2018-Jan/Feb - SSV Medicine by Sierra Sacramento Valley Medical Society

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MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2018

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MEDICINE 2

2017 Education Series

20 Diphtheria

PRESIDENT’S MESSAGE The Power of Community

Rajiv Misquitta, MD

EXECUTIVE DIRECTOR’S MESSAGE Celebrating 150 Years

Matthew Huh

2017 HOD: The Grand Experiment Continues

Richard Gray, MD

The Sacred Disease

Aileen Wetzel, Executive Director

Kent Perryman, Ph.D.

GUEST EDITORIAL Mentors Mentor

Letter to SSV Medicine

John Loofbourow, MD

On Story Listening

GUEST EDITORIAL The Goldwater Rule

Caroline Giroux, MD

Metabolic Syndrome

Caroline Giroux, MD

Neeraj Ramakrishnan, MS II

The Society’s Founders

Welcome New Members

Irma West, MD

Board Briefs

A Posit on Preceptor Pay

SSVMS Election Results

SSVMS Member Social

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

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays. SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our cover image, kicking off the 150th anniversary year for SSVMS, is of Dr. Frederick Winslow Hatch, MD, 1821-1888. Few Sacramento pioneers gave more time to public service than Dr. Hatch. He was elected Superintendent of Public Schools for the City and County of Sacramento and was a member of the Board of Education, serving from 1855 to well after 1860. He was the first President of the City Board of Health and served for 22 years. In 1889, he was elected superintendent of Agnew’s State Asylum, filling that position until 1897, when he was appointed by Governor James Budd to the office of general superintendent of state hospitals under the new lunacy law, which had just gone into effect. With Dr. Hatch at the helm for six terms, the Sacramento Society for Medical Improvement survived to become the oldest continuously operating local medical society in California. A reprint of Dr. Irma West’s history of our Society’s founders is on page 9.

January/February 2018

Volume 69/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2018 Officers & Board of Directors Rajiv Misquitta, MD, President Chris Serdahl, MD, President-Elect Ruenell Adams Jacobs, MD, Immed. Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD John Wiesenfarth, MD District 6 Carol Kimball, MD

2018 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 Ruenell Adams Jacobs, MD Barbara Arnold, MD Natasha Bir, MD Richard Gray, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Chris Serdahl, MD Don Wreden, MD CMA Trustees District XI Douglas Brosnan, MD

District 1 Harmeet Bhullar, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Richard Bermudes, MD District 5 Armine Sarchisian, MD District 6 Christopher Swales, MD At-Large Megan Anzar Babb, DO Helen Biren, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Ernesto Rivera, MD Ajay Singh, MD Vacant Vacant Vacant Vacant Vacant

Margaret Parsons, MD

CMA Immed. Past President Ruth Haskins, MD CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

Editorial Committee John Paul Aboubechara, Sean Deane, MD Maria Garnica, MS II 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 Karen Poirier-Brode, MD Neeraj Ramakrishnan, MS II Gerald Rogan, MD Tamara Taber, DO Glennah Trochet, MD Lee Welter, MD

Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2018 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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PRESIDENT’S MESSAGE

The Power of Community By Rajiv Misquitta, MD AS YOUR NEW PRESIDENT, I thought that I would share a little about myself with you. I was born in India, but spent my formative years in New York. At age 15, I experienced first-hand the importance of quality medical care when my father suffered a heart attack. The skilled and compassionate cardiologist and cardiothoracic surgeon who saved his life, forever changed mine as I sought to emulate their example. After training in Internal Medicine at UC Davis, I found a home in Sacramento. Fast forward a few decades and a lot has changed. Now, after 18 years of practice, I have watched the transformation of medicine. I have also realized the importance of staying active to preserve the integrity of our profession and to continue to serve others. Last year, especially, has been quite tumultuous. With uncertainty in the air, and the rapidly changing insurance environment, the medical landscape is evolving. Medicine is one of the most heavily regulated professions. With competing demands placed on the lives of physicians, it is not surprising that burnout is on the rise within the profession. Our medical society, once again, rose to the challenge by establishing the Joy of Medicine program. I had the opportunity to chair this group, which is composed of talented physicians from our member groups. We had a successful summit last September with 180 physicians in attendance. I have no doubt that if we put our minds together, we stand a better chance of coming up with solutions. Personal experience has made me realize that the connections and the relationships that we make with our families and our patients are really what matter. In the end, that is one of the ways that may actually help us sustain ourselves. I am reminded of the Roseto

effect from the Italian American community of Roseto in Pennsylvania that was studied extensively in the 1950s. This was a place where there were almost no heart attacks. The diet and activity levels were no different from the neighboring towns of Nazareth and Bangor that had twice the death rates. Researchers surmised that the close personal connections and the tight-knit community may have had something to do with this effect of buffering against stress. The inhabitants were, essentially, nourished by each other. It is my hope that we can build a tight-knit, supportive, physician community in Sacramento that can be a model for the rest of the country. This is a special time for all of us as we celebrate the 150th anniversary of our medical society. Moving from a handful of physicians to 3,600 members now, the medical society has become a powerful guiding force for our profession to enable us to continue serving our patients. The pen has been replaced by the computer, and email and iphones dominate. But compassion and connection are still elements that are vital qualities of physicians that cannot be replaced. As physicians, no matter the specialty, we all seek the same thing. Doing what is best for our patients and ensuring that our profession endures. Thank you for all you do for your patients and for the community. I look forward to your engagement as we tackle the issues of the new year and am confident that, together, we can sail through gracefully. Finally, I invite you all to take a moment to think about why you went into medicine. What better way to bring the joy back than to go back to the beginning. rajiv.misquitta@gmail.com

January/February 2018

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

EXECUTIVE DIRECTOR’S MESSAGE

Celebrating 150 Years By Aileen Wetzel, Executive Director

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

ON MARCH 17, 1868, 12 physicians met in Sacramento to form the Sacramento Society for Medical Improvement, which is now known as the Sierra Sacramento Valley Medical Society (SSVMS). For 150 years, SSVMS has brought together physicians from all specialties and 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. When a cholera epidemic swept through the Sacramento area in 1850, killing 1,000 people, the physicians who survived – about one third of them perished in the epidemic – went on to form the Medical Society of California on March 12, 1856. Benjamin Franklin Keene, MD of El Dorado County was elected as the first president of the State Medical Association, which is now known as the California Medical Association. SSVMS’ early goals – to learn more about diseases and their cures through sharing of information; to formulate and support ordinances for public health, sanitation and food inspection; and to support the principles and ethics of the medical profession – continue to benefit communities in the Sacramento region. The Sacramento Society for Medical Improvement, the initial name for our current Society, founded the Sacramento Board of Health, the second in the United States, and influenced the formation of the first State Board of Health and the first railroad hospital. In 1947, medical society leaders founded the Sacramento Medical Foundation, now known as BloodSource, as a regional blood supply for the Sacramento region’s growing population. The Medical Society’s founders were professional and civic leaders, serving as Presidents of the Sacramento, California, and

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the American Medical Associations, officers of the Sacramento City Council and State Board of Health, Surgeon General of California, City Health Officer, Superintendent of the County Hospital, Director of the State Library, President of the Board of Education, Superintendent of Public Schools, Mayor of Sacramento, State Senator, and Secretary of State for California. SSVMS continues to grow physician leaders. Seventeen SSVMS member physicians have been President of the California Medical Association, and three have gone on to serve as President of the American Medical Association. Today, SSVMS member physicians are serving as Immediate Past President of the CMA, as Speaker of CMA House of Delegates, as a California State Senator, and as a U.S. Representative in Congress. The practice of medicine, the care of patients, surgical techniques, hospital care and nearly every facet of the medical profession, for doctor and patient alike, have benefited in the past 150 years as a result of the Medical Society’s efforts. SSVMS is component county medical society of the California Medical Association and has grown to represent over 3,600 physicians, medical students, residents and fellows in the Counties of El Dorado, Sacramento and Yolo. Physicians: I invite you to join us as we celebrate 150 years of serving the community and the profession of medicine by attending the SSVMS and Alliance Annual Board Installation and Awards dinner on January 11. In addition, all physicians and their families are invited to our 150th anniversary celebration at Sutter’s Fort on the evening of Saturday, May 5, 2018. In the meantime, let me know what your Medical Society can do for you. awetzel@ssvms.org

GUEST EDITORIAL

Mentors Matter By John Loofbourow, MD Guest Editorials are welcome, as are comments regarding the editorials themselves. I DON’T KNOW WHY I was admitted to the University of Minnesota Medical School in 1952, one month after turning 19, without a particularly impressive undergraduate record. In large part, I attribute it to my friend who mentored me in high school and pre-med. He is the friend I have known and loved longest. All my prior friendships had been fleeting, a downside of being raised in mining towns all over the world; it has distinct and unique advantages, but long-lasting childhood friendships don’t happen. My mentor and I met in high school when we both were moved to Minneapolis, Minnesota in mid-January 1946. Despite time, distance, and different roads travelled, we have been close friends ever since. During pre-med years, it was his suggestion to take engineering physics and chemistry rather than pre-med classes because med school acceptance was unlikely. There were many highlyqualified applicants, among them those with real life experience like marriage, work, or serving in WWII. They were far more mature by any measure than I. Yet, maybe because pre-meds would kill for a point while engineers didn’t care about such things, we both were accepted in the Fall of 1951. The medical school apparently saw something in us. My friend was a better scholar than I, but they also saw something in me that I did not. From my point of view, it was a great leap of faith on their part. I was only a child who didn’t know who or what or where he was. My needs, as I saw them, were social, and economic rather than academic and intellectual. I had to pay my own way by working part-time, and migrating to California in summers to do farm work. I

was able to bus dishes and to work for room and board at a fraternity. My fraternity brothers tolerated the child in me. I was welcomed fully while trying to fake being grownup, but that was at the cost of academic excellence. I graduated in the bottom quartile of my class while my friend and first mentor was at the top. The MD degree has been my passport to places, people, languages, and human experience as reflected in my CV, more remarkable for its breadth, than its depth. Among other things, it includes what could be called the private practice of public health: establishing and operating free clinics for migrant workers, and Salúd Clinic in West Sacramento which still operates there. In the early ‘70s, Brooks Smith and I were the first physician lecturers for the Family Nurse Practitioner and Physician Assistant training project at UCD. It continues to this day, and I constantly meet graduates. Moreover, FNP/PA current students now participate in the Tepati Student Clinic. After 60 years of active medical practice, my mentor and I both remain active in “retirement;” he in business and medical politics, while I consult, do jail reviews for CMA Institute of Medical Quality (IMQ), volunteer, read, write, and blog. In mid 9th decade, we are in fairly good health, and sometimes fear the need to continue longer. I would like to encourage, to recommend, mentoring by SSVMS members. It is a two-way pleasure, a win-win. In addition to medical students, undergrad students who are interested in some aspect of medicine benefit greatly from an association with a mentor. They are the muscle, heart, and guts of the free clinics, which are not easy to fund, organize, and operate. The clinics would not exist without undergrad students. No one else has enough time, motivacontinued on page 8 January/February 2018

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. 5

GUEST EDITORIAL

The Goldwater Rule Benevolent Hermeneutics on Ambiguityland

By Caroline Giroux, MD Guest Editorials are welcome, as are comments regarding the editorials themselves.

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

THE GOLDWATER RULE WAS adopted by the American Psychiatric Association (APA) in 1973 to regulate experts in mental health who were too tempted to diagnose public figures, condemning this unsolicited expertise as “unethical,” arguing that consent and faceto-face assessment were both necessary before doing so. It originated after a libel suit in the context of Fact magazine’s cover: “1,189 Psychiatrists Say Goldwater Is Psychologically Unfit To Be President.” This rule has been invoked since our peri-electoral period. Findings from recent publications revealed how protected and unchallenged this rule is. In his article, “Interpreting the Goldwater Rule,” Massachusetts psychiatrist John Martin-Joy writes: “It has not always been clear from popular or scholarly accounts how ambiguous the text of Section 7.3 is…” However, ambiguity and inconsistency are not the primary problems of the Goldwater Rule. We have to wonder if the rule is a devious (and apparently very effective) way of protecting the psychiatric profession’s image from the damage that can be caused by unprofessional and cavalier assessment, precisely at the expense of suppressing potentially ethical application of professional knowledge for the common good. In the medical context, “ethical” refers to behavior and practice that is consistent with accepted core principles. In the context of individual medicine, they are beneficience, nonmaleficience (do no harm), justice, and respect for autonomy. From the perspective of public health, we need to include other inescapable concepts, such as health maximization (the goal

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is to improve the overall health of the population as much as possible), efficiency (the need to use limited resources as efficiently as possible), and proportionality (negative impacts on some must be outweighed significantly by positive impacts on others). Medical ethics tracks very well with a traditional concept of morality, as there is widespread agreement that these core principles are “right” rather than “wrong.” Yet, “ethics” can refer to a completely different concept, divorced entirely from morality. A code of conduct, for example, need not be derivable from core moral principles at all. A company can decide that its code of ethics (code of conduct) is to treat certain clients better than others because they are wealthier. This may have advantages for the company, and may be socially acceptable, but has nothing to do with what is right and wrong in a metaphysical sense. Medicine, as a profession, generally has sought to align itself very closely with a metaphysical sense of right and wrong, rather than opting for a more arbitrary code of conduct. Unfortunately, the APA, in establishing its ethical code, seems to have construed something that resembles a corporate code of conduct, with questionable use of the word “ethical.” Martin-Joy further wrote: “In 2017, the Ethics Committee said that profiling of historical figures in peer-reviewed scholarly work ‘should not include a diagnosis.’” The application of the concept of diagnosis in the rule is rather vague and questionable: Would an elaborate analytical statement be considered different from a “diagnosis”? I am fine with paraphrasing… I rarely swear by the DSM (The Diagnostic and Statistical Manual of Mental Disorders) anyway! Plus, diagnosis represents only a small portion of a figure’s political phe-

notype. What is relevant is an assessment of whether there are significant outliers in behavior that may indicate unstable and dangerous decision-making. Other parameters (such as posing a direct threat to civilians, violation of human rights, fraudulent behavior, potential for destruction, etc.) should be taken into consideration and are not just under a psychiatrists’ scope. Psychiatrists must evaluate fitness to stand trial, for instance. But a whole team to evaluate fitness for presidency should also include: economists, sociologists, philosophers, etc. The stakes are high. History has shown us that some public figures with identifiably dangerous character pathologies and transgressive behaviors have caused the death of tens of millions and the suffering of countless more. Most ethical rules have boundaries that are defined by their infringement on more fundamental ethical principles, and in the same way, the Goldwater Rule must break down in situations of grave danger, and is necessarily superseded by a generally-accepted duty to warn of grave and imminent danger. Such erroneous foundations of the rule (its application of the words “ethical” and “diagnosis”) greatly affect its validity. This poses the risk of creating a witch hunt towards psychiatrists. The psychiatrists’ expertise (which is to serve the sufferer) is turned against them. I am wondering if pointing fingers at the psychiatrists has evolved into an attempt to distract from the core issues? Even Barry Goldwater’s libel suit never targeted them, but rather focused on the actions and behaviors of the journalists who edited and published the comments. Far more damaging than diagnosis itself is the equation between “mental illness” and “unfit for presidency.” With such a rule in the current context, I am afraid that it will give our patients a bad reputation. Those two elements are distinct. What does “fit for presidency” mean? It should encompass moral principles like justice, honesty, equity, and integrity as well as necessary stamina for the job description (conflict resolution, fairness, communication abilities, political acumen, experiences in community service, resource

management...). Again, this goes beyond the dimension of our current nosology (a classification or list of diseases) in medical settings. Additionally, isn’t it inherent upon human nature to form an opinion on other people’s character? Every thinking or perceiving human being does that. Children do that, thanks to such a valuable survival skill allowing them to “classify” or interpret their parents’ moods (to determine when it is best to ask for a special favor, or when to run away from a scary reprimand). Hermeneutic means exactly that – interpretation, just like we do for literature or movies. Meaning-making, trying to make sense, is another necessary survival method when facing the unexplainable. Interpretations are not facts. Anybody who reads can do a book review. Anybody who can observe human behavior can interpret, criticize, and, yes, to a certain degree, judge. Politics affect allocation of resources, public protection, and patient care, and voicing one’s own concerns from a personal or professional perspective can ultimately affect health policies. At what point do we decide that we step out of the pseudo therapeutic frame (our secret conclusions about a public figure) and extrapolate our concerns and share our predictions with the world? What is our “duty to warn” threshold? Plus, physicians know many examples where consent and face-to-face evaluation are not possible (unconscious or delirious patient, telemedicine, etc.). In fact, the Ethics Committee viewed forensic testimony without interview or consent as acceptable. But Meredith Levine, a journalist in Canada, wrote: “Distant psychiatric evaluations move us out of the territory of evidence into the arena of speculation.” Many physicians would disagree: We can form diagnostic hypotheses on our patients’ relatives based on the description of the patient. Of course, it is an incomplete perspective, but a significant one nonetheless. In certain institutions, psychiatry is referred to as “behavioral science” (probably because behaviors, attitudes, and choice of narrative are observable, hence, closer to “facts”). After all, what is a diagnosis, if not a conclusion based on often incomplete observations, fragmentary January/February 2018

What is our “duty to warn” threshold?

There is an undeniable, historical truth to the concept that “silence is complicity”…

collateral information, samples of attitudes, or behaviors. In sum, everybody possesses some tools to come up with a diagnosis, so to speak. Only the explanatory model or jargon will differ: a writer can label the head of a country as a dictator, and a psychologist might call the same a malignant narcissist (which is not even a DSM diagnosis at this time). Although different, they are equivalent languages, different angles to describe the same reality. Moreover, is it for the APA to decide or “regulate” such a natural tendency? At least the medical boards from each state and the American Board of Psychiatry and Neurology should be consulted. And are we running the risk of being unethical if we interpret, dissect, diagnose… the Goldwater Rule itself? Can we simply call it an imperfect tool? Let’s go back full circle to the APA’s code of ethics itself. It is almost farcical that Section 7.3 is an annotation to the American Medical Association’s more general principle “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” I like to believe that we should all act as “good Samaritans.” Morals should triumph over so-called ethics. To comment on public figures can actually help society challenge their prejudices about mental illness by conveying a message like: “Some can behave in an evil manner without having a diagnosable psychi-

atric condition, and conversely, you can suffer from a severe mental disorder, yet still be a wellintentioned person!” The issue of diagnostic label matters less than the ability to be accountable. Once a problem or maladaptive behavior is identified or condemned, what the individual does to rectify a problematic situation is what matters. By expressing a professional opinion, we can fulfill our duty by educating and sharing recommendations, which could lead to more responsible, ethical behavior. The fact that the Goldwater Rule remains largely unchallenged and highly protected demonstrates the power of words. No doctor wants to be “unethical.” The APA needs to determine whether its mission is to protect the profession from controversy, or to abide by the foundational principles of medical ethics that most doctors hold dear. There is an undeniable, historical truth to the concept that “silence is complicity,” and it is self-evident that there are no perfect actions in this very imperfect world. We might cause controversy in our attempts to do what is right or create adversarial dynamics. We will sometimes be wrong and have to apologize. There is no growth possible without stepping out of our comfort zone. Do we really want to leave future generations, once again, baffled and asking, “Why didn’t more people speak up?” cgiroux@ucdavis.edu

Mentors Matter continued from page 5 tion, and fire in the belly. They are full of raw energy, life and hope. It’s exhilarating to be around them. While I have few med school regrets, I would have liked to have had an adult physician mentor in pre-med and/or med school; a physician to talk with regularly about the life of physicians – the raison d’etre for our magazine, a mentor who is a blood and guts doc in private practice, whether group or solo, with a volun-

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teer med school clinical appointment. There are now two medical schools in our area. I believe Mentors Matter. My first mentor is still with me. Our lives, as physicians, have been quite different, reflecting our natures. We have traveled separate roads, and yet the same road, together. In the words of Robert Frost, “that has made all the difference.” john@loofbourow.com

The Society’s Founders By Irma West, MD (NOTE: This article is reprinted from the Mar/Apr 2004 issue of SSV Medicine.) ON ST. PATRICK’S DAY OF 1868, in the office of Gustavus L. Simmons, MD, at 46 J Street, 12 prominent physicians met to form a new Sacramento medical society. Three earlier medical societies had not survived – the MedicoChirurgical Association (1850-1856), the Sacramento Medical Society (1855-1860), and the Sacramento County Pathological Society (1858-1863). These organizations had been active in promoting public health and ridding the community of medical charlatans and other unscientific and fraudulent practitioners. However, they were unable to cope with internal strife, transient membership and the fires, floods, epidemics and other gold rush events that left the city in disarray during its first decade. By 1868, the western arm of the transcontinental railroad had reached the summit of the Sierra and Sacramento was showing signs of economic stability and growth. Dr. Gustavus L. Simmons, a graduate of Harvard Medical School, was the guiding force of the new medical society, becoming its first secretary. He named the organization the Sacramento Society for Medical Improvement 1 after an organization in Boston. Frederick Hatch, MD, from Virginia, served six terms as President and refused the seventh. He had outstanding talent as a diplomat and impeccable credentials as a community and medical leader. His stewardship led the society through contentious issues and is credited with its survival, making it the oldest continuously operating medical society in California. A short constitution was adopted, which stated that the object of the Society was the promotion of medical science and good feeling among the members, who must be medical

school graduates and adopt the Code of Ethics of the American Medical Association. Bimonthly meetings were held at homes or offices of members, where many original papers were presented. All 12 founding members are listed below. Notable by their absence were the most prominent of the earliest Sacramento physicians, Drs. John Morse and Thomas Logan. Both had moved to San Francisco by 1868. Dr. Logan did return to Sacramento later and joined the Society.

William Cluness, MD, 1835-1918 Dr. Cluness was one of 12 children of a farm family living near London, Ontario, Canada. From Queen’s University at Kingston, Ontario, he received an AB degree in 1855, and both an MA and an MD in 1859. That year he moved to Petaluma, California, coming to Sacramento in 1863 and opening his office in the Morse Building at Second and K Streets. He enjoyed a prosperous practice for the next 30 years, specializing in obstetrics and gynecology. Dr. Cluness was appointed to the Sacramento City Board of Health in 1867, 1883 and 1886, and to the State Board from 1880-1892. He was President of the California State Medical Society 1890 -1891 and was on the staff of the Sacramento Medical Times, reporting regularly on public health matters, particularly sanitation and disease control. He was a member of the Committee to establish the Board of Medical Examiners. One of his more interesting investments was 350 acres in Yolo County where he planted mulberry trees and built two large cocooneries for producing silk. After several years the project January/February 2018

William Cluness, MD

Joseph Frey, MD

was abandoned. More profitable was his part in organizing the Pacific Life Insurance Company where he became Medical Director in 1889. On leaving for retirement in San Francisco in 1893, the Sacramento Society for Medical Improvement held a testimonial dinner for him at the Sutter Club where he received many tributes. He was described as a gentleman of the old school, pleasant, well-mannered, immaculate, and well-attired which made him an attractive figure wherever he went. It was said of him that he was one of nature’s gentlemen: one of God’s noblemen. Dr. Cluness was the last survivor of the 12 founding members of the Sacramento Society. He left five children, including W. R. Cluness Jr., MD, who also practiced in Sacramento.

Joseph Frey, MD, 1818-1888

Harvey W. Harkness, MD

Dr. Frey came from New York City and graduated in medicine from New York University in 1841. He mined gold at Rattlesnake Bar on the American River in 1849 before moving to Sacramento to open his medical practice at Second and K Streets in 1856. In 1859 he shared an office with Dr. Harvey Harkness. From 1860 to 1862, he practiced with Dr. Samuel Thomas. Dr. Frey was President of the Sacramento Board of Education in 1859. Dr. Frey was the first member of the Sacramento Society for Medical Improvement to present an original paper in 1869. It was entitled What Connection Exists Between Diphtheria, Erysipelas and Scarlet Fever as Epidemics, Both as Regards the Causes of Disease, its Treatment and its Modification by Malaria? The author suggested a close relationship among the causes of the three illnesses, which was so soundly ridiculed by the membership that Dr. Frey left the Society. He moved to Newcastle, established a 12-acre ranch, built an elegant home, and divided his time between a country practice and scientific farming. Notable were his

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flower garden and his prize-winning produce, particularly citrus. Twenty years later, when infectious agents causing the diseases he wrote about were being discovered, it was apparent that Dr. Frey had been ahead of his time. He was a visionary and did not fit the mind-set of most of early medical pioneers. He was the first to report that deafness could follow continued use of quinine. Dr. Frey was a bachelor. He is buried in Sacramento’s Historic City Cemetery in the Pioneer Section where his monument is among the most elegant in the cemetery.

Harvey W. Harkness, MD, 1821-1901 Dr. Harkness was one of many physicians who came to California in 1849 seeking gold. Unlike most of his colleagues, he was successful. He mined and practiced medicine at Bidwell’s Bar on the Feather River before moving his practice to Sacramento in 1850. He was born in Pelham, Massachusetts, the youngest of seven children of a poor Scotch farming family. Five of his siblings died in their youth of tuberculosis. Dr. Harkness received his medical degree from Pittsfield College after serving an apprenticeship with Drs. Barrett and Thompson in Northampton, Massachusetts. Among his patients and friends were Sacramento’s notables, including railroad magnates Leland Stanford, Charles Crocker, Collis Huntington, and Mark Hopkins. Dr. Harkness was a trustee for the grant by Governor Stanford to establish Leland Stanford Jr. University. He probably delivered Leland Stanford, Jr. Dr. Harkness took great interest in the transcontinental railroad and was present at the laying of the last rail at Promontory, Utah, May 10, 1869. Dr. Harkness was a member of Sacramento’s first Board of Health in 1868, and presented many original scientific papers before the Society. He was Sacramento’s first microscopist. Education, finance and fungi were of great interest to Dr. Harkness. He was President of the first Sacramento Board of Education in 1853, and the elementary school named for him still stands at 2147 54th Avenue. Because of astute

investments in Sacramento commercial real estate, he was able to retire at age 48 and move to the Pacific Union Club in San Francisco where he devoted full time to the study of Pacific Coast Fungi. He became President of the California Academy of Sciences 1887- 1896 which published his work in its bulletins. He prepared a catalog of 2000 genera and species of fungi with a colleague, J.P. Moore, which, along with his collection of 10,000 species, attracted attention throughout the world. Dr. Harkness’ cremated remains were buried in Sacramento’s Historic City Cemetery after a funeral at the Odd Fellow’s Cemetery in San Francisco. His wife, Amelia Griswald Harkness, preceded him in death in 1854, less than a year after their marriage. He never remarried. He was survived by a brother and nephew. His estate was estimated at $150 million.

Frederick Winslow Hatch, MD, 1821-1888 Monticello, Thomas Jefferson’s farm at Charlottesville, Virginia, was two miles down the road from Dr. Hatch’s home. As a small child he could wave to General Lafayette, James Madison and other revolutionary figures on their way to see the former President. Dr. Hatch’s father was an Episcopalian minister and served as Chaplain for the US Senate for 12 years. Dr. Hatch was an outstanding scholar. At 19 years, he received a Masters degree in classic studies from Union College at Schenectady, New York, and in 1844, at 23 years, an MD from New York University. He practiced medicine in Beloit, Wisconsin, but hoping to improve his tuberculosis moved with his family in 1853 to Sacramento. On the way they were shipwrecked and rescued near Bolinas Bay, losing all their possessions. Undaunted, Dr. Hatch established his medical practice at 56 K Street. Few Sacramento pioneers gave more time to public service than Dr. Hatch. He was elected Superintendent of Public Schools for the City and County of Sacramento and was a member of the Board of Education, serving from 1855 to well after 1860. He was the first President of the City Board of Health and served for 22

years. He was appointed by the Governor to the State Board of Health in 1876 and served as its Secretary until his death. With Dr. Hatch at the helm for six terms, the Society for Medical Improvement survived to become the oldest continuously operating local medical society in California. He was also a Professor at the Medical Department of the University of California at San Francisco from 1880 to 1884. He maintained a practice as long as his health permitted. Dr. Hatch was active in the Episcopalian Church. He died of tuberculosis and is buried in Sacramento’s Historic City Cemetery. He left a wife and five children. Two of his sons became physicians.

Frederick Winslow Hatch, MD

G.H. Hoffman, MD Of the 12 founding members of the Sacramento Society for Medical Improvement, the least known is about Dr. Hoffman. He practiced during 1854-1855 on Fourth Street between K and L Street. After May 1868, his name no longer appeared in minutes of the Society or in the census.

Joseph F. Montgomery, MD, 1812-1883 Dr. Montgomery held two medical degrees: one from the Medical College of Virginia in 1832 at 21 years, and the other from the Philadelphia Medical School in 1834. He came from Virginia, moving to Mississippi where he practiced in Jackson from 1836 to 1842. Little is known of his earlier years or his whereabouts before coming to Sacramento in 1849 where he was soon testing his skills during the devastating cholera epidemic of 1850. An outstanding leader in medical and civic affairs, Dr. Montgomery was a founding member of all four of Sacramento’s earliest medical organizations. It was at a meeting of the last one, the SSMI, in 1871 that he delivered his memorable presidential essay on Ethics of the Medical Profession, a subject he promoted at every opportunity.

January/February 2018

Henry L. Nichols, MD

In 1853, Dr. Montgomery was City Physician and became resident physician at the County Hospital from 1856 to 1861. He was appointed to the City Board of Health in 1862, 1868 and 1882, to the State Board of Health in 1870 and to the State Board of Medical Examiners in 1876. He was elected as a city school trustee in 1869 and again in 1874. Although he gave firm and progressive leadership in medical and public health matters and was active in the Episcopalian church, Dr. Montgomery left little information about himself. He was a bachelor described as very modest and reserved. He left no portraits of himself. Even his grave marker in the Old Masonic Section of Sacramento’s Historic City Cemetery is inconspicuous compared to most of his medical contemporaries.

Henry L. Nichols, MD, 1823-1915

Alexander B. Nixon, MD

Dr. Nichols came by ship through Panama from Augusta, Maine, to Sacramento in 1853 to join his uncle, Allen Lambard, who owned the Sacramento Iron Works and the Lambard Flour Mill. Dr. Nichols’ father, an attorney, had been Maine’s Secretary of State. In 1845 Dr. Nichols graduated from Maine Medical School, Bowdoin College in Brunswick, Maine, after which he completed post graduate studies at Philadelphia Medical College. His Sacramento office was at Second and I Streets. Few physicians were as active in community service and in politics as Dr. Nichols. He was a conservative Democrat and brought his party to prominence; he was elected to the Board of Supervisors and served as mayor of Sacramento in 1858. He was Secretary of State for California in 1867-71 when the State Capitol building was completed. He climbed to the top of the dome to place the golden ball into position. While in this office, the location was selected for the University of California

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at Berkeley. He held other public offices too numerous to mention, including State Prison Director, Director of the State Library, City Health Officer, Emergency Hospital Surgeon, Secretary of the State Board of Health and Secretary of the Sacramento Board of Health. Sanitation was his great concern. His essay “Water Supply of Sacramento” sparked the changes necessary for safe drinking water for Sacramento. His practice spanned 62 years. Dr. Nichols was president of the Sacramento Society for Medical Improvement in 1885. His daughter wrote about the dinner meetings of the Society held at the Nichols’ home. She would help the servants serve an elegant New England dinner supervised by her mother, a celebrated cook. Dr. Nichols was President of the Board of Trustees for the Unitarian Society of Sacramento 1868-1915 and is considered its founder. Dr. Nichols is buried in Sacramento’s Historic City Cemetery. He lived 91 years, the longest of the pioneer physicians of Sacramento.

Alexander B. Nixon, MD, 1820-1889 Three years after his graduation from Ohio Medical College in Cincinnati, Dr. Nixon traveled overland in 1849 from his home in Hamilton, Ohio, to Coloma, California, in search of gold. His medical practice in Sacramento began in 1852 after returning to Ohio to pick up his family. He was active in medical, civic, political and religious organizations, serving as Sacramento’s state Senator from 1862-1863. Tall, impeccably dressed with a Prince Albert coat, tall hat and carrying a gold handled cane, Dr. Nixon could be seen in downtown Sacramento walking toward 13th and D Streets to the Central Pacific Railroad Hospital where he was chief surgeon from 1869 to 1885. His cane is on exhibit in the Medical History Museum of the Sierra Sacramento Valley Medical Society. History was made by Dr. Nixon when he was President of the California State Medical Society in 1875. Five women physicians led by Euthanasia Meade, MD, applied for membership. The vote to admit them was a tie and Dr.

Nixon cast the deciding vote to make them the first female members. Dr. Nixon was President of the Sacramento Society for Medical Improvement in 1875. He was State Commissioner of Lunacy for 22 years. During the Civil War, he was a United States examining physician for the Board of Enrollment. He was instrumental in popularizing the Republican Party in Sacramento, although in later years he supported the Prohibition Party and ran for mayor on that ticket. For many years he served on the Board of the Unitarian Society. Dr. Nixon is buried in the Pioneer Section of Sacramento’s Historic City Cemetery. He was survived by three sons, a daughter, and his second wife, Anne Wisewell, who in 1892 obtained her MD from Cooper Medical College (now Stanford School of Medicine) in San Francisco.

Ira E. Oatman, MD, 1819-1888 Gold lured Dr. Oatman to Sacramento in 1849. He returned to Illinois for his family in 1853 before establishing his Sacramento practice at 264 J Street. He was born in Indiana near New Albany and received his medical degree from Rush Medical College in Chicago before practicing there and in Dundee, Illinois. Dr. Oatman was a charter member of the Sacramento Medical Society of 1856, serving as Vice President in 1857. He was active in the first California State Medical Society and was Vice President in 1858. He presented many essays before the Sacramento Society for Medical Improvement on the then-popular miasma theory as a cause of disease. His practice was primarily obstetrics, gynecology and internal medicine. He was a member of the Gynecological Society of Boston and was appointed to the Section on Obstetrics of the Ninth International Congress. After serving on the Sacramento Board of Health for six years, Drs. Oatman and Cluness were expelled in 1879 by the mayor and newlyelected board of trustees to make room for two homeopathic physicians. Mayor Taylor had been persuaded by Dr. George Dixon, a leader

in the homeopathic movement, to open official medical positions to homeopaths. All remaining physicians on the Board resigned in furious indignation and were replaced by homeopathic physicians. This “coup” lasted over a year before “regular” physicians regained all the appointments. Dr. Oatman was State Commissioner of Insanity for five years, and served the military as assistant surgeon for the Fourth Infantry Regiment and as examining physician for pensioners. Dr. Oatman is buried in Sacramento’s Historic City Cemetery. He was survived by three sons and a daughter. His portrait hung in the California Room of the State library for many years.

Gregory J. Phelan, MD, 1822-1902 Dr. Phelan was Sacramento’s first ophthalmologist. He was born in New York and received his medical Degree in 1847 from the University Medical College of New York. He established his Sacramento practice in 1849 and was active in founding its early medical organizations: the Medico-Chirurgical Association of 1850, the Sacramento Medical Society of 1855, the State Medical Society in 1856 and 1870, and the Sacramento Society for Medical Improvement in 1868. He was physician for the Cholera Hospital in 1850, and County physician as well as Superintendent of the County Hospital from 18631870. He served on the Board of Education in 1858 and was Director of the Sacramento California Pioneers. Dr. Phelan left Sacramento for Europe in 1870, returning briefly in 1876 before moving to San Francisco where he died, to be interred in Santa Clara. He was survived by three daughters and three sons; two of the sons were physicians.

Ira E. Oatman, MD

Gregory J. Phelan, MD January/February 2018

Gustavus L. Simmons, MD, 1832-1910

Gustavus L. Simmons, MD

George G. Tyrrell, MD

Dr. Simmons was 17 when he left his home in Hingham, Massachusetts, in 1849. After a ninemonth voyage around Cape Horn, he arrived in Sacramento to assist his brother- in-law, Dr. Henry May, at the Old Boston Drug store at 48 J Street. He worked as a pharmacist and “irregular” physician until 1854 when he boarded the steamer, Yankee Blade, for Boston. With 800 aboard the ship struck a reef and sunk off Point Arguello. Dr. Simmons lost his possessions but was rescued. His books washed ashore and at least one was returned to him years later. He boarded another ship for Boston and in two years was the first from California to receive an MD from the Medical Department of Harvard University. On his return to Sacramento he began 50 years as a beloved family practitioner. He made many contributions to the community, among them the Italian stone pine trees in Capitol Park. As a tree expert, he and Mr. B.B. Redding from the Park Commission traveled to Italy, selected the saplings and tended them on the long voyage home. They were planted around the park where Dr. Simmons could supervise their progress from his home across the street, where the State Library now stands. Dr. Simmons made it possible for the Sisters of Mercy to start what is now Mercy Hospital. He sold his hospital, Ridge Home, to the Sisters at a bargain price, lent them the money to pay for it and refused the last payment. He also taught the sisters how to run a hospital. Throughout his life Dr. Simmons was active in medical, educational and civic affairs. He was appointed to the City Board of Health in 1868 and served several terms. He was elected to the City Board of Education in 1858 and was its first secretary. He was state Commissioner of Lunacy for 20 years and served as Brigade Surgeon for

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the National Guard. He was President of the California State Medical Society 1894-95 and President of the Sacramento Society for Medical Improvement 1878-79. Dr. Simmons is buried in the Pioneer Section of Sacramento’s Historic City Cemetery following the largest and most expensive funeral of the time. It cost $595. He was survived by his wife and two sons, both graduates of Harvard Medical School.

George G. Tyrrell, MD, 1831-1895 Dr. Tyrrell was born in Dublin, Ireland, and received his medical education there at the Carmichael School of Medicine. He obtained additional diplomas from the Royal College of Surgeons in 1856 and from the Kings and Queens College of Physicians in 1859, including one in midwifery. His career began as a physician for ships carrying immigrants to America. After a few voyages, he decided to remain in the United States, starting a practice in Milwaukee, Wisconsin. He moved to Grass Valley in 1861 and to Sacramento in 1868 where he practiced for 20 years. Dr. Tyrrell was elected President of the Sacramento Society for Medical Improvement in 1880. He was President of the California State Medical Society in 1881 after serving as Secretary. The Governor appointed him Surgeon General of California with the rank of Colonel. In 1884, Dr. Tyrrell succeeded Dr. Hatch as the third Secretary of the State Board of Health. He pursued the Legislature aggressively to act on his proposals for sanitation programs, burial permits, vital statistics registration and small pox vaccination. When he was ignored, he used the press to castigate the Legislature and gain public support for his recommendations. As a result, he was not reappointed in 1891, but his proposals were eventually adopted. Dr. Tyrrell was survived by three daughters and two sons who were physicians. 1 Although the Sacramento Society for Medical Improvement remains its official name, additional titles were adopted when neighboring societies joined. It became the Sacramento-El Dorado Medical Society in the mid-seventies and the Sierra Sacramento Valley Medical Society when the Yolo County Society joined in 2001.

A Posit on Preceptor Pay “Medical schools should compensate community preceptors for their time in teaching.”

Background: Traditionally, the off-shore Caribbean medical schools have been known to compensate stateside preceptors for taking on their medical students. Now some stateside medical schools are doing the same. In medical education, can altruism and capitalism coexist? 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.

I disagree. We should welcome the opportunity to teach and serve as role models. It encourages you to keep current, and I always learn new things from those I precept. The origin of the word “doctor” is the Latin docere, “to teach.” I feel it’s our obligation to give back, no compensation necessary. –Scott C. Budd, MD Over time I’ve come close to agreeing. I’ve been on the Volunteer Clinical Faculty of UCD since I left the full-time faculty in 1988. For quite a few years, I enjoyed teaching in clinic and didn’t expect payment. Then I was asked to give lectures and precept small group exercises in the Endocrine, Nutrition, Reproduction and Genetics course, which I continue to do. Then I joined the preceptors at one of the UCD studentrun clinics. All of this time was uncompensated, and that was OK as long as I felt appreciated. Over time, I have felt more taken for granted and less appreciated, especially by the students. Young people accustomed to delivering searing anonymous criticism online transferred that practice to faculty evaluations. The always-right generation assumed that they knew more about what they needed to know than did practicing physicians. The faculty with whom I work remain appreciative, but any show of gratitude from students and administration has all but disappeared.

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Without appreciation, the only reason to teach now is to continue the fight to put decent history-taking, physical examination and critical thinking back into students’ armamentarium. It’s feeling more like work and less fun, and if that continues, I’d like to be paid to do the job. Though he was talking about full-time faculty, even the great William Osler, MD agreed that medical teachers are “wretchedly underpaid.” (“After Twenty-Five Years,” in Aequanimitas, 3rd ed. Philadelphia: P Blakisyon; 1932, p 197) –Ann Gerhardt, MD I agree. Teaching is a profession. Like all professions, it is work, and the transfer of value through the provision of teaching services is accompanied by the right to expect payment for that transfer of value. Fundamentally, the student-teacher relationship is one of employer and employee, in which the student is the employer. I’m reminded of that every time my son’s school hands me a tuition bill. However, some of us (myself included) so enjoy that work that we choose to participate in it without monetary pay, although it could be argued that volunteer teachers simply receive a payment that they accept in alternate form (i.e., intangible satisfaction value in lieu of monies). Indeed, most volunteer physician preceptors forfeit monetary pay to teach through decreased productivity. However, that is not, and should not be, the expectation. The act of teaching is an act of work. No person has the right to expect, much less compel, another person to work for them without duly compensating the worker for the transfer of value they provide to the employer. –Sean Deane, MD Medical schools do not compensate their full-time faculty for teaching. –William Pevec, MD Teaching takes time away from direct patient

care which is how revenue is generated for the preceptor. –Amy G. Wandel, MD This is a challenging and complex issue. While I support teachers receiving some monetary compensation for significant teaching responsibilities, I believe the most important compensation for teaching will never be monetary, as the best teachers always do more than they receive in payment and role model altruism and professionalism in doing so. Ultimately, the real rewards of teaching are about contributing to the next generation of physicians and their future patients. –Mark E. Servis, MD I consider this nominal stipend as an honorarium (not compensation) for mentoring the next generation of physicians. –Marvin H. Kamras, MD We have all benefited from living in a society that helps pass on knowledge and wisdom. It might even negatively affect the students’ experience if compensation becomes the motivation of the community to volunteer to teach. It would be helpful for all involved to make the process of volunteering easier and less politicized. –Charles W. Perry, MD Appropriately precepting students requires time, resources, energy, and can often cause productivity to decrease. In addition, several medical schools (including private schools and those off-shore) are charging their students increasingly higher fees for tuition, yet not providing any additional benefits, and also will not cover expenses for those students to rotate off-site. In order for more physicians to answer the call to help bring up the next generation of physicians, and for schools to offer their students more options to learn, I believe medical schools have an obligation to compensate preceptors for their time. –Kevin M. Jones, DO I strongly disagree. In a time where medical school costs are skyrocketing, this would further add to those costs. It would take money from the generally cash-strapped medical students and redistribute it to the more financially secure practicing physicians. It is robbing Peter to pay Paul. –Blake A. Hambly, MD I agree they should be compensated in some way. –Karuna Kem, DO

Paid teachers are faculty. Community preceptors are not. When you start paying everyone, teaching becomes a commodity, and you incentivize “teaching” for income rather than professionalism. –K. Michael Conroy, MD I both agree and disagree to the proposal to compensate physicians for teaching. For centuries, physicians have taken the Hippocratic Oath on completion of their studies. It marks the recognition of the student, not just as a master of their art and craft, but as having achieved the level of doctor or teacher. The oath obligates the new physician to pass on their knowledge: “To consider (my teacher’s) family as my own brothers and to teach them this art, if they want to learn it without fee or indenture ...and to indentured pupils who have taken the physician’s oath but to no one else.” The current 2017 Declaration of Geneva, which medical students also may choose to take, contains the phrase, “I will share my medical knowledge for the benefit of the patient and the advancement of healthcare.” Clearly, being admitted to the profession has long entailed teaching what has been passed to us. However.... In today’s world, physicians must balance many more conflicting demands on their time (and income) than in the past. We risk becoming wounded healers. In fact, the 2017 Declaration also includes a promise to guard our own wellbeing – recognizing that the efficiency and effectiveness of our endeavors and the welfare of our patients require a healthy physician and doctor. So if the teaching is in the form of taking clerks into an office or clinic practice where, as medical students in the past often did, they assist in the providing of patient care, then compensation is perhaps not so much an issue. But if the physician must stop seeing their patients to provide services usually provided by paid faculty in some other setting, then some form of recompense agreeable and necessary to support the needs of the teaching physician should be provided. Note this begs the issue of whether medical schools should pay hospitals to assist in completing their students’ education. That is another problem entirely. –Sandra Hand, MD

January/February 2018

The oath obligates the new physician to pass on their knowledge: “To consider (my teacher’s) family as my own brothers and to teach them this art…”

SSVMS Member Social ON NOVEMBER 28, 2017, SSVMS held the “Celebrate the Season Social and Volunteer Recognition Event” at Studio 817 in Sacramento with over 150 physicians and guests in attendance. The event was an opportunity for the Medical Society to express its gratitude to member physicians for supporting SSVMS’ community programs, and for choosing to practice medicine in the Sacramento Region.

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Volunteer physicians who champion SSVMS’ programs, including SPIRIT, the Museum of Medical History, Joy of Medicine Program, and the Future of Medicine, were honored at the event. SSVMS President, Dr. Ruenell Adams Jacobs, also took the opportunity to thank all physicians who actively participate on committees, and those who serve in leadership positions for the Medical Society.

January/February 2018

Diphtheria By Matthew Huh Editor’s/SSVMS Museum Curator’s note: Matthew is an 11th grade student at Mira Loma High School who has done several historical reviews of artifacts in our Museum of Medical History. To help celebrate the 150th Anniversary of SSVMS and remind us of the evolution of medical care, some issues this year will contain a “disease synopsis,” illustrating the evolution of a different disease over the past 150 years.

The Mulford Improved Antitoxin Syringe (circa 1890), above, is from the SSVMS Museum of Medical History. The H.K. Mulford Company was a pioneer in diphtheria antitoxin.

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MUCH OF THE 1800s was challenging as it antedated the recognition of the cause of many diseases by “germs,” knowledge later clarified by bacteriologists Louis Pasteur and Robert Koch. Not knowing the cause of diseases such as diphtheria and cholera, rational treatment was not available and the mortality was high. Diphtheria is caused by the bacterium Corynebacterium diphtheriae, which causes a gray “pseudomembrane” around the airway, preventing air from entering the lungs. Diphtheria toxins also cause damage to vital organs like the heart, brain, and kidneys. It is spread directly, from person to person, through respiratory droplets or by coming in contact with objects with bacteria on it. Pierre-Fidele Bretonneau, the first person to perform a successful tracheostomy, identified and named this disease in 1826. He derived its name from the Greek word “diphthera” which means “leather.” Diphtheritis, as it was originally called, was a common childhood disease. When our Medical Society started in 1868, the cause of this “strangling angel of children” was shrouded in mystery and was considered an epidemic disease. A case study in 1868 involving 461 diphtheria patients showed that 346 of them were children between the ages of 5-15. The main method of prevention was to keep children away from areas with high incidences of diphtheria. Doctors treated the larynx by applying a solution of silver nitrate, hydrochloric acid, copper sulfate, alum, and iron multiple times a day, as well as gargling with a solution of chlorate or potassium nitrate. If this was ineffective, which was frequently the case, a tracheostomy, or the use of O’Dwyer’s Larynx Tubes, might have been required. The high mortality was exemplified during the 1870s, when New York City reported approximately

2,000 deaths of children each year. However, in the late 1800s, several discoveries were responsible for substantially reducing the mortality rate. Between 1880 and 1890, Drs. Emile Roux and Alexander Yersin discovered the toxin which caused the lethal symptoms. This led to Emil von Behring creating an anti-toxin on Christmas day in 1891 at the Institute of Hygiene in Berlin. It was mass produced by 1894, when the mortality rate

peaked at 785 per 100,000 population. In 1921, the United States still recorded high mortality – 206,000 cases of diphtheria and 15,520 deaths. But as the immunization of children started to become regulated, the disease rates dramatically dropped. Today, diphtheria is very rare. In the United States, only two cases were reported between 2004 and 2015, thanks to the required immunizations of all children. Treatment today also includes the use of antibiotics. One of the more memorable stories of diphtheria took place in 1925. A small town in Nome, Alaska was suffering from an epidemic of diphtheria. A relay of dog sleds rode 674 miles to deliver the diphtheria antitoxin to save the town. This came to be known as the Great Race of Mercy and inspired the creation of the Annual Iditarod Dog Sled Race to honor this event.

At left are O’Dwyer Larynx Tubes from our Museum of Medical History. In the late 1800s, Dr. O’Dwyer introduced his life-saving method of intubating the larynx of young diphtheria victims with these instruments and cannulas.

matthewdhuh@yahoo.com

Donate blood. Give hope.

Bobby needed red blood cells, platelets, plasma and plasmabased medicine to survive Wiscott-Aldrich Syndrome. Blood donors helped him to experience a healthy future today.

There are more ways than ever to help patients in need celebrate the healthy futures they imagine. Blood donors deliver hope in very specific ways by donating the blood components needed by patients each and every day: red blood cells, platelets, transfusable plasma or source plasma. Schedule an appointment at a BloodSource Donor Center or mobile blood drive soon. Learn more by visiting bloodsource.org or calling 866.822.5663. Together, we do save lives.

January/February 2018

2017 HOD: The Grand Experiment Continues Richard Gray, MD, Chair, District XI Delegation

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 2017 CALIFORNIA Medical Association (CMA) House of Delegates (HOD) met over the weekend of October 21-22. This was the second year under the new format instituted to use time more efficiently. The experiment has been a success so far. Rather than bogging down physicians with dozens of resolutions, ranging from the sublime to the mundane, a small number of items of great importance are identified by delegation leaders. Reports are generated by various CMA councils and are provided to the delegates before the HOD. Education is then provided at the HOD on those subjects by experts in the field, with a subsequent question-andanswer period, followed by debate and voting on various recommendations from the council reports. Shepherded by the Speaker of the House, SSVMS’s own Lee T. Snook, Jr., MD, and the ViceSpeaker, Tanya Spirtos, MD, the HOD quickly moved through the report’s recommendations, and policy was recommended to the CMA Board of Trustees. Topics reviewed this year dealt with what were, indeed, major issues: Options in health care reform, overcoming challenges in mental health, and developing, preserving and supporting the health care work force. Each of the reports had multiple recommendations, and with approximately 300 physicians in the room, one might expect the usual confusion of herding cats. Instead, with the guidance of the speakers and parliamentary procedure, the democratic process allowed for efficient disposal of all issues. Additionally, delegates received a report from the CMA’s chief financial officer showing

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the CMA to be in great fiscal shape, having a $20M reserve, compared to its annual budget of approximately $15M. Delegates were advised how, under the influence of the CMA, legislators got Governor Jerry Brown to return Proposition 56 funds (the tobacco tax), which had been diverted to the general fund, back to MediCal for payment to participating physicians, as earmarked in that proposition. Finally, delegates were informed of the debacle at the Tulare Regional Hospital, where the hospital administration locked out the medical staff officers and replaced them with a set of its own. Obviously indignant, these officers turned to CMA, and its Organized Medical Staff Section, who involved the AMA in its legal response, culminating in a restoration of the elected medical staff leadership and replacement of the hospital board of trustees responsible for the hospital’s operation. All this demonstrates that CMA, made up of its individual medical societies, is truly working for physicians, helping with problems and anticipating challenges, while seeking solutions to them before these challenges become insurmountable. Your membership makes all this possible, and any CMA member is allowed to weigh in on all these issues by logging in to the CMA website at www.cmanet.org. Should you desire a greater voice in these issues, then consider becoming a delegate and/ or serving on one of CMA’s councils. This and other CMA benefits are yours with membership. Encourage your colleagues to join SSVMS/CMA to receive these benefits too. rgraymd@comcast.net

Clockwise from the top: Delegates Drs. Richard Pan, Senator, Kuldip Sandhu and Richard Gray address the House of Delegates; CMA President (2017) Dr. Ruth Haskins and Outgoing Immediate Past President, Dr. Steve Larson; Dr. David Aizuss and Dr. Lee Snook, recipient of the Gary S. Nye, MD Award; Dr. Don Lyman, Chair, CMA Council on Science and Public Health; and the House of Delegates.

January/February 2018

The Sacred Disease By Kent Perryman, Ph.D.

The History of Epilepsy and its Treatments THERE HAS BEEN AN abundance of medical literature and data published on the epilepsy disease process. In ancient times, epilepsy was referred to as a “sacred disease,” resulting from some supernatural event or power. This article will cover both the supernatural and scientific basis for understanding the nature of epilepsy, as well as their treatment approaches. No attempt will be made to explain the numerous classification schemas based on localization and seizure types. It is difficult to place an exact medical definition on epilepsy due to the range of extensive clinical phenomena associated with this disease process. Currently, the term “epilepsy” applies to an underlying paroxysmal disturbance of brain function.

Historical Perspectives of the Epileptic Process

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.

Over the course of history, the definition of epilepsy has been modified numerous times, depending on its reference to a fit, convulsion or seizure attributed to an abnormal behavioral state. Epileptic episodes were also associated with hysteria or emotional excesses that were exhibited as physical symptoms (somatization). The physical manifestations of seizures were believed to be more psychological than neurophysiological in origin. This lack for an appreciation of the disease was related more to the times and different cultures than to a true medical understanding. The one common feature that characterized epilepsy over the centuries was the generalized tonic-clonic seizures. The earliest known reference to epilepsy has been translated from a Babylonian cuneiform

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labeled “Sakikki” (All Diseases) dated between 1067-1046 B.C. Epileptic events in this ancient script were referred to as the “falling disease” with symptoms described as convulsing, unconsciousness and frothing of the mouth, as well as fecal incontinence. The Babylonians attributed these seizures to demonic possession. Rich Atrey, an ancient Hindu physician in the 6th century B.C, describes epilepsy as “paroxysmal loss of consciousness due to disturbances of memory and understanding of mind attended with convulsive seizures.” Hippocrates (450-370 B.C.), who refers to epilepsy in the 4th century B.C. as the “sacred disease,” did not believe this disorder to have a supernatural origin. He advocated that, like other diseases, epilepsy is primarily a hereditary trait whose origin lies in the brain due to phlegm overwhelming the brain’s blood vessels. Treatment was relegated, not by magic, but by diet. The humoral theory that predominated most of medical thought during these times was also believed responsible for epileptic seizures. Epileptogenesis was thought to be caused from an imbalance between black bile and phlegm which obstructed blood flow to the brain. Plato (427-347 B.C.) went on to suggest the imbalance could “confuse the divine circles in the head” and cause a seizure, while Aristotle (384-322 B.C.), in his “On Sleep and Waking III,” attributed seizures to gas associated with indigestion reaching the brain. Later, in 221 B.C., the Chinese described convulsions as “Dian-Kuang” (epilepsy-mania) that included tonic-clonic seizures with prodromes (partial seizures that become more generalized). Other ancient physicians, includ-

ing Celsus (30 A.D.), Aretaeus (200 S.D.) and Galen (210 A.D.) also described the symptoms of epilepsy. Galen provided the earliest and most insightful appreciation of this disorder with a more restrictive definition that focused on the interruption of conscious and intellectual functions. However, he only recognized three types of epilepsy based their seizure symptoms: (1) cerebral or idiopathic, (2) “analepsy” and (3) “cataplexy.” Galen was also the first medical practitioner to describe the “aura epileptica” as a prodigal experience in a convulsive epileptic seizure. Today, we recognize his description as a type of motor or sensory experience by the sufferer at the beginning of a seizure process. There was very little deviation in medical thought from Galen’s concepts of epilepsy in regard to symptoms later during the middle ages. It was during this era that epileptic symptoms were weighted down with supernatural interpretations. There was the belief by the religious community that epilepsy was the consequence of sinning, as well as depending on the phase of the moon. This belief was partially drawn from a false deduction that a woman’s menstrual cycle was related to the lunar one: The moon had an influence on biological activity. Consequently, there were various assumptions of the biological and supernatural nature of epileptogenisis. Even the King James 1611 version of the Bible relates childhood epilepsy to “lunatic.” These early Christian beliefs attributed epilepsy to a temporary possession by evil spirits that enticed the Catholic Church to be removed by the practice of exorcism. Later, during the scientific revolution of the 17th century, Thomas Willis (1621-1675), an English physician and the father of neurology, has been attributed with making the first significant scientific medical contribution to, or understanding of, epiletogenesis. He addressed convulsive disorders in his text, “Pathology of the Brain and Nervous Stock” in 1684 where he considered epilepsy to be the chief convulsive disease at the time. Among convulsive disorders he included St. Vitus dance, rabies and the “rigors of fevers,” as

well as any disorder that included symptoms of sudden, temporary, involuntary muscle contractions. However, Willis still incorporated animal spirits into his explanations on the mechanisms involved in the production of epileptic seizures. Albrecht von Haller (1708-1777), a German physiologist, and his collaborators believed that irritation of the brain’s dura matter was the origin of some convulsive disorders. He was also convinced that convulsive muscle spasms were caused by animal spirits originating from cerebral irritation. The 18th century also witnessed the anatomical exploration of cerebral pathologies that could possibly cause convulsive disturbances without any successful results. Baron Antoine Portal (1742-1832), a French physician, was unable to discover any lesions in the epileptic brain, but he was convinced there was some obstruction from a ”lard-like” substance he referred to as “amyloid” in the cerebral blood flow that caused an irritation. Most physicians at the time didn’t believe that an post-mortem investigation of the brain would reveal the etiology of epilepsy. Joseph Wenzel (1768-1808), a German anatomist, claimed to have discovered abnormal tissue surrounding the pituitary gland, thus concluding this region of the brain to be the origin of epilepsy. Karl Friedrich Burdach (1776-1847), a German Physiologist, in his work, “Of the Structure and Life of the Brain,” purported that there was a relationship between lesions of the globus pallidus and lateral ventricles with general convulsions. During this time, there was a popular belief that epilepsy could be divided between the “idiopathic” and the “sympathetic” types. Idiopathic epilepsy originated from the brain, while sympathetic convulsions were the result of some disease process traveling to the brain. It wasn’t until the 19th century that the clinical manifestations of epilepsy were broadened. John Hughlings Jackson (1835-1911), an English neurologist posted to the National

January/February 2018

Prior to the 19th century, there were no successful treatments for seizure disorders.

Hospital for the Paralyzed and Epileptic in London, is recognized as revolutionizing our understanding of the pathogenesis of epilepsy. While observing his wife’s bouts of epileptic seizures in 1863, he deduced a pattern to the progression of her spasms as they traveled from the wrist up the arm to the face and leg on the same side of the body. These localized convulsions became known as Jacksonian epilepsy and the “Jacksonian March,” later referred to as “focal motor seizures,” originating from the motor cortex. Jackson attributed these seizures to the propagation of neuronal discharges that arose from localized brain lesions. His deductions would be confirmed much later with the aid of technological innovations such as electroencephalography (EEG). He was also recognized for his medical insight into the temporal lobe origin of psychomotor seizures associated with a “dreamy state” and various patterns of pathological automatism.

The Evolution of Pharmacological and Surgical Treatments Prior to the 19th century, there were no successful treatments for seizure disorders. Epileptics in many European and American jurisdictions were sometimes confined to asylums for the insane. Jean-Etienne Esquirol (17721840), a French psychiatrist who studied under Phillippe Pinel (1745-1826), was responsible for first separating epileptics from the insane in his private asylum, “Maison de Sante” in 1801. He believed, by providing this isolation, that the insane would not contract a seizure disorder believed to be an infectious disease. By 1850, many European countries, especially England, were confining their epileptic patients to separate wards in lunatic asylums. During this period, it was assumed that convulsive attacks were more prone to commence during childhood, and that special precautions should be taken to isolate the children from adult epileptics for the proper development of their minds. It wasn’t until the late 19th century, with an appreciation for the neurological basis of epilepsy, that the pharmacological development

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of anticonvulsants to treat epilepsy came about. Prior to this, only herbal remedies were unsuccessfully employed to control seizures. From about 1857 to 1912, potassium bromide was the only anticonvulsant prescribed. The German psychiatrist and neurologist, Alfred Hauptman (1881-1948), who introduced phenobarbarbital, brought it to market by Bayer under the name “Luminal” in 1912. Neurologists Tracy J. Putnam (1894-1975) and H. Houston Merit (1902-1979) discovered the anticonvulsant properties of phenytoin (Dilantin) in 1938. Dilantin became the drug of choice for patients not responding to bromides or barbiturates. The 1950s witnessed the introduction of many new anticonvulsant medicines including brivaracetam, carbamazepine, diazepam, ethosuximice and felbamate. There has been some speculation among anthropologists concerning the practice of trephining (a surgical intervention where a hole is drilled, incised or scraped into the skull using simple surgical tools) during prehistoric times as a treatment for convulsive symptoms. Some historians attribute the physical evidence of burr holes in skull fragments from South America as a method to release evil spirits for abnormal behavior. There were some occasional attempts to treat epilepsy in the 19th century by employing trephination to release cranial pressure. Once the technology of electroencephalography was refined to localize epileptic foci in the brain, there was a renewed interest in employing neurosurgical techniques to treat convulsive disorders. Harvey Cushing (1869-1939), an American neurosurgeon, performed some of the first early anti-epileptic surgeries during the turn of the 20th century. Wilder Penfield (1891-1976), a Canadian neurosurgeon, pioneered the surgical removal of epileptogenic lesions at the Montreal Neurological Institute in 1934. Using his “Montreal procedure,” a small portion of the brain is exposed in a conscious patient for the insertion of a probe that allows the surgeon to identify the exact location of seizure activity. Following many of these procedures, Penfield was able to compile maps of sensory and motor

regions of the cortex that were later published as “Epilepsy and the Functional Anatomy of the Human Brain.” A more exact localization of seizure sites occurred in the late ‘50s with the development of stereotactic surgery and parallel x-rays that eliminated distortions of the skull, vessels and ventricles. Later, in 1962, stereoelectroencephalography (SEEG) was introduced demonstrating that irritative lesion sites could be better differentiated from the surrounding neural tissue. The 1970s witnessed new developments in radio surgery using ionizing radiation instead of a blade excision that led to stereotactic radio surgery (SRS) and the Gamma Knife (also known as the Leksell Gamma Knife) which employs high-intensity cobalt radiation to bombard both lesion sites and tumors. The UCLA Medical Center also pioneered the use of telemetry for localizing seizure sites. Typically, long-term EEGs are recorded from implantable electrodes over a number of cortical and subcortical regions for several weeks and neuronal activity wirelessly transmitted to

a bank of computers that reconstructs a threedimensional image of the seizure sites.

Conclusion What was once thought of as demonic possession and an incurable disease process has been proven to be a curable illness, thanks to the efforts of many pioneering medical specialists and the further developments of medical technology. The many neurophysiological forms of epilepsy are more fully understood today and, consequently, can be treated more effectively with a combination of surgical and pharmacological interventions. kperryman@suddenlink.net REFERENCES Edie, MJ. And Bladin, PF. A Disease once Sacred: A History of the Medical Understanding of Epilepsy. 2001, John Libby Eastleigh England Temkin, O. The Falling Sickness: A History of Epilepsy from the Greeks to the Beginnings of Modern Neurology. 1971, Johns Hopkins University Press Baltimore Highlights in the History of Epilepsy: The Last 200 Years. https:// www.hindawi.com/journals/ert/2014/582039

Letter to SSV Medicine Re: Bellevue Book Review by Jack Ostrich, MD I thoroughly enjoyed your review of the book “Bellevue” in The Medical Society journal. I have purchased it on Amazon for my next great read. I have always been interested in the history of our great institutions, having visited several of them during my career and during my travels. I made a point in allowing extra time to visit some of these noteworthy institutions. Besides Bellevue, I have visited Central Receiving (now Detroit Medical Center) in Detroit, Parkland in Dallas, Charity in New Orleans, Cook County in Chicago, Jackson Memorial in Miami, LA County/USC

in Los Angeles, San Francisco General and the UCSF/ Moffitt complex, as well as Walter Reed and Bethesda Naval in Washington, D.C. I have also visited the University of Michigan hospitals and, the grand daddy of them all, Mass General in Boston. Walking through these institutions gives me a feeling of being closer to our medical heritage. Again, thank you for that excellent book review and taking time to write it. Sincerely, – Steve Mandaro, MD

January/February 2018

On Story Listening 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.

STORYTELLING IS ONE OF the four pillars of meaning. It is also the first necessary step towards healing. Storytelling is a precious educational tool; when something went wrong in the person’s life, it is a privilege for the listener to try to find a trace of wisdom in it, or a profound understanding of human nature. The trauma story doesn’t exist unless it is told to someone else; the listener must choose to become part of the story. So many stories have unfolded before my eyes and ears, and I have stepped onto so many pages I never thought could be written. Being an attentive reader of my patients’ distress is one of the most enlightening tasks of my professional life. Earlier this year, a woman in her late 20s, whom I will call Susan, came for an assessment with the nonspecific “postpartum depression” as a reason for referral, after she had experienced fear of shaking her baby. She had mild symptoms that seemed mostly due to the frequent overwhelming sense of her new reality, and she never acted out on her thoughts. Expanding her support system, joining a breastfeeding group to meet new moms, and even adjusting her schedule for a more optimal family-work balance, made a tremendous difference. No medications were needed. Based on her rapid progress, I concluded that her impulse phobia was situational and the result of a mismatch between the needs of motherhood and the available resources. I thought I had done a comprehensive history, including screening for adverse childhood experiences, etc. I had good confidence in her ability to parent: she deeply cared for, and bonded well with, her baby boy. When she came for a regular follow-up recently, I was not expecting her request for medication for anxiety. She admitted having been anxious prepregnancy. I explored the nature of her anxiety

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to discover that she was frequently waking up with horrific nightmares in which she would see her baby dead. She didn’t feel safe when her husband was not sleeping at home and feared that someone would break in. As a result, she slept with the lights on. During the prelude to a potentially intimate encounter with him, she started feeling tense, seeing a catastrophic and lethal scenario if it were to go further. My trauma antenna started humming. The seemingly irrational or disproportionate nature of the response compared to the stimulus suggested that she had been triggered. I don’t think there is a big mystery in patients’ symptoms. Such vivid anxiety is usually the result of an impeded sense of safety, and usually, when people don’t feel safe, it is because something happened to them. I asked Susan if she had ever experienced a situation during which she wasn’t safe, or if someone had ever broken into her house. Her facial expression changed, she avoided eye contact, became more tearful, and looked frightened, saying “I don’t like to talk about this.” Her stress response systems were activated in front of me. I waited because trauma-informed care implies not forcing disclosure. Then, she admitted that she had been victim of a sexual assault in college. I inquired if she had told anyone else before. She sought help, but the psychology fellow implied that she might have had some responsibility in it, so the patient decided to forget about it. But the body always remembers. Whenever I hear such invalidation, I want to scream. Since my early residency years, I discovered that many patients who had disclosed sexual abuse to a parent or significant caretaker had been ignored, not believed, or blamed. I realized that this was often experienced as more traumatic than the abuse itself.

In front of my patient, I tried to remain calm while feeling a wave of outrage. I was furious while imagining the response from this supposed mental health professional (a female). This is incomprehensible. Regardless of the reason, this type of collusion with a rape culture is unacceptable. I decided that I needed to write about this and channel the voice of those who have been victimized and re-traumatized by the very people who were supposed to support and protect them. I also hope that each one of us will become more deeply aware of our own trauma (small t or big T) stories, and more attuned to ourselves and to our patients. Symptoms, especially in psychiatry, do not occur in a vacuum. I cannot imagine how consensual sex could lead to the disabling and frightening symptoms Susan is describing. I do believe that she has been a victim. Unfortunately, the silencing of the victims is a recurrent issue. And such wounds rarely heal themselves with time only… She was raped around the period of year she shared her story with me, which is probably triggering a quite sordid anniversary reaction. Becoming a mother most likely changed the representation of her body in a way that going back to being a sexualized woman became suddenly uncomfortable. I am so pleased to see this recent #metoo movement. The more people to break the silence, the harder it will become to ignore the problem, and the more empowered the victims will feel. The recent explosion of accusations and scandals in the showbiz world generates outrage, sympathy and support from women and men, which is what victims acutely need. It conveys the message that a human body is private and should not be violated. I hope this movement will give confidence to vulnerable people to seek help – those with low self-esteem, those who are going through a challenging developmental stage or who are socially isolated. So many problems are created by what victims are forced to trivialize because they were dismissed or invalidated. Denying someone’s

suffering is annihilating this person’s essence. It is almost a form of spiritual “honor killing.” I am concerned by the realization that we live in a world where bestiality is pushed under the rug to save a university or prominent figure’s reputation, for instance. Statistics promulgated by the Obama White House declare that an estimated one in five college women will be sexually assaulted. And this is most likely an underestimate. The University of California tackled the rape culture in 2016 by developing a policy on sexual violence. The policy states: “Consent is affirmative, conscious, voluntary, and revocable. Consent to sexual activity requires of both persons an affirmative, conscious, and voluntary agreement to engage in sexual activity. It is the responsibility of each person to ensure they have the affirmative consent of the other to engage in the sexual activity. Lack of protest, lack of resistance, or silence, do not alone constitute consent. Affirmative consent must be ongoing and can be revoked at any time during sexual activity. The existence of a dating relationship or past sexual relations between the persons involved should never, by itself, be assumed to be an indicator of consent (nor will subsequent sexual relations or dating relationship alone suffice as evidence of consent to prior conduct).” I do not know how widespread such an initiative is, but I think the above can dispel potentially grey areas. I will be even more at peace when predators cease to use their “arm of massive destruction.” Meanwhile, we, as a society, should do a better job at preventing entitlement, boundary violation and sexual misconduct by modeling respect and empathy and emulating core values for our children. And as doctors, our role is to listen to the story, the story of the body that uses the symptom dictionary. Once upon a time, a wounded person had to develop a new language for the words of the story that was ignored, ridiculed or minimized. If we can bear witness to all our patients’ hardship, the healing becomes the rule rather than the exception.

Symptoms, especially in psychiatry, do not occur in a vacuum.

cgiroux@ucdavis.edu

January/February 2018

Metabolic Syndrome The Gateway to Chronic Disease

By Neeraj Ramakrishnan, MS II

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to e.LetterSSV Medicine@gmail. com.

THE UNITED STATES CURRENTLY faces a formidable challenge: the growing crisis of chronic disease. In fact, chronic diseases are the leading cause of death and disability in the United States. A major precursor for many of the chronic diseases that the United States population suffers from is Metabolic Syndrome. Metabolic Syndrome is a cardio-metabolic cluster that predisposes one to increased risk for both diabetes and cardiovascular disease. Moreover, it is a pro-inflammatory state that is clinically defined as fulfilling three of the following five categories: hypertriglyceridemia, elevated plasma glucose levels, low HDL-cholesterol levels, increased waist circumference, and hypertension. Metabolic Syndrome alarmingly occurs in 34 percent of adults and 50 percent of those 60 years of age or older in the United States. Because Metabolic Syndrome affects so much of our population, finding methods to both treat and prevent it is key to reducing the overall burden of chronic disease. Before entering medical school, I was unaware about this syndrome. However, as I began to work on a research project with Dr. Ishwarlal Jialal, a professor at California Northstate University, I learned more and more about this condition, and I was surprised to find that it disproportionately affects the South Asian community, the roots of my own ethnicity. South Asia has one of the largest populations of people with Metabolic Syndrome. In fact, about one-third of the urban populations in large cities in India have it. The presentation of this condition and its sequelae are peculiar in South Asians. For example, compared to Caucasians, higher body fat is seen at a similar BMI in Asian Indians. Hyperglycemia, hyperten-

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sion, and hypertriglyceridemia, clinical categories used to diagnose Metabolic Syndrome, were seen at lower levels of BMI and waist circumference in Asian Indians compared to Caucasians, as well. Realizing that this condition has affected so many of my own family members, I became curious in finding out why Metabolic Syndrome affects the South Asian community so significantly. There are a variety of determinants and causative factors. Increased industrialization has, in turn, led to increased usage of computers and mechanization, at both work and the home. Hobbies and leisurely activities have shifted from sports and outdoor games to television and computer games.

Urbanization has resulted in a nutritional imbalance, physical inactivity, and increased consumption of drugs and alcohol. Asian Indians consume significantly more carbohydrates, such as white rice and breads, compared to Europeans. Increased carbohydrate and fat intake, combined with decreased fiber consumption, is likely a main contributing factor to the increased Metabolic Syndrome incidence in South Asians. Additionally, there has been an increase in migration from villages to cities and increased consumption of nontraditional fast foods. Urbanization has resulted in a nutritional imbalance, physical inactivity, and increased consumption of drugs and alcohol. Interestingly, genetic studies in Indians have not found exclusive genetic correlates of

Metabolic Syndrome. In addition to the background research I conducted on Metabolic Syndrome, I also became highly interested in exploring methods of screening for this in patients at an early stage. Because the pathogenesis of this illness is not well understood, there currently are no effective early screening tools to diagnose Metabolic Syndrome in patients. However, recent studies have shown that up regulated levels of acylcarnitine, a lipid metabolite, is significantly associated with Metabolic Syndrome. This has led to a boom in the field of exploratory lipidomics, where there has been a search for characterizing additional biomarkers that could predict onset of this disease. Exploratory lipidomics involves using techniques of lipid chromatography and mass spectrometry to identify and quantify lipid metabolites in patient urine samples. Through my own research under Dr. Jialal, I found that phosphatidylcholine 34:2, a particular lipid metabolite, was up regulated significantly in patients with Metabolic Syndrome compared to control groups. In the future, metabolites such as phosphatidylcholine 34:2 could potentially be screened for through noninvasive and simple urine tests to diagnose Metabolic Syndrome in patients at very early stages. The field of research in Metabolic Syndrome is rapidly expanding. For instance, tracking clinical biomarkers to predict onset of this disease expands beyond even lipidomics. Fellow medical students at California Northstate University have also worked with Dr. Jialal to explore these various biomarkers. Biogenic amines such as L-carnitine, which is commonly found in meat and dairy products, and its metabolite, Trimethylamine-N-Oxide (TMAO), were found to be markers of inflammation in patients with Metabolic Syndrome. High concentrations of branched-chained amino acids (BCAA) have also been shown to damage circulating red blood cells promoting a pro-inflammatory state. This has sparked further studies in exploring the role of amino acids in predicting onset of Metabolic Syndrome before it progresses to Cardiovascular Disease or Type

2 Diabetes. Increased levels of isoleucine and decreased levels of lysine are significantly correlated with patients having Metabolic Syndrome. Physiologically relevant predictors for insulin resistance and Metabolic Syndrome are also emerging. InsuTAG, a calculation of fasting insulin multiplied by fasting triglycerides, has recently gained recognition. A recent study demonstrated a significant association between high values of InsuTAG and HOMA-IR, a marker of insulin resistance. Moreover, InsuTAG had a 93 percent probability of identifying patients with insulin resistance involved in this study. This marker could represent an easily calculable and accurate identifier of populations at risk. The causative factors of Metabolic Syndrome in South Asia could very well apply to the United States. As the U.S. has become more industrialized, its population has become more sedentary and dependent on unhealthy and refined foods. Hispanic and South Asian populations, in particular, that eat large amounts of carbohydrates, have the highest incidence of Metabolic Syndrome in the United States. This problem is exacerbated even further in impoverished areas that are food deserts where there is a lack of access to healthy food and means of exercise. As the lifespan of the American population increases, so does the burden of chronic disease. Though pharmacologic therapy and genetic testing could still play a role in curbing the incidence of Metabolic Syndrome, the adage, â&#x20AC;&#x153;prevention is better than cure,â&#x20AC;? rings most powerfully. A multi-faceted approach that starts with behavior and dietary modifications in the population must be employed to combat Metabolic Syndrome. Screening tests that use biomarkers like lipid metabolites can aid in this by identifying at-risk or early-stage Metabolic Syndrome patients and employing prevention strategies before the condition progresses. If there is emphasis and advancement of preventive care, there is truly great potential for tackling the daunting crisis that chronic disease poses in the United States.

As the lifespan of the American population increases, so does the burden of chronic disease.

neerajramakrishnan178@gmail.com

January/February 2018

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, President-Elect. APPLICANTS FOR ACTIVE MEMBERSHIP: Maxine Barish-Wreden, MD, Internal Medicine, Chicago Univ/Pritzker – 1985, Sutter Medical Group, 2801 K St #502, Sacramento, CA 95816 Benjamin Bluth, MD, Orthopaedic Surgery, David Geffen School of Medicine at UCLA – 2011, Mercy Medical Group, 6555 Coyle Ave. Suite 180, Carmichael, CA 95608 J. Andrew Brothers, MD, Family Practice, Ohio State University College of Medicine – 2000, Sutter Medical Group, 1201 Alhambra Blvd #300, Sacramento, CA 95816 Craighton Chin, MD, Otolaryngology, Univ Kansas – 1987, Woodland Clinic Medical Group, 1321 Cottonwood St. – Woodland, CA 95695 Alison Chow, MD, Pediatrics, University of Hawaii School of Medicine – 2002, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670 Drew-Anne Drapala, MD, Hospitalist, State University of New York – 2014, Mercy Medical Group, 4001 J St., Sacramento, CA 95819 Nisrin Fadul, MD, Pediatrics, University of Medical Sciences and Technology – 2003, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Sarah Favila, MD, Pediatrics, Tufts University School of Medicine – 2012, Woodland Clinic Medical Group, 2081 Bronze Star Dr. - Woodland, CA 95776 Matthew Fields, DO, Family Medicine, Arizona College of Osteopathic Medicine – 2014, The Permanente Medical Group, 2155 Iron Point Rd, Folsom, CA 95630 Katherine Garvey, MD, Ob/Gyn, University of Texas Medical School - San Antonio – 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Devon Ganter, MD, Pediatrics, Drexel University College of Medicine – 2014, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Kathryn Griffin, MD, Pediatrics, Duke University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Kriti Gwal, MD, Pediatric Radiology, New Jersey Medical School – 2007, UC Davis Medical Group, 4860 Y St., Suite 3100, Sacramento, CA 95817

Tuongvi Ha, DO, Family Medicine, Family Medicine, Arizona College of Osteopathic Medicine – 2014, The Permanente Medical Group, 1955 Cowell Blvd, El Macero, CA 95618

Sapoora Manshaii, MD, General Surgery, Technical University of Munich– 1991, Sapoora Manshaii, MD, INC, 2045 Hurley Way, Suite 415, Sacramento, CA 95825

Jamal Haleem, MD, Hospitalist, Peoples’ Friendship University of Russia – 1996, Mercy Medical Group, 4001 J St., Sacramento, CA 95819

Seth Miller, MD, Family Medicine, The University of Queensland Mayne Medical School – 2011, The Permanente Medical Group, 2155 Iron Point Rd, Folsom, CA 95630

Jennifer Hallock, MD, Ob/Gyn, Columbia University College of Physicians & Surgeons – 2010, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Gwendolyn Ho, MD, Internal Medicine, UC San Francisco School of Medicine – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Beheshteh Nakhaee, MD, Hospitalist, Shahid Beheshti University – 1992, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Stephen Jamieson, MD, Emergency Medicine, University of Texas Medical School - San Antonio – 2013, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Latifa Pacheco, DO, Family Medicine, Michigan State University College of Osteopathic – 2014, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758

Anil Jasti, MD, Rheumatology, J.S.S Medical College – 1999, Mercy Medical Group, 6555 Coyle Ave. Suite 180, Carmichael, CA 95608

Michelle Palvolgyi, MD, Occupational Medicine, David Geffen School of Medicine at UCLA – 2013, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Jason J. Kim, MD, Orthopaedic Surgery, University of California School of Medical - San Diego – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Christopher Lawrence, MD, Emergency Medicine, Washington University School of Medicine – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Jenny Lee, MD, Pediatrics, University of Alabama School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Robert Levy, MD, Internal Medicine, Jefferson Medical College of Thomas Jefferson University – 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Pooja Rathi, DO, Pediatrics, Midwestern University College of Osteopathic Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Damoon Rejaei, MD, Pain Management, University of Vermont – 2012, Woodland Clinic Medical Group, 1207 Fairchild Ct. - Woodland, CA 95695 Brian Rezvani, MD, Thoracic and Cardiac Surgery, University of Washington School of Medicine – 2010, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Syed Safdar, MD, Internal Medicine, St. George’s University School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Pachida Lo, MD, Psychiatry, Oregon Health Science University Medical School – 2013, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Sameera Sandhu, MD, Hospice & Palliative Medicine, Punjab Univ, India – 1995, Mercy Medical Group, 3301 C St Suite 550, Sacramento, CA 95816

Robert Lucas, MD, Orthopedic Surgery, Wake Forest University School of Medicine – 2006, Mercy Medical Group, 3000 Q St. 4th Floor, Sacramento, CA 95816

Ulfat Shaikh, MD, Pediatrics, Goa Medical College – 1993, UC Davis Medical Group, 2516 Stockton Blvd #340, Sacramento, CA 95817

Alayna Ly, MD, Hospitalist, Touro University Nevada, College of Osteopathic Medicine – 2013, Mercy Medical Group, 4001 J Street, Sacramento, CA 95819

Amanpal Singh, MD, Gastroenterology, All India Institute of Medical Sciences – 2004, Mercy Medical Group, 6555 Coyle Ave. Suite 341, Carmichael, CA 95608

Nuzhat Majid, MD, Family Medicine, Aga Khan Medical College – 1994, Mercy Medical Group, 6555 Coyle Ave., Carmichael, CA 95608

Jonathan Najman, MD, Emergency Medicine, Rush University Medical Center – 2014, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

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Sukwinder Singh, DO, Internal Medicine, Touro University College of Osteopathic Medicine – 2012, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Anton Sisante, DO, Hospitalist, Western University of Health Sciences/College of Osteopathic Medicine of the Pacific – 2014, Mercy Medical Group, 6501 Coyle Ave, Carmichael, CA 95608 Gregory Smith, MD, Internal Medicine, State University of New York at Buffalo Medical School – 1979, 7600 Hospital Dr Suite G, Sacramento, CA 95823

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Physicians Nurse Practitioners ~ Physician Assistants

Steven Stockslager, MD, Ophthalmology, New York Medical College – 2009, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Ra’ad Tashman, MD, Internal Medicine, University of Jordan School of Medicine – 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Sooraj Tejaswi, MD, Gastroenterology, Rajiv Gandhi University, Mysore Medical College – 2001, UC Davis Medical Center, 4150 V St, Sacramento, CA 95817 Nay Nay Thiri, MD, Hospitalist, Institute of Medicine, Yangon, Myanmar – 2004, Mercy Medical Group, 6555 Coyle Ave., Carmichael, CA 95608 Loc Ton, MD, Internal Medicine, Boston University School of Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

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Brenden Tu, MD, Family Medicine, Bowman Gray School Medical of Wake Forest University – 2005, UCD Student Health & Counseling Svcs, 1 Shields Avenue, Davis, CA 95616 Julie Westberg, MD, OB/Gyn, Albany Medical College of Union University – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Daniel Wong, MD, Endocrinology, Temple University School of Medicine – 2007, Sutter Medical Group, 1020 - 29th St Ste 270, Sacramento, CA 95816 APPLICANTS FOR RESIDENT/FELLOW MEMBERSHIP:

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Michelle Engle, MD, Family Practice, UC Davis Medical Center Resident & Fellow Program, 4860 Y Street, Suite 2320, Sacramento, CA 95817

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Eve Angeline Hood-Medland, MD, Internal Medicine, UC Davis Medical Center Resident & Fellow Prog – 2019, 4150 V Street Ste 2400, Sacramento, CA 95817

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James P. Dompor, DO, Neurology, UC Davis Medical Center Resident & Fellow Prog – 2019, 4860 Y Street, Ste 3700, Sacramento, CA 95817

Jaire Saunders, MD, Internal Medicine, UC Davis Medical Center Resident & Fellow Program, 4150 V Street, Suite 3100, Sacramento, CA 95817

Investment Management Consultants Association is the owner of the certification mark “CIMA®” and the service marks “Certified Investment Management AnalystSM,” “Investment Management Consultants AssociationSM” and “IMCA®.” Use of CIMA® or Certified Investment Management AnalystSM signifies that the user has successfully completed IMCA’s initial and ongoing credentialing requirements for investment management consultants. ©2017 Robert W. Baird & Co. Member SIPC. MC-100308.

January/February 2018

Board Briefs November 13, 2017 The Board: Received an update from Glennah Trochet, MD, Chair of the Public and Environmental Health Committee and approved the following proposals from the committee: 1) Encourage the Board of Supervisors and other elected bodies in Sacramento County to work together to address homelessness by increasing housing availability at all levels of income, but especially for low income residents of the county; 2) Encourage the Sacramento County Board of Supervisors to authorize and implement Laura’s Law in Sacramento County. The law provides community-based, assisted outpatient treatment to a small population of individuals who meet strict legal criteria and who, as a result of their mental illness, are unable to voluntarily access community mental health services; 3) Encourage the Sacramento County Board of Supervisors to provide homeless people access to basic sanitation in order to prevent a Hepatitis A Epidemic. Approved the following Scholarship and Awards Committee recommendations for the 2017 annual awards: Mary Pat Pauly, MD, Golden Stethoscope Award; Gordon Garcia, MD, Medical Honor Award; and My Sister’s House, Medical Community Service Award. Approved the 3rd Quarter 2017 Financial Statements, Investment Reports and Recommendations. Approved the 2018 Budgets for the Sierra Sacramento Valley Medical Society (SSVMS) and the Community Service, Education and Research Fund (CSERF). Approved the Following Membership Reports: October 26, 2017 For Active Membership — Drew-Anne Drapala, MD; Sarah Favila, MD; Kriti Gwal, MD; Jamal Haleem, MD; Robert Levy, MD; Damoon Rejaei, MD; Ulfat Shaikh, MD; Amanpal Singh, MD; Anton Sisante, DO; Sooraj Tejaswi, MD; Nay Nay Thiri, MD; Brenden Tu, MD. For Reinstatement to Active Membership — Maxine

Sierra Sacramento Valley Medicine

Barish-Wreden, MD; Craighton Chin, MD; Sapoora Manshaii, MD; Gregory Smith, MD. For Active Resident Membership — Michelle Engle, MD; Jaire Sunders, MD. For a Change in Membership Status from Active to Active 65/20 — Marcia Gollober, MD; Michael Pirruccello, MD. For Retired Membership — James Goodnight, Jr., MD; Stephen Nagy, Jr., MD; Steven Polansky, MD; Dean Rinard, MD; David Ruderman, MD; James Vasser, MD. For Transfer to Membership — Francis Canet, MD to Placer-Nevada; Rajbarinder Hundal, MD to San Joaquin; Salim Wehbe, MD to Placer-Nevada. For Resignation — Muhammad Choudry, MD (moved to New York); Murat Mardirossian, MD (moved to Arizona); Faryal Michaud, DO (moved to Hawaii); Ripul Panchal, DO (moved to Texas); Stanley Sady, MD (moved to Colorado; Gregory Spears, DO (moved to Arkansas). November 13, 2017 For Active Membership — Benjamin Bluth, MD; Alison Chow, MD; Katherine Garvey, MD; Devon Ganter, MD; Kathryn Griffin, MD; Nisrin Fadul, MD; Matthew Fields, DO; Tuongvi Ha, DO; Jennifer Hallock, MD; Gwendolyn Ho, MD; Stephen Jamieson, MD; Anil Jasti, MD; Jason J. Kim, MD; Christopher Lawrence, MD; Jenny Lee, MD; Pachida Lo, MD; Robert Lucas, MD; Alayna Ly, MD; Nuzhat Majid, MD; Seth Miller, MD; Jonathan Najman, MD; Beheshteh Nakhaee, MD; Latifa Pacheco, DO; Michelle Palvolgyi, MD; Pooja Rathi, DO; Brian Rezvani, MD; Syed Safdar, MD; Sameera Sandhu, MD; Sukwinder Singh, DO; Steven Stockslager, MD; Ra’ad Taashman, MD; Loc Ton, MD; Julie Westberg, MD. For Reinstatement to Active Membership — J. Andrew Brothers, MD. For Retired Membership — William Bommer, MD. For Transfer of Membership — Medical Student Cesar Soria (to Ventura). For Resignation — Christina Ortega-Chen, MD; Pankaj Ranka, MD.

President: Rajiv Misquitta, MD President-Elect: Chris Serdahl, MD Immediate Past President: Ruenell Adams Jacobs, MD District 1, North: Seth Thomas, MD District 2, Central: Tonya Fancher, MD, J. Bianca Roberts, MD; Vanessa Walker, DO District 3, South: Ravinder Khaira, MD District 4, El Dorado County: Ranjit Bajwa, MD District 5, The Permanente Medical Group: Sean Deane, MD, Cynthia Ramos, MD, Vijay Rathore, Paul Reynolds, MD, John Wiesenfarth, MD District 6, Yolo County: Carol Kimball, MD

District 1, North Area: Reinhardt Hilzinger, MD, Delegate; Harmeet Bhullar, MD, Alternate District 2, Central Area: Lydia Wytrzes, MD, Delegate; Ann Gerhardt, MD, Alternate District 3, South Area: Katherine Gillogley, MD, Delegate; Thomas Valdez, MD, Alternate District 4, El Dorado County: Russell Jacoby, MD, Delegate; Richard Bermudes, MD, Alternate District 5, The Permanente Medical Group: Sean Deane, MD, Delegate; Armine Sarchisian, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Christopher Swales, MD, Alternate At-Large Office 7: Chris Serdahl, MD, Delegate; Alternate Office Vacant At-Large Office 8: Rajiv Misquitta, MD, Delegate; Alternate Office Vacant At-Large Office 9: Don Wreden, MD, Delegate; Carol Kimball, MD, Alternate At-Large Office 10: Ruenell Adams Jacobs, MD, Delegate; Megan Frost Babb, MD, Alternate At-Large Office 11: Natasha Bir, MD, Delegate; Helen Biren, MD, Alternate At-Large Office 12: Kuldip Sandhu, MD, Delegate; Alternate Office Vacant At-Large Office 13: Charles McDonnell, MD, Delegate; Alternate Office Vacant At-Large Office 14: Richard Jones, MD, Delegate; Ajay Singh, MD, Alternate At-Large Office 15: Richard Gray, MD, Delegate; Derek Marsee, MD, Alternate At-Large Office 16: Janet Oâ&#x20AC;&#x2122;Brien, MD, Delegate; Alternate Office Vacant At-Large Office 17: Tom Ormiston, MD, Delegate; Arlene Burton, MD, Alternate At-Large Office 18: Barbara Arnold, MD, Delegate; Ernesto Rivera, MD, Alternate At-Large Office 19: James Sehr, MD, Delegate; Alternate Mark Drabkin, MD At-Large Office 20: Senator Richard Pan, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office 21: Sandra Mendez, MD, Delegate; Amber Chatwin, MD, Alternate At-Large Office 22: Kevin Jones, DO, Delegate; Ronald Chambers, MD, Alternate

January/February 2018

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