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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2017


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Sierra Sacramento Valley

MEDICINE 2

2017 Education Series

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A Posit on Physician Burnout

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PRESIDENT’S MESSAGE Meet Our Committees

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BOOK REVIEW Crazy Like Us

Ruenell Adams Jacobs, MD

Reviewed by Lee Welter, MD

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GUEST EDITORIAL Retirement Countdown

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Dementia and Its History

Kent Perryman, PhD.

Nate Hitzeman, MD

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Mentorship, Exploration and Inspiration

Between Hearing Loss and Dementia − A Link

Patricia M. González, MA, Ed

Laura Assante Robinson, Au.D, MHA

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Call to Community Service

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Loose Ends

Andrew Hudnut, MD

Marion Leff, MD

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Who’d A Thunk − Excerpts From 1882 Legal Medicine

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Medical Mission

Shelby Roberts, MS II

Ann Gerhardt, MD

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Jellyfish Memories

IN MEMORIAM Irma West, MD

Jack Ostrich, MD

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Welcome New Members

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A Prior Auth for Parental Oxytocin, Please!

Caroline Giroux, MD

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Board Briefs

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BOOK REVIEW Myth or Magic

Reviewed by Manish Shah

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

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

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx “Jellies” – This is another in a series of covers by Sacramento otolaryngologist, Dr. David A. Evans. The Monterey Bay Aquarium offers a plethora of photographic opportunities, not the least of which is the mesmerizing display of jellyfish. Obtaining a clear photographic image presents a challenge as the light level is low and the creatures are in constant motion. A steady hand is required as tripods and monopods are not allowed. It is a balance between raising your ISO (but not too much to avoid excess noise in the image), opening up your aperture (but maintaining focus), and a shutter speed fast enough to avoid motion blur. An article about jellyfish and a possible link to memory improvement is on page 10, written by Dr. Jack Ostrich. −devans@sacent.com

September/October 2017

Volume 68/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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Sierra Sacramento Valley

MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 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 Richard Bermudes, MD Natasha Bir, MD Helen Biren, MD Arlene Burton, MD Ronald Chambers, 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 Ajay Singh, MD Eric Williams, MD

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 III John Ostrich, MD Neeraj Ramakrishnan, MS II Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD

Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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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.

Sierra Sacramento Valley Medicine


PRESIDENT’S MESSAGE

Meet Our Committees By Ruenell Adams Jacobs, MD A FEW MONTHS AGO, I spoke at the medical staff meeting at Sutter Medical Center. The main purpose was to provide information about SSVMS in general, and to educate those attending on the benefits of belonging to, or becoming a member of, the Society. Part of that discussion involved the activities of our various committees. Many people attending were not aware of these activities, so I thought it would be helpful to provide a brief update in my message this month. First Up: Editorial Committee − The Editorial Committee is primarily responsible for vetting and editing articles written by Society members, medical students and other guests. This magazine is published six times a year, and provides interesting and informative articles on a wide range of subjects. For example, I have enjoyed learning about the health care system in Cuba, the prevalence of diabetes in India and the community garden that a dedicated group of local medical students started to help address the problem of food deserts here in Sacramento. The magazine is also a hit with my other half who is not in the medical field. Emergency Care Committee − This committee includes medical directors of the Emergency Departments of the area hospitals who meet bimonthly to communicate, educate and explore the complex issues related to emergency care services in the Sacramento region. One significant issue in recent years has been the increase in ED visits by patients experiencing a mental health crisis. This issue was initially reported by the ECC members. As a result, a mental health coalition was formed which resulted in the publication of a white paper in 2015. Additionally, a standardized medical clearance form (SMART form) was developed and is has now being used in several hospitals in this region. It has also caught the attention of medical entities outside of the

Sacramento region. Scholarships and Awards − The Scholarship and Awards Committee convenes two times a year. It administers the student scholarship fund and recommends to the Board special awards for members of the Society and the medical community. The scholarship application is open to entering or continuing full-time medical students who have graduated from a high school in El Dorado, Sacramento or Yolo Counties. This year the committee will also select a student applicant for the Paul J. Rosenberg, MD Medical Student Scholarship. Public and Environmental Health − This committee studies and makes recommendations on public health and environmental issues that may affect the health and well-being of our community. So far this year, the committee has met to discuss the problems of homelessness, access to medical care and the medical implications of the legalization of recreational use of marijuana. Expert guests are often invited to educate the committee on these issues. Historical Committee − The Historical Committee members maintain and collect historical artifacts relative to the history of medicine. They also research local/regional medical history and serve as docents for school tours of the SSVMS Museum of Medical History. The museum is free and open to the public Monday-Friday 9-4. Lastly: The Nominating Committee − This committee nominates candidates for each elected office of SSVMS and delegates from SSVMS to the California Medical Association House of Delegates. Physicians who are members of SSVMS and have an interest in any of these committees are encouraged to contact the Medical Society office at any time for more information on how to join. adamsr78@comcast.net September/October 2017

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 3


GUEST EDITORIAL

Retirement Countdown By Nate Hitzeman, 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.

“WHEN WILL I RETIRE?” is a question I reflect on periodically. Not because I don’t like my job. I love it. Medicine is fun. It’s the Forrest Gump box-of-chocolates fun. But I also love the idea of travel, reading, eight hours of sleep, revisiting hobbies that now exist only on my CV, and more physical activity than being a desk jockey and EMR whisperer. Let’s face it. We physicians don’t always retire well. Physicians like control, like structure, and like managing teams of people. And, we like to feel like we are making a valuable difference in peoples’ lives. So we don’t always transition well to being the Average-Joe-retired-guy reading the paper and mowing the lawn. If your home is anything like mine, you probably won’t be the team leader anymore. So what is the secret to a good retirement? Two of my longtime mentors have recently retired. One keeps his toe in the water and does some urgent care and precepting. Another made a clean break concurrently with her physician husband, and travels, bicycles, and does per diem grandparenting. While wishing them well, we and their patients have felt the loss. There is so much more than knowledge, RVUs, or ubiquitous signatures that leave when a physician retires. There is institutional history, the relationship connections, the personality of the office and – for lack of a better word – the essence of the healer. These things both linger and fade, and if we are lucky, continue to permeate the walls and halls. His old school radio announcer voice and boisterous laugh. Her keen eye and knack for cutting to the heart of the matter. His repertoire of anecdotes that started with, “I’ve probably told you this story…” and you hear it again

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and enjoy it just as much as the first time, while reinforcing the important clinical pearl. Her love of the restaurant scene, theatre, and the performing arts. Their second-natured way of touching patients, doing the full physical exam, not shortcutting. Their measured gaze and confidence of experience that made others seldom question their judgement. The patients who adore them. I have also had the honor of caring for retired physicians as patients. They are, in general, a gracious group who understand that eventual decline and death is the rightful continuum of life. They tend to have a few too many specialists in the kitchen to monitor things, but often do not want heroic or futile care. They do vary in how they have dealt with retirement, degree of active, and staying engaged. Like most non-physicians, their long-term well-being is tied to the fate of their life partner and the strength of that bond. And sometimes their faith and religion. I have befriended retired physicians through our medical society. Their stories of how medicine and health care have changed throughout their lives fill me with wonder. What I have read about, they have lived. Combat medicine. Apprenticeship-type medicine. Home visits. The rise and disenchantment with HMO medicine. Lavish cruise ship CME. These experiences and stories of physicians who have retired and are retiring need to live on. SSVMS provides one of those venues, through our committees, volunteer opportunities, our museum, and social activities. Medicine has always been a noble profession. It is also a beacon that the world looks up to as it stretches ever higher and more gallantly into the sky. Where will your stone fit? Upon whose will it rest? And whose will follow? hitzemn@sutterhealth.org


Mentorship, Exploration and Inspiration Local Health Careers Conference Offers Regional Pathways for Students

By Patricia M. González, MA, Ed ON MAY 20TH OF THIS YEAR, 150 high school students, parents, and undergraduate and graduate students from Northern and Central California attended the inaugural Regional Pathways to Health Careers Conference at Sacramento City College. The result of new partnerships among the Center for a Diverse Healthcare Workforce at UC Davis School of Medicine and School of Nursing, Sacramento City College, MiMentor and the Sierra Sacramento Valley Medical Society, the conference sought to: • Increase student exposure to health careers enrichment programs; • Introduce attendees to clinical skills; and • Increase the confidence of aspiring and current health professionals to pursue basic sciences, research, and volunteer opportunities. Attendees engaged with health care professionals, regional non-profits and college program representatives to learn about careers in health care. The importance of mentorship, diversity and inclusion, and service to the community were strongly threaded throughout the day. The conference kicked off with a warm welcome from Sacramento City College nursing students, Jennifer Martinez and Peter Xuan, followed by Jim Collins, Dean of Science and Allied Health at Sacramento City College, and Dr. Piri Ackerman-Barger, Assistant Director of the Master’s Entry Program in Nursing at UC Davis Betty Irene Moore School of Nursing. Dr. Ackerman-Barger shared her career journey as a

woman of color navigating the nursing, research and leadership fields, and she encouraged students to follow their passion and to seek mentors who will contribute to their success in achieving their health career dream. Among top highlights of the conference was the Power Mentoring Breakfast where small groups of students enjoyed breakfast with a health care professional mentor. Students had the opportunity to ask the mentor their own question, or fish for a question from the table’s pre-filled bowl of questions for health care professionals submitted by conference attendees during registration. Students were particularly excited by the opportunity to connect with a career mentor and to learn about shadowing and research opportunities. Carmela Castellano-Garcia, President and CEO of the California Primary Care Association, was an inspiring keynote speaker for the conference. She quickly captured the attention of current and aspiring health professionals as she encouraged them to push boundaries to pursue health career opportunities while serving those most in need. She shared the broad range of clinical and non-clinical health career opportunities available by working in a Federally Qualified Health Center. In all, 18 individual breakout sessions were held during the one-day conference. Sessions focused on clinical and non-clinical careers including nursing, medicine, physician assistant, occupational therapy assisting, research, public health, and advocacy. Hands-on workshops included clinical skills, suturing, pediSeptember/October 2017

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

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was a nice treat for the mentors and those who wanted to network with others leading regional volunteer programs. Overall, the conference was a great success. We were thrilled to see the collaboration among local colleges, high schools and community organizations and to help students learn about health careers, pipeline programs, and internships to support their career journey. High school student and mentor participation was higher than anticipated. The Center for a Diverse Healthcare Workforce is committed to continue growing Sacramento-wide community partnerships and to host career events and future conferences. Above, attendees learned suturing skills in a general surgery workshop led by Dr. Ajay Ranade. At near right is Myel Jenkins and the Spirit of Giving panel. Dr. Andrew Hudnut shares a grateful moment with a patient, below right.

atrics, primary care, and imaging. The lunchtime resource fair showcased local health programs, organizations, and schools, including Consumnes River College, University of the Pacific, Sacramento City College, and UC Davis. “The Spirit of Giving Back,” a panel session led by Myel Jenkins, Program Director, Community Service, Education, and Research Fund from the Sierra Sacramento Valley Medical Society, was a conference highlight. Drs. Andrew Hudnut, Tony Tsai, and Eric Williams shared how they take the time to give back, despite their busy schedules. Dr. Efrain Talamantes, a mentor who attended Myel’s session, shared that he “felt a great sense of solidarity with these mentors and was refreshed to gain new perspectives from other mentors on how to stay fresh and continue giving back.” This workshop

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NOTE: The Center for a Diverse Healthcare Workforce (CDHW) is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP29965, titled Academic Units for Primary Care Training and Enhancement (AU-PCTE). The purpose of the AU-PCTE is to improve clinical teaching and research in primary care training in order to strengthen the primary care workforce. CDHW’s mission is to lead research focused on recruiting, training, and retaining a diverse healthcare workforce to advance health equity. pmgonzalez@ucdavis.edu


Call to Community Service By Andrew Hudnut, MD A call to community service A cultivation of non-self Action based on the needs of others Commitment to organizations in the non-profit space. Take a break from the rat race Move away from the treadmill of productivity Plant seeds in the hearts and minds of those in need Restore your spirit Live your soul Be guided by compassion Redefine success. Care for the homeless Understand their reality Help people move beyond addiction Help people heal their mind Let this experience change you Heal you Grow the potential greatness within each of us. Teach students Transfer knowledge Attack ignorance Help the next generation move beyond fear Build health foundations within each developing young mind Role model Be present.

Step into the voids left by our society Allow this to guide you On a spiritual path Less self More interdependence Guided by balance Find serenity Find peace Live it Share it.

ahudnut@stanfordalumni.org

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September/October 2017

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Who’d A Thunk Excerpts From 1882 Legal Medicine, Volume II by Charles Meymott Tidy, MB, FCS

By Ann Gerhardt, MD

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

THIS IS A REPORT OF random, curious excerpts from a part-text, part-list of legal cases. It was interesting to read about now-standard pathology as revelations. The Table of Contents alone is fascinating. Numbering 9 pages, it directs the reader to subjects like, “The Onus of Proving the Death of an Insured Person rests with those who will Benefit by it,” “Death from Starvation possible without Emaciation,” and “Spontaneous Ignition of Organic Substances moistened with Water.” The “Illustrative Cases,” sometimes sad, sometimes convoluted, confirm the adage that truth can be stranger than fiction. Chapter I: Expectation of Life and Presumption of Death and of Survivorship. This chapter deals mostly with fraud by life insurance applicants, conditions that increase risk, making sure that the policy-holder is dead before pay-out, suicide and survivorship. The Table of the Expectation of Life gives the life expectancy of newborns as 58.43 years for a males and 55.53 years for females. After age 2 years, each year of avoiding death slightly increases the chances of living longer, except for those in the “Diseased Lives” column. At age 97, men can kiss life goodbye, since they had no further life expectancy. Many of the cases related to life insurance companies not wanting to pay benefits for dead policy holders who lied about having phthisis (a progressively wasting or consumptive condition such as pulmonary tuberculosis), gout, organic dyspepsia, syphilis, insanity or vegetarianisminduced heart disease. Drowning poses particular problems for policy beneficiaries, since it’s hard to definitively confirm a death if all the boat’s witnesses also perish at sea. There’s also the problem of determining who dies first

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if the insured and beneficiary both drown: If primary beneficiary’s beneficiaries differ from the policy holder’s secondary beneficiaries, who gets the money? In “the influence of climate on the duration of life must not be overlooked,” the author’s not talking about death from drought, famine, fires and temperature extremes resulting from climate change. He refers to regions with poor life expectancy in the 1800s being “marshy and undrained lands where ague predominates,” the tropics where “sunstroke, plague, yellow fever, cholera, dysentery, small-pox, leprosy and other diseases” were common and “certain districts of the Alps renowned for goitre and cretinism.” It’s not wrong to associate infectious disease and iodine deficiency with geography, but it’s interesting that those issues which might make one’s life less insurable were labeled “climate.” Chapter II: Heat and Cold. This discussion attempts to define extremes of heat and cold, as well as human conditions which predispose to succumbing to them. The cases describe interesting autopsy findings, such as “Vessels of the brain turgid, with serous lymph effused in the ventricles,” and “Large veins and arteries filled with polypous concretions.” The cases describe parents who abandon children in extreme heat or cold or abuse them by submersion in freezing water. This case is odd: “A girl suddenly delivered of a child whilst sitting on a night-stool. She stated that she fainted, and on recovery found the child on the floor dead... The girl was found guilty of causing its death by imprudence, inattention, and negligence...” and sentenced to two years’ imprisonment. Quite a few cases described workers dying


from sunstroke. Some, however, recovered after treatment with venesection, brandy enemas, blisters, Croton oil (a caustic laxative), saline, atropia (atropine) or quinine subcutaneous injections, stimulants, cold shower, iced water in Robert’s coils, sinapisms (topical irritants) to the extremities, ice to the head and mustard plaster to the loins – Surely proof that some patients recover in spite of their doctor’s best efforts. Chapter III: Burns and Scalds. Who’d a thunk that one could be burned by so many things and die from them in so many ways? In addition to contact with a hot object, burning flame or scalding hot water, people have been burned accidentally or intentionally by molten metals, phosphorus, gunpowder, petroleum, coal mine fire damp and acids. Tidy reports investigators’ experiments on dead people, testing the vesicant and blistering effects of various burn types. Many of the cases are really sickening. Children severely scalded their mouths and glottises by putting their mouths to the steaming spout of a kettle. Bystanders lit a straw fire under the body of a drowned man with the hope of resuscitating him. An attendant was charged with manslaughter after a lunatic scalded to death in a hot bath. Quite a few people died from their clothes catching fire after contact with a stove. Murderers incinerated their victims to conceal strangulation. A mother was accused of pouring melted pewter in the ear of her idiot son (who recovered), and a husband poured strong nitric acid into his wife’s ear while she slept and died. There’s a report of “A pretty citizeness of London had had six husbands, one after the other: the first to please her parents, the rest to please herself. One of her countrymen was brave enough to allow her to make him her seventh husband.” For a while, things went well, and she told him about all the faults of his predecessors. Suspecting foul-play, he set her up by staying out late and pretending to be a drunk. When he feigned drunken stupor, she melted a lead button and approached to pour it into his ear. He caught her up and turned her over to authorities who exhumed the previous

husbands and found lead in their ears and brains. Who knew a button could be a murder weapon? Chapter IV: Lightning. About causation, we are reminded that “The identity of the lightning flash with electricity of great quantity was first noted by Franklin.” There are various lightning types causing odd patterns of physical damage explained by differential electrical conductance by the body’s tissues and clothing. Blood conducts electricity better than water, nerve matter or muscle, but has conductivity 3 million times weaker than that of mercury and 15 million times weaker than that of copper. Lightning’s medico-legal aspects relate to the possibility that the effects of lightning might simulate those of violence, leading to a suspicion of foul play and/or an insurance company not having to pay for damages. The cases describe odd sequelae, like hemiplegia, ruptured tympanic membranes, insanity, tetanus, fractures and unusual tracts of burned tissue leaving surrounding skin unharmed. Chapter V: Combustibles and Explosives. A wide variety of now better-regulated substances ignite and burn, including dynamite, then recently patented by Alfred Nobel. Many of the legal cases involved an accused person alleging the fire resulted from spontaneous combustion of coal, iron sulphide, lime, lampblack, various silver and mercury compounds, and damp hay. The most interesting discussion relates to spontaneous combustion of the human body, concluding that there are no authentic cases on record. However, cases of old and infirm alcoholics, whose bodies burned out of proportion to their clothes, suggest that “spirit-drinkers” are more combustible than teetotalers. These flammable drunks were more often female and fat, burned more brightly when doused with water, and left “unctuous and stinking soot.” Experts suggest that they might have been more susceptible to a minor spark or murder. Chapter VI: Starvation. The author spends a great deal of words on signs and symptoms of nutritional deficiency which we know now to be then-undiscovered vitamin and micronutrient continued on page 11 September/October 2017

The most interesting discussion relates to spontaneous combustion of the human body…

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Jellyfish Memories By Jack Ostrich, MD

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

“CAN A PROTEIN ORIGINALLY found in a jellyfish improve your memory? Our scientists say, ‘Yes!’” So begins a television advertisement for “Prevagen,” which has become the best selling over-the-counter brand name nootropic supplement in history. And how, indeed, did it happen that a protein isolated from a small bioluminescent jellyfish found commonly in Puget Sound was suspected of improving memory? As The Bard once wrote: Thereby hangs a tale. The story begins in 1978, when a 75-yearold researcher at l’Institut de La Mer in Nice, France found himself locked in his laboratory. The scientist, Marcel La Meduse, was working late on a Friday evening and had forgotten to notify the housekeeping staff of his presence. All at once, the lights went out and the doors were electronically locked and sealed. Now, alone in his dark, locked lab, he realized that he would not be free till Monday morning. Luckily, the creatures he was studying were bioluminescent jellyfish named Aequorea victoria, and there were many hundreds of them in the large aquarium that sat in the center of the lab. The aquarium glowed with a soft bluegreen light, bright enough so that La Meduse could read and edit his handwritten lab notes, if he got close enough to the jellyfish colony. He was depressed and miserable as he was quite hungry, not having eaten for over 10 hours, and also because of the consternation that this situation was sure to create with his wife, family and friends. But, he could do nothing about it. He had no telephone, and no one would be back to his area of the institute until Monday morning. Plus, as previously noted, he was very hungry. Very, very hungry. He slept fitfully overnight on the cold concrete floor of the lab, and he felt quite

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miserable the next morning. And even hungrier. It would be another 48 hours or so before he would be able to eat, and he was used to strong black coffee every morning, and a hearty lunch and dinner, both accompanied by appropriate wines. He was actively despairing when he began to wonder what jellyfish tasted like, and decided to find out. Using a small, hand-held net, he scooped some of the Aequorea out of the aquarium, put them in a beaker, rinsed them with tap water, then warmed them over a Bunsen burner. He then popped them into his mouth, a few at a time, as if eating oysters. He was surprised that they were almost taste free, and were certainly not unappetizing. He repeated his unusual meal Saturday night, and thrice more on Sunday. His hunger was quelled and, except for missing his coffee and wine, and having to sleep on the floor of the lab, he felt quite well. And there were plenty more Aequorea swimming in the aquarium when Monday morning rolled around. He went home that morning to a warm greeting from his wife, and he told her all that had happened, including his meals of jellyfish. Later in the day, his wife became upset because she had misplaced her little book that contained phone numbers, addresses and important birthdays of friends and relatives. She asked him if, by any chance, he could remember her own brother’s address, phone number, and the birth date of his younger son, Jules. Marcel, without hesitation, rattled off all of the requested information. Over the next several days, his wife, his friends, and Marcel himself were astonished by his feats of memory. And this was a fellow who seemed, in the judgment of most, to be quite absent-minded. But he relapsed back to his usual, easily distracted self in the next week or two.


So, he determined to experiment by surreptitiously ingesting more of his Aequorea, and, once again, his memory blossomed. Over the next few years, he continued to eat the little creatures. He found they were more palatable if warmed in olive oil with a bit of finely chopped garlic. His memory remained sharp. He died in his lab in 1982. His assistant found him drowned in his lab aquarium into which he had somehow launched himself. His wife’s brother’s second son, Jules, earned a degree in pharmacology and married a nice American girl from Wisconsin. Jules found a job with Quincy Bioscience in Madison. One day, over lunch, he told his boss about his uncle Marcel’s remarkable transformation after he had eaten some Aequorea. The rest, as they say, is history. The folks at Quincy reckoned, for whatever reason, that the substance responsible for Marcel La Meduse’s remarkable memory improvement was a protein called aequorin and, slightly altered and now called apoaequorin, it could be mass produced in Madison. No need to send a fleet of boats to Puget Sound to harvest those jellyfish. Several years of testing suggested that, if one ingested 10 or 20 mg. of apoaequorin daily, you could expect maybe 10 or 20 or even 30 per cent better memory. Maybe. On August 5, 2014, US Patent number US 8,796,213 B2 was granted to Quincy Bioscience for apoaequorin. In its patent application, the company claimed that the compound helped maintain “calcium homeostasis” and was “useful in preventing and/or alleviating diseases or

symptoms associated with calcium imbalance.” Those many ills included, but were not limited to, “sleep quality, energy quality, mood quality, pain, (and) memory quality.” Apoaequrin, sold as Prevagen, is marketed as a “nutraceutical,” a supplement that is supposed to relieve the symptoms of age-related memory loss. A 30-day supply of the 10 mg pills costs $35 to $40, and the double strength 20 mg pills cost $55 to $60. Apoaequrin is now also marketed as a supplement for cats and dogs. The dose for any cat or any dog is 5 mg a day, and costs about $30 for a 30-day supply. The veterinary product is cleverly named, “Neutricks,” pronounced “new tricks.” On the website for Neutricks there is a brief animated video describing what symptoms a pet owner would observe that might indicate age-related memory problems in his or her furry friend. During the video, the bubbly female narrator mentions that the discovery of aequorin (not apoaequorin) “won the Nobel Prize for chemistry in 2008.” And that is a fact. But the three scientists who won that prize were investigating mechanisms of bioluminescence, protein-calcium interactions, and something called “resonant energy transfer.” They had no idea that they had missed out on one of the first great medical discoveries of the 21st century. And there it was, right under their noses. Thank goodness Marcel La Meduse became trapped in his lab that fateful night in 1978.

The veterinary product is cleverly named, “Neutricks,” pronounced “new tricks.”

jmost119@aol.com

Who’d A Thunk continued from page 9 deficiencies. Most of the legal cases involved abuse by starvation of a child, servant, spouse, etc. The more challenging descriptions involved witches and self-starvation due to melancholia, hysteria, dysphagia and ecstasy. Most died, but some who claimed to eat and drink nothing appeared to function normally, their deception undetected in a world without hidden cameras.

algerhardt@sbcglobal.net NOTE: 1882 Legal Medicine, recently donated by Dr. Douglas Schwilk, is one of many volumes in the book collection of the SSVMS Museum of Medical History.

September/October 2017

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A Prior Auth For Parental Oxytocin, Please! 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.

“IN OUR CULTURE, we don’t admit mental illness, but I think she had a postpartum.” The relative of Jenna,* a patient I recently assessed at a county clinic, explained that Jenna had issues after the birth of her third child, being a single mother, from African-American descent, grieving the “white-picket-fence-house” American dream she had contemplated. Post-partum… She had postpartum… Perplexity? Post-partum joy? Post-partum overwhelm? Existential crisis? Post-partum euphoria or fatigue? The concept of postpartum depression is so ingrained in our “symptom pool” that we don’t even bother mentioning the depression. Of course, I can relate to the shock of motherhood. Entering the Sisyphean universe of body fluids. She lactates, he burps, so that there is always a fragrance of yogurt following her… Living in dread of experiencing the nightmare of a lost pacifier. Only the thought of having to develop the logistics of taking a shower fills her with fear, dilemmas that she would have never anticipated arise… Is there an algorithm to follow when stomach flu plagues the household? (I remember calling to the rescue a childless, academician neighbor to hold my baby so he wouldn’t crawl in his brother’s puddle, while I was trying to prevent my own from adding to the disaster). But I was lucky enough to be able to stay home after giving birth for a few months at least (at my own expense, of course). I felt like I could give my children love, attention, and the good stuff my body was producing for them (not long enough, but still more ounces than was ever given to me). Jenna was not that lucky. She went back to

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work after two weeks. Postpartum or not, this is brutal. Intercourse is proscribed for about six weeks after the delivery. So how work could possibly be less strenuous on a recovering body, on a shrinking uterus crying its lochia, on an overloaded mind, groggy from completely messed up biorhythms? While I was doing my residency training in Montreal, I was envious of my female colleagues who could take a year off, paid at 90 percent of their salary, because I knew it wouldn’t be my fate once I would end up under the border. My sister, an employee of the federal government, benefited from a full year of paid leave for each of her two pregnancies (RQAP, or Régime Québécois d’Assurance Parentale, covered about 50 percent and her employer paid the rest). Estonia is offering 87 weeks of paid leave, which is over a year and a half. Mexico and Haiti offer 12 weeks of paid leave. The United States? A fat ZERO. Shameful… And, as if it were not enough to have not a single paid day, some women feel pressured to go to work too soon by fear of losing their job, even if they would rather have a non-paid leave than no leave at all. Because work, status and productivity dominate certain value systems in our society, you have to work, sooner or later. So, if you want to continue to give a derivative of your love to your baby, you have to pump at work. For an illusion of bonding. To treat mother’s guilt. Sterilization of dairy paraphernalia: that’s a LOT of work. I remember too well the once white foldable shield in the filthy break room of a sordid jail unit where that ritual took place. No wonder this is so hard on new moms.


Imagine being among a cultural group already vulnerable because of unconscious bias, poverty etc. I was very fortunate to have stayed home four months the first time, six months the second (unpaid, of course), and for our third I postponed the start date of a new job as much as I could, so I got almost eight months of precious “maman-bébé” time, cuddling, tasting the bliss of carrying my infant like a mother kangaroo. If I could do it again, I would probably take longer. But at some point I was craving adult verbal exchanges and wasn’t quite fulfilled exclaiming myself in front of zoo animals or anxiously monitoring my adventurous toddler at the playground, watching every move, every climb while suffering numerous arrhythmias. I am thankful for my flexible employers who supported me in my desire to be present for my children while having an opportunity to thrive professionally, even by going back part-time. What will it take for policy-makers to see the bigger picture, to realize that consistent presence of parental figures during the first year of life is the main ingredient to secure attachment, which is the foundation for everything else later in life, from self-esteem, to healthy lifestyle, to the way people contribute to the world? Why not invest in the virtues of oxytocin and give the pioneers of our tomorrow the best brain nutrient? To get to that, we need rested, minimally-stressed parents. Nowadays, the pressure to be the perfect mother (while continuing to be the most enthusiastic lover, housewife, sensational birthday party organizer, productive or accomplished employee, etc.) is enormous. Add to that a twin pregnancy after 40 from IVF, and the mood can crash as drastically as the roller-coaster hormones. Such biological factors, plus vandalism of the white-picket fence dream, and we have someone like Jenna who started hearing a voice while sitting quietly one day. This was almost three years after the birth of her third child that she had so much trouble bonding with. She felt she could no longer keep up with the demands of life. She ended up in the hospital, frightened by that voice, maybe the murmur of her soul

that needed nurturing so bad... All this could have been prevented if we had addressed the potential sources of her stress (lack of social support, single motherhood, precarious finances, stressful work). If we could simply follow the body’s biology and work at home or from home (no more pumping in awful conditions!), realize that it take months (if not years, as was my case) to have a normal sleep schedule again, and more importantly, for the child to feel securely attached enough so that mom can resume part of her former life. This would create the possibility of a return in full force to a job that is supportive, facilitating a contribution to the world in a way that all the babies on earth would benefit from. I think that the reality of depression with postpartum onset is serious, and screening extensively after birth is fine. But I am also concerned about the overemphasis on individual factors. The mother suffers, but could it be the end result of the crazy pace and unattainable expectations of our world? Instead of pushing anti-depressant after antidepressant, augmentation therapy (I hate the concept of “treatment-resistant patient,” which makes the person sounds defective somehow), we should always revise our diagnosis first, with a biopsychosocial, systemic perspective. Worldwide, about 10 percent of pregnant women and 13 percent who have just given birth experience a mental disorder, primarily depression. In developing countries, the rates climb to almost 16 percent and 19 percent respectively. It would be interesting to see if there is a correlation between social benefits and paid leave for parents after birth and lower rates of post-partum depression. For instance, in one study, Austria and Denmark, which offer almost 60 and 30 weeks of paid maternity leave respectively, were among the countries with fewer reports of post-partum symptoms. The World Health Organization emphasizes that the mother’s functional impairment can negatively impact the children’s growth and development (and in many cases, as we can easily imagine, it is not only the newborn who will suffer, but the continued on page 15 September/October 2017

…consistent presence of parental figures during the first year of life is the main ingredient to secure attachment…

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BOOK REVIEW

Myth or Magic The Singapore Healthcare System, By Jeremy Lim; Select Publishing; ISBN-13: 978-9810773625

Reviewed By Manish Shah

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 DEBATE SURROUNDING the approaches to providing health care coverage have never been more prevalent than today. Media coverage related to health care policy can be seen on the evening news, on the front page of local and national newspapers, and in the opening monologues given by late night show hosts. This debate at a base level comes down to a choice: Should the state absorb health care costs through single-payer coverage (tax-funded) or should individuals purchase individual and family coverage via open markets (marketmodel)? In the US, we have a hybrid of partial coverage paid by state programs (Medicare/ Medicaid) and market-based programs paid through exchanges and employer programs. In “Myth or Magic - The Singapore Healthcare System,” the author Jeremy Lim offers a deeper look at the Singapore health care system with a paralleled reflection of the U.S. health care coverage architecture. The Singapore health care system is known to be a marvel of the developed world, and has inspired many conservative frameworks for market-based health care coverage in the U.S. In fact, the life expectancy in Singapore is 80 years old, which is two years older than in the U.S. In addition, the Singaporean approach to health care delivers results while managing to spend only 4.6 percent of GDP while the U.S healthcare spending is 17.8 percent of GDP (and growing). The structure of the system is based on three main pillars: Medisave, MediShield, and Medifund (3-Ms). Author, Jeremy Lim, provides a guide to the 3-Ms with a necessary depth to understand the effectiveness of each. Medisave − A mandatory health savings

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account that is withdrawn from paychecks (much like Social Security in the U.S.) and deposited in bank accounts owned by the individual (not like Social Security). Individuals are able to use these funds to purchase health care services for themselves and their extended family. MediShield − A government-run health plan that protects people during catastrophic situations that would not be fundable via accrued savings within Medisave accounts. Should individuals require more than catastrophic coverage, they are able to purchase extra coverage on the open market. However, all individuals must first have a MediShield plan. Medifund − A safety net structured as an endowment fund to cover the care of the most at-risk population (below the poverty line and unable to build Medisave funds or purchase MediShield coverage). This program functions as an endowment, meaning the funds available for spending are capped based on investment returns and fluctuates based on the health of the economy. Beyond documenting the pillars and basic structures of the Singaporean health care coverage model, Lim illustrates how the social and political climate of Singapore shaped the system all together. In 1958, Singapore shifted from a colony into a self-governing state. At the time, with the precarious nature of the state, options such as tax-funded health care coverage were not available, as government tax receipts were not fully developed. These options were considered an expense that the state could not, and should not, bear. The state chose to invest in public health measures such as sanitation,


food security, and housing. After learning from the pitfalls of tax-funded programs like NHS, the founders of the Singaporean system took heavy caution to avoid the “moral hazard” of people neglecting preventative health care and their own primary care needs: “...under such an egalitarian system each individual would be more interested in what he could get out of the common pool than in striving to do better for himself, which had been the driving force for progress through human evolution.” Rather, the founders went about instilling in the populous a culture of individuals taking responsibility for their own care. The state would be a safety net only to be relied upon when things went beyond an individual’s capacity. Throughout the chapters, Lim showcases how the government took great care to disconnect the state’s responsibility from individual health care. For example, the tier-based system allows for patients to pay out-of-pocket for extra services like private rooms or to see a private practice doctor to expedite treatment. There is also rigorous means-testing to determine when and at what level the government should subsidize the care for an individual within a hospital. There is a lot to be learned from Lim’s documenting of the Singapore health system and how it has evolved over time. It provides

a valuable reflection to the varying health care approaches in the U.S. − between tax-funded models of the far left and the market-based models of the far right. However, Lim brings to the surface a key insight: Whether the models are tax-funded or market-based, the government is playing an active role in shaping the health care environment and making it affordable to its citizens. The hidden hand is not the market, but rather the government with its leaders controlling prices on prescription drugs, subsidies, the remuneration for physicians, and much more. The main lesson to be learned from the Singapore health care system is that the debate over how much control the government should have over the health care system is misappropriated. Instead, governments will play a central role in the health care system in any model. We must decide on the framework for what the involvement is and how best the government can support a system that is accessible, transparent, achieves the health goals of the society, and is affordable − whether it’s through taxes or personal income.

The hidden hand is not the market, but rather the government…

manish@peerwell.co NOTE: The reviewer is an entrepreneur interested in health care.

Prior Auth continued from page 13 older siblings as well, experiencing the toxicity of maternal stress, neglect, emotional distance etc.). Identifying and treating depression in new mothers is fine, but wouldn’t it be even better to not even have to get to that point? To me, the solution is simple. This country has no excuse. European countries, Japan, Mexico, Canada do it. Why not here? Ask parents-to-be if 6 to 12 months (or 25 to 50 weeks) of paid maternity leave, and flexible schedule for spouses or significant others

supporting the mothers would do. For the sake of holding our precious ones more, for the healthy development of their sense of self. To give them all we have, so they can give back to the world. cgiroux@ucdavis.edu *To protect my patient’s privacy, I use a fictitious name throughout the article.

September/October 2017

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A Posit on Physician Burnout “I have the same zest for medicine that I had when I was a medical student or resident.”

Background: Many young people choose the hard path to practicing medicine for a multitude of reasons including: a gift for applied science, being a trusted figure in the community, and/or a general desire to help people in need. Despite their dedication and sacrifice, physicians are experiencing burnout at near-epidemic levels, forcing many to leave the profession. With the unprecedented change in the health care delivery system in the United States, some physicians feel that their role as healers, comforters, and listeners is diminished. Despite experiencing burnout and disillusionment, many still choose to practice medicine and to care for their patients. There is still hope for the profession, and great satisfaction can be found in caring for patients. Note: Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Commentary follows.

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

My enthusiasm for the practice of medicine and the challenges and responsibilities associated with it remain undiminished and vibrant. However, if you ask me on a Monday or Friday if I feel undiminished and vibrant, my answer will NOT be an enthusiastic Yes! The greatest stressor and source of burnout is not the realities of medical science, commitment to compassionate care, or responsibility to practice evidence-based medicine, but it is the challenge of performing quality care in the setting of the current regulatory and medical-legal landscape. Every year I travel abroad to practice medical relief work in underserved Third World countries. Every year I am reminded why I chose this profession and why it continues to be my calling. Removing the regulatory burdens, logistical headaches, oppressive legal scrutiny, and productivity pressures serves to open my eyes to the beauty and the nobility of our

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profession once more. I cannot fully describe how freeing it is to do this work, and I strongly advise any colleagues interested in international medical service to try it. We can still make the world a better place. I propose that physician idealism is not lost, just hibernating under the weight of the current medical marketplace! − Ryan Nicholas, MD Same enthusiasm but less energy. At 78, 10 hrs. a week is still doable but more wears me out. –James Margolis, MD.

Business is taking over medicine and is changing it entirely. Knowledge has changed the zest. I have less zest than as a student, but much more than when I was a resident. I am still passionate about my profession, but with caveats. When I talk to my children, I discourage them of walking the same path, unless they really find they have a strong talent for it and can’t imagine any other profession, like myself. Business is taking over medicine and is changing it entirely. Time with a patient and Love for the care of another human are declared invaluable and systematically extinguished by layers of productivity tables. One day it will change back when society notices that throughput does not heal. –Gudrun Kungys, MD Actual patient care does not burn me out, administrative pressures do. –Asmaneh Yamagata, MD Long hours and political burden, not having an appropriate union in the medical field puts physicians at significantly higher risk of burnout. No political support. –Hemal Amin, MD 1) Most of what occupies my time is NOT medicine as taught in school and residency;


2) Corporate Medicine where everything is commoditized, productivity is king, and sadistic narcissists rise to leadership roles is destroying our field. –Harel Ho, MD I disagree. I feel our voices as physicians are not being heard. It is often overlooked what we as physicians have to bear with the profession: long hours (even past the normal clinic hours), trying to keep up with patient satisfaction, less time with family. –Karen Grace De Aquino, MD Over my nearly 30-year career in medicine, I went from being passionate about medicine to enjoying medicine to tolerating medicine, to now almost dreading medicine. −Norman Chow, MD

I would undoubtedly do the same again if I had the opportunity to restart my career. The facts speak for themselves. There is an incredible amount of burnout among physicians which I believe has much more to do with the logistics of practice rather than patient care and interaction. Many issues over the last 10 years have contributed to physician frustration including the electronic medical record, insurance issues, hospital length of stay and readmission issues and very unrealistic expectations regarding patient outcomes and other very unrealistic metrics by which physician performance is measured while the physicians have little or no capacity to impact many of these situations. There are numerous issues such as access to medical providers in the community, timely consultant appointments, the cost of and access to medications and testing, to name but a few over which physicians have no control. Nonetheless, we are expected to get outstanding results with substandard or marginal access to care. The malpractice arena continues to be a considerable source of physician irritation and discussed with little or no prospects of any improvement. However, as a physician approaching 40 years practicing in this community, I can

say without reservation that I have been very fortunate to have had an amazingly enjoyable and successful practice. I would undoubtedly do the same again if I had the opportunity to restart my career. With the amazing new developments in medicine, I think the next 50 years will be an amazing time to practice medicine. –Peter J. Murphy, MD I love the clinical aspect of my job: operating and taking care of patients, but the administrative demands and the expectation that I can see more and more patients has a negative impact on how I view my career now. −Amy Wandel, MD Agree. Even after 44 years. It’s the people. Making them comfortable. Reassuring them. Going to a doctor is not a relaxing walk in the park. That’s why patients forget what we tell them. They’re listening, but they’re not hearing. −Lawrence Bass, MD It is sad to think that many physicians may have lost their zest for medicine. No one can practice high-quality medicine without this level of enthusiasm. I have practiced for 34 years and have seen many changes, particularly in the regulatory arena. Despite that, I remain committed to delivering the highest quality medicine to my patients. Perhaps there should be some support for physicians experiencing burnout, but if they cannot maintain their enthusiasm, it is probably best for them to leave the field to those who remain committed. −Gary Roach, MD I do have the same love for medicine, but certainly not the politics of medicine. −William Junglas, MD Not as much zest only because of the burdens and sacrifices that must be made to be a physician, but SAME desire to help those in need. −Bryan Lee, MD I have the same passion that I anticipated during my years in training and have experienced early in my career. I feel extremely fortunate to describe my contentment, which is primarily because I have found my niche in laboratory medicine (pathology). Honestly, had I continued my initially selected career in primary care, I might have been “spent” by now. −Jeffrey Moore, MD September/October 2017

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After recovering from burnout, I do (agree.) −Carol Kimball, MD The highjacking of small practices by large HMOs where business values and profit margins dictate the bottom line and physicians man an assembly line has completely overshadowed the JOY I once experienced. −Stacie Walton, MD Focus on physician wellness including balanced, reasonable schedules is key to preventing burnout. Our PCPs, family physicians, and ER physicians have particularly high volumes. −Ying Wu, MD I agree. The good parts of my Ob/Gyn practice are better than I even imagined. The thrill of a healthy delivery has not diminished one little bit! I’m still amazed when a tiny human emerges from its mother, and a family grows before my eyes. I am still moved to tears by the selflessness I often observe in surrogacies or deliveries involving adoption. I enjoy surgery to a degree that some may consider obsessive. I am touched by the opportunity to find the right words and actions to carry my patients through their most difficult moments. All these aspects of my work keep me motivated and give my life meaning.

An unexpected source of grief is the constant, progressive diminishment of value and respect for physicians... The regulatory interference is far worse than I ever could have predicted, and it seems to just keep getting more burdensome as time goes by. My work as an advocate for my patients has come second nature. But my work as a physician advocate, trying to protect my colleagues from layers and layers of unnecessary documentation, procedural delays, repetitious oversight, spurious certification (that doesn’t correlate with decreased errors or improved patient care), and other interference is not a routine part of medical training and is not directed by our Hippocratic Oath. An unexpected source of grief is the constant, progressive diminishment of value and respect for physicians that has been promulgated by the commodification of health care. 18

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Changing the negatives and focusing on the positives takes a group effort. I retain my zest for medicine by actively participating in organized medicine. I stave off burnout by volunteering to treat the underserved, to teach those just starting in their health careers and to speak to students and the public about why I truly love what I do. At the end of the day, we matter! Our impact on our patients’ lives and the health of our community is immeasurable. As physicians, there is much to be grateful for: the privilege of caring for patients, the honor of service, the life-affirming benefits of being a healer. For me, these experiences rejuvenate my zest for practicing medicine. −Ruth Haskins, MD I graduated in 1963, started practice here in 1971. The “zest” is still there, but the complex business side and increased hassle factor, along with the loss of intraprofessional relationships and camaraderie, have not made it easier. − Ralph Koldinger, MD I disagree. Too much pressure to see more patients in less time, and the expectation that the physician will pick up the slack in clinic. − Thomas Valdez, MD YES! As a Gen X’er, I have become disillusioned with institutions, corporations, and governments. How often have we been let down? I came into medicine hoping to see universal health care in my lifetime. I now question that. But one thing hasn’t changed. I’m holding my 2nd and 3rd digits in the air. That’s me and the patient, and when we are in the room, the background noise and bad orange hair comb-overs are distant. That special relationship and privileged role of being part of someone else’s health and well-being is still priceless. −Nate Hitzeman, MD Actually, I have MORE zest for medicine than as a medical student/resident. Along my journey to my current ophthalmology practice at Kaiser Permanente, I have learned more about medicine and humanity than I was aware of as a trainee. I am so glad I chose this path because it fulfills my mind and my soul. −Jennifer Long, MD I agree. However, I wouldn’t call it a “zest” for medicine, but more of a calling and duty for the profession and practice of medicine.


Consider what a long road it took to become a physician: many years of dedicated study and effort just to be accepted into medical school, then four long years of incredible work and sacrifice during medical school, to learn as much as one can to be prepared to work in this field. Then at least three years of residency (for some specialties much more): years spent forsaking family, friends, cultural events and often delaying starting a family, before we finally enter the world as a fully trained and capable physician. Over the many years, I have been privileged to practice medicine. I continue to be in awe of the trust and respect my patients place in me. This human connection, the intimate bond we hold with our patients is truly remarkable and unique among professions. I feel so lucky to be able to do this. It is and will always be felt as a privilege bestowed upon me by the people whom I serve.

I actually remember when the hospital CEO was friendly with physicians on the medical staff... As to burnout, I have been practicing in Sacramento since 1985 and have been witness to the gradual unraveling of our profession. We have been labeled “providers” for many years, so as to simplify our role in the “delivery team.” The physician as the “captain of the ship” is now only seen at times of blame, not as a leader in the current world of corporate medicine. I actually remember when the hospital CEO was friendly with physicians on the medical staff – knew us by name! Those days seemingly have vanished. The physician is simply a part of the work force. Independence has waned and more California physicians are working in a “foundation model.” Fewer of us are independent, practicing solo or in a small group. The administrative burden and cost of running a practice are oppressive for physicians. Many of my colleagues have given up: retired early, limited their practices, or have yielded to the benefits of working in a larger group.

We have cherished our diversity in our physician workforce modes of practice. CMA established many different modes of practices as distinct delegations. These included solo and small practice physicians, medium sized group, large group and very large group in 1995. CMA has long valued the various models of care physicians chose to provide care to their patients. Those of us who valued a smaller or solo practice particularly enjoyed the sense of ownership and stewardship a solo practice provided. It is increasingly difficult to maintain viability as a solo physician in the current environment that values “health care delivery systems” over independent physician practices. The insurance game has been rigged against physicians at least since managed care took over medicine in the late ‘80s. There is simply no credible reason to make practicing medicine so complex, other than to make it nearly impossible for physicians to be paid fairly and in a timely fashion for services rendered. We went to medical school. There was no business training, only medical training. We did not enter medicine to become business people. We entered medicine to be physicians. That is our full-time job. The ever increasing federal, state, and payer regulations are driving physicians out of and away from practice. Recent “new” examples of MACRA, MIPPS and an ever-changing playing field make for increased stress in our practices. There is no wonder why we have a burnout epidemic! When physicians reclaim the art and science of our profession, spend more time practicing medicine and less time worrying about the costs and burdens of doing so, our burnout crisis will diminish. Every day we must renew the passion, reclaim the value and hold dear our profession. Despite all the troubles and challenges we face, it remains an incredible experience to practice medicine. The joy of helping our patients cannot be underestimated or undervalued. We are truly blessed to be physicians. –Lee Snook, MD The saddest part is that “leaving the profession” means also 300 doctors kill themselves by suicide. That does not count the suicides of medical students. September/October 2017

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We have sold our souls to the devil and our role of a healer has been dilbertized to satisfy corporate targets, our medical groups are acting like Vichy agents in enforcing the often meaningless dictates from CMS. It is like adding sweetener to the cup of hemlock. Doctors are sitting and doing tabs on the template so that a beautiful document is created that will bring money in, and avoiding penalties becomes the purpose of what we do, far disconnected from our personal statement that we wrote to get into medical school. It means listening to the patient and using the history as a tool has been diminished. It was a valuable tool, now often done by the scribe. I have one instance where the scribe to the assistant to the doctor missed an important medication distinction “patient denies taking an anticoagulant, is on Xarelto”... The course of treatment diverted. The bloated EHR histories designed to capture dollars are often not read or hard to read.

On a patient after discharge, I noted there was no action taken on an X-ray: nodules on lung are new and may be serious [like cancer]. On my inquiry, the doctor replied: “It is unfortunate that the X-ray report was not noticed by staff and all three consultants.” Your Posit shows also a better metric in this since it measures the loss of joy, and did not ask if doctors are burnt out. Doctors don’t admit to that. That explains why all of a sudden they kill themselves. It’s not all of a sudden. What ennobles our profession is that we are healers. Templates and tab medicine detracts from that. There is no tab, no pull down menu that produces a human voice to the patient: “Go not gentle into that good night, rage, rage the dimming of the light.” –Henry Go, MD I enjoy my life as a physician now more than I could have anticipated in medical school or residency. I love what I do. −Leina Singh, MD

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Course can be offered in a group training using a single log-in. Contact Leslie Iacopi at (415) 882-5167 for more details.

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BOOK REVIEW

Crazy Like Us The Globalization of the American Psyche, By Ethan Watters; Free Press Publisher; ISBN-13: 978-1416587088

Reviewed By Lee Welter, MD UNDER THE TITLE UMBRELLA, this book consists of four chapters, each of which may be read independently. Their topics: 1) anorexia; 2) PTSD; 3) schizophrenia; and 4) depression. A fascinating nugget from each may help your reading decision. “The Rise of Anorexia in Hong Kong” featured Dr. Sing Lee, China’s eating disorders’ expert. He had encountered a few victims yearly, suffering mainly from somaticized emotional burdens. However, after Western (led by American) views popularized anorexia as a fixation on the stylishly slender, the numbers rose dramatically … of a very different form of the disease. Deciding to “truly be an expert,” Dr. Lee followed a regime of calorie restriction and exercise that initially brought weight loss, lack of energy, and dark mood. After three months, his energy returned and he “felt great” — superior to those ruled by hunger. He realized what one patient had described: “Anorexia was like getting on a train, only to learn it was headed the wrong direction.” “The Wave That Brought PTSD to Sri Lanka” depicts the tsunami of 2004’s impact, killing a quarter million people. Soon afterward, the world’s PTSD experts arrived to help survivors recover. Closer scrutiny revealed how greatly the local culture’s stress-coping approach differed from that of Western medicine. Reflecting the cultural value of family connectedness, one mother calmed her children: “If we are to die, I promise you we will all die together.” “The Shifting Mask of Schizophrenia in Zanzibar” contrasts the traditional beliefs of

spirit possession with the Western explanation of altered brain chemistry — another example of DSM’s (Diagnostic and Statistical Manual of Mental Disorders) failure of cultural harmony. “The Mega-Marketing of Depression in Japan” focuses upon the ability of skilled pharmaceutical marketing in growing a few million dollars in academic conferences into billions in revenue. The traditional Japanese views of depression and its stigma had become overwhelmed by the advertising campaign touting its support by the world experts in this modern condition, and its need for drugs to balance brain chemistry. One expert confessed: “The strong force of the pharmaceutical industry threatens to turn medicine into a pseudoscience in the same way they have made opinion leaders…into a type of prostitute…We were very cheap prostitutes.” I’m impressed and intrigued with how author, Ethan Watters, found such fascinating material. My reaction was of amusement and disappointment with how our assumptions may be wrong in so many ways. Clearly, we don’t always know what’s best, nor even understand underlying problems. Sometimes “we” are the problem, such as the influence our pharmaceutical companies gained to generate billions in revenue while selling products with dubious benefits. This latter problem prompts me to question the motivations of this enterprise. Profit without ethics? welter@computer.org

September/October 2017

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

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Dementia and Its History By Kent Perryman, Ph.D. THE LAST 100 YEARS have witnessed a doubling of the average health span in the civilized world. We can attribute much of our longevity to improvements in medical interventions, sanitation, shelter, nutrition and lifestyle. However, the brain, as well as the body, do not have an infinite life span. Even with healthy aging, innovations in medical science cannot prevent the brain from losing mass over time. Cognitive processes that depend on communication between neural networks can rapidly decline for a variety of reasons. Head trauma, interruptions in cerebral blood flow, neural degenerative and viral diseases all can impact cognitive functions over an individual’s life span. Prior to the 19th century, the clinical concept of dementia included a mental illness for anyone who had lost the ability to reason. Behavioral changes in the elderly were sometimes mistakenly attributed to “senile dementia,” or “senile psychosis,” caused by cerebral arteriosclerosis or a decreased efficiency in cerebral blood flow. Recent medical evidence using post-mortem examinations of older individuals have demonstrated a lack of correspondence between brain damage and quality of behavior.

History of Dementia 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 word “dementia” first appeared around 600 A.D. in the text Etymologie by the Archbishop of Seville. The root of the word “dementia” refers to “a state out of mind.” There is hieroglyphic evidence of dementia-like symptoms dating back in ancient Egypt to 250 B.C. by Ptahhotep, when he describes an aging individual who eventually reverted to childish behavior. One of the earliest known documented accounts of dementia dates back to 700 B.C.

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by the Greek physician, Pythagoras (570-495 B.C.). He ascribed individuals over the age of 63 as “senium” or suffering mental and physical decay. He believed that at the end of a very long life, one’s mind was eventually reduced to imbecility. Plato (428-347 B.C.) also suggested that mental performance is destined to inevitable decline, while Hippocrates (460370 B.C.) believed that brain injury resulted in mental disorders. The Roman poet, Juvenal, characterized dementia 2000 years ago as: “Diseases of all kind dance around the old man in a troop. But worse than any loss in the body is the failing mind which forgets the names of slaves and cannot recognize the face of the old friend who dined with him last night, nor those of the children whom he has begotten and brought up.” However, the Roman statesman, Marcus Tullius Cicero (106-43 B.C.), took issue with this opinion and believed that dementia was not inevitable for all elders. He fostered the belief that the human mind could remain fully functional if individuals maintained mentally and physically active lifestyle. Subsequent Greek physicians, such as Galen (13-210 A.D.) and Lulus Cornelius Celsus (14 B.C.-50 A.D.), continued to support Plato’s and Aristotle’s view of declining intellectual function with aging. Around the 2nd century A.D., the Greek physician, Aretheus of Cappadocia, distinguished between “delirium” as a reversible acute disorder, compared to dementia, which was an irreversible chronic condition. The middle ages was a dark period for anyone suffering from some sort of mental aberration. The church regarded senility as “fruitful punishment” of man’s original sin. Any sort of mental symptoms were also considered to be demonic possession. Many individuals


Fig. 1

suffering from a mental malady were considered by the church to be witches and were burned at the stake. Later, in the early 1600s, the English philosopher, Francis Bacon, was one of the first to recognize dementia as a brain disease in his publication, “Methods of Preventing the Appearance of Senility.” He believed that the posterior area of the older brain is responsible for memory loss. William Shakespeare (1564-1616) refers to senile dementia in both of his plays, Hamlet and King Lear. It was during this same time period in the 17th century that the English physician, Thomas Willis (1621-1675), first described vascular dementia in his text, “De Anima Brutorum.” The term, “dementia,” wasn’t medically accepted as a diagnostic entity until the 18th century when it was described by the French physician, Philippe Pinel (1745-1826). Following in Pinel’s footsteps, Jean Etienne Dominique Esquiroi (1772-1840) described dementia as: “Dementia is that disabilities are shown in discernment, intellectual ability and will due to brain diseases, and is to lose joyfulness enjoyed and is that the rich became poor” (loose translation).

Fig. 2

Aloysius Alzheimer (1864-1915), a German physician trained in psychiatry and neuropathology, acquired the brain of Auguste Deter, a 51-year-old female patient he had previously diagnosed four years earlier as suffering from presenile dementia. Upon performing a biopsy at the Munich Medical School, he discovered thinning of the cerebral cortex. Using a newly-developed Nissl stain, senile plaques were found in the hippocampal region of the temporal cortex, along with tangles in their nerve fibers. Dr. Alzheimer reported these finding in 1906 at the 37th psychiatry conference of southwestern Germany at Tubingen. Later, in 1910, a more detailed description of the dementia symptoms and neuropathological results were officially published, referring to this inflammation process as “Alzheimer’s Disease.” Alzheimer passed away in 1915 at the age of 51 due to heart failure by endocarditis and kidney failure. For many years during the 20th century, Alzheimer’s disease was considered to be presenile dementia with an early onset of occurrence prior to age 65. Some clinicians still refer to this early onset Alzheimer’s disease as the presenile form of the disease. This form of

September/October 2017

Fig.1, LEFT − A patient with early Alzheimer disease, 77 years of age, Mini-Mental State Examination score = 25. A) Minimal atrophy was seen in the right hippocampus. B) FDG-PET shows reduced glucose metabolism in the bilaterial parietotemporal association cortices and posterior cingulate gyri and precuneus. C) PiB accumulations are demonstrated in the cerebral cortices except for the occipital and medial temporal regions. Medial parietal and frontal accumulations of PiB are high, indicative of positive amyloid deposit. Fig. 2, RIGHT − Healthy elderly male subject, 78 years of age, Mini-Mental State Examination score = 30. A) A slight enlargement of the right inferior horn of the lateral ventricle is seen on the TI-weighted MR image. B) The regional glucose metabolism is not reduced on the FDG-PET images. Note that the posterior cingulate glucose metabolism is much larger than that in other regions. C) Pib-PET shows non-specific accumulation in the white matter, but no PiB accumulation in the gray matter. The amyloid deposit is negative.

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Dementia is a symptom of many disorders and not a diagnostic entity.

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the disease may be linked with mutations on chromosomes 1, 14 and 21. The build-up of beta amyloid in the senile plaques, an amino acid peptide, gradually destroys the neuronal cell bodies preventing neural transmission. Working alongside Dr. Alzheimer at the time were Otto Ludwick Binswanger (1852-1929) and Franz Nissl (1860-1919). Binswanger, a Swiss physician who was studying neurosyphilis at the time, coined the term “presenile dementia” as a form of vascular dementia in 1894. Later, the scientific community reclassified Binswanger’s findings as Binswanger’s disease or subcortical leukencephalopathy relating to small vessel vascular disease affecting the white brain matter of older individuals. Franz Nissl was responsible for developing many of the cell staining techniques that Alzheimer employed to identify the plaques and tangles he observed.

Dementia Diagnosis Dementia is a symptom of many disorders and not a diagnostic entity. The earlier neurological literature referred to dementia as an “organic mental syndrome.” The primary symptoms include memory impairment, loss of concentration and lowering of abstract thought processes with marked changes in personality, including mood. Many times it’s left up to the family physician in general practice to make a diagnosis, or the individual is referred to a neurologist. In many university and VA hospitals, as well as in specialty clinics, an integrative team approach is utilized to evaluate a patient’s intellectual performance. A dementia clinic team may be comprised of a neurologist and neuropsychiatrist who have experienced a neurobehavioral fellowship following their residency training. The team may also include a neuropsychologist and a nurse practitioner who specializes in geropsychiatry. Some of the university and VA clinics include third- and fourth-year medical students for their clerkship exposure to dementia patients. Any candidate for cognitive assessment may go through a triage procedure, including blood tests, that includes an evaluation of their current

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medications, as well as their psycho-social history of drug and alcohol use, to rule out treatable causes. Their possible exposure to heavy metals must also be taken into consideration, along with any previous head trauma. An extensive neurological exam and neuropsychological mental status evaluation are included in what may entail six to eight hours of pen-and-paper cognitive tests given over several days. If the members of the team deem that imaging is also necessary to rule out any structural or metabolic aberrations involving the central nervous system, an MRI and/or PET scan will be ordered. A spinal tap could also be considered to confirm or rule out neural syphilis or normal pressure hydrocephalus (NPH). Many times, especially with geriatric patients, there can be a number of medical etiologies responsible for changes in cognition, such as vascular and degenerative diseases like with Alzheimer’s disease. Major depression has also been known to mimic the cognitive symptoms of dementia. Symptoms must be present for at least six months to support a diagnosis of dementia. Anything of a shorter duration may be a delirium with clouded sensorium. The sudden, fluctuating and short duration of cognitive symptoms may be due to medical disturbances, i.e., pharmaceutical interaction. Cognitive symptoms associated with hypothyroidism, vitamin B12 deficiency, Lyme disease and neurosyphilis can all be reversed. Some individuals present with Mild Cognitive Impairment (MCI). These are individuals who are displaying some cognitive slippage with scores on the Mini-Mental Status Exam (MMSE) of between 25 and 30. Seventy percent of these individuals may go on to develop some form of dementia. Evaluating individuals for a dementia workup can be a complex and tedious procedure, to say the least.

Dementia Categorization Dementia, by definition, is a progressive and usually profound intellectual deterioration. “Intellectual” means mental operations involving orientation (person, place and time),


cognition (abstract vs. concrete) and memory (short- and long-term). Language, skilled movements and perception can also be affected. The classification of various dementias is based on age of onset, medical etiology, accompanying neurological symptoms and whether or not it is treatable. There are several classification schemes employed by medical professionals that aide in the diagnosis. The central nervous system (CNS) location and extent-based system is one of the earliest and basic classification systems of dementia. There are the localized cortical dementias, such as Alzheimer’s, and the subcortical dementias of Huntington’s and Parkinson disease. Under this schema, there are the axial dementias, such as the Wernicke-Korsakoff syndrome, and the Global dementias that include advanced Alzheimer’s disease. A more recent and inclusive detailed dementia classification schema focuses on the specific etiology of the neurological disease process. Under the category of diffuse degenerative diseases of the CNS are 1) Alzheimer’s disease, 2) Pick’s disease and 3) Dementia with Lewy bodies. Next would be a vascular etiology such as multiple infarct dementia (MID). Then there are the dementias associated with head trauma, such as chronic traumatic encephalography (CTE) and dementia pugilistic. Wilson’s disease and Cushing’s syndrome are both forms of dementia associated with metabolic disorders. Brain tumors in the prefrontal cortex can sometime give rise to a dementia. Hydrocephalus associated with excessive cerebral spinal fluid pressure can also give rise to dementia unless its not treated early enough. Various CNS infections such as encephalitis, bacterial meningitis and tertiary syphilis are responsible for encouraging dementia symptoms. The Wernicke-Korsakoff syndrome associated with excessive alcohol abuse falls under the category of deficiency dementia. Finally, excessive exposure to many heavy metals is sometimes an occupational hazard that can result in dementia. This list of subcategories is

representative of the more recognized prevalent types and does not include some of the more exotic, more difficult to diagnose forms. By far, the most prevalent dementias associated with aging are MID (25 percent) and the degenerative inflammation of Alzheimer’s disease (50-70 percent), or a combination of the two with cerebral small vessel disease (CSVD). Uncontrolled type II diabetes with Alzheimer’s disease is also the most common type of dementia found in the United States. About three percent of individuals between the ages of 65-74 have dementia, 19 percent between 75 and 84 and nearly half of those over 85 years of age.

Aloysius Alzheimer

Conclusion Although cerebral vascular disease is partially manageable and preventable through pharmaceutical intervention and diet, neurodegenerative disorders, such as Alzheimer’s disease, are currently irreversible. Numerous clinical drug trials employing anticholinesterase inhibitors (AChEi), including my own, have been without clinical benefit in reversing the inflammation process. We can only hope that some progress in alleviating this egregious disorder eventually transpires through continued research. kperryman@suddenlink.net REFERENCES Walsh, KW. Neuropsychology: A Clinical Approach. 1978, Churchill Livingston New York Italian, KM And Valenstein, E. Clinical Neuropsychology. 1979, Oxford University Press New York Dementia. https://en.wikipedia.org/wik/Dementia History of Alzheimer’s Disease. https://synapse.koreamed.org/DOix. php?id=10.12779/dnd.2016.15.4.115 History of Alzheimer’s and Dementia. http://www.aplaceformom. com/blog/dementia-across-space-and-time Kaplan, HI. And Sadock, BJ. Comprehensive Textbook of Psychiatry/ Fourth Edition. 1985, Williams & Wilkins Baltimore Diagnostic and Statistical Manual of Mental Disorders. 1994, American Psychiatric Association Washington, DC

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Between Hearing Loss and Dementia – A Link By Laura Assante Robinson, Au.D, MHA ACCORDING TO RESEARCHERS, Liesi Hebert, Jennifer Weuve, Paul Scherr, and Denis Evans, in a 2013 study funded by the Alzheimer’s Association and NIH/National Institute on Aging, 4.7 million Americans over the age of 65 were diagnosed with dementia. Audiology Today reports that 40 percent of those over 65 years old will present with hearing loss and 66 percent over 75 will have hearing loss. In 2011, a link between hearing loss and cognitive decline was discovered. So how has hearing loss been linked to dementia?

Researchers at John Hopkins School of Medicine looked at 639 adults from 36-90 years of age for 12 years and monitored cognitive health and hearing health. While none of the subjects had dementia at the start of the study, 184 of the 639 subjects had some degree of hearing loss. Researcher, Otologist, and Epidemiologist, Dr. Frank Lin, discovered a link between those who had hearing loss at the beginning of the study and those who developed dementia at the end of the study. Linn and his associates also found the greater the hearing loss, the bigger chance of developing dementia; and with every 10 decibels of hearing loss, the likelihood of dementia increased by 20 percent. INC. In 2013, another study revealed A REGISTRY & PLACEMENT FIRM similar results. Lin looked at nearly 2,000 adults and found those with hearing loss experienced more loss of memory, concentration or thinking capabilities 40 percent faster than Nurse Practitioners ~ Physician Assistants those with normal hearing. He also found accelerated rates of brain atrophy in those with hearing loss, compared with those with normal hearing. Dr. Arthur Wingfield, Professor of Neuroscience at Brandeis University, studied brain volume using MRIs and found that those Locum Tenens ~ Permanent Placement with poorer hearing show that the frontal part of the brain works harder. 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 Wingfield concluded that this effort FA X : 8 0 5 - 6 4 1 - 9 1 4 3 to try to listen and comprehend may take a toll on cognitive resources. tzweig@tracyzweig.com This link of hearing loss and w w w. t r a c y z w e i g . c o m dementia is also backed by researcher continued on page 28

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Loose Ends By Marion Leff, MD I LIKE THINGS NEAT and tidy. I don’t like to wait until the last minute to pack for a trip, study for an exam or pay my bills. Consequently, I started to prepare for my retirement from medicine long before that final day. Preparing meant doing research. I picked the brains of my retired colleagues: How did they know it was time? How did they fill their time? Did they walk away 100 percent or continue to practice in a reduced fashion? Did they leave because of burnout, threat of malpractice, boredom, or to pursue something else long put on the back burner? I also read the many AARP articles that arrived unsolicited, directed to the glut of boomers about to retire. After 38 years of a successful run as a family physician doing what I love, leading a family medicine residency program and achieving my first and foremost professional goal – that of being a good doctor serving my community – I had more than my share of plaques, certificates, thank you letters and opportunities to mentor a younger generation. Of course, there were bumps along the way (including the feared malpractice suit), but overall I felt I was at the top of my game… and that was when I realized it was time for me to retire. Ironically, it came just before my institution was about to begin a mandatory policy to require a “fitness to practice” evaluation for physicians over a particular age. This is a trend popping up across the country not welcome by all aging physicians (see the June 24th article in the Wall Street Journal). Each of us comes to this recognition at our own time. As much as working with Gen X and Millennial resident physicians has kept me on my toes, it also amplified for me the areas where I was losing ground and maybe even relevance. I wish I could say, “Never too old to learn new tricks,” but learning new systems and processes

comes slower now, and my enthusiasm to embrace the change is becoming insincere. I was getting stale, and my younger, talented colleagues needed a chance to flourish. It was time. The decision was sealed by the arrival of not one but three young grandchildren. As a working professional mother, I wasn’t always present for my kids. Now I am determined not to miss out on being a “present” grandmother. So, the date is set, and time marches on, as time does. Human Resources is contacted. Paperwork must be completed. I need to enroll in Medicare part-B ASAP or sign up for COBRA or find myself with no health insurance. Exit interviews are scheduled. I start cleaning out decade-old files of articles I thought might be valuable one day to re-read, separating the outdated from the very few that might have historical value to my colleagues. Isn’t everything today worth reading available online? I gift items once cherished and adorning my office with the hope that my partners will value them as a way to remember me. I am not unaware of my conflicted behavior such as taking recertification boards just in case… As the time for my actual departure grew closer, every patient visit was an emotional goodbye. This is, by far, the most difficult task of all for a primary care doctor who has stayed put and planted roots in a community for more than 30 years. We take for granted sometimes that being there for our patients – something we do as simply part of our job – carries great significance for our patients. Over and over, a patient reminded me of something I had done that seemed just in the line of work for me, but not for them: “You were the only doctor who got me to quit smoking” or “You took care of my mother [father or child]…” or “You saved my life when you diagnosed [x, y or z] and got me the help I needed.” With each recitation came a September/October 2017

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

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little nagging voice: Am I making a mistake? Am I abandoning them? It was overwhelming. “Sad for me, glad for you” was the common thread as patients came with cards, flowers, chocolates and tokens of affection. No question for me, the hardest of all was saying goodbye to the oldest of the senior patients. One lovely woman articulated exactly what I read in all of their faces, “I thought you would be here with me for this last journey.” Nonetheless, I retire almost embarrassed by how happy I am to start this next adventure. I don’t want to be the doctor who waited too long to leave, or who, upon leaving, claims to have lived the only “golden age” of medicine. I don’t believe that to be true. I do have some anxiety that I leave behind much unfinished hard work and loose ends for the next generation of physicians, but when was that ever not the case?

Even when leaving is right and certain and desired, it is hard. Patient woes cannot be tidied up on the last day. Abnormal labs and x-rays continue to trickle in as I hand a patient a cancer diagnosis and a new doctor almost in the same breath. I feel terrible. Hand-offs must be made to just the right colleague. “You must take good care of this one, she is fragile.” “He’s cantankerous, but will grow on you with time,” and so on and so forth. It is my last actual clinic day. I take off my white jacket and empty all the pockets, and into the laundry it goes for the very last time. I remember the day 40 years ago when, in a ceremony, I first put it on. I became “doctor.” Crumpled upon the laundry basket now, I wonder who I will become next. leffmarion@gmail.com

Hearing Loss and Dementia continued from page 26 Dr. Richard Gurgel. Gurgel, in 2014, studied 4,400 adults over the age of 65 and found that those with hearing loss at the beginning of the study developed dementia at a higher rate and earlier than those with normal hearing. Why is there a link? Three theories exist according to Dr. Lin: Cognitive Overload: The brain works harder to cope when sounds are degraded. Brain Atrophy: Hearing loss may contribute to accelerated rates of atrophy in parts of the brain that process sound, which may also involve vascular aspects. Social Isolation: Those who have difficulty hearing may withdraw from social situations. Numerous studies have found that a loss of engagement and loneliness are risk factors for cognitive decline. Will treating hearing loss reduce the risk of dementia? Dr. Lin and his team are currently looking for answers and are conducting a fiveyear study with 800 older adults. Since it is already known that hearing impairment is independently associated with a 30-40 percent rate 28

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of accelerated cognitive decline, Dr. Lin will look at whether treating hearing loss will reduce this risk factor of dementia. In this study, some of the subjects will receive state-of-the-art hearing technology and others will receive only “wellness advice.” Cognitive decline of the subjects will be measured at the end of the study. If Dr. Lin’s study finds the risk factors for cognitive decline are modifiable, then recommending hearing loss treatment will become a priority. Results of this study could provide promising results. larobinson@sacent.com REFERENCES Herbert, L., Weuve, J. Scherr, P., Evans, D. (2013). Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology 80, 1778-1783. Jorgensen, L. (2014). Evaluation of hearing status at the time of dementia diagnosis. Audiology Today, 39-44. Lin, FR, Albert, M. (2014). Hearing loss and dementia, who’s listening? Aging Mental Health, 18, 671-673. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. (2011). Hearing loss and incident dementia. Arch Neurology. 68,(2), 214–220. doi: 68/2/214 [pii] 10.1001/archneurol.2010.362 Rokins, T. (2013). The links between hearing loss and dementia. The Huffington Post.


Medical Mission Students Gain Foreign Hands-On Experience Before Practicing Medicine at Home

By Shelby Roberts, MS II OVER MY SPRING BREAK THIS past March, I traveled to Honduras for nine days, along with about 15 other medical students and 20 health care providers, to offer medical care in communities with little access to health care. This trip was actually my fourth medical mission to Honduras. Now, as a new medical student, I was excited to return to Honduras with the perspective of using what I had been learning in school and applying it to patients. Each time I return to Honduras, the unique lifestyle and culture of the Honduran people strike me. I noticed that even though they owned few possessions due to poverty, the Honduran people were full of love and happiness. Each community was like a family with everyone in close relationships with one another. Most of the country itself is very rural, with vast beautiful green hills and canyons surrounded by bustling towns. In these towns, there are typically one-room churches, shack stores selling drinks and chips, and small communities of homes. Most of the homes are made of metal sheets and wood simply nailed together, along with dirt floors. I traveled on the mission trip this spring, which was sponsored by the Christian Medical Association, with medical students from California Northstate University College of Medicine, Touro University, and the UC Davis School of Medicine. We traveled to many small and rural communities surrounding San Pedro Sula, located in the far Northwest of Honduras. Our group traveled each day by bus on mountain roads to one of the local schools to set up a day clinic. Usually a long line of people stood outside the school awaiting our arrival. In each room of the school, we set up

a different part of the clinic, such as triage, medicine, dentistry, and pharmacy. We worked as a team by efficiently bringing the hundreds of patients we had to see each day through the stations of the clinic. With a background in medical Spanish and previous medical mission trips, I was able to work as a translator for the physicians in the medicine section of the clinic. I typically took patient histories, performed physical exams, and counseled patients about their medications and general health. The most common problems patients had were ones that were usually easily addressed in the United States, but in those areas were almost impossible to treat, given their limited access to medications and health resources. Typical problems were diabetes, hypertension, asthma, and cavities. In Honduras, only residents of the wealthiest cities, such as Tegucigalpa and San Pedro, have proper access to medical resources. However, communities we visited throughout our trip were often located in mountainous areas that were far away from hospitals. One family explained to me that their entire community had one clinic that was an hour’s walk away, and only had one nurse. If they could muster up the money to ride a bus or donkey down the mountain to the nearest hospital, they were usually prescribed medications that they could not afford or would need specialized imaging that they did not have access to. Throughout my time in Honduras, I valued the powerful impact that the team members of my clinic and I were able to make on patient lives. For instance, during one of the clinic days, a father came to me in tears because his child was told he needed a filling for a bad cavity. Coming up with the expenses for filling this

September/October 2017

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The author traveled on a mission trip this spring, which was sponsored by the Christian Medical Association, with medical students from California Northstate University College of Medicine, Touro University, and the UC Davis School of Medicine. They traveled to many small and rural communities surrounding San Pedro Sula, located in the far Northwest of Honduras.

cavity would take months of work in the fields. Through the use of our mobile clinic, we were able to fill the child’s cavity for free and save the family stress and money. I was also able to utilize health education to better the health of another patient, a woman who was diabetic, overweight, and had lower extremity peripheral neuropathy. I spent an hour with her trying to understand her daily diet, her accessibility to fruits and vegetables,

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and her exercise habits. I learned from her that getting fresh fruits and vegetables would take four hours of walking each way. Using this information, I gave her advice about general health and wellness that she had never learned. From this advice, she realized that she did have the power to take her health into her own hands, even though she had many restrictions because of her geographical location. Although there was a lack of access, we discussed lifestyle modifications that worked for her. Many patients like this one wanted to receive health education and then teach what they learned to their own local community and schools. Although the medications given through the clinic had a temporary effect on patient health, I was inspired that my health education was taken to heart and was spread throughout the entire community. Despite the positive contributions that our clinic were able to make, the reality is that Honduras will take years to develop a health care system that allows access, geographically and economically, for the hundreds of thousands of patients who currently don’t receive it. Fortunately, there are now many organizations


and groups, such as ours, that consistently return to Honduras to provide health care. I believe it is vital to increase the amount of health care education in these communities to give them the power to initiate small lifestyle changes to prevent chronic diseases. Eventually, the hope is that we can provide resources and medications to the small local clinics for longterm management of chronic conditions such as diabetes and hypertension. I believe it is very important for medical student education to include global medical experiences such as these, to acquire a global perspective on health care and to understand different cultures and lifestyles to better work with a variety of patient populations. It is also an opportunity to gain hands-on experience working with patients years before practicing medicine in the United States. These life-changing experiences have inspired me to continue incorporating global health care perspective into my medical educa-

tion through future trips, and that will help continue to shape me to become a better physician in the future. shelbyro19@gmail.com

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.

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IN MEMORIAM

Irma West, MD 1917–2017

Irma West, MD

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SACRAMENTO’S MEDICAL Community has lost one of its oldest, most delightful, and pioneering physicians. Just short of the century mark, Dr. Irma West died at age 99 on July 2, 2017, shortly after suffering a fractured femur. She maintained an active life until her recent injury. Irma Marie Calvert was born around midnight on December 31, 1917 in Hespeler (now part of Cambridge), Ontario, about 40 miles west of Toronto. She emigrated with her family to the USA when she was 12. Even then she wanted to be a physician. She moved again to Bremerton, Washington and then to Willamette University in Salem, Oregon where she graduated in 1940, majoring in chemistry. She took pre-med courses, “just in case.” After college, she passed a science-based Federal Civil Service exam and was given a job at the Moffett Field research facility as a “computer.” She and lots of other scientificallyinclined young women were tasked to process an immense amount of data derived from aeronautical wind tunnel tests. She earned $1,800 a year. She was eligible to enter the University of Oregon School of Medicine, but was told, due to the demands of the military, that they were under orders to admit only men. So, she went to Philadelphia to begin medical studies at Woman’s Medical College which later merged with Hahnemann Medical College. Both schools are now part of Drexel University College of Medicine. Upon entering her clinical years of medical school, Irma had to confront two immediate prob­lems − a positive TB skin test and a positive throat swab for beta hemolytic strep. No Sierra Sacramento Valley Medicine

clinical work would be allowed until she had no evidence of infectious disease. A thorough exam revealed no findings of TB, and she was given a supply of penicillin, which was then very scarce on the home front, and she injected herself eight times a day (every three hours) for three weeks. Her follow-up culture was negative, and she was allowed to proceed with her medical training. She and a friend earned money working as attendants at Norristown State Hospital (originally called the “State Lunatic Hospital at Norristown”) which housed about 3,000 mentally ill patients. After her 1947 graduation from medical school, Irma returned to California to intern at St. Joseph’s Hospital in San Francisco where she was the only female intern. She married the chief resident, Ernest James West, and the couple moved to Santa Rosa where Irma worked at Sonoma State Hospital as a staff physician. She gave birth to a son, her only child, and she was divorced in 1951. Irma did extremely well despite the potential obstacles of raising a child as a single, working parent and a woman physician in an era when they were not accepted as well as they are today. She moved to the Bay Area and got a job with the State Department of Public Health, subsequently completing her Master’s Degree in Public Health at UC Berkeley. She was involved in investigating multiple cases of pulmonary tuberculosis among workers at a diatomaceous earth quarry. Biopsies also revealed silicotuberculosis, an incident that received national coverage. A subsequent assignment involved investigating the poisonings of farm workers and aerial crop dusting pilots from organophosphate pesticides that were becoming epidemic in California. Dr. West educated the doctors


in agricultural areas on how to recognize and handle organophosphate toxicity. Information gathered by Dr. West and staff prompted the development of a new generation of crop duster aircraft. In 1968, Dr. West was the lead author for a paper published in JAMA (July 29, 1968; vol 204, pp 266-271) which studied 1,024 single vehicle accidents in California with 871 driver deaths. The prior assumption that these were due to “natural” causes was negated by Dr. West when she found 648 had an average blood alcohol level of 0.19 mg/100 ml., sparking a long-needed national discussion about drunk driving. Based in Sacramento, she received a call from a local doctor who said he had two patients who were seriously ill with lead poisoning at a car battery recycling operation. At the poorlyventilated plant, furnaces melted the batteries to recover the lead. The owner was served with papers to cease all operations, and shortly after he held a gun to the head of Dr. West’s co-worker whose signature was also on the papers. In the 1960s, the State Department of Public Health was tasked with doing a survey and making recommendations to meet the Federal standard for ambulance service. This was at a time when ambulances in California did not provide enough headroom to provide emergency care, and only 10 percent had direct radio communication with a hospital. Dr. West was the lead member of this project (SSV Medicine – Vol. 59/No. 6 – Nov/Dec 2008). Dr. West retired in 1980. She was a long-time member of the SSVMS Historical Committee and toured the Sacramento Historic City Cemetery with the committee looking for the final resting places of our early physicians. She subsequently became very involved with the Sacramento Historic City Cemetery and was a member of the Old City Cemetery Committee at its inception and for decades after. She was the only person to research the lives and practices of over 50 early Sacramento physicians who lie at rest there. She also created and conducted the “Medical Bag” tours at the cemetery and wrote a publication containing biographies of many

of the physicians buried there. In addition to her work at the cemetery, Irma became more active at the Medical Society, greatly supporting and being involved with the Museum of Medical History and serving as a docent. She wrote numerous articles, mostly regarding local medical history, for this magazine. Her pamphlet entitled, “Cholera and Other Plagues of the Gold Rush,” was published by the Sacramento Historical Society. Students touring the museum were always amazed when she talked about her early experience as a “guinea pig” for penicillin. There was a memorable event last December when her family organized a wonderful surprise birthday party for Irma at her home, with a wonderful sharing of stories and memories. She was also honored at the SSVMS Annual Dinner in January, where she received a resolution recognizing her contributions to the field of medicine and its history. Dr. West is survived by her son, Michael, her daughter-in-law, Mary, five grandchildren, Tanya, Heidi, Michael, Mason and Molly and five great grandchildren ranging from 18 months to 24 years. Several of her grandchildren have followed her into the public health field. She also had a brother who died several years ago and a sister who died as a child. A celebration of life for Dr. West will be scheduled in September. Donations in her memory can be made to the SSVMS Museum of Medical History or the SSVMS Medical Student Scholarship Fund, or to the Old City Cemetery Committee. For more history of Dr. West, see the extensive article by Dr. Jack Ostrich in the Sept/ Oct 2015 issue of SSV Medicine. Much of this article is excerpted from it. A link to her articles and publications can be found at at www.ssvms. org/museum.aspx. − Bob LaPerriere, MD September/October 2017

Dr. West was honored at the Annual Meeting and Banquet of the SSVMS in January, where she received a resolution.

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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: Amir Akhzari, MD, Internal Medicine, Ross University School of Medicine – 2007, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, 95670 Thomas Balsbaugh, MD, Family Medicine, Jefferson Medical College of Thomas Jefferson University – 1995, The Permanente Group, 2025 Morse Avenue, Sacramento, CA 95825 Francis Baltasar, MD, Internal Medicine, Loyola University - Stritch School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Sumana Bangalore, MD, Internal Medicine, Kempegowda Institute of Medical Sciences – 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Otilia Braescu, MD, Ob/Gyn, The University of Medicine and Pharmacy of Tnrgu Mure – 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Thea Bregman, MD, Pediatrics, University of California Davis Medical Center – 2012, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Kathlynn Caguiat, MD, Gastroenterology, Ross University School of Medicine – 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Puneet Kaur, MD, Internal Medicine, Government Medical College, Mysore University – 2005, The Permanente Medical Group, 10725 International Dr., Rancho Cordova, CA 95670

Tressa Reynolds, MD, Emergency Medicine, Tulane University School of Medicine – 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Joey Kenney, MD, Internal Medicine, University of Texas Medical Branch – 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Katherine Shea, MD, Emergency Medicine, Tufts University School of Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Jin-Yon Jeany Kim, MD, Internal Medicine, University of Rochester School of Medicine & Dentistry – 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Liza Kim, MD, Plastic Surgery, George Washington University School of Medicine – 2003, Mercy Medical Group, 2200 Sunrise Blvd., Ste 250, Gold River, CA 95670 Toya Mathis, MD, Emergency Medicine, St George’S University School of Medicine – 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Siriwan Mingbunjerdsuk, MD, Pediatrics, Siriraj Hospital, Mahidol University, School of Medicine – 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Arjun Nepal, MD, Pediatrics, B.P. Koirala Institute of Health Sciences – 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Marylynn Cardona, MD, Ob/Gyn, University of Nevada School of Medical Sciences – 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Thuy Rose Ngoc Nguyen, DO, Family Medicine, Des Moines Univ Coll of Osteo Med Surg – 2009, The Permanente Medical Group, 2155 Iron Point Rd., Folsom, CA 95630

Richard Carvolth, MD, Emergency Medicine, Cornell University – 1978, Dignity Health, 3400 Data Dr., Rancho Cordova, CA 95670

Anna Nidecker, MD, Radiology, Albany Medical College of Union University – 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Ronald Chambers Jr., MD, Family Medicine, George Washington University School of Medicine – 2005, Mercy Family Health Center - 7601 Hospital Drive # 103, Sacramento, CA 95823

Anoop Nundkumar, MD, Radiology, Wayne State University School of Medicine – 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Amy Flores, MD, Emergency Medicine, University of Connecticut School of Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Corina Gonzalez, MD, Pediatrics, Universidad De Carabobo Facultad de Medicina – 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Adam Greenberg, MD, Internal Medicine, SUNY Downstate Medical College – 1992, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95758 Rudolf Iskandar, MD, Occupational Medicine, Hahnemann University School of Medicine – 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Sandra Johnson, MD, Addiction Medicine, University of California, Davis – 1985, Chemical Dependency Treatment Associates, 455 University Avenue Ste 320, Sacramento, CA 95825

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Andrea Pana, MD, Sports Medicine, George Washington University School of Medicine – 1991, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95758 Jason Park, MD, General Surgery, University of California, Davis – 1995, Jason A. Park, MD, 1111 Exposition Blvd., Building 400, Suite A, Sacramento CA 95815 Karen Parker, MD, Internal Medicine, University of California School of Medical - S.F. – 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Akshay Raizada, MD, Internal Medicine, Lugansk State Medical University – 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Pallavi Rajput, MD, Psychiatry, PTBDS Postgraduate Institute of Medical School, M Dayanand University – 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Sierra Sacramento Valley Medicine

Gurtej Singh, MD, Cardiovascular Disease, Government Medical College, Mysore University – 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Leina Singh, MD, Pediatrics, Albany Medical College of Union University – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Ranjeeta Singh, DO, Family Medicine, Touro College of Osteopathic Medicine, New York – 2003, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, 95758 Lin So, MD, Hematology Oncology, Inst Medicine, Rangoon – 1985, Marshall Medical Group, 1100 Marshall Way, Placerville, CA 95667 Ryan Stevenson, MD, Hemotology Oncology, Case Western Reserve University School of Medicine – 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Brendan Thelen, MD, Anesthesiology, Creighton Universtiy School of Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Clifford Tse, MD, Family Medicine, Ross University School of Medicine – 2008, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95758 Christina Ward, MD, Internal Medicine, Creighton University School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Ying Wu, MD, Gastroenterology, Harvard Medical School – 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 APPLICANTS FOR RESIDENT/FELLOW MEMBERSHIP: Nolan Bayen, MD, Family Medicine, Mercy Family Residency Program – 2017, 7500 Hospital Dr., Sacramento, CA 95823 Lindsay Boothby, MD, Sutter Medical Family Residency – 2019, 1201 Alhambra Blvd #340, Sacramento, CA 95816 Ross Caulfield, MD, Family Medicine, Mercy Family Residency Program – 2019, 7500 Hospital Dr., Sacramento, CA 95823 Sarah Chaffin, MD, Family Medicine, Mercy Family Residency Program – 2018, 7500 Hospital Dr., Sacramento, CA 95823


Virag Shah, MD, Emergency Medicine, Rosalind Franklin University The Chicago Medical School – 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Drew-Anne Drapala, MD, Family Medicine, Mercy Family Residency Program – 2017, 7500 Hospital Dr., Sacramento, CA 95823

Cheng Nguyen-Xiong, MD, Family Medicine, Mercy Family Residency Program – 2019, 7500 Hospital Dr., Sacramento, CA 95823

Corwin Eder, MD, Family Medicine, Mercy Family Residency Program – 2018, 7500 Hospital Dr., Sacramento, CA 95823

Javier Rodriguez, MD, Family Medicine, Mercy Family Residency Program – 2019, 7500 Hospital Dr., Sacramento, CA 95823

W. Alexander Ellis, MD, Family Medicine, Mercy Family Residency Program – 2017, 7500 Hospital Dr., Sacramento, CA 95823

Ahson Saeed, MD, Family Medicine, Mercy Family Residency Program – 2019, 7500 Hospital Dr., Sacramento, CA 95823

Hao “Harry” Li, MD, Family Medicine, Mercy Family Residency Program – 2018, 7500 Hospital Dr., Sacramento, CA 95823

Romero Santiago, MD, UC Davis Medical Center Resident & Fellow Prog – 2020, UC Davis Medical Center Residents, 2315 Stockton Blvd, Sacramento, CA 95817

Thomas Miller, MD, Family Medicine, Mercy Family Residency Program – 2017, 7500 Hospital Dr., Sacramento, CA 95823

Seema Shah, MD, Family Medicine, Mercy Family Residency Program – 2019, 7500 Hospital Dr., Sacramento, CA 95823

Board Briefs July 10, 2017 The Board: Approved the appointment of Ranjit Bajwa, MD to the Board of Directors representing District 4, (El Dorado County). Received a presentation regarding the Homeless Death Report for Sacramento County from Bob Erlenbusch, Executive Director, Sacramento Regional Coalition to End Homelessness. Ratified the Bylaws and amendments approved by the Regular Active Members. Approved the 1st Quarter 2017 Financial Statements, Investment Reports and Recommendations. Approved the following appointments to the SSVMS Delegation to the California Medical Association: Richard Bermudes, MD, Alternate-Delegate, District 4, Office 4; Ajay Singh, MD, Alternate-Delegate, At-Large, Office 14; Ronald Chambers, MD, Alternate-Delegate, At-Large, Office 22. Approved sending a letter of support for SB 406, (Leyva) HOV Lane Access for Vehicles Transporting Blood. Approved EXP Realty as an SSVMS Vetted Vendor Program. Approved the July 10, 2017, June 26, 2017 and May 22, 2017 Membership Reports as follows: For Active Membership — Amir Akhzari, MD; Thomas Balsbaugh, MD; Francis Baltasar, MD; Sumana Bangalore, MD; Otilia Braescu, MD; Thea Bregman, MD; Kathlynn Caguiat, MD; Marylynn Cardona, MD; Richard Carvolth,

Schuyler Wood, MD, Family Medicine, Sutter Family Medicine Residency Program – 2017, 1201 Alhambra Blvd #340, Sacramento, CA 95816 Amanda Woodward, MD, Family Medicine, Mercy Family Residency Program – 2018, 7500 Hospital Dr., Sacramento, CA 95823 Paterra Yang, MD, Family Medicine, Mercy Family Residency Program – 2018, 7500 Hospital Dr., Sacramento, CA 95823

MD; Ronald Chambers, MD; Amy Flores, MD; Corina Gonzalez, MD; Adam Greenberg, MD; Rudolf Iskandar, MD; Sandra Johnson, MD; Puneet Kaur, MD; Joey Kenney, MD; Jin-Yon Jeany Kim, MD; Liza Kim, MD; Toya Mathis, MD; Siriwan Mingbunjerdsuk, MD; Arjun Nepal, MD; Thuy Rose Ngoc Nguyen, DO; Anna Nidecker, MD; Anoop Nundkumar, MD; Andrea Pana, MD; Jason Park, MD; Karen Parker, MD; Akshay Raizada, MD; Pallavi Rajput, MD; Tressa Reynolds, MD; Virag Shah, MD; Katherine Shea, MD; Gurtej Singh, MD; Leina Singh, MD; Ranjeeta Singh, DO; Lin So, MD; Ryan Stevenson, MD; Brendan Thelen, MD; Clifford Tse, MD; Christina Ward, MD; Ying Wu, MD. For Reinstatement to Active Membership — Vinay Reddy, MD. For Resident Active Membership — Nolan Bayen, MD; Lindsay Boothby, MD; Jacob Burns, MD; Ross Caulfield, MD; Sarah Chaffin, MD; Drew-Anne Drapala, MD; Corwin Eder, MD; W. Alexander Ellis, MD; W. Alexander Ellis, MD; Hao “Harry” Li, MD; Thomas Miller, MD; Cheng NguyenXiong, MD; Hunter Pattison, MD; Javier Rodriguez, MD; Ahson Saeed, MD; Romero Santiago, MD; Seema Shah, MD; Schuyler Wood, MD; Amanda Woodward, MD; Paterra Yang, MD. For Retired Membership — Sidney Gutmann, MD; Efraim Lavi, MD. For Transfer of Membership — John McClain, MD; Nicole Takeda, MD; For Resignation — Julie Freischlag, MD; Mary Cathy Tran, DO. Dropped for Nonpayment of Dues — Robert C. Duncan, DO; Tiffany Ginger May Liean Heu, DO; Rebekah Latham, DO; Katie M. Lukasek, MD; John Moser, MD; Soheil Nafeei, MD; Michael Salomon, MD; Scott Yu, MD.

September/October 2017

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September/October 2017  
September/October 2017  

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