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PRESIDENT’S MESSAGE Prescription Drug Spiral
Rajiv Misquitta, MD
Letters From Our Readers
GUEST EDITORIAL Dirty Money
Reviewed by Bob LaPerriere, MD
Gerald Rogan, MD
A Garden in Your Hand
To Parent or Not to Parent?
Caroline Giroux, MD
Brenda Tran Wu, MS II
From Students’ Farm Project to Seniors’ Fork
Jack Ostrich, MD
Daniella Lent-Schochet, MS II
Medical Student Burnout
Sehra Rahmany, MS II
Social Security Medicare Debut 1966
Fueling Patient Hope in the Midst of Illness
How the Teacup Got Its Handle
Sandra Hand, MD
BOOK REVIEW Dr. Morse – Reflections of Early Sacramento
Scaife Student Fellowship
Juliette Gerardo, MS II
Welcome New Members
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We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to SSVMedicine@ ssvms.org or to the author.
History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.
SSVMS 150th Anniversary Celebration
SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx On May 5, 2018, the Sierra Sacramento Valley Medical Society celebrated its 150th Anniversary at historic Sutter’s Fort in Sacramento. Over 250 members and their families attended the event and relived the Gold Rush era. Attendees enjoyed food, beverages, pioneer games, crafts, music and dancing. The board member on the cover is Paul Reynolds, MD with his wife Mary Jo. More photos of the event are on pages 18–19.
Volume 69/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax email@example.com
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MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 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
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 J. Bianca Roberts, MD Ajay Singh, MD Vacant Vacant Vacant Vacant Vacant
Wednesday, August 29, 2018 6:00pm-8:30pm The Painted Cork in Historic Folsom, CA 726 Sutter St., Folsom, CA 95630
Cost to Attend: $10.00 Enjoy an evening of guided painting, light appetizers, a beverage of your choice, and socializing with colleagues!
To register contact Mei Lin Jackson at firstname.lastname@example.org or (916) 452-2671.
Margaret Parsons, MD
CMA Immed. Past President Ruth Haskins, MD CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD
Sandra Mendez, MD MS III Steven Nemcek, MS III John Ostrich, MD Karen Poirier-Brode, MD Neeraj Ramakrishnan, MS II Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD
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Physician Paint & Sip Night!
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 Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Chris Serdahl, MD Don Wreden, 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
SSVMS’ Joy of Medicine Presents:
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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Prescription Drug Spiral By Rajiv Misquitta, MD BY ALL ACCOUNTS, the use of prescription drugs seems to have spiraled upwards in the United States. According to the Centers for Disease Control (CDC), almost 50 percent of Americans have used at least one prescription drug while an astounding 30 percent use more than three prescription drugs. These numbers were actually increased from 2013 to 2014 when the data was collected.1 Spending on prescription medications is higher in the U.S., per capita, than in any other country in the world, according to a recent Journal of the American Medical Association study.2 Furthermore, prescription drugs in the United States will increase four to seven percent through 2021, reaching $580 billion to $610 billion, according to a report released by QuintilesIMS. Increased prescription drug use is likely related to several factors that include medical need due to increased disease prevalence and increased direct-to-consumer advertising, expansion in health insurance and drug coverage.3 In addition, rising public health threats include the misuse of antibiotics and the rise of antibiotic resistance, and the increasing overuse of prescription opioid painkillers, contributing to a national drug overdose epidemic and rising drug-related deaths.4,5 According to the CDC, half of all opioid overdose deaths involve a prescription drug, and those overdose deaths have increased steadily since 1999. Many of these patients also end up in emergency rooms for addiction of opioids. In 10 states, the top prescription was opioid pills (Vicodin or Norco), according to data from Goodrx, an online prescription service. In California, opioids (Norco, Vicodin) rank as the number 2 drug, while Atorvastatin tops the list at number one.6 These two classes of medicines are very different and here are my
thoughts on each: Opioids: The rise in opioid deaths is likely related to the rise in prescriptions for that class of drug. The medical community has responded to this problem. I had a chance to speak with Dr. Sameer Awsare, who has been heading an initiative aimed at reducing opioid prescriptions at Kaiser Permanente. Since March 2015, Kaiser Permanente has cut the number of opioid prescriptions by one-third. They developed an education program in 2014 for physicians, clinicians and pharmacists to gather and review the guidelines around opioid medications. They have added more protocols around pain medications, and offer more lifestyle and complementary alternatives. Since 2014, Kaiser Permanente has also adjusted its electronic medical records with “smart tools” that alert doctors about risks and guidelines before they sign off on a prescription. Our medical society has also been leading the charge in Sacramento with the SSVMS RX Safe Physicians program. This coalition of physicians and community experts focuses on educating providers, promoting complimentary methods of pain management to physicians and patients, and increasing access to Naloxone. It is a great resource for any of our physicians. Non-Opioids: It is no surprise that Atorvastatin is the number one drug prescribed in California. Recent guidelines for cholesterol management proposed by the American College of Cardiology (ACC) and American Heart Association (AHA) recommend statin therapy for most men in their 60s and most women in their 70s. In addition, the National Committee on Quality Assurance (NCQA) in its Healthcare Effectiveness Data and Information Set (HEDIS) has clearly made the prescription of statins a priority in patients with cardiovascular disease
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.
and diabetes. Conspicuously absent is any measure of lifestyle interventions, such as diet and exercise, which can be just as powerful when deployed correctly. As a result, it is much easier for organizations to pull the medication lever to meet the metric while sacrificing resource allocation to lifestyle interventions which, I will argue, is more important. This could easily apply to other medications used to treat chronic conditions. Although it is much more difficult to get funding for non-pharmaceutical or lifestyle studies, there is increasing data on the impact of regimented lifestyle programs on conditions such as prediabetes, diabetes, coronary heart disease and weight-related disorders. A classic example is the prediabetes program that has lowered the number of patients progressing to diabetes.7,8 As a principal investigator of an ongoing lifestyle clinical trial to reverse diabetes and heart disease, the value of these interventions is clear to me. I routinely am able to wean down and, in several cases, take diabetic patients completely off their insulin as they progress through the program. Developing programs such as these to change behavior is not easy in the current medical model, as a singular office visit is usually not sufficient. The complexity of behavior change is better approached through a multi-disciplinary, longterm program that is evidence-based. I am lucky enough to belong to an organization that can support such a model; however, it is not directly reimbursable in most other systems. The savings that would come from reduced complications and surgeries are not easily captured, as reimbursement is based mostly on disease burden with little to no support for structuring lifestyle programs. These trends are slowly starting to change with CMS now offering reimbursement for prediabetes programs. Furthermore, a new field called Lifestyle
According to the CDC, half of all opioid overdose deaths involve a prescription drug…
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Medicine, which focuses on evidence-based behavioral programs to prevent and treat chronic disease, has finally matured into a discipline, complete with board certification, as well as curricula that are being developed in medical schools to train our next generation of physicians.9,10 It is applicable to all physicians, regardless of specialty. As physicians, we can do more to restore the health of our patients while reversing this trend of increasing prescription usage and polypharmacy. I invite you to think about your current practices and to speculate as to whether there might be options for the development of lifestyle intervention programs to achieve the best health outcomes in your patients. In closing, I would like to extend a heartfelt thanks to all of you for your compassion and continued work to heal our patients and our community. email@example.com REFERENCES 1 1 CDC, Health, United States 2016 National Center for Health Statistics. Health, United States, 2016: With Chartbook on Longterm Trends in Health. Hyattsville, MD. 2017. 2 Kesselheim AS, Avorn J, Sarpatwari A. The High Cost of Prescription Drugs in the United States Origins and Prospects for Reform. JAMA. 2016;316(8):858–871. doi:10.1001/ jama.2016.11237. https://jamanetwork.com/journals/jama/articleabstract/2545691. 3 Wilkes M, Bell R, Kravitz R. Direct-to-consumer prescription drug advertising: trends, impact, and implications. Health A 2000;19(2):1–19. 4 Rossen LM, Bastian B, Warner M, Khan D, Chong Y. Drug poisoning mortality: United States, 1999–2014. NCHS. 2016. [website] Last updated March 30, 2016, https://blogs.cdc.gov/ nchs-data-visualization/drug-poisoning-mortality/. 5 American Society of Addiction Medicine. Opioid addiction 2016 facts and cures. [website] Accessed December 15, 2016. http:// www.asam.org/docs/default-source/advocacy/opioid addictiondisease-facts- gures.pdf. 6 https://www.goodrx.com/blog/the-most-popular-drugs-in-americaby-state/. 7 The Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): Description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171. 8 The Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403. 9 Kushner, R.F.; Sorensen, K.W. Lifestyle medicine. Curr. Opin. Endocrinol. Diabetes Obes. 2013, 20, 389–395. 10 https://www.lifestylemedicine.org/.
Letters From Our Readers Dear Editor, I just finished reading the March/April issue of Sierra Sacramento Valley Medicine and enjoyed it from front to back. I read each issue faithfully and always learn something. Thank you for continuing to send me the magazine. Dr. Fred Pratt, my late husband was a SPIRIT volunteer and occasionally wrote for the magazine. Keep up the great work. Sincerely, Patricia Pratt
Dear Ms. Wetzel, I received the SSVMS Bulletin this week. I want to tell you that you are doing a great managing the Medical Society. I know this is not an easy job. The articles are timely and interesting, but most of all it keeps us in contact with our colleagues and current problems facing our profession. Please keep up the good work. Sincerely yours, R.J. Frink, MD
Dear Editor, Yes, I am pro-life. Here’s why. Our colleague, Dr. Elizabeth Mathew, wrote in the May/June 2018 issue of SSV Medicine about her encounter with a pro-life demonstrator near an abortion facility in Sacramento. Bravo! One of the most unfortunate aspects of the enduring conflict over abortion is that those on either side of the debate rarely engage with each other over the issue. Dr. Mathew’s willingness to do so is both noteworthy and laudable. However, in my opinion Dr. Mathew’s arguments miss the mark. She expresses a common tendency in the pro-choice community of
attempting to discredit the pro-life movement by identifying apparent hypocrisies among its members, such as unwillingness to support children after birth and to oppose the death penalty, war, environmental degradation, etc. Apart from the fact that this is an inaccurate depiction of the pro-life community, the argument itself crumbles under scrutiny. Consider this: If I see a child about to wander into the path of a speeding car, should I first pause and determine whether or not I am willing to adopt that child should he or she be subsequently abandoned by the parents? To avoid the taint of hypocrisy, must I first assure that the child will be well cared for after the rescue? Are my views on war or the death penalty or the environment relevant to my decision to snatch – or not to snatch – the child from harm’s way? I think not. Does the intentional nature of abortion – in the above example perhaps better illustrated by considering whether I should push the child into the path of the car to spare him or her a difficult future – change the calculus? Again, I think not. While such broad social questions are important in themselves, they should not be used to justify the taking of a human life, either through direct action, such as abortion, or failure to act. Most importantly, the search for supposed moral inconsistencies in abortion opponents ignores the central argument against most legalized abortions. That argument is based on the scientific fact that the human fetus is a human life. The human fetus meets all scientific definitions of life (metabolism, growth, development, etc.), and the fact that the gametes contributing to this life are from Homo sapiens means that the new life is of that same species, i.e., human. Those who insist on certain additional functional and developmental characteristics before acknowledging human life – characteristics
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.
Dirty Money By Gerald Rogan, MD Guest Editorials are welcome, as are comments regarding the editorials themselves. FOR SSV MEDICINE READERS who want to know more about corruption, watch “Dirty Money” on Netflix. Exposés include prescription drug rip-offs by Valeant Pharmaceuticals (VRX), money laundering for narco-terrorist organizations by HSBC bank and holdings (HSBC), failure of our U.S. criminal justice system to prosecute white collar collaborators, and allowance by European governments to permit Volkswagen (VLKAY), BMW (BAMXF), and Mercedes (DDAIF) to pollute the air with toxins from diesel engines, in order to maintain manufacturing jobs. In the drug business, Valeant Pharmaceuticals acquired many drug companies that are the only manufacturers of life-sustaining drugs for rare conditions such as Wilson’s disease of copper metabolism. After acquisition, Valeant raises the price of each drug several hundred percent. To assuage consumer anger, Valeant provides patient assistance programs to fund the co-payments and deductibles. Insurance companies pay the higher prices and raise insurance premiums to cover their increases. Other
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ ssvms.org.
pharmaceutical companies have adopted the same business plan, which is not illegal. In the automobile business, Volkswagen, Mercedes Benz, and BMW install defeat devices into their diesel cars which allow the car to pass emission inspections during testing. Tests of the car while driven shows the actual pollution is 40-50 times the legal limit. The U.S. stopped this for Volkswagen, but the European countries have not in order to maintain manufacturing jobs. Under European law, protecting the life of the engine is more important than protecting the health of its citizens. In the banking business, HSBC admits it launders money for drug cartels and terrorist organizations. The U.S. Government fined HSBC, but no one went to jail, unlike those who are caught selling illegal drugs on the streets of our communities. Tens of thousands of Mexicans have been killed in order to assure the insatiable U.S. market demand for recreational drugs is met. The web link to this program is: https://www.netflix.com/title/80118100. firstname.lastname@example.org
Letters From Our Readers continued from page 5 conveniently not yet present in the developing fetus – are trading in casuistry and prejudice, not science. This, then, is where the true hypocrisy lies: How can we pride ourselves on our respect for science and opposition to war, the death penalty, lack of social support systems, and devotion to
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myriad other humane causes, yet deny the humanity and protection of the human fetus? I am pro-life because the scientist in me knows that the human fetus is a human life, and the human being in me knows it is wrong to take it. Stephen A. McCurdy, MD
To Parent or Not to Parent? A 2018 ACOG Medical Student Essay Contest Winner
By Brenda Tran Wu, MS II EDITOR’S NOTE: In January of this year, the American College of Obstetricians and Gynecologists, District IX (California), sponsored its 11th annual medical student essay contest, inviting original compositions on why the writer is interested in the OB/GYN specialty. Brenda Tran Wu, a second year medical student at UC Davis, was one of two chosen winners this year. This is her essay, unedited. MY MOM RAISED ME WITH no help from my father. An immigrant from Vietnam, she hardly spoke English as she moved through her jobs in San Francisco as a hostess at the local Holiday Inn, a bank teller, and ultimately as a letter carrier for the US Postal Service. She loves singing, ballroom dancing, cooking, and – above all – my brother and me. In her, I see every reason to believe that moms are little short of superheroes; and that parenting ultimately requires sacrifice only those willing and ready should be subjected to. As I reflect on my interest in OBGYN, specifically in Family Planning (FP) and Reproductive Endocrinology & Infertility, I realize my passion lies in providing the freedom of choice to, or not to, pursue motherhood. Any outcome of pregnancy has lifelong effects on emotional, physical, and socioeconomic status. Thus, it is imperative that this choice be appropriately supported by healthcare providers, whether that means terminating an unwanted/unplanned pregnancy or taking advantage of technology to suspend the biological clock. “To parent or not to parent?” is a difficult decision to make. What an honor it will be to support my patients in such a deeply personal decision. Having a child is no frivolous undertaking. I am pro-choice, but also pro-life. What kind of
life will a child live if their existence was against the will of their bearer? My attendance at the 2017 National Medical Students for Choice Conference opened my eyes to how privileged I am to live and train in California, a state mostly supportive of abortion rights, especially at an institution home to a robust FP program. A recurring theme at the conference was the inaccessibility of abortion care for women in rural parts of the country. I met colleagues from schools that forbid abortion training and others whose nearest FP doctor is a 6-hour drive away. In addition to varying legal restrictions, the sparsity of clinics in rural areas is another barrier to the time-sensitive treatment that abortion requires. Few of these clinics offer abortion care at all, necessitating hours of travel for a simple procedure. Unwanted pregnancy has an inherent emotional toll, reducible with two pills; but without ready access to these pills, women – many of whom with low-income status – are forced to put off treatment until their second or third trimester, drastically increasing risks and costs of the procedure. Although CA is mostly supportive of abortion rights, there are still barriers for accessing health care in rural communities. A recent study by BMC Health Services assessed distancetraveled for Medicaid-covered abortion care in CA and found that 51% of women who traveled 50+ miles identified as rural women.1 While shadowing a FP mentor, I met patients who traveled 3+ hours to receive care. One did not have a car and worked an inflexible job, so she postponed her trip until a day off from work that suited the bus schedule. To increase access for rural populations, I hope to see progress in a) allied health July/August 2018
professionals, including NPs and PAs, trained and licensed to provide medication abortions; and b) medical abortion care via telemedicine.* Unfortunately, the current state of affairs in 34 states requires medication abortion be performed by licensed physicians; and 19 states require that the provider be physically present during the procedure, inadvertently prohibiting telemedicine.2 Policy change of these restrictions will dramatically improve access to care for rural populations and reduce risk and costs of second and third trimester terminations. The pending CA Senate Bill 320 would increase access for students by allowing medical abortions on college campuses; this can serve as a model for colleges in rural communities nationwide. The unfair stigma surrounding abortion further exacerbates the issue. As I see it, many medical issues result from poor lifestyle choices: smoking causes lung cancer, which is treated without restriction; unsafe sex causes STDs, also
treated without restriction. Unprotected sex may cause pregnancy, a medical consequence like the rest, that should also be fairly treated – by choice, of course – without restrictions. In the capacity my career will afford me, I aspire to close the gap between the supply and demand for women’s reproductive healthcare. “To parent or not to parent?” There is one right answer, and that is the one each woman makes for herself. email@example.com REFERENCES 1 Johns, N.E., Foster, D.G. & Upadhyay, U.D. BMC Health Serv Res (2017) 17: 287. https://doi.org/10.1186/s12913-017-2241-0 2 Medication Abortion. Guttmacher Institute, January 2018. https://www.guttmacher.org/state-policy/explore/medicationabortion.
*AUTHOR’S NOTE: By that, I mean offering remote access to medical advice (i.e. via video call/Skype) and prescription of abortion medication, if appropriate.
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Crypto, Shmypto Things My Father Never Had to Worry About
By Jack Ostrich, MD
MY FATHER DIED IN 1974 at the age of 64. He graduated from Hartford (Connecticut) High School in 1927 and at once went to work at the Phoenix State Bank, which institution was housed in a handsome, wrought iron bedecked building across from the Old State House on Main Street in downtown Hartford. The bank had no branch offices, and was open for business from 9 to 3, Monday through Friday. There were never any evening or weekend hours. Hence the term, “banker’s hours,” I suppose. His first job at the bank was as a “runner,” carrying paperwork, documents, and messages between departments. He soon became a teller, then Chief Cashier, and finally Vice President and Comptroller. As I recall, Dad mostly worried about common domestic issues such as making mortgage payments, and saving enough for family summer vacations at a New Hampshire lake or at Cape Cod. My mom was always at home, so we relied solely on his salary. He somehow managed to send my sister and me to private four-year colleges and then me to an out-ofstate medical school. As the years went by, he had few worries. The Eisenhower years were fairly benign, and the contentious 1960s seemed a world away. So he was not a worrywart and was slow to be upset or angry. But I bet that he might be worried and agitated nowadays. I recently found myself musing how he might respond to some of our modern topics, personalities, and preoccupations. Here follows a partial list:
MARTIN SHKRELI – Who became a poster boy for capitalist greed for raising the cost of Daraprim by 5,000
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percent and so earned the nickname “Pharma Bro.” Posing as a financial wizard, he also managed to extract a lot of money from a goodly number of foolishly greedy people. He spent much of that money on himself, most famously to buy a one-of-a-kind recording called “Once Upon A Time In Shaolin” by a group called Wu-Tang Clan. He claims that he paid $2 million for the recording. Shkreli was recently sentenced to several years in federal prison because of securities fraud, and ordered to pay back, at least in part, his former investors by liquidating his own $5 million brokerage account and by selling the Wu-Tang Clan recording, the proceeds of that sale also to go towards repaying the bilked investors. If any of you are interested in buying the recording, contact Mr. Shkreli at the Federal Correctional Institution at Fort Dix, New Jersey. The phone number there is (609) 723-1100. The riskiest investment my father ever made was buying some American gold coins. After he died, my wife and I sold many of them and used that money as a down payment to buy our first house in Van Nuys, in the heart of the San Fernando Valley.
WU-TANG CLAN – Is a New York-based “hip hop” or “rap” music group that formed in 1991. Original members included RZA, GZA, Ol’ Dirty Bastard, Method Man, Raekwon (Da Chef), Ghostface Killa, Inspectah Deck, U-God, and Masta Killah. Ol’ Dirty Bastard died in 2004 at age 35 due to a drug overdose. His given name was Russell Jones. Wu-Tang created four gold and platinum
studio albums, and they have been praised by some modern music critics as the most influential hip-hop or rap group in history. But their greatest, or at least most famous, production is titled “Once Upon A Time In Shaolin.” Only one copy was made, and it was sold by an online auction house called Paddie8. Martin Shkreli (see above) bought it for a reported $2 million. One can “Google” Wu-Tang Clan and go to a site that features many of their hits. I am sure my father would not appreciate any of Wu-Tang’s musical offerings. He liked singers like Doris Day and Perry Como, vocal groups like the Mills Brothers, and bands like Harry James’ and Lawrence Welk’s. Doris Day’s given name, by the way, was Doris Kappelhoff. As of this writing, she is alive and reasonably well at age 96.
FURRIES – Are people, mostly adult males, interestingly, who, for whatever reason, develop strong feelings for, and then identify with, a specific animal. They then assign a personality to that animal, called a “fursona” and finally have an appropriate costume made for themselves. Most of the costumes look like the ones you see being worn by mascots at football or basketball games. Many defy precise classification, but most seem primarily mammalian. Some are exotically colored, and all, of necessity, are bipedal. There are an estimated 250,000 Furries in this country and many more in foreign lands. In the USA, the Furries have for many years held a national convention, called “Anthrocon,” in Pittsburgh, Pennsylvania. It was the world’s largest Furry convention until, in 2017, the Midwest FurFest, held in Rosemont, Illinois, attracted 8,700 Furries, thereby wresting the title from the Pittsburgh gathering. Every Furry is now on tenterhooks waiting to see whether Rosemont or Pittsburgh will emerge as the Furry first choice for 2018. The only time I recall my father in any sort of costume was when he took part in the annual “Hospital Days” parade in New London,
New Hampshire. We were staying at a lodge on nearby Pleasant Lake, and the lodge had sponsored a float in the parade that consisted of a boat towed by a pickup truck. My dad was in the boat dressed as a sloppily-clad fisherman, holding a broken fishing pole. On the boat was painted, in large red letters, “Fishing Stinks At Linc’s.” The first name of the fellow who ran the lodge was Lincoln, “Linc” for short. Linc was happily driving the pickup truck. Otherwise, my father dressed for work every day in a suit, white shirt, muted tie, wellpolished wing tip shoes, and dark colored over-the-calf socks held up by garters. In fall and winter, he wore a gray felt fedora and, in spring and summer, he sported a snap-brim Panama hat. Both were Stetsons. The only convention he ever went to was the national Kiwanis meeting in Los Angeles in June 1948. He was the national Kiwanis treasurer that year. He took the NYNH&H train to New York, then the Twentieth Century Limited to Chicago, then the Super Chief from Chicago to LA.
BITCOIN – Is the most famous and notorious “cryptocurrency.” There are over 1,300 cryptocurrencies presently in existence. One of the most recent was started by a performer named Barsun Jones, whose stage name is “Young Dirty.” He is the son of Russell Jones, AKA Ol’ Dirty Bastard (see above, under Wang-Tu Clan). Young Dirty’s cryptocurrency is called Dirty Coin. As for Bitcoin, it began in 2009 and was designed to contain a maximum of 21 million Bitcoins. The purported founder’s name is Satoshi Nakamoto, which is probably a pseudonym for a person or persons. In his/her/their honor, the Bitcoin is divided into much smaller units called “Satoshis.” There are 100 million Satoshis in one Bitcoin. As of this point in 2018, one Bitcoin is worth between 9 and 10 thousand U.S. dollars, so that you can buy a six-pack of pretty good beer for about 100 thousand Satoshis. One does not buy Bitcoins; one “mines” continued on page 13
There are an estimated 250,000 Furries in this country and many more in foreign lands.
Medical Student Burnout By Sehra Rahmany, MS II
FOR MOST STUDENTS, earning admission to medical school is a dream come true. The excitement is hardly containable and, as classes start, it is easy to feel invincible. You are ready to fill your calendar with new opportunities, interest group meetings, research projects, and anything else that comes your way, only to top it off with studying well into the night. As a first-year medical student, I was bombarded with generalizations and platitudes pushed on me and my class. We were told, “Sleep deprivation is normal,” or, “You should have anticipated the pressure of med school.” Indeed, there are lots of nights when medical students get only a few hours of sleep, and, yes, there is a lot of pressure on all of us, related to the fact that one day we will be caring for others. However, this does not justify the regular practice of depriving yourself of sleep. Nor must you belittle yourself if you are having trouble with the pressures and rigors of medical school. Furthermore, these exaggerated stressors placed on individuals may eventually manifest as anxiety and potentially lead to depression, for which medical students are at particular risk. A meta-analysis done in 2016 indicated that the overall prevalence of depression or depressive symptoms in American medical students was 27.2 percent, and 11.1 percent reported suicidal thoughts.1 Research done by Ishak, et al., concluded that burnout, if not controlled, may lead to potentially disabling psychiatric disorders and suicidal ideation.2 Moreover, a meta-analysis by Frajerman, et al., which included thousands of European medical students, found that 46 percent were suffering from burnout and subsequent emotional exhaustion.3 It seems clear those findings suggest that trouble lies ahead if no intervention takes place.
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How can medical students and their mentors help prevent burnout? Prevention begins with the implementation of curricular and extracurricular programs that promote and teach psychological health strategies. These programs can be an incentive for students to focus on the importance of self-care during medical school and for the many years after graduation. If we cannot care for ourselves, we cannot be expected to care properly for our patients. I can attest to being a medical student who experienced burnout without realizing it. My excitement for learning never faded, but I came to a point in my first year when endless hours of studying were no longer effective. My entire life revolved around studying and practicing skills. I became anxious, which led to impaired performance in my courses. I had, unintentionally, built a system so strongly favoring schoolwork that it had led to deterioration of my psychological, and even physical, health. Since that realization, I have been actively focused on restoring the balance in my life. I have set aside time for self-care, which, I believe, has allowed me to meet the demands of my rigorous curriculum much more effectively than when I had solely concentrated on my studies. Along the way, I have learned strategies which have helped me cope with the demands of school. These strategies include meditation, positive self-talk, exercise, and breathing techniques. All of these have significantly reduced my anxiety. Practicing deep breathing prior to exams, and focused meditation have been instrumental in my ability to cope and develop a stronger sense of self. In addition, I have a more acute mental awareness, and I practice healthier daily routines. The transition into medical school was not easy, and many students will, of course,
continue to find it difficult. That is why we have to change the dialogue from, “You should have known what you were getting into,” to one that proclaims, “You are not alone.” Currently, my mentor and I are planning for 20-minute guided meditation sessions prior to exams or quizzes to be offered to all interested students. As I move toward my second year of medical school, I will both advocate for, and strive to maintain, healthy routines that will promote physical and mental wellbeing. My hope is that all medical students will find a formula for mental, physical, and academic success. Sehra.Rahmany4931@cnsu.edu REFERENCES 1 A Systematic Review and Meta-Analysis. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students. Rotenstein L. et al. December 6, 2016. Jamanetwork.com.
2 Burnout in medical students: A Systemic Review. Ishak W. et al.August 10, 2013. Ncbi.nlm.nih. gov/pubmed. 3 Burnout in medical students before residency: systematic review and meta-analysis. Abstract presented at the 26th European Congress of Psychiatry: March 5, 2018: Nice, France. Abstract 0R0050.
Medical Student Wellness Library The SSVMS Medical Student Wellness Library is comprised of resources that address themes students in medical school may encounter such as student burnout, anxiety, and depression. The resources range from articles, podcasts and videos, and include information on local university wellness programs, anecdotes from past medical students and how to address stress and depression. The Library also provides recommended reading for medical students. To view the Medical Student Wellness Library, go to http://joyofmedicine. org/medical-student-wellness-library/.
Crypto, Shmypto continued from page 11 them and then keeps them in a web-based “wallet” that is, in turn, electronically connected to a “blockchain.” The folks who maintain the wallets and blockchains must, of course, be trusted implicitly. Transactions do not create easy-to-follow internet or paper trails, so Bitcoin is often the first choice for terrorists, arms dealers, or rogue nations who need to move a large amount of money. Profits made by selling Bitcoins are easy to hide, so our own Internal Revenue Service has a burning interest in Bitcoin. My dad, I am sure, would not cotton to cryptocurrencies in general. He liked the look, feel and smell of the brand new banknotes that arrived every couple of weeks from the Federal Reserve Bank in Boston. When he was head cashier at the bank, I used to help, on rare occasions, to riffle through the accumulated cash deposits that were held in the huge walk-in vault at the west end of the bank lobby. My job was to locate and extract worn or tattered bills, and sort them by denomination. They would then be counted, bound, and sent
back to Boston. The folks there would then send back nice, new, crisp notes. When we did the sorting and counting, at least two bank officers and an armed guard were present. The interior of the vault was always cool, even on the muggiest Hartford summer day. There would be a Brinks armored truck parked in front of the bank, and, when we had finished our sorting and counting, the armed Brinks men would come in, take the old cash out to their truck, and whisk it off to Boston. The Phoenix State Bank and its building are long gone, and Hartford’s Main Street has changed mightily. I guess Bitcoin, or something like it, is the future of money. If I told my dad that, as he settled down after work in his favorite rocking chair in front of our living room Philco TV set, he would probably have muttered, “Crypto, shmypto,” but only after he had turned on the evening news with John Cameron Swayze. Had to stay informed and up to date, after all. firstname.lastname@example.org July/August 2018
By Bob LaPerriere, MD
Comments or letters, which may be published in a future issue, should be sent to the authorâ€™s email or to SSVMedicine@ ssvms.org.
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Reprinted from June 1966
as to the need for rigid self-discipline and understanding, by physicians, of their responsibility to see to it that the charges for persons under this law are not greater than for their other patients. There are many problems which have not yet been resolved, including the problem of payment for radiologists and pathologists in hospitals, but solutions are developing which will gradually become apparent. TWO DIFFERENT PROGRAMS The Medicare provisions for persons 65 and over, (included in Title XVIII, Parts A & B) contain significant differences from the provisions under the Medical Assistance programs, (Title XIX of the Social Security Law, known in California as the Cal-MAP or Casey-Bill program). A considerable amount of confusion will develop because of these differences. It will be very important to keep them separated in our thinking, even though both will be administered in Northern California by CPS and Blue Cross. There has been much speculation as to the potential increased load on hospitals and physicians’ offices with the beginning of this new law. It is true that in the Sacramento area we do not have any excess, or even a comfortable margin of flexibility, in available hospital beds. However, there is a strong feeling that most persons here, both over and under 65, who needed care, have received it in the past, that there is no large reservoir waiting for the July 1 deadline, and that the surge of demand will be relatively slight and relatively short-lived. No one can be certain of this and we must all await the experience of the next three months. There will probably be an increased load on physicians’ offices, particularly in internal medicine and general practice, but not beyond the ability of our Sacramento physicians to accommodate.
RESPONSIBILITY REMAINS In spite of all the publicity, irritation, and emotionalism, the beginning of Federal Medicare on July 1 is not the millennium. It does not spell the end of freedom in American medical practice, even though it may rightly be regarded as a significant step in that direction. Our responsibility remains exactly as it was before – to provide the maximum quality, availability, and acceptability of medical care to all the people of our community, regardless of their financial or social circumstances. We need to be alert to identify influences
of this new program which interfere with this maximum quality. To the extent that we make an accurate identification of such interfering influences and to the extent that we continue to accept our own social and political responsibility, our opportunity to control continued expansion of the law or its concepts will grow, and will remain to large degree in our own hands. RALPH C. TEALL, M.D. Immediate Past-President California Medical Assn.
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Fueling Patient Hope in the Midst of Illness Reflections From the Front Lines
By Vicki Wolfe, Communications Manager, BloodSource
I ARRIVED AT BLOODSOURCE in 2000 to work in a communications role after two bouts with acute promyelocytic leukemia (APL or AML/M3), a Phase II clinical trial, an allogeneic bone marrow transplant (BMT) and a massive number of blood transfusions. It is easy to see where my passion for a safe and plentiful blood supply originates. As critical as the need for blood was the need to find hope in a journey containing an abundance of bad news and situations. The list seemed endless: fungal infections, poor blood counts, adverse reactions, unbearable pain, delays in treatments, relapse, being ineligible for innovative treatments, additional hospitalizations, deteriorating finances, separation from my children and so much more. In the midst of the miasma of despair, there was always hope. I just needed to know where to look because hope shows her face in many ways. I was diagnosed with a rare leukemia, but a new medication (all-trans-retinoic acid or ATRA) had recently been approved and changed the dismal survival rates of APL exponentially.1 Hope. I was in disseminated intravascular coagulation (DIC) – a brutal condition that frequently leads to death in APL patients – but with ATRA, high-dose chemotherapy and availability of blood, I went into remission. Hope. When I relapsed and needed a bone marrow transplant (BMT), a perfectly matched sibling leaped to my side. Hope. I was too sick to go to transplant, but there was a clinical trial specifically for patients in my situation. Hope. You get the idea. Elusive
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hope could be found. Even on my worst day when death actually didn’t seem that fearful due to unremitting and unbearable pain, hope appeared in little ways – a smile, a better test result, a handmade card from my young daughter, a caring medical professional, even a bag of platelets. Each day I was reminded of brilliant researchers, great medical professionals and the kindness of strangers, all fueling hope for my future. Those reminders are still available for patients today and, for those of us with leukemia, are displayed through the availability of blood, clinical trials, and hematopoietic transplantation.
Blood Upon my diagnosis, a solemn doctor declared, “You are going to need a lot of blood.” My first thought was of tennis pro Arthur Ashe, who contracted HIV from blood transfusions he received during heart surgery and subsequently died from AIDS. I waved the doctor off, assuring him that I had many family members who could donate to me. I was clueless about so many things: my disease, leukemia, DIC, and blood, including the specific roles of red cells, platelets, plasma and what the heck were fibrinogen and cryoprecipitate? That first round of treatment included 158 blood transfusions, and not one was from a family member. My future held relapse, a BMT and a lot more blood. Before my medical care for APL ended, I would receive approximately
300 blood transfusions or 37.5 gallons. When I take a moment to imagine all that blood needed by one small patient, it’s overwhelming. I’ve received blood from three different blood centers in three different states. The safeguards surrounding blood collection, testing and transfusion have made the blood supply today safer than ever before.
Clinical Trials Relapse was unexpected and devastating, but during remission, there had been great fanfare about a new clinical trial for APL treatment.2 Eleven of 12 relapsed APL patients were able to achieve a second remission with this new drug: arsenic trioxide.3 Naturally, the first thought that occurs after a moment of reflection, is, “Doesn’t arsenic cause cancer?” The short answer is yes, sometimes but in this case, no. Chinese researchers had explored a rural medicine concoction that included components of arsenic, mercury, and toad venom that led to a U.S. clinical trial with just one of those deadly components.4 A Phase II clinical trial was beginning as my relapse firmly took hold. My medical team enthusiastically encouraged me to enroll. I declined participation twice wanting to head directly to BMT having read the fine print that even if the clinical trial was successful, a transplant would still be needed. However, by the time I got to the transplant center and completed the barrage of pre-transplant exams and tests, my disease had advanced so quickly that going directly to transplant was no longer an option. Thus, as the nurses donned hazmat protective gear to infuse small amounts of arsenic trioxide into my body, I settled in to trust that this three-month experiment with arsenic would work. When remission finally came, so did the dawning realization that just maybe I would live to mother my young daughters to adulthood. Hope. Arsenic trioxide is now approved as one of the front-line treatments for APL leukemia.
Transplantation APL/M3 today is considered a “better”
leukemia to have than others and seldom demands hematopoietic transplants, but not in my case. By the time I actually made it to transplant, the informed consent process would do its best to banish hope much like the 10 percent prognosis of survival initially received. But by that point hope had won so many times, I would not leave her behind.
SSVMS founded BloodSource in 1948. Thanks to the generosity of donors throughout Northern and Central California, BloodSource, now a Blood Systems Blood Center, provides nearly every drop of blood used in over 40 hospitals in the region. While safer today than ever, a BMT is still a high-risk procedure with potentially life-threatening and life-altering toxic effects.5 In layman’s terms, a bone marrow transplant involves destroying the very system that has had as its lifetime mission to protect you from the random virus, bacteria, microbe, or any number of ill-intentioned bugs that can potentially harm you, maybe even kill you. Once your original immune system has been decimated by chemotherapy and/or radiation, new blood stem cells are infused that match your originals as closely as possible, but without the flaw that necessitated this whole process in the first place. Those precious donor blood stem cells are infused along with the hope that your body will welcome them and give them space to grow and live in harmony with the rest of the body. Fortunately, in my case, it worked quite beautifully. Throughout it all, it was clear that there are no guarantees as to the outcome. Grace is as much a part of this picture as is blood, a clinical trial, and successful transplant. But you cannot enter into this journey without hope in the happy ending. Nineteen years later, I am healthy and still grateful each day for mine. firstname.lastname@example.org
REFERENCES 1 https://bit. ly/2gYZnnr 2 https:// ab.co/2IBVF0W 3 https://bit. ly/2s2kdZY 4 https://nyti. ms/2IBJYHD 5 https://bit.ly/2LklLYo
SSVMS 150th Annivers On May 5, 2018, the Sierra Sacramento Valley Medical Society (SSVMS) celebrated its 150th Anniversary at historic Sutterâ€™s Fort in Sacramento. Over 250 members and their families attended the event and relived the Gold Rush era. Attendees enjoyed food, beverages, pioneer games, crafts, music and dancing. SSVMS was founded in 1868, and for 150 years has been dedicated to bringing 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. â€“Photos by Bob LaPerriere, MD
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How the Teacup Got Its Handle A story of state secrets, espionage, royal prisoners and the chances of geography
By Sandra Hand, MD
WE FREQUENTLY HEAR that drinking tea may improve our health with such benefits as: “Tea contains antioxidants.” “Tea has less caffeine than coffee.” “Tea may reduce your risk of heart attack and stroke.” “Tea may boost the immune system.” Tea drinking dates back centuries, and the teacup itself is steeped in rich history. Tea has been enjoyed in China for millennia, and since at least 100 years BCE, the Han Chinese had drunk it from porcelain tea bowls. Porcelain has a very highfiring temperature which turns feldspar silicates and kaolin clay found in certain parts of China into a very hard white glass-like material that is translucent, resonant, tough and very resistant to thermal shock. It is nonporous even without a glaze, though cobalt blue was often added for decoration. It can be made very delicate, and the hard paste (as the material is called) before firing, is very easy to mold and will hold intricate shapes through the high temperatures in the kiln. Chinese porcelain objects had been known in 13th century Europe and were called fine china because of their country of origin, but the knowledge of how to make it was a carefully held secret by the Chinese. Thus it was a very expensive import ware mostly bought by the aristocracy and wealthy traders. Tea made it to Europe in the 16th century, brought in mostly by Dutch traders from China and later India, and sold in apothecary shops as
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a bitter-tasting medicinal. It was recommended by Dutch physicians for indigestion and low spirits. Its mood elevating and calming effects were soon sought after by aristocratic ladies who would take it in their dressing rooms as a morning libation. It was brought to England from Portugal by Queen Catherine in 1652. When sugar from the West Indies became available in the late 1600s to sweeten it, the popularity increased significantly. Chinese tea traders sent their chinaware with the exported tea. The Dutch merchants called it White Gold and charged high prices, as it was otherwise unavailable. Tea tasted best, of course, in those little china tea bowls, but to drink it hot, as they wished to in damp cold Holland or England, meant burning their fingers. The Chinese tea drinkers were quite happy with their little cups (the teapots had handles, so they did know how to make one) because they used the thin-walled material to cool the tea until it was comfortable to sip. With tea drinking spreading throughout Europe and the colonies, the search for the secret of Chinese porcelain became imperative. Since porcelain, named for pearl-like shells that looked like little pigs, was vitrified or glasslike, several potteries in France and in England tried adding ground glass (“frit”) to the clay. Indeed, this resulted in a high-gloss white pottery that fired at around 1800F instead of 2500F. The paste was soft, difficult to mold, and
slumped readily in the kiln and, despite the frit, did not vitrify. It was thicker, not very resonant, required glazing to be nonporous and, certainly, would not allow a delicate translucent cup (or a handle) to be made. This soft-paste porcelain was excellent, though, for tableware and figurines, and took cobalt or gilding for decoration readily. One king, Augustus, King of Poland and Elector of Saxony, was so anxious to grab the monopoly on hard-paste porcelain that he imprisoned a young pharmacist-turnedalchemist. Augustus assigned the man, who had bragged he could turn base earth into gold and needed to find high-temperature resistant bowls for the process, to work with a potter who had already been working on porcelain’s secrets for 20 years. Together this team worked for another decade and finally broke the barrier. The secret had been on their dressing tables for years. The very thing that whitened hair and wigs, kaolin, was the secret ingredient. In 1708, the first hard-paste porcelain cups (without handles) were produced in the area of Meissen, Germany where there was a significant deposit of kaolin. This is the magic material added to feldspar, alabaster or quartz that withstands firing at high enough temperatures to create vitreous or glasslike “china.” Eventually, the Meissen potters added a handle to the teacup so the tea could be drunk fresh and hot. In the 1740s, a Jesuit missionary priest smuggled the secret out of China and published it. The Meissen potters also developed high-temperature colored glazes. Much of the colored ware previously was hand-painted and re-fired more slowly. This slower glazing process continued to be true of soft-paste china. Meanwhile, the soft-paste potteries were continuing to secretly improve their products. The kaolin clay kilns burned a lot of fuel, so
spies would hide in competing factories to learn of any new discoveries. Soft-paste potteries in England were trying all sorts of experiments and additives to achieve vitrification without the high firing temperatures and fuel that kaolin clay (the secret of Chinese and Meissen porcelain) requires. Industrial espionage was rife. An English potter added oxen bone to a local clay that was rich in kaolin. The resultant “bone” china was as moldable as the hard paste, but it fired at the lower soft-paste temperatures and the delicate handle survived the kiln stress. Josiah Spode in 1740 perfected the process and created a much cheaper, but equally lovely and useful, translucent and thin porcelain as the hard-paste varieties. Both types of porcelain, soft-paste (including bone china) and hard continue to be made, but the majority of tea cups today are made of bone china – and they have a handle. email@example.com
Imagine a Financial Partner You Can Trust Families and businesses have relied on our financial advice and services since 1919. And because Baird is employee-owned, you can trust we’re focused on only your best interests. Patty M. Estopinal, CIMA®, CDFA 916-783-6554 . 877-792-3667 pattyestopinal.com | firstname.lastname@example.org 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.
Dr. Morse – Reflections of Early Sacramento By Bob LaPerriere, MD
YOU LIKELY HAVE your favorite doctors to provide medical care, but do you have favorite doctors from history? Familiar with dozens of physicians who have contributed to the development of medicine in our region, I have two favorites – Dr. John F. Morse and Dr. Thomas Logan. Dr. Logan wrote the first medical history of Sacramento and made numerous contributions to local medicine. A future article will feature him. Dr. Morse, however, is my favorite. He was not only involved in a myriad of health, medical and community advancements in Sacramento, he also wrote the first History of Sacramento, published in Samuel Colville’s Sacramento Directory for the year 1853-54. In his very engaging and graphic style of writing, the reader is transported back to the 1800s. Though Dr. John Morse had moved to San Francisco in 1863, his involvement in organized medicine in Sacramento was critical in the eventual formation of our current Medical Society in 1868. Dr. Morse was Vice President of the Medico-Chirurgical Association, the first medical society in California, formed in 1850. He was also Vice President of the Sacramento Medical Society that formed in 1855, barely a year after the demise of the Medico-Chirurgical Association. At its first meeting, Dr. Morse participated in a general discussion on the action of chloroform and opiates. On March 12, 1856, doctors assembled in Pioneer Hall, 20-22 J Street, and brought the California State Medical Society into being. Dr. Morse was chosen temporary Chairman of the Convention. This convention marked the beginning of organized medicine and health
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care in California. The Sacramento County Pathological Society came into being in 1858. Again, Dr. Morse was one of the first members. In addition to his intensive medical involvement, he was the first editor of the Sacramento Daily Union, a member of the Board of Directors of Central Pacific Railroad, the co-founder of the first agricultural paper on the Pacific Coast, editor of the California State Medical Journal and Vice President of the California Prison Commission. His most memorable contribution, however, is his early history of Sacramento. The following excerpts illustrate his detailed and interesting writing style: “The dishes provided consisted of boiled ham, roast beef, and a bountiful supply of hard bread. After the gastric economy had been thoroughly feasted upon these, the more substantial and necessary elements of physical life, then, sailor like, champagne, at a cost of $16 per bottle.” “From the first of August, ‘49, the deluging tides of immigration began to roll into the city of San Francisco their hundreds and thousands daily; not men made robust and hearty by a pleasant and comfortable sea voyage, but poor miserable beings so famished and filthy, so saturated with scorbutic diseases, or so depressed and despondent in spirits as to make them the easy prey of disease and death where they had expected nought but health and fortune.” “The supper was most sumptuously prepared, and champagne circulated so freely that identity became jeopardized and the very illumination of the room converted into a grand magnifying medium for the revels of fancy and delights of illusion.”
“From these sources, Sacramento became a perfect lazar house of disease, suffering, and death months before anything like an effective city government was organized. The more urgent and importunate the cries and beseeching miseries of the sick and destitute, the more obdurate, despotic, and terrible became the reign of cupidity that could give him relief –death and the grave. The grave he was not sure of, but death was certain and soon realized.” This history has just been reissued by the Sacramento Book Collectors Club (SBCC) in conjunction with the Sacramento County Historical Society. It was previously reprinted in 1945, in a collector’s edition, by the SBCC and later in a replica of the 1853-54 City Directory, now out of print. It includes historical notes on Dr. Morse by Caroline Wenzel, a former librarian at the California State Library. The current volume is an affordable paperback version with additional notes on Caroline Wenzel by Gary Kurutz and comments on early medicine by me. It is available from Amazon.com or from the Medical Society at a reduced rate for members. For further information, call the (916) 452-2671 or email email@example.com. firstname.lastname@example.org
CLASSIFIED ADVERTISING Doctor-Mentors Needed Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: email@example.com.
Seeking Physician Mentors for Medical/PA Students Are you a physician willing to donate a few hours of your time to mentor medical, PA, and NP students? The Joan Viteri Memorial Clinic (JVMC), a UC Davis School of Medicine student-run clinic, is searching for physicians to serve as mentors and preceptors to teach future month from 10:30am to 2pm. Scheduling is flexible, volunteer physicians are welcome to come as often as they desire. For more information, please contact firstname.lastname@example.org.
A Garden in Your Hand By Caroline Giroux, MD
“MAMA-A-A, WHY DO you have grey hair?” This question from my six-year-old has become more frequent, or so it seems to me. Kids appear quite gifted to mirror our own soul’s deepest torments. They can be attuned enough to voice without censorship what haunts us in the midst of mundane occupations and preoccupations. Because I do not have the energy to maintain a lie about my long-lost youth in the form of hair dye, honey. Or, like my dad who had a stressful career as an attorney, and unlike my beloved uncle with profound mental retardation who didn’t experience the luxury of an intact brain to fabricate neuroses, the exhausting activity of constantly worrying somehow depletes my body of its pigment. Because, having a husband who doesn’t care if I shave my legs or not, it would be pointless to waste time over extra, Sisyphean coquetterie steps that such high maintenance of illusory youth imply. (It would be the only goal, since I wouldn’t dare venture outside of my palette). Plus, if I were to dye my hair, he would, of course, take notice almost disapprovingly, “What is that about? It is so un-you!” (Yes, indeed, so “un-me.” But then, what is me?) Instead, I tell my adorable, inquisitive sloth face (he likes these mammals, and I find them cute too, therefore the designation is intended as a compliment) that aging is inevitable. Then he proceeds to talk about these “folds” he has also noticed in older people’s faces. Yep, we call those wrinkles. (Great that you haven’t counted mine already, and to avoid a lengthy exposé on the mysteries and other joys of senescence, I prefer to keep to myself my observation that cartilage growth seems spared of the decline process that characterizes aging. In fact, some people’s ears and noses appear to grow prominent).
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And then I go about the usual tasks of being a husbandless-for-the-day mother at home (by cleaning, cooking, sweeping, losing the battle against laundry, breaking territorial feuds between his brothers, etc.) on this supposedly blissful day. It’s Mother’s Day, a pre-Monday. (I used to hate Sundays because for many years I dreaded Mondays). My whole purpose becomes a noise trying to silence my anticipatory mind already not far from the clinical problemsolving mode, my professional persona always crossing the boundaries of my home life. I feel already dizzy by all the chaos that started during breakfast. (How can creatures smaller than me produce that many sounds and crumbs all over the house?) Amid this whirlwind, I am struggling to reach my own mother by phone or tablet to tell her the expected, almost scripted, yearly words of gratitude on this day we used to celebrate with the extended family when I was a child. But there is no room for nostalgia that day. Or for the expectation of an idyllic, motherlysonly celebration. (I hear asylum-like screams coming from upstairs). I considered myself blessed by some mythological figure emulating limitless peace once I had that quiet minute sipping tea after lunch, bathed in the enthralling noon rays crossing our kitchen windows. My little guy then hands me a card with an adorable drawing of us side by side. Above our mutual smile, I admire his unmistakably wild, curly blond hair and mine, long, straight, without a hint of a silvery strand. We look happy, like in all his drawings. I am touched to realize once again that his representation of me is not this frowning, disheveled middle-aged woman who is still baffled by the many ways existence let itself become so dysregulated. I can barely catch my breath in this insanelypaced life, with endless, tyrannical parameters
and rules that take a sadistic pleasure in randomness and versatility. How to keep up with daily reminders from school, weekly events like the Teacher Appreciation week (and its different things to bring every day, times three in our family…), email sign-up sheet for a hundredth class party supply list, dress code for the kids (what to wear on Autism Awareness day, or for the pajama party, or when core value is citizenship, or tolerance), for the adults (how professional should I look during this pseudo important meeting), torrential emails from work, the practice of clerical medicine, notes to compose and review within a certain number of hours, the scheduling of three volunteering sessions during a swim team meet, health maintenance (colonoscopy at 50, after the mammogram at 40… but 50 in Canada), make sure you book a flight before your miles expire, get reimbursed by department for conference-related expenses, being hooked on a TV show, new CURES* requirements because at some point, the practice of prescribing narcotics became dysregulated (and now we all have to pay the price of our time and sanity for it), not to mention keeping track of all corresponding acronyms. Let’s face it: life is high maintenance not only in monarchical states, but in different, more universal spheres: parenthood, marriage, career, finances. I am still trying to navigate adult life at the intersection of motherhood and medicine, an exotic land for which I have no map. A complex role for which I have no template. Given this very partial list above, it is astonishing that my hair has not gone entirely snow-white (like my dad’s at my age). I marvel at my son’s ability to still live in his own world, devoid of cluttering rules and contingencies. He proudly shows me his beanstalk that is growing out of the bottom of a plastic bottle. Delicately, he waters around this green miracle that thrives, with his plump hands displaying some grains of pure earth. He wonders if it will get even taller tomorrow. He smiles irresistibly as I anticipate that he might be able to escalate it to climb to the sky like Jack in the famous tale. Maybe we should read a version of the Magic Bean tonight, Monsieur Curieux et le Haricot Magique.
Thankfully, he still enjoys bedtime stories. Later that day, he proudly shows me a small, green tomato in our backyard. He wonders if by tomorrow it will be red, and if so, he will make sure to pick it right upon getting up in the morning to offer it to me. Despite the intrusion of a romanticism-murdering vision of a bulimic squirrel faster than my nobly-intentioned son, I am swept by a wave of metaphysical love, an antidote to the awareness of graying of hair or petrifying of soul. Matrescence, the “process of becoming a mother,” is still ongoing in all the cells of my body. How long will this innocence last, until his voice achieves a low-pitched virility, until his muscular, clumsy arms become suddenly distant, and his mind, contaminated by cynicism or the parade of the futility of modern life fashions? In the meantime, still shocked by the endless requirements, inescapable checklists for the multitude of roles from adult routine, I look for the purity of life, in my boy’s beautiful, sparkly eyes, in his beanstalk growing from his labor of love, in a delightful sloth-hugging moment after he gave me his card. I want to immortalize what matters and use a bit of stolen freedom through wanderings in a notebook, where I feel I can be me, my mind’s pigments tracing prose as a pen skates softly on a white page. Visiting the stationary garden, the relief of my mental pruritus, can uncover the bit of essence that we all share, by not feeling constrained to divide time or force it into the sandglass of our schedules. Trying to resist filling up my life with too many flamboyant distractions makes it simpler, quieter, richer. I am learning that a happy Mother’s Day can be as pure as dirt on tiny but full, dedicated hands, as moving as the intent behind a mini tomato offering, and as memorable as candid questions paving the way to one’s sanctuary of enoughness when we take time to look at them. Once we loosen grip on the very idea of control (of our aging process, of other people’s opinions, of the convoluted world we live in), we can even find a garden in our hand if we open it wide enough. email@example.com July/August 2018
*Note: CURES is an acronym for Controlled Substance Utilization, Review and Evaluation System. 25
From Student’s Farm Project to Seniors’ Fork A medical school project transforms into a nutritional education program for Sacramento’s vulnerable seniors.
By Daniella Lent-Schochet, MS II
MARY IS A 75-YEAR-OLD woman diagnosed with high blood pressure and type II diabetes. Her physician instructs her to make dietary changes to improve her health, but she is unsure how to make these changes or if she can afford them. She merely stares blankly and nods along as her physician speaks. She is confused and overwhelmed. Thoughts come rushing into her head: How will she get the food she needs? How should she prepare these meals? Will this food taste good? This scenario is one of many I experienced as an undergraduate gerontology student. As seniors age, food insecurity, or the state of not having reliable access to sufficient quantities of nutritious or affordable food, becomes an increasingly dangerous threat to their wellbeing. Seniors are often on fixed finances, and healthier foods tend to be less available in low-income areas. Additionally, seniors often are limited in their mobility, either physically or due to the loss of transportation, causing them to rely on the closest food options available. Fast-food alternatives are often plentiful, accessible, and cheap, resulting in poor nutrition for the aging population. The public has a general misunderstanding of nutritional needs and concerns, and community members in the most fragile of dietary circumstances resort to the easiest and often least healthful choices when they can meet their needs at all. Since 2015, students of the Internal Medicine Interest Group (IMIG) at California Northstate University College of Medicine (CNUCOM)
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have focused on addressing food insecurity in the Sacramento area. The inaugural class chose to combat food insecurity by creating the CNUCOM IMIG Organic Garden, which has since yielded over 300 pounds of produce that were donated to local food banks in Sacramento and Elk Grove. Students have been volunteering on a regular basis at the Sacramento Food Bank. Upon reflecting on the program’s previous efforts, I realized that I had not seen how the food was being utilized and prepared nor met the recipients of the donated food. I, along with the IMIG board, spearheaded the creation of CNUiors for Hunger: Fighting Food Insecurity in the Geriatric Community to bring fresh foods from the Organic Garden and local community to the at-risk senior population. This program augments the IMIG’s existing efforts to address food insecurity while also educating vulnerable seniors about healthy eating. Seniors are one of the fastest growing demographic groups facing food insecurity in the United States, and more than 10 million seniors in the U.S. are unsure of where they will find their next meal. Nutritional deficiency is a leading consequence of the abuse and neglect suffered by the senior population. The fact that 15 percent of all seniors in this country live in poverty compounds the problems. The IMIG partnered with Volunteers of America Senior Safe House (VASSH), an organization that temporarily houses abused and neglected seniors and prepares them for independent living. This partnership allowed
CNUCOM students to visit the safe house monthly, and to provide a warm, nutritious meal, along with needed nutritional education, to the residents. IMIG felt it could have a lasting impact by focusing on this population since many of these seniors will soon be in a position to prepare their meals. With the generosity of the California Medical Association Foundation Medical Student Leadership Grant, the IMIG designed this program to teach seniors, their caregivers, and CNU medical students that food insecurity in the aging population is a critical issue. Since February 2018, students visit the Senior Safe Home monthly and bring a nutritious meal cooked by the IMIG students, enabling us to feed current residents and to use the food prepared as a teaching point. The students provide detailed fliers containing nutritional information for the meal served. They explain to the seniors how to read and understand a nutritional label to make better food choices while shopping or cooking for themselves. The IMIG students also provide a detailed cost breakdown of the recipe, note locations in the neighborhood where seniors can purchase affordable ingredients, and print out the cooking instructions to guide those who choose to replicate the recipes provided. Students try to incorporate produce and herbs from the
Organic Garden, the original IMIG project, into the meals, coming full circle in the IMIG’s effort to fight food insecurity from farm to fork. On the night before the first visit, CNUCOM students gathered together to prepare the meal. The following day, these students went to the VASSH and cooked plates of roasted vegetables and herbed chicken breasts for eight seniors. The entire home filled with the aroma of the delicious meal. Many seniors asked for second servings of the food prepared and devoured almost every piece of the dish. Participants were excited to take the recipe to their new home, anxious to make it themselves. The most memorable part of this experience was the opportunity to form bonds with the seniors. The students felt they could make a small, but significant difference in these seniors’ lives. The California Northstate University IMIG’s aim is for the CNUiors for Hunger program, like the Organic Garden before it, to become a recurring and sustainable program. The focus for these programs is to support, advocate for, and educate the susceptible in Sacramento. More importantly, the students hope that the program empowers seniors to take control of their nutritional choices and to become selfadvocates for their health. firstname.lastname@example.org
Above left is the CNU Organic Garden. At right are CNU IMIG students volunteering with the CNUiors for Hunger program February 2018
REFERENCES Cubanski, J., Orgera, K., Damico, A., & Neuman, T. 2018. How Many Seniors Are Living in Poverty? National and State Estimates Under the Official and Supplemental Poverty Measures in 2016. Kaiser Family Foundation. Gundersen, C. and J. Ziliak. 2017. The Health Consequences of Senior Hunger in the United States: Evidence from the 1999-2014 NHANES. Report submitted to Feeding America. Ziliak, J., and C. Gundersen. 2016. The State of Senior Hunger in America 2014: An Annual Report. Report submitted to National Foundation to End Senior Hunger.
Smallpox By Matthew Huh Editor’s/SSVMS Museum Curator’s note: This is the fourth article in a series by Mira Loma High School student Matthew Huh, featuring diseases that were common and often fatal at the time of the inception of our Medical Society in 1868.
SMALLPOX (VARIOLA), once universally feared, represents a scientific success story. It is an acute contagious disease caused by the variola virus, a member of the genus Orthopoxvirus, in the Poxviridae family. The history of smallpox is marked by the devastation it wreaked upon civilization. Through global vaccination programs, modern medicine has successfully eradicated this pathogen. In England, the disease was known as “the pox,” until the late 15th century when “smallpox” was adopted to distinguish it from the French pox (the “great pox”) which was syphilis. Around the time of the beginning of the Sierra Sacramento Valley Medical Society, smallpox was still considered the most infamous of infectious diseases, even though serious epidemics were relatively uncommon in the U.S. The cause would not be found until the invention of the electron microscope in the 1930s. The clinical features of this “speckled monster” (Variola is Latin for speckled) were very well understood. They knew the incubation period was 10-14 days. The onset of disease was called the “The Invasion” when the patient felt a sudden chill, with severe pain in the back, bad headache, and a very high fever with vomiting. In 1863, when President Abraham Lincoln gave the Gettysburg Address, it is believed that he may have been fighting the smallpox fever. His personal doctor told him he had a “mild case of smallpox,” to which Lincoln joked, “For once in my life as President, I find myself in a position to give everybody something!” After 2-3 days, the fever would then subside,
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but the rash would appear. This next stage, “The Eruption,” was very orderly and stages were described as “macule, papule, vesicle, and pustule, ending in desiccation and desquamation.” However, their understanding of the infective nature was not as accurate. In 1899, Surgeon General Walter Wyman claimed that smallpox was primarily spread by fomites and dust in the wind. Now we know that spreading via sneezes and coughs is more important than fomites. Variola is spread most efficiently by means of inhalation and less efficiently by means of direct contact with scabs or pustular material from skin lesions. The origin of smallpox is unknown. The first descriptions date to the 4th century AD in Chinese texts, but pustules similar to those formed by smallpox have been found on Egyptian mummies dating to the 12th century BC. Smallpox only naturally infects humans, so communities had to reach a critical population before smallpox could be considered endemic. Epidemiologic study found that smallpox requires more than 250,000 people to perpetuate itself before the infection either kills or immunizes. Smallpox spread along trade routes throughout Asia, Africa, and Europe before reaching the Americas (Cuba) in 1520 via an African slave on a Spanish ship. Since the Native American population had no natural immunity to the germs the Europeans brought, more than 90 percent of their population died from diseases like smallpox, measles and the flu. The fight against smallpox dates back 2,000 years. In Asia, a technique known as variolation involved deliberately infecting a person by blowing dried smallpox scabs up their nose. Those who received this treatment contracted a mild form of the disease. In America, at the time of the American Revolution in 1777, more
than 100,000 people died due to a smallpox epidemic. Because of this, George Washington made it mandatory for all new recruits entering the Continental Army to undergo variolation. Benjamin Franklin lost his only legitimate son to smallpox in 1736 and was an avid supporter of this inoculation. In 1796, Dr. Edward Jenner, a survivor of smallpox himself, made vaccination history. He was trying to persuade people to undergo variolation, but had a hard time with the dairy workers. Milkmaids and milk hands believed they were protected by exposure to diseased cows. Jenner speculated that it would be possible for others to develop immunity from smallpox if they were infected successfully with cowpox. So, he extracted pus from the cowpox ulcers of milkmaid Sarah Nelmesâ€™ hands and then injected it into a 9-year-old servant boy, James Phipps, to innoculate him. Vaccination was born. Since Jennerâ€™s use of cowpox, the virus used to immunize against smallpox has been vaccinia. For decades there has been speculation about the origin of vaccinia. It has not been clear whether it is a product of genetic recombination, or a species derived from cowpox or variola by prolonged serial passage, or if it is the living representative of a now extinct virus. In 1858, Dr. George Wood discussed the mortality of smallpox in his Treatise on the Practice of Medicine. He stated that death is very frequent for smallpox patients and can occur anytime over the period of five to six weeks. Out of 168 fatal cases of smallpox at that time, the greatest number of people died on the second week (99 deaths), specifically the 8th and 11th day. With the mortality of smallpox so high, and treatment extremely inefficient, prevention methods and techniques became crucial. The last case of endemic smallpox occurred in Somalia in 1977, and the last recorded case in humans occurred in England in 1978. This final case resulted from an accidental laboratory infection of a photographer working at the University of Birmingham. The last outbreak of smallpox in the United States was in 1947, when 12 cases were reported in New York City. An interesting dilemma occurred in 1972
in Calcutta, India when outbreaks of smallpox broke out concurrently with chickenpox. There are many illnesses which present with a rash, but chickenpox may be the disease most confused with smallpox. It is caused by a different virus, the varicella zoster virus, so immunity against one does not protect against the other. There are several ways to distinguish the two. In smallpox, the fever is present for two to four days before the rash, but with chickenpox, the fever and rash develop at the same time. The progression of the rash is distinctive as well; smallpox lesions occur all in the same stage, whereas the rash of chickenpox is characterized by different stages of papules, vesicles, pustules and scabs which evolve rapidly. Smallpox tended to leave scarring, but chickenpox lesions usually do not. Smallpox lesions tend to be more dense on the head, extremities, and hands and feet including palms and soles. Chickenpox lesions are uncommon on the palms and soles and are more dense on the body than extremities. Death from smallpox was not uncommon. Death from chickenpox is very rare. In 1980, the World Health Organization (WHO) officially declared that smallpox had been eradicated. Currently, the only remaining known variola virus isolates are frozen in closely-guarded repositories at the Centers for Disease Control and Prevention (CDC) in Atlanta and at the VECTOR Institute in Russia. email@example.com REFERENCES The list of sources used in this article is available upon request from the author.
At left are smallpox vaccine vials from our SSVMS Museum of Medical History.
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Scaife Student Fellowship Connecting Students to Addiction Medicine
By Juliette Gerardo, MS II OPIOID-RELATED OVERDOSES in the United States (including from prescription drugs, heroin, and fentanyl) were responsible for more than 42,000 deaths in 2016, according to the Centers for Disease Control (CDC), and were expected to be greater than 59,000 for 2017.1 In fall of 2017, the President of the United States declared the opioid crisis to be a public health emergency, and publicly announced his intention to request $10 billion of the Congressional budget be allocated to combat prescription painkiller and heroin abuse in 2019.2 In light of the opioid crisis, is enough being done to prepare our future providers to adequately address current and future effects of prescription painkiller and opioid addiction? Last summer, I was awarded the opportunity to further explore issues surrounding substance use disorders and to learn how to address, manage, and connect individuals with addiction to local resources. In a three-week intensive session in Pittsburgh, PA through the Institute for Research, Education, and Training in Addiction (IRETA), six other medical students and I were exposed to current practices in identifying and treating individuals with substance use disorders beyond the scope of current medical school curriculum.3 We began with an introduction to the basic science of substance use and associated disorders, progressed to workshops focusing on motivational interviewing, and performed site visits around Pittsburgh aimed at aiding this population. Touring the jail, in-patient and out-patient rehabilitation facilities and halfway houses, and while attending the MARTI Conference at Indiana University of Pennsylvania, and Alcoholics Anonymous/Narcotics Anonymous
meetings, we reflected on current medical school programs addressing interacting with individuals with substance use disorders. After my first year at California Northstate University College of Medicine, I had been introduced to motivational interviewing through our standardized patient scenarios. The IRETA program built on this foundation with formal workshops for interviewing patients with addiction. With greater time and individual feedback to shape motivational interviewing style, focusing on the patient as the process of change, I appreciated our training to address community need for physicians to screen, provide brief intervention, and referral for addiction services. Patient stories take the information from our textbooks and give them life. Their perspectives make the pathologies tangible when shared with medical students. The most impactful experiences last summer were interacting with individuals at different levels of treatment. We shadowed Western Psychiatric Hospital admits at the University of Pittsburgh Medical Center, substance use disorder group sessions in Alleghany County jail, inpatient facilities, the Salvation Army, and Alcoholics/Narcotics Anonymous. One of the most impactful stories was a nurse in inpatient treatment for detox. She shared her fears of separation from her kids, and job uncertainty when managing her addiction. Connecting a face in health care imparted to us that this issue is pervasive in patients we will serve as well as in our peers. Questions we ask all volunteer patient speakers at California Northstate University is, â€œWhat would you want us to know as future physicians? What could have been done better July/August 2018
Comments or letters, which may be published in a future issue, should be sent to the authorâ€™s email or to SSVMedicine@ ssvms.org.
for your care?” Asking these same questions last summer to individuals at various stages of recovery, the main goal was to see them as people beyond their disease. All had stories of negative experiences with health care providers because of their history. At the height of their addiction, they will try to con and manipulate in drug seeking behavior, but we need to remember our oath to “do no harm” and act with respect. Substance abuse disorders disproportionally affect the homeless population. Through IRETA, we had the opportunity to participate in Operation Safety Net, an outreach program started by Dr. Jim Withers that is aimed at providing health care to homeless individuals. In addition to walk-up clinical hours, providing food and resource information has helped form a bond between the Pittsburgh homeless community and health care providers. I was lucky enough to spend a shift with Dr. Withers, who has come to know patients by name whom he has been serving for years. All program attendees had personal experience with an individual with addiction. As the opioid crisis continues, and shows no signs of slowing, this exposure will likely increase.
Hopefully, more programs similar to the Scaife Medical Student Fellowship focusing on patient contact will become integrated into medical school curriculums. This will help future professionals to identify, interact, and refer individuals to medical services related to substance use disorders. The IRETA summer program increased our confidence to approach future difficult circumstances, understanding that in any specialty, we will encounter individuals in different stages of recovery or active use, and will need to understand available treatment resources. Last summer was an invaluable experience in exposure and practice, and provided a greater appreciation for motivational interviewing to supplement our medical education. firstname.lastname@example.org REFERENCES 1 “Opioid Overdose.” CDC. cdc.gov/drugoverdose/index.html 2 Howell, Tom. “Trump seeks billions for opioids fight: wants $10B in new money for 2019, exceeding Congress’ call.” The Washington Times. 12 Feb 2018. 3 “Apply for the Scaife Summer Medical Student Fellowship.” IRETA: Institute for Research, Education, and Training in Addictions. http://ireta.org/improve-practice/health-and-humanservice-professionals/scaifestudentprogram/
Call for Awards Nominations THE SSVMS AWARDS Committee is seeking nominations for the Society’s most prestigious awards to be presented to the recipients 2019. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award, is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado 32
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Sacramento-Yolo region. The candidate must be an SSVMS member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship & Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, email@example.com. Deadline: October 1.
Board Briefs May 14, 2018 The Board: Received a presentation on the Joy of Financial Wellness from Rick Love, Principal Financial. Approved the appointment to the 2018 Nominating Committee as follows: Chair, Ruenell Adams Jacobs, MD, Immediate Past President; District Representatives: Ruth Haskins, MD, District 1; Margaret Parsons, MD, District 2; Barbara Arnold, MD, District 3; Russell Jacoby, MD, District 4; Paul Reynolds, MD, District 5; Marcia Gollober, MD, District 6; At-Large Members: Richard Jones, MD and Katherine Gillogley, MD. The Nominating Committee nominates members to vacancies on the Board of Directors and Delegation to the California Medical Association. The committee submits its report to the Board of Directors at its September meeting. Following that meeting, the Nominating Committee Report is sent to all Active Members to provide the opportunity to submit additional nominations. Approved a recommendation for SSVMS to advocate and cobrand with the AMA to urge removing all barriers to treatment for substance use disorder. Approved a proposal to encourage Sacramento County to participate in the Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver which will make improvements to the Drug Medi-Cal service delivery system. Approved Crumley & Associates, a private wealth advisory practice of Ameriprise Financial, as an addition to the SSVMS Vetted Vendor Program. Approved joining the coalition, Patients and Caregivers to Protect Dialysis Patients, in opposing the proposed deeply-flawed California Dialysis Initiative slated for the November ballot. The proposition would impose arbitrary limits on what insurance companies reimburse dialysis clinics to provide patient care. Approved the 1st Quarter 2018 Financial Statements, Investment Reports and Recommendations. Approved the Membership Reports: March 26, 2018 For Active Membership – Sharon George, MD. For Reinstatement to Active Membership – Bahram
Chehrazi, MD; Christopher Molitor, MD; Catherine Nagy, MD; Miguel Nieves, MD; Vinay Reddy, MD. May 14, 2018 For Active Membership – Amer Ali, MD; Rowan Baird, MD; David Beffa, MD; Kulvinder Boparai, MD; Qi Cui, MD; Sarah Dehaybi, MD; Adam Dougherty, MD; Cesar Dua, MD; Michael Fargusson, MD; Isabella Flores-Merritt, MD; Kristin Gates, MD; James Goldberg, MD: Kamara Graham, MD; Valerie Green, MD; Robin Greenstein, MD; Steven Harris, Jr., MD; Juan Hernandez, MD; Deann Hoelscher, MD; Jean Howell, MD; Barbara Hull, MD; Halsey Jakle, MD; Danish Javed, MD; Jeremy kaddish, DO; Sirisha Karri, MD; Ruben Koshy, MD; Hiu Fung Lam, MD; Matthew Lopez, MD; Kenneth Low, MD; Healani McConnell, MD; Sam Moradian, MD; Atul Munjal, MD; Miali Nanda, MD; Jung Park, MD; Marybelle Pe, MD; Julie Phan, MD; Karl Reiber, MD; John Riddle, MD; Keith Rosing, MD; Karn Scarpa, MD; Amit Shah, MD; Nathaniel Silvestri, MD; David Smith, MD; Sarah Teles, MD; Malti Tewari, DO; Azeza Uddin, MD; Jasmin Villatoro, MD; Brian Wagner, MD; Travis Walker, MD; Kerilee Wenker, MD; Eric Wevers, MD; Shawn Youngs, MD. For Reinstatement to Active Membership – Janine Bera, MD; Lawrence Bercutt, MD; Shannon Dillon, MD; Tim Grennan, MD; Tiffany Heu, DO; Katie Lukasek, MD; Marsha Snyder, MD; Amanda Tagle, MD; Helen Vinogradova, MD; Brian Wagner, MD. For Active Resident Membership – Kristian Borofka, DO; Nicole DelValle, MD; Marlowe Dieckmann, MD; Jessica Fortin, MD; Sophia Irvin, DO; Xaunna Krehn, MD; Daniel Lara, DO; Nurah Lawal, MD; Kim Le, MD; Sherry Liao, MD; Megan Lung, DO; Kristine Meade, DO; Abigail Miller, MD; Erin Platter, MD; Arlene Reyna, MD; Peter Roberts, MD; Gurjeet Sanghera, DO; Kyle Smith, MD; Tamar Stokelman, MD; Mai Vang, MD; Kathrin Wilkowski, MD. For Retired Membership – Stephen Bauer, MD. For Transfer to Placer-Nevada Medical Society – Kulvinder Boparai, MD. For Termination of Membership for Nonpayment of Dues – Lakshmi Avala, MD; Pooja Desa, MD; Shannon Dillon, MD; Stephanie Hawkins, DO; Nikki Pham, MD; Harini Racherla, MD; David Walters, MD.
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. — Carol Kimball, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP:
Sharon George, MD, Family Medicine, University of Missouri School of Medicine – 1991, UC Davis Medical Center, 4860 Y Street, Suite 2300, Sacramento, CA 95817
Jeremy Kadish, DO, Emergency Medicine, Touro University College of Osteopathic Medicine – 2011, Vituity-Mercy San Juan Medical Center, 6501 Coyle Ave, Carmichael, CA 95608
James Goldberg, MD, Emergency Medicine, Rosalind Franklin University, The Chicago Medical School – 2004, Vituity-Mercy Hospital of Folsom, 1650 Creekside Drive, Folsom, CA 95630
Sirisha Karri, MD, Internal Medicine, Osmania Medical Coll Inst MedSci – 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Kamara Graham, MD, Emergency Medicine, Ross University School of Medicine – 2014, Vituity-Mercy San Juan Medical Center, 6501 Coyle Avenue, Sacramento, CA 95608
Ruben Koshy, MD, Anesthesiology, University of Illinois College of Medicine – 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823
Valerie Green, MD, Family Medicine, Temple University School of Medicine – 1998, Golden Shore Medical Group, 7777 Sunrise Blvd., Suite 2500, Citrus Heights, CA 95610
Hiu Fung Lam, MD, Emergency Medicine, Boston University School of Medicine – 1998, Vituity-Sutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816
Robin Greenstein, MD, Emergency Medicine, Touro University College of Osteopathic Medicine – 2013, Vituity-Mercy General Hospital, 4001 J Street, Sacramento, CA 95819
Matthew Lopez, MD, Emergency Medicine, University of California School of Medicine – Davis – 2013, Vituity-Methodist Hospital of Sacramento, 7500 Hospital Dr., Sacramento, CA 95823
Qi Cui, MD, Anesthesiology, Washington University School of Medicine – 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Steven Harris Jr., MD, Emergency Medicine, Howard University College of Medicine – 2008, Vituity-Methodist Hospital of Sacramento, 7500 Hospital Dr., Sacramento, CA 95823
Kenneth Low, MD, Internal Medicine, Pritzker School of Medicine of University of Chicago – 1976, Golden Shore Medical Group, 6339 Mack Rd., Sacramento, CA 95823
Sarah Dehaybi MD, Ophthalmology, University of Arizona College of Medicine – 2013, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815
Juan Hernandez, MD, University of California San Francisco School of Medicine – 2010, Vituity-Sutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816
Katie Lukasek, MD, Emergency Medicine, SUNY Brooklyn – 2007, Vituity-Sutter Medical CenterSacramento, 2825 Capitol Ave., Sacramento, CA 95816
Shannon Dillon, MD, Pediatrics, University of Michigan Medical School – 2004, The Permanente Medical Group, 2155 Iron Point Rd, Folsom, CA 95630
Tiffany Heu, DO, Emergency Medicine, Nova Southeastern University – 2010, Vituity-Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael, CA 95608
Healani Mcconnell, MD, Ob/Gyn, John A Burns School of Medicine - University of Hawaii at Manoa – 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823
Adam Dougherty, MD, Emergency Medicine, University of California School of Medicine – Davis – 2014, Vituity-Sutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816
Deann Hoelscher, MD, Emergency Medicine, New York Medical College – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Sam Moradian, MD, Emergency Medicine, Boston University School of Medicine – 2014, VituityMethodist Hospital of Sacramento, 7500 Hospital Dr., Sacramento, CA 95823
Cesar Dua, MD, Pediatrics, Cebu College of Medicine – 1986, Golden Shore Medical Group, 3234 Marysville Blvd, Sacramento, CA 95815
Jean Howell, MD, Family Practice, University of Minnesota Medical School – 2009, The Permanente Medical Group, 1650 Response Rd., Sacramento, CA 95815
Atul Munjal, MD, Internal Medicine, University of Southern California School of Medicine – 2014, Golden Shore Medical Group, 3234 Marysville Blvd, Sacramento, CA 95815
Barbara Hull, MD, Family Medicine, University of Texas Southwestern Medical School – 1992, Golden Shore Medical Group, 7215 55th St, Sacramento, CA 95823
Mitali Nanda, MD, Pediatrics, Grant Medical College, Bombay University – 2010, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670
Halsey Jakle, MD, Emergency Medicine, University of California, Irvine School of Medicine – 2013, Vituity-Mercy San Juan Medical Center, 6501 Coyle Ave, Carmichael, CA 95608
Jung Park, MD, Pediatrics, Yonsei University College of Medicine – 1971, Golden Shore Medical Group, 7215 55th St, Sacramento, CA 95823
Amer Ali, MD, Hospitalist, Baqai Medical University – 2003, Mercy Medical Group, 6501 Coyle Ave., Carmichael, CA 95608 Rowan Baird, MD, General Practice, St. George’s University School of Medicine – 2005, Golden Shore Medical Group, 3946 Norwood Ave., Sacramento, CA 95838 David Beffa, MD, Emergency Medicine, Loyola Univ Of Chicago Stritch School Of Medicine – 2004, Vituity-Sutter Medical Center-Sacramento SURG, 2825 Capitol Ave., Sacramento, CA 95816 Lawrence Bercutt, MD, Emergency Medicine, Washington University School of Medicine – 2000, Vituity-Mercy General Hospital- AN, 4001 J Street, Sacramento, CA 95819 Kulvinder Boparai, MD, Internal Medicine, Ross University School of Medicine – 1989, Golden Shore Medical Group, 3234 Marysville Blvd, Sacramento, CA 95815
Michael Fargusson, MD, Emergency Medicine, Loma Linda University School of Medicine – 2014, Vituity-Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael, CA 95608 Isabella Flores-Merritt, MD, Emergency Medicine, Temple University School of Medicine – 1999, VituitySutter Medical Center-Sacramento SURG, 2825 Capitol Ave., Sacramento, CA 95816 Kristin Gates, MD, Family Practice, George Washington University Hospital School of Medicine and Health Sciences – 2011, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758
Danish Javed, MD, Pediatrics, University of Cincinnati College of Medicine – 2014, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815
Sierra Sacramento Valley Medicine
Marybelle Pe, MD, Emergency Medicine, University of Illinois College of Medicine – 2013, Vituity-Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael, CA 95608
Julie Phan, MD, Emergency Medicine, State University of New York at Buffalo Medical School – 2011, Vituity-Sutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816
Kerilee Wenker, MD, Emergency Medicine, University of Chicago Medical Center – 1998, VituitySutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816
Karl Reiber, MD, Pediatrics, Loma Linda University School of Medicine – 2012, Golden Shore Medical Group, 3234 Marysville Blvd, Sacramento, CA 95815
Eric Wevers, MD, Emergency Medicine, St. Louis University School of Medicine – 2014, Vituity-Mercy General Hospital, 4001 J Street, Sacramento, 95819
John Riddle, MD, Family Practice, University of Oklahoma College of Medicine – 1983, Central Valley Comprehensive Care 869 West Lacey, Hanford, CA 93230
Shawn Youngs, MD, Family Practice, University of Illinois College of Medicine – 2000, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95757
Keith Rosing, MD, Emergency Medicine, Vanderbilt University School of Medicine – 1974, Vituity-Mercy General Hospital, 4001 J Street, Sacramento, 95819
APPLICANTS FOR RESIDENT ACTIVE MEMBERSHIP:
Karen Scarpa, MD, Emergency Medicine, Temple University School of Medicine – 1993, Vituity-Sutter Medical Center-Sacramento, 2825 Capitol Ave., Sacramento, CA 95816 Amit Shah, MD, Internal Medicine, Duke University School of Medicine – 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Nathaniel Silvestri, MD, Emergency Medicine, Loma Linda Medical Group – 2014, Vituity-Mercy San Juan Medical Center, 6501 Coyle Avenue, Carmichael, CA 95608 David Smith, MD, Emergency Medicine, University of California Davis School of Medicine – 2006, VituityMercy Hospital of Folsom, 1650 Creekside Drive, Folsom, CA 95630 Amanda Tagle, MD, Pediatrics, University of the East, Ramon Magsaysay Memorial Medical Center – 1980, Golden Shore Medical Group, 7215 55th St, Sacramento, CA 95823 Sarah Telles, MD, Psychiatry, George Washington University School of Medicine – 2001, The Permanente Medical Group, 2031 Howe Ave, Sacramento, CA 95825 Malti Tewari, DO, Emergency Medicine, New York College of Osteopathic Medicine of the New York Institute of Technology – 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Kristian Borofka, DO, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Nicole DelValle, MD, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento, CA 95823 Marlowe Dieckmann, MD, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento 95823 Jessica Fortin, MD, Sutter Family Medicine Residency Program – 1201 Alhambra Blvd #340, Sacramento 95816 Sophia Irvin, DO, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento, CA 95816 Xaunna Krehn, MD, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento 95816 Daniel Lara, DO, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Nurah Lawal, MD, Pediatrics, UC Davis Resident & Fellow Prog –2516 Stockton Blvd., Sacramento, CA 95817
Kim Le, MD, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Sherry Liao, MD, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Megan Lung, DO, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento, CA 95816 Kristine Meade, DO, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento 95816 Abigail Miller, MD, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento, CA 95823 Erin Platter, MD, Pediatrics, UC Davis Resident & Fellow Prog – 2018, 2516 Stockton Blvd., Sacramento 95817 Arlene Reyna, MD, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Peter Roberts, MD, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento 95816 Gurjeet Sanghera, DO, Mercy Family Med Residency Program – 2021, 7500 Hospital Dr, Sacramento, CA 95823 Kyle Smith, MD, Sutter Family Medicine Residency – 2020, 1201 Alhambra Blvd #340, Sacramento, CA 95816 Tamar Stokelman, MD, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento 95823 Mai Vang, MD, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento, CA 95823 Kathrin Wilkowski, MD, Sutter Family Medicine Residency – 1201 Alhambra Blvd #340, Sacramento 95816
Azeza Uddin, MD, Psychiatry, Meharry Medical College – 2005, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758 Jasmin Villatoro, MD, Family Practice, Universidad Evangelica De El Salvador – 2006, The Permanente Medical Group, 1650 Response Rd, Sacramento, CA 95815 Helen Vinogradova, MD, General Surgery, The First Leningrad Academy I.P. Pavlov Medical Institute – 1985, Golden Shore Medical Group, 7215 55th St, Sacramento, CA 95823 Brian Wagner, MD, Emergency Medicine, University of Iowa School of Medicine – 2001, Vituity-Mercy General Hospital- AN, 4001 J Street, Sacramento, 95819 Travis Walker, MD, Emergency Medicine, Drexel University College of Medicine - 2014, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
E L LY
DESIGN / MARKETING
Kelly K elly Rackham Rackha m  616 6270 firstname.lastname@example.org www.planetkelly.com
Contact SSVMS TODAY to Access These
M EMBER O NLY B ENEFITS (916) 452-2671 BENEFIT
Reimbursement Helpline FREE assistance with contracting or reimbursement
CMA’s Center for Economic Services (CES) www.cmanet.org/ces | 800.401.5911 | email@example.com
Legal Services CMA On-Call, California Physician’s Legal Handbook (CPLH) and more...
CMA’s Center for Legal Affairs www.cmanet.org/resources/legal-assistance firstname.lastname@example.org
Insurance Services Mercer Health & Benefits Insurance Services LLC Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, and Cmacountyemail@example.com more... www.countyCMAmemberinsurance.com Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.
Prudential Travel Accident Policy & AXA Travel Assistance Program http://tinyurl.com/SSVMS-travel-policy
ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD10 Code Set Boot Camps
Mobile Physician Websites Save up to $1,000 on unique website packages
MAYACO Marketing & Internet www.mayaco.com/physicians
Auto/Homeowners Insurance Save up to 10% on insurance services
Mercury Insurance Group www.mercuryinsurance.com/cma
Car Rental Save up to 25% - Members-only coupon codes required
Avis or Hertz www.cmanet.org/groupdiscounts
CME Certification Services Discounted CME Certification for members
CMA’s Institute for Medical Quality (IMQ)
Health Information Technology Free secure messaging application
HIPAA Compliance Toolkit Various discounts; see website for details
PrivaPlan Associates, Inc www.privaplan.com
Magazine Subscriptions 50% off all subscriptions
Subscription Services, Inc
Medical ID’s 24-hour emergency identification and family notification services
Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services
EnviroMerica www.cmanet.org/groupdiscounts www.enviromerica.com
Office supplies, facility, technology, furniture, custom printing and more… Save up to 80%
Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required
Security Prescription Products 15% off tamper-resistant security subscription pads
PUBLICATIONS CMA Publications
www.cmanet.org/news-and-events/ publications CMA Alert e-newsletter CMA Practice Resources CMA Resource Library & Store www.cmanet.org/resource-library/list? category=publications
Advance Health Care Directive Kit California Physician's Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPAA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physician Orders for Life Sustaining Treatment Kit
www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)
firstname.lastname@example.org | (916) 452-2671
Back to Back
on a Workers’ Compensation insurance program designed
for physician practices!
Rates remain level for another year for the SSVMS/CMA-sponsored program. Why buy workers’ compensation insurance from just anyone, when you can purchase it through the SSVMS/CMA-sponsored program and save 5% on your premiums?
As you know, if you have employees, Workers’ Compensation is required in California. Looking to your association for a comprehensive program is one of the best ways to make use of your member benefits. CMA and SSVMS partner with Mercer Health & Benefits Insurance Services and Preferred Employers Insurance to provide safety, stability, service and savings to physician practices participating in the program.
Stability: Preferred prides itself on its stability, which includes maintaining some
of the best and most consistent pricing available for members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.
Safety: In addition to mandatory CalOSHA information and videos on workplace
safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.
PREFERRED EMPLOYERS Insurance
| a Berkley Company
Service: Mercer’s team of advisors is knowledgeable about the needs of
physician practices and is available to walk you through the application process, either by phone, or in person. Preferred handles and manages its own claims, rather than using third-party adjusters. This means more efficient and expert claim handling. With Preferred, injured employees tend to return to work faster than the industry average and effective management of medical fraud means lower overall insurance costs for members.
All of these features add up to Savings for SSVMS/CMA members! See how safety, stability and service can save you money by requesting a premium indication today! Call a Mercer Client Advisor at 800-842-3761 to get started. Or, visit www.CountyCMAMemberInsurance.com for more information and to download an application.
82717 SSVMS JulyAug18 WC Ad.indd 1
82717 SSVMS WC Ad (7/18)
Program Administered by Mercer Health & Benefits Insurance Services LLC
CA Insurance License #0G39709
82717 (7/18) Copyright 2018 Mercer LLC. All rights reserved. 633 West 5th Street, Suite 1200, Los Angeles, CA 90071 CMACounty.Insurance.email@example.com www.CountyCMAMemberInsurance.com • 800-842-3761
5/24/18 4:57 PM
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on Jun 25, 2018
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...