “Johns.” These purchasers of sex are generally common, employed, middle class, married males with a family. Emily was easily located via websites containing numerous posts, all containing semi-nude photographs and provocative inviting messages from young women “eager to please,” all arranged by the trafficker. Between “dates,” the victim would be mentally, sexually, and physically abused, but would never be left with a scar on the face that would damage the trafficker’s “property.” Her life was one of continuous torture, beatings and rape … a series of events strewn together that represented the deepest, darkest aspects of mankind. Emily had never known a caring person. She was physically scarred and mentally broken. She did not sit during the exam with me, and made no eye contact. Her PTSD was palpable. She was not the Pretty Woman Hollywood depiction of prostitution. Emily was, truly, a modernday slave. A local community organization, struggling to get medical care for its victims from health care providers who were educated and trained in human trafficking and would not re-traumatize them, referred Emily to me. Inadvertent re-traumatization is a common scenario. Since that first day seeing Emily, I have, unfortunately, come to know that her
story is not unique or even uncommon. I have seen scores of young women and men, scarred by an incredibly-prevalent, public health crisis, largely unaddressed by the medical field. I began to realize that I had been seeing these victims throughout my life. They were on the streets I walked, in the neighborhoods I lived in, in line at 7-Eleven, in the hospital, in my clinic. I just wasn’t recognizing them. Many people have the false vision that the typical trafficking victim is someone illegally brought to the U.S. and sold on the black market. Human trafficking, as defined by the Trafficking Victims Protection Act of 2000, includes the inducement, recruitment, harboring, transportation, obtaining, or providing of a person by force, fraud, or coercion for commercial sex or labor services. A caveat is that persons under the age of 18 involved in commercial sex are automatically considered victims of human trafficking − for example, a 16-year-old dancing nude in a strip club. It is a definition, primarily, of exploitation, not movement, of people. Domestic sex workers are the most common category of trafficking victims identified in the U.S. In our clinic, most victims we see were born and raised in the Sacramento region. Although the vast majority of our patients are survivors of sex trafficking, we also see trafficked patients who worked around our community in restaurants, construction sites and hotels. Controversy surrounds the statistics, as the illegal and underground nature of the problem lends itself to inherently poor data collection. The United Nations International Labour Organization (ILO) Report estimated that
U.S victims number approximately 471,000. According to the Justice Department’s National Incidence Study, 1.7 million children run away each year with only 357,000 (21 percent) being reported. A separate study indicated one in five is forced into commercial and/or survival sex … an estimated 340,000 each year. Some may argue these numbers are sensationalized or the methodology is faulty. But it just takes a simple look at websites such as backpage.com, nightshift. co, or eros.com to view the hundreds of women, men, and children being sold all around us this minute. Look at these websites again an hour from now, and you’ll see all the new listings. Decide for yourself if this issue is prevalent in our communities.
Often these victims report a history of abuse and neglect as a child, being abandoned or running away from home… There are many reasons these victims do not leave their situation, go to the police, or seek other help. An undocumented labor trafficking victim might be threatened with deportation. For many of our patients, trauma-bonding plays a role, a concept difficult to comprehend. Often these victims report a history of abuse and neglect as a child, being abandoned or running away from home, and ending up on the street where they are easily identified and picked up by a trafficker. The trafficker then uses a combination of coercion methods such as beatings, forced drug use, and sexual activity, intertwined with gifts, attention, and demonstrations of “caring” to trauma-bond the victim. This creates a powerful, complex and enduring emotional bond which ties the victim to the trafficker as strongly as any metal chain. Sadly enough, there are instruction manuals on how to do this. For a disturbing glimpse of this, read the reviews of the book, Pimpology, on Amazon.com.
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It has 156 ratings and 4 stars. It is extremely important for health care providers to be aware of the issue and to understand these concepts, as they are some of the few people who actually see and interact with these victims. A study in Annuals of Health Law indicated 88 percent of sex trafficking victims reported encounters with a health care professional while they were being trafficked; of these, 0 percent were identified as victims. A study out of Oakland, California indicated that 77 percent of sexually-exploited youth saw a physician regularly, 33 percent were on prescribed meds and 49 percent had been hospitalized. Victims are seen in ERs, primary care offices, and all inpatient and outpatient settings. If medical providers do not know the red flags (the physical indicators and signs and symptoms) to identify these victims, potential intervention is missed. They need education to develop a basic, working knowledge of the principles of trauma-informed, victim-centered care. They need protocols for proper intervention techniques. They need to know how to get victims tied in with law enforcement and community agencies that provide case management and housing. We, in medicine, have failed this vulnerable population. As we are becoming aware of the issue, it is now our obligation to become involved and to advocate for their care. Despite the high emotional toll involved in caring for these victims, I can honestly say it has been one of the most rewarding experiences in my medical career. It reminds me daily why I first applied to medical school. In my seven years as Program Director for the Methodist Family Medicine Residency Program, this endeavor has, in my opinion, been the most important component added to our residents’ training.
Dignity Health Programs for Trafficking Victims Dignity Health, for whom I work, initiated a 39 hospital Human Trafficking Response under the direction of Program Director, Holly Gibbs, author, nationally-known advocate, and human trafficking survivor. I was fortunate to have been involved with the education and training early
victims who encounter a health care provider will be seeing someone knowledgeable on the issue, someone who knows where and how to access help. Following this article is a personal story from one of our second-year residents concerning her impressions caring for this population. I hope it touches you as it did me, and perhaps encourages you to reach out to learn more. In doing so, you may recognize the next victim you see. You may play a role in their path from victim to survivor. on, and have since participated in the thousands of hours spent training staff and physicians with Holly. We have worked with others to develop policies and procedures which create a safe environment for victim recognition and intervention. Mercy Family Health Center, an outpatient department of Methodist Hospital, with the help of Mercy Foundation, has established a safehaven medical home for victims and survivors of trafficking where every staff member, from the front desk to the medical assistants, nursing to physicians, have undergone extensive training in human trafficking using victim-centered, trauma-informed care. In a single visit and with a single provider, a victim may be treated for a STI, a dental infection, a rash, receive psychiatric medications and immunizations, and have their child seen and evaluated. We have partnered with the Family Justice Center, law enforcement, and many amazing organizations working in human trafficking that bring their clients to us, knowing it is a safe space where they can receive full-spectrum care. As a family medicine residency program, we have created curriculums for resident education, written a medical text book chapter and medical journal article, are publishing best practice guidelines learned from our experiences, and have initiated a multi-hospital study on training residents with the ultimate goal of getting the training incorporated into residency education nationwide. We hope to change the game, and work with others so that someday the 88 percent of
This photo was taken recently of a placard on the inside door in the women’s restroom at Las Vegas’ McCarran Airport.
Ronald.Chambers@DignityHealth.org RESOURCES Chambers RG, Chaffin S, Lo V (2017). Human Trafficking. In Domino FJ (Ed.), The 5-Minute Clinical Consult, Philadelphia: Wolters Kluwer Health. dignityhealth.org/humantraffickingclinic www.polarisproject.org/ https://www.dhs.gov/blue-campaign https://www.jscimedcentral.com/FamilyMedicine/familymedicine-3-1084.pdf https://dignityhealth.org/human-trafficking-response www.youtube.com/watch?v=myZrUgEE5OY
A Personal Encounter By Sarah Chaffin MD, Resident Physician THE SILENCE IN THE ROOM is palpable. I forget now what question was asked, but it must have touched a nerve because the stony-faced, 17-year-old girl sitting in front of me suddenly seems small and vulnerable instead of apathetic and hardened. The whole of her body quivers with the effort of holding back tears. And I sit there, waiting, letting her know that I’m here when she’s ready to tell me her story. There has been an abundance of transformative moments for me in my training as a Resident with the Mercy/Methodist Family Medicine Program. But as a female provider and, more importantly, a human being, none has been quite as earth shattering in nature as my work with survivors of human trafficking. We’re taught, as doctors, to empower our
Tips on Recognizing Victims Signs/Symptoms • Controlling 3rd party (boyfriend, husband, uncle, brother, sister, mom or dad) who does not want to leave, controls conversation. • Texting/calls: trained so that pimp can keep tabs on them at all times. • Not in control of their documents, money. • Unable to give address or does not know what city they are in. • Very poor historian (trauma disrupts the timeline). • Late presentation. • Substance addiction. • You get the “what is going on here” feeling of a strange encounter. • Patient avoids eye contact. • Bruising/scars/burns/cuts in “hidden” places. • Protection trauma (example: forearms). • Branding tattoos of pimp’s name or a strange symbol. • Recurrent STIs, pregnancy tests. • Exposure trauma. • Appears to be lying about age. • Acts in sexually provocative ways, wears clothing inappropriate with weather. • Body language: unwarranted fear, anger, anxiety, submission. What to Do If a Victim is in Office Providers must avoid the “rescue fantasy.” Protocols need to be developed ahead of time and must ensure safety for both the patient and provider in the immediate time frame and in the days to come. Patient involvement in the decision for police involvement is an important aspect of victim-centered care. Providers must also follow mandated reporting laws. Dignity Health’s protocols can be found at https://dignityhealth.org/human-trafficking-response. Call Polaris, the National Human Trafficking Hotline: 1-888-3737888 (or have patient memorize number). Patient may also reach Polaris via text “BeFree.”
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patients to take back their health, to lend an empathetic ear to their grieving, and to optimize the treatment of disease while working to prevent other illnesses. The patients I have seen through our human trafficking program test me to the core: They require (and deserve) gentle empowerment, need more empathy than I previously thought I had, and call for more creativity and sensitivity in treating and preventing disease. Every encounter stretches me, and I am a better doctor and person for it. A few months ago, if that same 17-year-old girl sat in front of me, I can guarantee you that I would have been exasperated by her indifference. How many times have I internally posed the question, “If you’re not going to talk to me or listen to anything I say, why are you here?” Our program’s efforts in educating residents about the challenges these young men and women face have deeply transformed how I see the patient in front of me, whether they are a victim of human trafficking or not. It’s taught me to ask the hard questions, to lean into my own discomfort for the sake of hearing this person’s story. It’s taught me to look and listen for what is really happening, understanding that the “poor historian” may be so severely traumatized that she is not capable of stringing together events in time. It’s taught me to be patient with silence. To say that I have benefitted from this training is an understatement. It is a privilege. It is humbling. It makes me a better family doctor.
Ultrasound Training for Medical Students By Tanmayee Yenumula, MS II RAPIDLY BECOMING “the visual stethoscope of the 21st century,” ultrasound has made leaps and bounds in its use in the medical field. Due to its real-time imaging, safety, and low-cost, it is the “go-to” imaging machine in the emergency department (ED). However, it is not limited to just the ED. Ultrasound is utilized in almost every specialty, from OB/GYN for following a pregnancy to term, to Interventional Radiology for providing visualization for creating a Transjugular Intrahepatic Portal Shunt (TIPS). With its expanding indications and bedside use, ultrasound training is now being integrated as part of the medical education for medical students, especially when students are rotating in the hospitals. I believe that ultrasound training should be taught even earlier, starting in the preclinical years to create a stronger foundation for clinical care with patients.
I believe that ultrasound training should be taught even earlier, starting in the preclinical years… Ultrasound is an excellent way to correlate anatomy with clinical knowledge. Recognizing this, last year, the anatomy lab director at California Northstate University College of Medicine (CNUCOM), Dr. Nena Mason, organized a six-session introductory course teaching the inaugural class’ MS I students the basics of ultrasound: how to work the machine, how to interpret the images on the screen, what sorts of pathologies typically are detected, and of course, how to perform the ultrasound. These
sessions review the most common ultrasound procedures, including the Focused Assessment in Sonography and Trauma (FAST) exam, which is the main procedure used in the ER to assess injuries in trauma cases. While these sessions gave the students an excellent introduction into ultrasound, there was still much to learn. Inspired by the initial introductory classes, now-MS IIs Spencer Salazar, Lexi Mullen, and I, worked with Dr. Mason to integrate ultrasound training deeper into our medical education. Because CNUCOM’s curriculum is organ systems-based, we found that ultrasound training integrates a dynamic understanding of anatomy with its reflection on the body’s surface. Over the summer, we formed the CNUCOM Ultrasound Society, where interested MS I and MS II students could have more time to learn about ultrasound and its uses as it pertains to each organ system, as well as to practice performing ultrasounds and interpreting the images for a better clinical perspective. The set-up is simple. Each month, the Ultrasound Society sets up a lunch talk with a guest speaker in the field on which we are currently focusing, usually pertaining to the anatomic block that MS I students are learning. Then, throughout the month following the talk, a group of up to four students can sign up for a one-hour session with student trainers to practice the skills they are taught. With five student trainers (Spencer Salazar, Lexi Mullen, Sam Sullivan, Glenn Geesman and myself) and Dr. Mason, students are given numerous chances to practice multiple times throughout the month until they feel
training has helped me to further solidify my clinical knowledge. As I prepare for my Step 1 exam, I have found that ultrasound training has given me more opportunities to practice interpreting ultrasound images on the exam, something I have had difficulty with in the past. Because images are now increasingly integrated into the exam questions, ultrasound training has enabled me to better understand what I am looking at, enabling me to answer the questions with confidence. Furthermore, by learning the ultrasound findings associated with certain anatomic pathologies (e.g. a “double bubble” finding which can be indicative of duodenal atresia and stenosis), I can better integrate the image findings with clinical medicine.
…ultrasound training has enabled me to better understand what I am looking at…
CNUCOM medical students practice using ultrasound on each other.
comfortable with the technique. As we wind up the first year, we’ve covered the carotid exam, the entirety of the FAST exam, as well as the cardiac assessment. This provides a strong foundation for students to hone their skills during the second year and to fully integrate their knowledge, as the soon-to-be MS IIs begin to prepare for the Step 1 of their United States Medical Licensing Exams (USMLE). As a student trainer preparing for the first exam in my boards, and as an MS II preparing for clinical rotations, I have found that ultrasound
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As more and more medical schools move toward integrating clinical skills throughout the preclinical years, I believe that ultrasound should also be included in this integration. After all, at our school, from our very first week of classes, we have had a clinical skills session that ties in with the cases we cover. Many of these sessions have focused on taking histories and the physical exam, although other sessions have covered common procedures such as sutures, intubation, catheter placement, and of course, ultrasound, as they pertain to the diseases of the week. Many of my classmates have found these sessions to be helpful, and have particularly enjoyed the ultrasound sessions, finding them to be both extremely interesting and applicable in clinical practice to the basic sciences. Ultrasound is only growing in significance to the medical field, and may even come to hold the same importance some day as the stethoscope. email@example.com
Call for Awards Nominations NOMINATIONS ARE BEING sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting in January 2018. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado-
Sacramento-Yolo region. The candidate must be an SSVMS member for at least five years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship & Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, firstname.lastname@example.org. Deadline: November 1, 2017.
Giving What’s Needed There are more ways than ever to help patients in need. Donors have a variety of options to donate blood components that help patients in specific ways. Individuals can give priceless gifts by donating whole blood, red blood cells, platelets, transfusable plasma and source plasma. Emily needed a variety of blood components to help her survive leukemia.
Visit bloodsource.org or call 866.822.5663 to learn more about the best way(s) you are able to help others. Schedule an appointment at a BloodSource Donor Center or mobile blood drive soon. Together, we do save lives.
Word of the Year or ... “Surreal, Dude” By Jack Ostrich, MD
I TOOK THE PHOTO that accompanies this article. It is a close-up view of a device that sits astride the drain at the bottom of one of the urinals in the men’s locker room at the “health club” where I gently exercise a few times a week. It is called a urinal screen. The blue glow in the center of the roughly triangular gadget is a gelatinous tablet designed to emit a pleasant odor into the immediate environment. And, if you look closely at the inferior aspect of the thingamajig, you can see the words, one above the other, “Brighton” and “Professional.” “Brighton,” I reckon, is the name of the company that produced the object, but what special feature, I wondered, made it “professional”? Did the person who installed it have to take a state or national exam in order to be allowed to handle it? Maybe that blue glob in the middle is toxic. I imagined a person in a hazmat suit coming into the health club in the dead of night, replacing all the old blue globs with new blue globs, tossing the old ones into vacuum-sealed bags and then driving out to the Nevada desert where other people in hazmat suits took the sealed bags and buried them, thousands of feet underground. Does the Brighton company provide continuing education for the janitors who handle its products? Do you have to attend and pass a course devoted to the handling, installation and troubleshooting of these things? Did a Brighton corporate jet whisk you to company headquarters and, from there, did a limo take you to the local Marriott where you attended classes designed to teach you to handle the “Brighton Professional Model Urinal Screen
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and Deodorant System”? At the end of the course, do you receive a certificate suitable for framing? Do you need to go back every two or three years for continuing education? Or maybe the folks at Brighton slapped “Professional” on the item, simply to help dissuade the casual urinal screen thief from stealing it. (“Gee, I guess I better not take this one, it might be too much to handle...”). But, truth be known, it is simpler than that. I pulled out my daughter’s copy of Roget’s College Thesaurus, 2001 edition, and looked up “profession.” The list of synonyms included, “vocation” and “calling,” but also “sham,” “pretension” and “affectation.” Our language certainly is supple and constantly changing, daily adding new words and terms, as well as dropping old words or creating new meanings for words that are, in many cases, quite ancient. Not long ago, my wife, Mary, and I were standing in front of Picasso’s famous “Guernica” at the Museo Reina Sofia in Madrid. Two young American men were nearby, and one said to the other, as they gazed at the huge painting, “That’s awesome, dude.” To which the other replied, “Surreal, dude.” The word “awe” first appears in the mid-13th century. Originally it meant, according to the Oxford English Dictionary (OED), “active fear, terror (or) dread.” Its meaning softened as it was applied to the biblical God, and, says the OED, it soon denoted “dread mingled with veneration, reverential or respectful fear... the attitude of a mind subdued to profound reverence.” The adjective “awesome” initially meant, not surprisingly, “full of awe” and “profoundly reverential.”
The American Heritage Dictionary (AHD) gives a similar definition of “awesome,” but the meaning of the word employed by the museum-going dude in Madrid was obviously different. He, no doubt, was greatly impressed, and probably puzzled, as he stood before Picasso’s work, as well as being struck by its size, composition and − who knew ? − the whole thing is painted in black and white and gray! The online Urban Dictionary (UD) sarcastically remarks that, “awesome is a word Americans use to describe everything” and adds that “it is a word used by Americans to cover up the huge gaps in their vocabulary.” And where and when did the word “dude” arise? The AHD states that the origin is unknown, but the OED claims to know. The UD does not care about the origins of words and defines “dude” as “a word that (male) Americans use to address each other. Particularly stoners, surfers and skaters.” The OED reports that “dude” first appeared in print in New York City in 1883 as “a name given in ridicule to a man affecting an exaggerated fastidiousness in dress, speech, and deportment, hence a dandy, a swell.” As we all know, it is in wide use in the USA, but is rarely heard elsewhere in the English-speaking world. By the way, the stodgy OED says that the feminine equivalent of “dude” is “dudine,” whereas “dudette” is now the much more popular word. So one dude thinks “Guernica” is awesome, but his buddy opines that it is clearly “surreal.” As I recall the floor plan at the Reina Sofia, there are plenty of authentic Surrealist paintings just a few steps from the room that contains “Guernica,” so maybe he was confused. But I am sure you are not surprised to find out that the meaning of “surreal” has been modified, just like “awesome,” “dude,” and even “professional.” “Surreal” is a so-called back formation from “surrealism,” “surrealist” and “surrealistic,” all now common English words first coined in French by author and critic, Guillaume Apollinaire, in the early 20th century and used by him to help categorize dreamlike and often
bizarre poems, plays, paintings and movies. It was the Merriam-Webster (M-W) “word of the year” for 2016. The M-W folks write, “It is a word that is used to express a reaction to something shocking or surprising. We need a word for what seems to be ‘above’, or ‘beyond’ reality. Surreal is such a word.” The UD disagrees and states, “Popular usage has transformed the word ‘surreal’ into little more than a synonym for ‘weird’ and so rendered it useless.” What hath Apollinaire wrought? Poor fellow is, no doubt, rolling over in his grave in Pere Lachaise Cemetery in Paris. My print copy of the OED, 1971 Edition, does not even have an entry for “surreal,” but the online OED does. It defines the word with synonyms such as “madcap,” “eccentric,” “nonsensical,” “crazy,” “absurd,” “weird,” “odd,” “freakish,” plus many more. But the dude at the Reina Sofia probably just meant, “weird.” And I agree with the other dude that Picasso’s creation is awesome. Totally. email@example.com The author pondered, “What makes a urinal screen ‘professional’”?
Lighting for Literacy A Journey to Baja With Students in Mind
By John Loofbourow, MD “The greatest Christian virtue is doing, the least is talking.” − John Wesley
I HAVE SELDOM BEEN so rewarded for working with my children and Methodists as on my fourth trip to Colonet, Baja California where I was privileged to interpret for a Lighting For Literacy (LFL) project, guiding middle school students in lighting up the lives of eight families living in Ejido Punta Colonet. In doing so, they also lit up middle school STEM projects (Science, Technology, Engineering, and Math) in the minds of students who put together the lighting systems and went to Colonet to install them. 1.5 billion people (20 percent of the world’s population) have no light after the sun sets. Opportunities for learning and literacy are lost with no light to read by. Lighting For Literacy is a humanitarian youth project of the Los Gatos Morning Rotary and the United Methodist Church, providing an educational pathway through math, science, and engineering. The goal is to engage local youth to design and install solar-powered LED lighting strips throughout the world, allowing communities a sustainable and renewable lighting source that doesn’t depend on a grid. Through the exploration of science, engineering and math, teens learn how to build a sustainable, renewable lighting system capable of providing two to three hours of evening light to homes without electricity. The benefit of a renewable lighting system in underserved countries is that it enables students there to have the opportunity to read and advance their education.
The LFL group’s very first solar lighting installation was actually in Colonet, Baja California. Within recent years, LFL projects (www.lightingforliteracy.org) have reached at least eight continents, and have introduced STEM and LFL to more than 1,200 middle school students who are at an age where inner places and lives can be “lighted up” in the process of lighting up remote places. At Colonet this past April, I felt enlightened, as well. These photographs and captions speak of the experience more clearly than words. It strikes me that this LFL project tells of the nature of family. Families who keep animals in, and desert varmints and coyotes out with closespaced, brittle, dead stalks of cactus plants, wire and plastic waste; who carve out a place in the desert to imagine a house – no, a home – into existence, largely made of trash. That’s what only families can do, like those pictured here. I would have never gone to Colonet without following my children, Amy and John, and their Los Gatos family. The April 2017 buildings would not have been successful without my son, Fred, who drove 3,600 miles roundtrip to be there. Or his Colonet counterpart, Ivan. Or pastor, Antonio. Or, need it even be said, the many helpers who were the glue that put it together. After completion, LFL recipients receive instructions for its best use. The switch is turned on by one of the children, and the student makes the final point by giving each child a set of age-appropriate Spanish books. We take a group photograph. Then, Adios is the perfect one word speech. firstname.lastname@example.org
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Two buildings are started on Sunday afternoon, the day of arrival, and by sunset the first walls are up. Each morning STEM students build eight LFL solar panels and controls for LFL; two are installed daily.
1 Start of framing house 2 Completed LFL installation 3 Cleaning cactus for nopales 4 Installing solar panel 5 Putting together control units 6 A wash house 7 STEM student at work 8 Helping set a wash house table
Links to videos and the complete report with more photos are at nwalmanac. wordpress.org.
Civil War Medicine Part II − Surgical and Medical Treatments
By Kent Perryman, Ph.D. DURING THE ANTEBELLUM period, centuriesold heroic medicine that “balanced the humors” by antiphlogistics, such as bleeding, was falling into disrespect. Disease processes such as malaria, cholera, consumption (tuberculosis) and syphilis were believed to be transferred from one individual to another by airborne particles from rotten vegetables and meat, commonly called “miasma.” The American Civil War broke out shortly before the discovery of the germ theory and the appreciation and importance of asepsis/ antisepsis. At the beginning of the Civil War, inadequate and antiquated medical practices contributed to the severity of wound infections and disease processes that infiltrated military camps and hospitals. Due to space limitation, I will only cover prevalent diseases and treatments.
Surgical Treatments for Injuries
The average soldier who enlisted in the army in 1861, for 90 days, had no idea what it would be like. Prior to engagements with the enemy, war-time conditions were tolerable and not taken too seriously for young Union and Confederate soldiers. It wasn’t until they were injured or became ill with the rapid spread of microbes that they appreciated the gravity of their health situation. Military engagements were conducted in much the same way battles had been fought for hundreds of years, with soldiers firing their weapons at each other in open field formations. The nine-ounce Minié ball, shot from a Springfield rifle, could carry for nearly a mile, shattering bone and macerating tissue. Many of the gunshot, saber, bayonet, and artillery wounds were contaminated by the soldier’s own
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dirty uniform and fragments of shell and soil. The field surgeon, who normally treated minor flesh wounds, would examine the soldier to determine the seriousness of his injuries and send him on to either a dressing station or a field hospital for further treatment. If there was no exit wound, another surgeon would probe for a bullet using either his finger or a probe. The cleanliness of the surgeon’s hands was of minor concern. Sometimes bullets and shell and shrapnel fragments remained as some surgeons did not feel skilled enough to remove them. Serious injuries to the skull and abdomen were generally beyond the surgical expertise of most physicians. Wounds to the arms and legs would be cleaned with a bromine disinfectant, iodine, nitric acid, or alcohol, if it was available, and silk or boiled horsehair were used to close some wounds, and cerate, a beeswax ointment, applied. It was common medical practice to not completely close a wound so it could drain, but it would be packed with lint and bandaged. (Among the many chores performed by women, both North and South, during the War was the making of dressings for wounds. Lint was pulled from old clothes and fashioned into an absorbent packing that was used by surgeons in military hospitals to staunch bleeding.) Some physicians discouraged the formation of scabs by applying cold water to the patient’s dressings that resulted in a greater incidence of infection. In some field hospitals where sanitary conditions were more relaxed, flies would lay eggs in the patient’s wounds, resulting in maggot debridement. Surgeons believed that a thin layer of “laudable pus” was necessary to form around the wound site for successful healing,
and to prevent the wound from becoming “putrefied” and developing gangrene, which could spread to other patients. Soldiers with gangrenous wounds were isolated at the Union general hospitals in separate wards that were washed and disinfected with fresh mattresses and bedding. Rather than dealing with mangled nerves, removing bony fragments and cleaning out infected bone, most surgeons in field hospitals preferred a speedy amputation that would prevent severe bleeding and sepsis. Mortality rates of 27-38 percent were improved, if amputations were performed within 48 to 72 hours. Compound fractures almost always resulted in amputated limbs. Surgical statistics later revealed that the closer the amputation to the trunk, the greater the likelihood of death. Gunshot and shrapnel wounds involving the hip joint led to an 83 percent mortality rate. Senior surgeons performed most amputations with assistants to administer chloroform or ether anesthesia. Another assistant would ligate the arteries while the surgeon sewed the stump. Contrary to popular belief, hot iron cauterization was never employed due to increased risks for infection. Some surgeons could perform an amputation in less than two minutes. The goal with amputations was to provide a suitable stump on which to fit a wooden prosthesis. Flaps of skin at the surgical site would be loosely sewn together with silk or silver wire sutures allowing for drainage. Postoperative care consisted of administering opiates for pain, as well as whiskey combined with milk or lemonade. Occasionally, morphine would be dusted directly into the wound. Out of 29,980 Union patients with amputations, 21,753 survived, resulting in a 27 percent mortality rate. Later in the war, with the introduction of splints, fewer lower arm amputations were performed.
Medical Treatments for Disease Processes Conditions during the Civil War, especially in the camps and field hospitals, were conducive
to the spread of diseases. Diseases could be easily spread as thousands of men were in close quarters. Most physicians had little or no experience treating outbreaks of yellow fever, measles and smallpox. There was no medicallyacceptable theory of disease. The “animalcular” theory of disease, where tiny living organisms might cause infections, was just beginning to catch the attention of the medical community. Another popular theory attributed “specific infectious poisons” as a causal agent to many illnesses: These poisons could be transmitted on porous substances and by air. During the Civil War, infectious diseases fell into three categories: (1)”certainly contagious” (smallpox and measles), (2) “showing some evidence of contingent contagion” (cholera, yellow fever, pneumonia and meningitis), and (3) “indicating no evidence of contagion at all” (continued fevers associated with diarrhea and dysentery). Civil War military surgeons were just beginning to experiment with the use of disinfectants to curb the spread of diseases. Physicians gradually began to appreciate the power of disinfectants in preventing the spread of infectious processes without any knowledge of bactericidal properties. Many primitive compounds were utilized to curtail the spread of diseases in the camps and hospitals, including burning sulfur to fumigate buildings and tents as well as the use of vinegar to clean wood operating tables and cots. Quicklime was sometimes spread over corpses at burial sites to promote dissolution. Bromine became the most popular disinfectant to control disease processes in both camp and hospital settings. Treatment processes fell into two categories depending on the disease: Those requiring depletion (blood-letting and purging), and those requiring stimulation (tonics such as quinine and alcohol). Chronic diarrhea and dysentery were epidemic in both armies, and a principle cause of morbidity and mortality. If there was blood in the stool and rectal cramping, emetics and purgatives were administered, along with opiates such as laudanum to slow the bowel. Mercurous chloride (calomel) was the most
The Civil War era hypodermic and amputation kit, above, are items from the SSVMS Museum of Medical History.
popular treatment, along with tartar emetic to clean the gastro-intestinal tract and improve liver function. Belladonna was also employed to treat intestinal cramps. The link between contaminated water and cholera was not understood at the time. However, Union Surgeon General, William A. Hammond, suspected that cholera and diarrhea were brought on by some sort of organic constituents in murky drinking water. His recommendations for boiling drinking water helped curb the spread of intestinal diseases. Tuberculosis (consumption), or “phthisis” as it was commonly referred to, generally occurred in crowded portions of larger cities. Physicians were not aware of how contagious this disease was and, consequently, did not isolate their infected patients. Soldiers, who were diagnosed and hospitalized with consumption, were treated with alcoholic stimulants and
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a tonic of decoction of black snakeroot and iodine. Many times, the soldier was discharged from military service or placed on furlough and sent home where many of them soon died. It wasn’t until 1882 that the bacterial cause of tuberculosis was discovered, and much later that antibiotics were developed for treatment. Although Edward Jenner had earlier pioneered the smallpox vaccine, many soldiers in both the North and South had not received vaccinations prior to their enlistments. Union army statistics indicate over 12,000 troops had the disease with a 23 percent mortality rate. The army did quarantine infected individuals with smallpox, but transmission was attributed to an airborne process rather than by direct contact with infected patients. Some enlistees, who knew more about the immunization process, would remove material from the pustules of smallpox patients and apply them to themselves. Some, unknowingly, would simultaneously infect themselves with syphilis in the process. Syphilis and gonorrhea were prevalent in both the Union and Confederate armies during the Civil War, especially near Memphis, Nashville, Louisville, and Cincinnati where there were numerous bordellos. There are no statistics on the exact number of soldiers who sought medical attention for venereal diseases. The union began to regulate prostitution in 1863, charging prostitutes fifty cents per week for a medical examination. Treatments for venereal diseases included poker roots, elder, prickly ash, silkweed root in whiskey, and pine rosin pills. Urethral injections of mercury were also prescribed to treat syphilis and gonorrhea. These diseases could present themselves again years later, resulting in more serious illnesses such as dementia from syphilis. Some medical historians felt that at least one third of both armies eventually died from the effects of venereal disease. It wasn’t until 1910 that Salvarsan was developed to treat syphilis, and not until 1945 that penicillin was available treat gonorrhea. On both sides, during the winter of 1863-64, there was an epidemic of measles. Subsequently, fresh Union recruits would be
housed in “seasoning camps” to weather the challenge to military physicians. Numerous infection period before being sent to the front. diseases demanded remedies that were unavailAll that doctors could do at the time was to able at the time. The medical community graduallow the disease to run its course and provide ally gained an appreciation for the importance nourishment. There were 76,318 cases reported of regimented sanitation, hygiene, antisepsis, by Union statistics, resulting in 5,177 deaths. and asepsis, as well as isolation to contain Many times, sequelae from the disease such as outbreaks of contagious diseases. It wouldn’t acute bronchitis and pneumonia, were much be until the late 1870s, long after the American more difficult to treat than the original disease Civil War had ended, that Robert Koch and process. Louis Pasteur’s concepts of disease transmission The insect vector for malaria transmission and prevention enlightened medical knowledge. was unknown during the time of the Civil War. Again, “bad air” was believed to be the email@example.com method of transmission. The fever associated REFERENCES with malaria was referred to as “quotidian,” Humphreys, M. Marrow of Tragedy: The Health Crisis of the “tertian,” and “quartan,” depending on the American Civil War. 2013,The Johns Hopkins University Press frequency of symptoms. Confederate troops Schroeder-Lein, GR. The Encyclopedia of Civil War Medicine. 2008, M.E. Sharpe experienced more cases of this disease than The Regimental Hospital www.civilwarhome.com/regimentalhospiUnion soldiers, due to the prevalence of tal.html Anopheles mosquitoes in the warmer, swampier South. The soldiers’ symptoms were treated with inconsistent and insufficient doses of quinine or derivatives of cinchona bark. Gradually, physicians began to realize the importance of setting up camp in dry, elevated places away from swamps and standing water in reducing the incidence of the disease. Many dermatological conditions, pneumonia, and pleurisy were As a trusted partner to businesses and families across generations treated with topical applications of since 1919, Baird has seen investors through many market cycles. mustard plasters. Some dermatologiAnd the insight we’ve gained from this experience informs all we do cal conditions employed dry cupping today as we strive to create great outcomes for our clients throughout to drain infections. Small glass jars their financial lives. were heated to form suction over the Put Baird’s time-tested expertise to work toward your long-term goals. inflamed area. Wet cupping involved making small incisions with a scariPatty M. Estopinal, CIMA®, CDFA ficator, and then using a heated cup Director to suck out blood from the inflamed Private Wealth Management body region. Maggots were also used 916-783-6554 . 877-792-3667 occasionally to remove dead tissue firstname.lastname@example.org from infected wounds. pattyestopinal.com
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Conclusion The epidemic of disease processes in military camps and hospitals on both sides of the American Civil War presented a formidable treatment
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Albert J Kahane, MD 1928–2017
DR. ALBERT KAHANE passed away on February 15th at Kaiser Hospital Morse Avenue at age 88, where he had spent 19 years as an obstetrician/ gynecologist and as the Physician-in-Chief from 1976 to 1984. He was, in the true sense, not only a pioneer in The Permanente Medical Group but, as demonstrated both in Sacramento during his 44-year association with SSVMS and CMA and during his time with the AlamedaContra Costa Medical Association (ACCMA), a strong supporter of organized medicine. He was also an advocate for the prerogatives of the medical profession, a strong proponent of high medical and ethical standards, and a strong supporter and facilitator of good relations between physicians Albert J Kahane, MD practicing in varied modes of medical practice. Dr. Kahane was born August 9, 1928 in the Bronx, New York, to immigrant parents who owned a grocery store. He graduated from Boys High and later, in 1948, from New York University with a major in English. His personal advice to “work hard” was exemplified in the Korean War where he worked as a combat medic in 1951 and 1952. He then entered medical school at Downstate New York, graduating in 1956. His internship was at Meadowbrook Hospital in Hempstead, New York, where he met his future wife, Mildred Loughlin. He did his OB/GYN residency in Brooklyn, sponsored by the U.S. Air Force. He was assigned to Elmendorf Air Force Base in Anchorage, Alaska. In 1960, he married Mildred (Millie) and they spent four years in Anchorage before moving to Fairfield, California, where Al was in private practice and a member of the Solano County Medical Society from 1964-1965. In May 1965, Dr. Kahane joined The 32
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Permanente Medical Group (TPMG) as one of the original physicians when it opened its facility on Morse Avenue in Sacramento. The original Physician-in-Chief was Dr. John Mott, and Al was one of John’s “Twelve Disciples.” As a pioneer with TPMG, he strove to be ahead of the times. In 1970, he received a grant to study the role and utilization of nurse practitioners in OB/GYN. This led to his collaboration on patient care with nurse practitioner Dorola Haley. Dr. Kahane also established, and obtained accreditation for, the first Sacramento Kaiser Foundation Hospital residency program in OB/GYN. He was the first in Sacramento to propose the then-radical idea of fathers in the delivery room. Though there was a lot of resistance to this in the medical community, he persisted, as he felt it to be beneficial for the family. Such advancements ran in the family. Millie, a registered nurse, was also involved in training nurse practitioners, and received high praise from them. They felt she helped them reach for a higher level of professionalism through education, which helped to ensure the stature of nurse practitioners in California. The growth of the Kaiser Health Plan throughout the Sacramento Region made it possible for Dr. Kahane to continue his goals, grooming and mentoring physicians for their roles in the South Sacramento and Roseville Medical Centers. He was involved with the development of many Kaiser Permanente programs including Hospice, Alcohol and Drug Abuse Clinic, Alternative Birthing Center (ABC), Neonatal Intensive Care Unit, Outpatient Surgery Services, and Continuity of Care. He felt that one of Kaiser Permanente’s greatest strengths was that everyone constantly worked together, sharing ideas and thoughts, meeting regularly and sharing the same goals. He believed in
helping to set standards for what was expected of all Kaiser Permanente physicians. His leadership positions in Sacramento included: Chief of OB/GYN, Assistant Physician-in-Chief, and Physician-in-Chief at Morse Avenue As a practicing physician, Dr. Kahane believed in the importance of being involved in professional organizations, demonstrated by his activity in the Sacramento El-Dorado Medical Society (now the Sierra Sacramento Valley Medical Society-SSVMS) from 1967 to 1984, and again after his retirement. He served on the SSVMS Board of Directors from1982-83 and as an SSVMS Delegate to the CMA for 8 years. He also served on numerous SSVMS committees throughout his 44 years of membership. He continued to be an active retired member, serving on the Public & Environmental Health Committee and Editorial Committee through the beginning of this year. He was a contributing author to SSV Medicine. His efforts were vital in getting Permanente physicians involved with the medical society. Having his OB/GYN boards, he went on to also be “boarded” as a physician executive with the American College of Physician Executives. From 1979 through 1989 Dr. Kahane, along with Millie, participated in the “Health Team” of the annual Capitol to Capitol delegation. He also was a member of the clinical faculty at UC Davis Medical Center. In 1984, the Kahanes moved to Oakland so Dr. Kahane could assume the position of Associate Executive Director of The Permanente Medical Group, which he held until his retirement in 1993. He was active with the Alameda-Contra Costa Medical Association from 1984-2000 where he was involved with numerous activities: ACCMA - ACCMA Council, Physicians Services Committee, Managed Care Committee, Community Service Committee, and Ethics Committee. CMA - Commission on Medical Services, Committee on Insurance and Prepayment, CMA Council on Legislation OTHER - District IX region of the American College of Obstetricians and Gynecologists, American Medical Association Advisory Committee on Group Practice, California
Hospital Association’s Committee on Hospital Governance, Board of Directors of the California Medical Review, Inc. Al and Millie then traveled and, in 1994, moved to Alameda, and in 2009 to Cameron Park. In 2013, they moved to Eskaton Village in Sacramento, where he formed a Veterans Group that sponsors a Memorial Day Service each year.
He also served on numerous SSVMS committees throughout his 44 years of membership. As he spent his medical career in large practices, he delivered more than 5,000 babies, and 10 years were devoted to service with the military. Over the years, Al enjoyed boating, skiing, cruising, travel and reading the Wall Street Journal. The Kahanes amassed a very eclectic art collection during their travels to all seven continents. Al and Millie established the Rocklin branch of the Bach to Rock music school in July, 2016, a dramatic career change in their 80s. He is survived by his wife, Millie, his sister Jacqueline, son, Robert, and daughter, Bonnie. As noted by Donald Waters, Former Executive Director, Alameda-Contra Costa Medical Association – “His many leadership positions outside of the leadership role he played in The Permanente Medical Group demonstrate the clarity and effectiveness with which he represented his profession, the camaraderie he established with physicians and others within the health care community, and high level of respect in which he was held by his colleagues throughout the medical profession.”Dr. Kahane was interred at a private graveside service at East Lawn Sierra Hills Memorial Park. The family requests that, in his remembrance, donations be made in Dr. Kahane’s name to the SSVMS Medical Student Scholarship Fund to support the future of medicine, or the charity of your choice. − Bob LaPerriere, MD
White of Cotton By Elizabeth Santos Oh, the white of cotton sheets, the perfect edge, the perfect pleats The dreary walls, the lonely halls, the soft excruciating calls
My heart was not prepared to see you tugging chains to set you free And oh, how much your eyes beseech a nurse’s button out of reach
I always gladly stood by you through every test they put you through The chemicals, the painful nights, the nightmare dreams and stinging bites
Never had I seen on earth discomfort’s torture on a berth With sheets of alabaster white, with ends and corners tucked in tight Your rose was but a thorny bush, a button there too weak to push
But when I saw you lying there so thin and weak, no voice, no hair Your chest, your head, your thinning back were left in radiation black My eyes were not prepared to view this dying man, this other you Who lived with me beneath blue sky, and now a man too weak to cry And oh, the white of cotton sheets, the tubes and needles, rhythmic beats Metallic bed, metallic sound, a skimpy robe they tied around
And all your pain I took as mine, til morphine’s regulation time A bowl of soup you could not eat, disturbing words you could not speak A skeleton between the threads of sheets of white on metal beds And every player played his part, but no one had prepared my heart email@example.com
NOTE: Elizabeth Santos from Pottstown, PA, is the Poet Laureate of The Poets’ Corner, www.silentwords.com, a website of original poetry from around the world, owned by Nan Crussell, SSV Medicine Managing Editor.
CLASSIFIED ADVERTISING Seeking Physician Mentors for Medical/PA Students
Are you a physician willing to donate a few hours of your time to mentor medical, PA, and NP students? The Joan Viteri Memorial Clinic (JVMC), a UC Davis School of Medicine student-run clinic, is searching for physicians to serve as mentors and preceptors to teach future providers and help the community. The clinic serves IV drug users, sex workers, homeless, and undocumented patients of the Oak Park community, and is open every Saturday from 1pm to 5pm. We are also seeking physicians for the Women’s Clinic on the first Saturday of every month from 10:30am to 2pm. Scheduling is flexible, volunteer physicians are welcome to come as often as they desire. For more information, please contact jvmclinic@ gmail.com.
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: firstname.lastname@example.org.
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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: Carolina Bonilla, MD, Psychiatry, Pontificia Universidad Javeriana School of Medicine – 1999, TMS Health Solutions, 120 Suncast Ln #108, El Dorado Hills, CA 95762 Nicole Braxley, MD, Emergency Medicine, Northwestern University Feinberg School of Medicine – 2007, CEP, 6501 Coyle Ave., Carmichael, CA 95608 Sherrill Brown, MD, New York Medical College – 2008, Internal Medicine, New York Medical College – 2008, UC Davis, Y St., Suite 101, Sacramento, CA 95817 Vaishali Desai, MD, Hospitalist, Albany Medical College – 2003, Mercy Medical Group, 1650 Creekside Drive, Folsom, CA 95630 Ronald Flores, MD, Emergency Medicine, UC San Diego – 1988, CEP, 1600 Creekside Dr. #1400, Folsom, CA 95630 Oana Galicki, MD, Psychiatry, “Carol Davila” University of Medicine and Phannacy – 1996, TMS Health Solutions, 360 Post Street # 1000, San Francisco, CA 94108 Raminder Gill, MD, Internal Medicine, Ohio State University – 1997, UC Davis Health Systems, 4150 V St. #3400, Sacramento, CA 95817 John Gillean, MD, Psychiatry, University of Arkansas for Medical Sciences – 2010, TMS Health Solutions, 3300 Webster Street #402, Oakland, CA 94609 Jennifer Griffith, MD, Emergency Medicine, University of Texas Medical School – 2008, CEP, 2825 Capitol Avenue, Sacramento, CA 95816 Christina Halldorson, MD, University of Washington School of Medicine – 2013, CEP, 4001 J Street, Sacramento, CA 95819
Joshua Kuluva, MD, Psychiatry, Sackler School of Medicine – 2002, TMS Health Solutions, 360 Post Street # 1000, San Francisco, CA 94108
Marsha Snyder, MD, Psychiatry, University of Pennsylvannia – 1980, TMS Health Solutions, 1731 E. Roseville Parkway, Suite #290, Roseville, CA 95661
Karl Lanocha, MD, Psychiatry, University of Maryland School of Medicine – 1982, TMS Health Solutions, 350 University Ave. Suite 101, Sacramento, CA 95825
Robert Trimmer, MD, Psychiatry, Loma Linda University – 2001, TMS Health Solutions, 120 Suncast Ln #108, El Dorado Hills, CA 95762 Paul Walsh, MD, Emergency Medicine, National University of Ireland – 1994, CEP, 2825 Capitol Ave., Sacramento, CA 95826
Kevin Rosi, MD, Psychiatry, St. George University School of Medicine – 2002, TMS Health Solutions, 350 University Ave. Suite 101, Sacramento, CA 95825
APPLICANTS FOR RESIDENT MEMBERSHIP:
Ramotse Saunders, MD, Psychiatry, University of the West Indies – 1998, TMS Health Solutions, 350 Parnassus Ave. #201, San Francisco, CA 94117
Jeffrey Barrett, MD, Emergency Medicine, UC Davis Residency Program – 2019, 2315 Stockton Blvd., Sacramento, CA 95817
Ajay Singh, MD, Psychiatry, Punjab University, Dayanand Medical College – 1997, Community Psychiatry, 1712 Picasso Ave Ste D, Davis, CA 95618
Leigha Winters, MD, Emergency Medicine, UC Davis Residency Program – 2019, 2315 Stockton Blvd., Sacramento, CA 95817
Brandon Slockbower, MD, Emergency Medicine, Loma Linda University – 2010, CEP, 2825 Capitol Ave., Sacramento, CA 95826
Tracy Zweig Associates INC.
Physicians Nurse Practitioners ~ Physician Assistants
Stephanie Hawkins, DO, Family Medicine, Ohio University College of Osteopathic Medicine – 1991, US Health Works, 9261 Folsom Blvd Ste 200, Sacramento, CA 95826 Jacqueline Johnsen, DO, Emergency Medicine, Western University of Health Sciences – 2008, CEP, 6501 Coyle Ave., Carmichael, CA 95608 Brian Jones, MD, Anesthesiology, UC San Diego – 1985, CASE Medical Group, 3315 Watt Ave., Sacramento, CA 95821 Keith Jones, MD, Vascular Surgery, University of Connecticut School of Medicine – 2006, Mercy Medical Group, 6555 Coyle Ave. Sacramento, CA 95608 Joel Kahn, MD, Emergency Medicine, University of Maryland School of Medicine – 1981, CEP, 6501 Coyle Ave., Carmichael, CA 95608
Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3
email@example.com w w w. t r a c y z w e i g . c o m July/August 2017
Contact SSVMS TODAY to Access These
M EMBER O NLY B ENEFITS (916) 452-2671 BENEFIT
Reimbursement Helpline FREE assistance with contracting or reimbursement
CMA’s Center for Economic Services (CES) www.cmanet.org/ces | 800.401.5911 | firstname.lastname@example.org
Legal Services CMA On-Call, California Physician’s Legal Handbook (CPLH) and more...
CMA’s Center for Legal Affairs www.cmanet.org/resources/legal-assistance email@example.com
Insurance Services Mercer Health & Benefits Insurance Services LLC Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, and Cmacountyfirstname.lastname@example.org 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
Mobile Physician Websites Save up to $1,000 on unique website packages
MAYACO Marketing & Internet www.mayaco.com/physicians
Auto/Homeowners Insurance Save up to 10% on insurance services
Mercury Insurance Group www.mercuryinsurance.com/cma
Car Rental Save up to 25% - Members-only coupon codes required
Avis or Hertz www.cmanet.org/groupdiscounts
CME Certification Services Discounted CME Certification for members
CMA’s Institute for Medical Quality (IMQ)
Health Information Technology Free secure messaging application
HIPAA Compliance Toolkit Various discounts; see website for details
PrivaPlan Associates, Inc www.privaplan.com
Magazine Subscriptions 50% off all subscriptions
Subscription Services, Inc
Medical ID’s 24-hour emergency identification and family notification services
Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services
EnviroMerica www.cmanet.org/groupdiscounts www.enviromerica.com
Office supplies, facility, technology, furniture, custom printing and more… Save up to 80%
Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required
Security Prescription Products 15% off tamper-resistant security subscription pads
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
www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)
email@example.com | (916) 452-2671
JOY of MEDICINE m i a l c Re ur Yo
Join other physicians in the region for fellowship and hands-on educational sessions to help you build resilience and bring joy back to your practice of medicine.
7:30 am - 2:00 pm Arden Hills Country Club Sacramento Limited Spots: Reservations Required by September 8th RSVP at LCoate@ssvms.org
Robert Emmons, PhD, “Gratitude Works! Why Gratefulness is Indispensable for Patient and Provider Wellness” Dr. Emmons is the world’s leading scientific expert on gratitude. He is a professor of psychology at the University of California, Davis, and the founding editor-in-chief of The Journal of Positive Psychology. Dr. Emmons’ session will focus on how gratitude heals, energizes, and transforms lives. He is the author of several books including, Thanks! How the New Science of Gratitude Can Make You Happier. Rajiv Misquitta, MD, “Practicing Mindful Medicine ” Dr. Misquitta is an internal medicine physician with The Permanente Medical Group and President-Elect of SSVMS. After suffering a heart attack at age 40, Dr. Misquitta dedicated himself to transforming his life and the lives of his colleagues and patients. At his session, you will be introduced to mindfulness techniques, the science and research behind mindfulness, and why this is important to physicians. Melissa Marshall, MD, “The Healers Arts” Dr. Marshall is the Chief Medical Officer for CommuniCare Health Centers. Her presentation seeks to answer several questions of physicians such as: “What do we give up in order to become healers; What parts of ourselves do we have to disconnect in order to do this work? And, how do we see in new ways and connect to our calling and the meaning of our service?” Other Presentations Include: Decluttering, Biofeedback and the Wheel of Life Exercise Free for Physicians, Residents & Medical Students Breakfast & Lunch Provided, CME Credits Available
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