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I Am Not a Pork Belly Christian Serdahl, MD
EXECUTIVE DIRECTOR’S MESSAGE
Physicians Are Happier Here… and We Can Prove It! Aileen Wetzel, Executive Director
Is There a Future for Independent Practice? David Herbert, MD
The Lasting Scars of Corporal Punishment Caroline Giroux, MD
The Extraordinary Predicament of Mary Mallon
#ThisIsOurLane: Firearm Injury Is a Public Health Crisis Glennah Trochet, MD
What to Do in Retirement George Meyer, MD
Ready for Their Closeups
A Hole in the Heart Sebastian Conti, MD
SSVMS Physicians Advocate for Patients With Opioid Use Disorder in New TV Spots
A Whole New (Virtual) World of Training Adam Darwish, MS IV
Eric Williams, MD
Faith T. Fitzgerald, MD
All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the Sierra Sacramento Valley Medical Society for permission to reprint.
Freckles and Fury: Some Simulations Don’t Go Quite as Planned
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.
New SSVMS Members
Not Just Cataracts and Hernias Anymore
Lindsay Coate, Director of Programs
Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 p.m. M–F, except holidays.
Sean Deane, MD
VOLUME 70/NUMBER 5 Official publication of the Sierra Sacramento Valley Medical Society
Cover photo: Gulls gather along the rugged Northern California coastline.
Photo by Eric Williams, MD
5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax firstname.lastname@example.org
SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx
Sierra Sacramento Valley 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.
2019 Officers & Board of Directors
Christian Serdahl, MD, President John Wiesenfarth, MD, President-Elect Rajiv Misquitta, MD, Immediate Past President District 1 Ashutosh Raina, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD
District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD Roderick Vitangcol, MD District 6 Carol Kimball, MD
2019 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 R. Adams Jacobs, MD Barbara Arnold, MD Helen Biren, MD Adam Dougherty, MD Richard Gray, MD Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Tom Ormiston, MD Sen. Richard Pan, MD Paul Reynolds, MD Kuldip Sandhu, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD John Wiesenfarth, MD Don Wreden, MD
District 1 Alternate Vacant District 2 Alternate Ann Gerhardt, MD District 3 Alternate Thomas Valdez, MD District 4 Alternate Richard Bermudes, MD District 5 Alternate Armine Sarchisian, MD District 6 Alternate Christopher Swales, MD At-Large Alternates Megan Anzar Babb, DO Natasha Bir, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Anand Mehta, MD Leena Mehta, MD Ernesto Rivera, MD J. Bianca Roberts, MD
HOSTED BY LOCAL PHYSICIANS
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District XI Douglas Brosnan, MD
Margaret Parsons, MD
CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD
Sandra Mendez, MD
Editorial Committee Mustafa Bahramand, MS III Joshua Bloomstein, MS I Sean Deane, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD
George Meyer, MD Eric Ovruchesky, MS II John Ostrich, MD Karen Poirier-Brode, MD Neeraj Ramakrishnan, MS III Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD
Executive Director Managing Editor Webmaster
Aileen Wetzel Ken Smith Melissa Darling
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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 membersâ€™ 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. ÂŠ2018 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bimonthly 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.
| FE ATURED CONTRIBUTORS |
Christian Serdahl, MD, email@example.com
Dr. Serdahl is the 2019 SSVMS President. As a private practice ophthalmologist, he is troubled by how medical practices are increasingly viewed as commodoties. He also resents being called a pork belly.
Glennah Trochet, MD firstname.lastname@example.org
Dr. Trochet, a retired family and public health physician, heads the SSVMS Public and Environmental Health Committee. She makes the case that addressing gun violence is definitely “in our lane.”
David Herbert, MD
Sean Deane, MD
Dr. Herbert, an infectious disease specialist, is President and CEO of Sutter Independent Physicians and a past president of SSVMS. He says predictions of the demise of private practice may be premature.
Dr. Deane, an allergist and immunologist, looks at the fascinating pursuit by public health officials of Mary Mallon—better known as “Typhoid Mary”—and how her case has parallels today.
Alex Darwish, MS IV
Faith T. Fitzgerald, MD
Alex, a fourth-year medical student at California Northstate University, discusses how advances in simulation technology can change the way students learn while putting patients at a lessened risk.
Dr. Fitzgerald is a UC Davis professor of internal medicine with a well-earned international reputation as a master clinician, diagnostician and humanitarian. Even better, she’s very, very funny.
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ssvms.org.
Sebastian Conti, MD
Eric Williams, MD
Dr. Conti is a writer who also happens to have a day job as a surgeon and even braved an open mic night to do stand-up. In this issue, he writes about an event far more serious: his attempt to keep a young man alive who had been shot in the heart.
A frequent SSV Medicine contributor as a poet, Dr. Williams is a general surgeon and also the photographer of this issue’s cover photo. His poem, “Waiting…” elegantly describes the anticipation, hope and angst found in a hospital waiting room.
| PRESIDENT’S MESSAGE |
I Am Not a Pork Belly (So Don’t Treat My Practice Like One)
By Christian Serdahl, MD email@example.com
may have a pork belly but please don’t refer to me acquisition of private medical practices by for-profit as a pork belly. equity groups that include physician owners. This raises Unfortunately, the medical care we physicians troubling questions about the quality and cost of mediprovide is viewed by many economic institutions, and cal care that can be provided by these organizations. perhaps by some of our patients, as a commodity, like This is not the first time that private equity groups pork bellies. According to Merriam-Webster dictionary, have made a pass at us. In the early 1990s we witnessed a commodity is “one that is subject to ready exchange or several attempts to make a profit off of our work. When exploitation within a market.” I first started private practice in 1991, I could not reach Private equity groups have been purchasing medical a purchase agreement with the physician owner and he practices throughout the United States over the past ended up selling to a private equity group. He was paid several years. All specialties have been targeted, includin cash and stock options that became worthless when ing anesthesia, Ob-Gyn, primary care and my specialty, the private equity group was unable to fulfill its goal ophthalmology. of lowering overhead costs and increasing physician These groups typically offer a multiple of EBITDA productivity. (earnings before tax, depreciation, and amortization) to In a recent op-ed article in the New York Times, the senior physician owners Dr. Danielle Ofri, author of The largest dermatology group in the U.S. is in return for several years What Patients Say, What of salaried work. The senior now owned by a Canadian retirement fund. Doctors Hear, described our physician hopefully retires frustration at being treated as with a nice nest egg, leaving the junior physicians to a commodity. “By now, corporate medicine has milked deal with their new employer. The long-term goal of the just about all the ‘efficiency’ it can out of the system,” entity is to sell to another investor at a higher price. she wrote. “With mergers and streamlining, it has As the overheated stock market continues its upward pushed the productivity numbers about as far as they 12-year run and interest rates remain low, corporate can go. But one resource that seems endless, and free, is America is trying to figure out where to put its money. the professional ethic of medical staff members.” One of the results: Approximately 15% of private equity How are we physicians supposed to deal with this acquisitions are now in health care. changing economic landscape? Medical practices are bundled and then “flipped.” The Let’s start by acknowledging that we are all in the largest dermatology group in the United States is now same boat whether we are in private or group practice. owned by a Canadian retirement fund. Obviously, there Next, we need to remember that our Medical Society and is the potential loss of health care dollars to non-health the CMA “have our backs” in this street fight of corporate care entities that have little incentive to reinvest their medical care. Contributions ensure that we have a seat profits. at the table when new laws are developed that have an A colleague in Reno told me that private equity effect on the ethical and financial issues we face. groups have recently purchased anesthesia, Ob-Gyn, Most importantly, remember that we are not providpain medicine and primary care medical groups there. ers of a commodity. We are physician leaders of a In Sacramento, ophthalmology has been targeted. national health care system that is in transition. And California law, which prohibits physicians from being now more than ever, we need to speak out against the employees of non-physician entities, has resulted in the ethical sin of treating health care as a commodity. 4
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| EXECUTIVE DIRECTORâ€™S MESSAGE |
Physicians Are Happier Here... And We Can Prove It!
hysician burnout has been a heavily debated topic in the health care community and media over the last several years with good reason. At least 400 physicians commit suicide annually in our country. Unprecedented changes in the health care delivery system have caused many physicians, no matter their specialty or how far they are into their careers, to feel that their roles as healers, comforters and listeners are being diminished to the point that they are not providing the best care for their patients. Along with the alarming number of suicides, several national studies have reported that over 50% of physicians are experiencing burnout. It is important to note that burnout is not simply stress, but is also characterized as emotional exhaustion, depersonalization, and reduced personal accomplishment. Physician burnout does more than affect physicians on personal and professional levels; it also affects patients. When physicians leave the practice of medicine due to burnout, doctor-patient relationships are broken and access to health care is reduced. A different narrative on physician burnout has emerged in Sacramento. The Sacramento medical community is doing right by physicians and the patients they serve, and we have the data to prove it. According to Joy of Medicine: Assessing Physician WellBeing in the Sacramento Region, a white paper recently released by SSVMS, local physicians are reporting higher levels of happiness compared to their colleagues in other parts of the country. Most notably, the survey revealed that physicians practicing medicine in the Sacramento region reported burnout rates of 35%, which while still notable is remarkably lower than the national numbers (greater than 50% burnout). SSVMS is passionate about physician well-being and addressing burnout. Our Joy of Medicine program encourages personal resilience, connection with colleagues, and collaboration with leaders to foster a
By Aileen Wetzel, firstname.lastname@example.org
culture of wellness in our local physician community. Since 2017, SSVMSâ€™s Joy of Medicine program has connected hundreds of physicians to counseling and coaching services, peer support groups and education to increase their personal resilience. However, the solution to community-wide physician burnout is not just promoting personal resilience. The solution lies within improving the health care delivery system and promoting a culture of wellness within physician organizations. With the goal of identifying strategies that medical groups and health systems can implement to reduce physician burnout, SSVMS deployed a survey to physicians practicing medicine in the Sacramento region. The response rate was not only large, it was insightful. The majority of respondents indicated they would like their medical groups and health systems to Read it now! take immediate steps to make the Electronic Health Record (EHR) more efficient, user friendly and less burdensome for physicians through the deployment of in-person scribes, voice recognition software and personalized EHR training. Respondents also desired organizational support of physician worklife balance by providing physicians with greater flexibility over their schedules, assistance with administrative tasks, and designated time for self-care and health-related activities. SSVMSâ€™s white paper analyzes the survey responses and lays out recommendations to reduce physician burnout in the Sacramento region. I encourage you to take the time to read the findings and recommendations by visiting www.joyofmedicine.org or scanning the QR code. Although improvements are needed to make the physician workforce happier and healthier, the conclusion is clear that Sacramento is a great place to practice medicine. That also makes it a great place to be a patient. September/October 2019
Is There a Future for Independent Practice?
Predictions of Its Demise May Be Premature
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so even considering independent practice can seem like jumping off a cliff into the unknown. And employed practice works well for many physicians and their patients, as I personally experienced for several decades (I won’t say just how many…). So why do some physicians even try to continue in independent practice, swimming against this stream? There may be as many answers as independents, but some common themes are clear. A key factor is autonomy: many physicians value the ability to determine their own office hours and appointment lengths, to select their own staff, and to hang out their shingle in the community. Others are entrepreneurial and enjoy running their business and expanding into new
aspects of care. But on their own, even autonomous entrepreneurs can have difficulty meeting the challenges of measuring and meeting quality goals, assessing patient satisfaction, providing coordinated care to complex patients, and managing a business. To help meet these challenges, most independent physicians have joined one or more independent practice associations (IPAs) that do much of this with quality outreach, case management, patient surveys, practice coaching, contracting, network management, discounted vendor arrangements, physician wellness, shared EMRs, and more. And the Medical Society provides valuable assistance in many of these areas as well, including practice assessment, insurer disputes,
Who Earns More: Employed or Self-Employed Physicians in California?
Source: Medscape 2019 Physician Compensation Report
ecent issues of Sierra Sacramento Valley Medicine have featured pieces about saving private practice and the resources available to independent practices through SSVMS and CMA. But the continued rapid growth of employed physician organizations raises the question as to whether independent practice can really survive. And should it? Throughout the country, more physicians are joining large groups. The AMA’s annual Physician Practice Benchmark Survey, which queried 3,500 doctors, showed that 47% of all physicians in 2018 were employed, compared with 46% of doctors who were self-employed, the first time that employed physicians exceeded independents. The Sacramento Valley, with its large employed groups at Kaiser, Sutter, Dignity, and UCD, likely has an even larger percentage of employed physicians. Large organizations can be attractive for physicians for many reasons including freedom from running a business, help with dealing with the never-ending stream of new regulations from government and insurers, built-in patient panels, financial security and benefits, and teams to assist with complex patient management. Residents and fellows no longer have much exposure to independent practitioners in their training—more exposure to Dr. House than to Marcus Welby, MD—
David Herbert, MD email@example.com
legal issues, vendors, and the Joy of Medicine program, so practices truly do not have to go it alone. These factors make independent practice rewarding for many physicians, including me in my present roles as CEO of an Independent Practice Association and infectious disease specialist in an independent group.
Percentage of Physicians With High Levels of Distress
Sutter Independent Physicians vs. Physicians Nationally
What do we know about compensation among employed and independent physicians? Income data is tricky since it may not fully capture benefits which are often higher for employed physicians, and national data may not be reflective of local trends. The most current data is Medscape’s 2019 Physician Compensation Report, which surveyed 19,328 physicians in California. This data was not adjusted for hours worked, but at least suggests that independent practice can be competitive or more versus employed practice.
Measuring physician well-being
Sources: Mayo Clinic
and burnout is also complicated. Medscape surveyed 15,069 physicians nationally in 2019 and found burnout to be highest within health care organizations. We also have some local data on physician well-being. The Mayo Clinic has developed a tool to assess the level of physician distress that has been widely used nationally (a mix of employed and independent physicians), which serves as a comparison for 468 local indepen-
Burnout by Work Setting Health Care Organization Outpatient Clinic Office-based Single Specialty Group Practice Office-based Multispecialty Group Practice
Hospital Academic (nonhospital), research, military, government
Office-based Solo Practice
dent physicians. A recent survey by SSVMS suggests that the local rate of burnout of 35% is lower than the above Mayo Clinic national rate, with most of the SSVMS respondents working in large groups (78% of 502; 11.4% response rate). So for at least some independent physicians locally, burnout is less prevalent than in other groups, although even the 20-25% rate among independents is disturbingly high and requires further action to address the systematic problems that contribute to burnout (or “moral injury”). SSVMS’s Joy of Medicine program is an important part of this effort.
The Pipeline of New Physicians
A major factor that will determine the future of independent practice is how it is perceived by residents and fellows. They have decreasing exposure to independent physicians in their training, and some find solo or small group practice to be unfamiliar and even frightening. After all, running a business is not September/October 2019
covered in medical school! Large groups may also have resources such as forgivable loans that are especially appealing to young physicians with significant debts, even if this is a relatively small component of lifetime compensation. Anecdotal local experience suggests that primary care residents are initially especially attracted to large groups. However, a 2019 Medscape national survey of 2,272 residents suggests that the new physician pipeline still has physicians open to both modes of practice, although the data was not broken down by specialty.
Current Growth Patterns
It is difficult to gather accurate data on the number of independent and large group physicians locally. SSVMS membership can be a guide to large group growth, since most groups offer membership to all of their physicians, and new SSVMS members from these large groups are clearly on the increase. Although more independent physicians have joined SSVMS in recent years due to the benefits and value membership provides, their membership does
I anticipate becoming a partner/practice owner 22%
I anticipate employment as a non-partner/practice owner 27%
I may want to do both 19%
I’m not sure/don’t know 33% Source: Medscape survey of residents
Is There a Future for Independent Practice?
not yet match the high levels seen among local employed physician groups. As a result, the more reliable indicator of the growth or independent physician numbers may be the number of independents in some local IPAs such as Sutter Independent Physicians. SIP continues to see an increase in members, both specialists and in primary care, and an increase in the number of patients they care for. Since few primary care physicians fresh out of residency are opting for independent practice locally, most of the increase in independent PCPs has been from physicians leaving large groups or moving from other areas. But this increase has not been as great as the growth of employed physicians.
It is at least clear that predictions of the imminent demise of independent practice were premature. Independent practice remains a viable option for primary care and most specialties in the Sacramento Valley, and offers advantages for those physicians who are willing to take on the additional challenges it entails. Other physicians may find that employed practice has its own advantages, and its growth is likely to continue to outpace independent practice. But both offer the opportunity to participate in what remains one of the best professions imaginable: a rewarding career connecting with patients and helping them through the practice of medicine.
SSVMS Fall Upcoming Events SEPT 17 SEPT 28 OCT 25-27
Ophthalmology Training for Primary Care Physicians, CME Dinner
Send Your Child to College, Dinner Workshop
3rd Annual Joy of Medicine Summit Clunie Community Center- Sacramento, CA
Colorectal Cancer Best Prac�ces CME, Dinner Michael Po�er, MD, UCSF
CMA House of Delegates, Disneyland, Anaheim, CA To RSVP contact Sam Mello at firstname.lastname@example.org or (916) 452-2671.
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| OPINION |
The Lasting Scars of Corporal Punishment
New Laws Create Hope, Dilemmas
can still remember the feeling of brutal warmth on my forearm. I can still see the red mark left by his large hand. Even though I was a very quiet, obedient child, I grew up in the 70s when hitting children on the butt or the arms was an accepted form of punishment. Even one of my grandmothers, said to have a “strong personality,” didn’t refrain from doing so once to my sister who was a toddler (who, in her indefectible spiritedness, tried to count the slaps, which made all of us laugh back then but horrifies me now). We were raised by a mercurial father who had frightening anger outbursts. Talking back to one’s parents was unacceptable so I didn’t have the luxury to be my full self as a dissenter and activist until I was a grownup. I remember an episode during summer when my dad reacted with a succession of slaps out of fear (most likely) that I would get injured after I had come near him to tell him something while he was mowing the lawn, but I ended up losing my balance and fell near the obnoxious and moving machine. Of course, after that I could no longer remember what I had meant to share with him. Touch is essential to normal development. Right after birth, full
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body contact of the newborn with parents is encouraged. It helps with regulation of basic functions (like temperature and heartbeat) and bonding. Touching babies and young children during care, diaper changing, bath, etc., are instinctive, nurturing activities that help with the development of a sense of self by providing feedback to the nervous system. It is challenging for a child who
By Caroline Giroux, MD email@example.com
emotional insecurity. The fear instilled by corporal punishment is antagonistic to secure attachment, not to mention the deep shame and humiliation that is so hard to name and process. I cannot begin to fathom or process how severe physical abuse could alter the experience of being in one’s own body. The idea of corporal punishment in people is disturbing. The body is like a home. How can
“I cannot begin to fathom or process how severe physical abuse could alter the experience of being in one’s own body.” is never touched to have a healthy self-concept or know where his/her body ends and the rest of the world’s boundaries start. In understaffed orphanages in some developing nations, children have a higher risk of failure to thrive or emotional issues later in life and deprivation of consistent affection (including physical touch) is a contributing factor. Physical brutality is as bad for development as the absence of physical contact. I cannot say the few doses of smacking received ever contributed to “better” me. If anything, they left me stunned every time and hypervigilant, digging further the well of my
one attack a child’s fortress, his/ her body? Where can one go if he/she can no longer feel safe in his/her body? In numbing through substances I guess, in dissociating, or in our psychotherapy offices with attachment trauma symptoms decades later, when the once abused child has become a parent. Even worse, some children might even end up seeking such punishment when this is the only attention they get from their parents, when being hit is the only feedback their body receives, the body so desperately needing hugging and gentle touch to be reassured about its existence, to consolidate a sense of self.
One might be confronted with ignorant speech based on pseudorationalizations such as “I barely touched him” or “I didn’t hit her with my full force, it was just symbolic.” There is no such thing as a soft slap when it comes to a child. A child’s ego will bruise just the same, regardless of the intensity of the hitting, just like the minor versus major distinction becomes useless for victims of sexual assault. The shame is burning with the same intensity. France has recently become the 56th nation to pass a vote banning all forms of violences éducatives (violence pertaining to raising children), whether it happens at school or at home. Its Senate recently passed a bill saying that parents must not resort to “physical, verbal or psychological violence, nor to corporal punishment or humiliation” when disciplining their children. The overwhelming majority (85%) of parents in France resort to corporal punishment even though child mistreatment is obviously frowned upon by most people. Where the French law creates some controversy is by banning other forms of violences éducatives beyond corporal punishment that are still commonly practiced, such as forcing a child to finish his/her plate, threatening a child, exhorting a child to wear certain clothes, etc. Sweden was the first to pass such a law in 1979. Among other countries that followed are Norway, Denmark, Germany, Kenya, Congo, Greece, New Zealand, Brazil, and Ireland, to name a few. It is good news to me that some nations have taken the well-being and emotional
security of children seriously. Some states have banned corporal punishment, often to the complaints of parents who feel a “nanny state” is getting in the way of their ability to treat their children as they see fit, but when will the USA and Canada follow as a whole?
if they had better awareness of their own trauma, they would be less reactive and more responsive towards their children, and such laws wouldn’t be necessary. We wouldn’t have to worry about kids being murdered by their parents or stepparents out of escalating rage.
France has recently become the 56th nation to pass a vote banning all forms of violences éducatives. Although these laws could be great news for any child activist, I am afraid this peripheral approach will create resistance. And the question of how to enforce the law has yet to be answered. Shouldn’t we rather ask why parents lose their cool in the first place? If parents were more attuned to themselves,
I commend those adult patients coming to our clinics with a history of adverse childhood experiences who feel terrible after hitting their children and who want to break the cycle of abuse. Perfect parenting doesn’t exist. In fact, good enough parenting means doing our best, and trying to be attuned to the
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child’s needs as much as possible. In psychiatry, attunement refers to the ability to be attentive to a person’s needs and respond accordingly. Misattunement, on the other hand, is either ignoring or misreading important cues, leading to maladapted emotional and behavioral response (avoidance, dismissal, shaming, abuse etc). When misattunement occurs and triggers violent reactions, the most crucial step is to acknowledge that one has hurt the child and make attempt to repair, starting with an apology. It is as simple as that. If my parents had apologized for losing their patience, I would have viewed them, parenting, and myself very differently. We should aim for increased awareness of the consequences that result from violence on children (fear, dissociation, poor self-esteem). I have never brought up to my parents how their methods might have affected me. I had a set of loving, safe grandparents who lived right next door and I am grateful for the fact that they buffered some of my childhood toxic stress. They were always there for me and provided a fundamental experience of secure attachment. I must say I am relieved to see that my parents “grandparent” differently than they raised my siblings and me. Blaming or bearing grudges would serve no purpose. My energy will be better utilized by trying to increase awareness, developing compassion towards my vulnerable, younger self and others, and understanding the cycle of violence and its transgenerational component to prevent further trauma. I hope I will be joined by others in this new crusade.
| HISTORY |
The Extraordinary Predicament of Mary Mallon Why Her Legendary Case Still Matters a Century Later
By Sean Deane, MD firstname.lastname@example.org
suspect that few among us could name John B. Finch as a treasured cultural icon, or indeed, recall his history at all. Yet it was he who uttered a phrase that I dare say any person educated or naturalized in the United States can recognize in one form or another, a phrase that perhaps any member of any free society can identify with as the basis for the legitimacy of appropriate boundaries on personal freedom that must accompany any social structure outside of anarchy: “Your right to swing your arm leaves off where my right not to have my nose struck begins.” The phrase implies a limitation on harm committed with intent. What about harm committed unintentionally, just by being present in society? Just as with Mr. Finch’s relative obscurity (if Temperance history buffs will excuse my calling it that), I would guess that most of us would raise a quizzical eyebrow at an offhand reference to the name Mary Mallon. But just about any health care provider, and most of American society, will recognize the title history
Mary Mallon, “Typhoid Mary,” in quarantine in 1909.
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has placed upon her: Typhoid Mary. Typhoid Mary is not just a name, it has become a taunt, a tabloid caricature of the sordid sort that has so polluted public discourse in journalism and politics in recent years. But Mary Mallon was a real person, a patient, a being with dignity, and it must be said, a person who suffered greatly as a result of her ignorance and misperception of reality. Unfortunately, she was also an accidental Grim Reaper who killed simply by discounting medical advice and continuing to serve in a perfectly normal job that she did well. Ms. Mallon was born in Victorian Ireland at a point of continuing struggle in Irish history. Barely 20 years out from the Great Potato Famine, conditions remained so horrific on the island that massive numbers of Irish had already departed for the U.S. by the time Ms. Mallon decided to cast her lot with them. She fled the poverty of her home country in her early teens, and once in the U.S. eventually developed a reputation for her culinary skills sufficient to secure serial employment as a personal chef to the families of the leisure class. It is perhaps no surprise that a person with her early life experience should develop the strength of will, sense of self-reliance, and more ominously, concomitant sense of persecution that historical accounts ascribe to her. George Soper could hardly have known the fury that awaited him when he entered her story. A “sanitary engineer” by title, he was an early epidemiologist hired by the owners of a 19th century rental property in New York’s wealthy vacation enclave of Oyster Bay. The property owners desperately needed to figure out why typhoid had inexplicably afflicted an affluent tenant family and their servants. Typhoid, after all, was considered a disease of the unwashed masses, and the property’s owners feared they would not be able to attract future well-heeled clients to a vacation rental with such a taint.
Photo from the U.S. National Library of Medicine
Dr. S. Josephine Baker, pictured in 1922.
Through meticulous detective work that Soper outlined in the June 1907 issue of the Journal of the American Medical Association, he deduced that Ms. Mallon was the source of not only the Oyster Bay outbreak but of at least six prior outbreaks as well. He did not publish the exact words he approached her with when he finally found her after a long search, but comments dryly in his report that “no information of value was obtainable from her. She refused to speak to me or anyone about herself or her history.” His social skills may not have matched his epidemiologic prowess; he well recognized the importance of, as he later said, having “her excretions made the subject of careful bacteriological examinations.” She apparently did not share his view on the matter. Other descriptions of his encounter with her promote the more colorful story that she chased him away with kitchen implements under threat of violence. Despite further attempts, including sending Dr. S. Josephine Baker—the renowned public health physician who was the assistant to New York City’s health commissioner at the time—as a physician envoy in his stead, he was
never able to convince Ms. Mallon to willingly cooperate with his investigation. The New York City Department of Health evidently looked more favorably upon Soper’s request than Ms. Mallon did. She continued to work as a cook, infecting her employers, stubbornly refusing to believe that she could be a cause of disease even as she refused to provide the public health team with the samples they needed to rule her out. Given her unwillingness to assist the public health authorities, on Soper’s advice a team was sent to give Ms. Mallon the choice to either provide samples willingly or be taken into custody as a menace to the public health. Dr. Baker was the physician actually present for the effort, and she recorded the dramatic events in her book Fighting for Life. “Mary was on the lookout and peered out, a long kitchen fork in her hand like a rapier… she lunged at me with the fork,” Dr. Baker wrote. The attack knocked Dr. Baker backward into the police officer accompanying her, gaining the fugitive a moment to dash past and seemingly vanish. Ms. Mallon’s co-workers no doubt colluded in her brief escape, but refused to admit any knowledge of where she could possibly have gone. Dr. Baker and the officers continued searching for five hours, eventually finding a hidden Ms. Mallon who “came out fighting and swearing, both of which she could do with appalling vigor.” One cannot help but marvel at the temerity of both parties in the physician’s tale of the event. “I literally sat on her all the way to the hospital,” Dr. Baker wrote. “It was like being in a cage with an angry lion.” Ms. Mallon found herself quarantined in a hospital bungalow on an island in the East River for the next three years. Fixed in what Dr. Baker describes as her delusion that “the law was wantonly persecuting her, when she had done nothing wrong,” she fought back from her bungalow, finding allies enough to help her take a legal battle to the courts. She lost. Justice Mitchell Erlanger heard the Health Department’s arguments that the danger to the community outweighed her right to liberty, and ruled that she would remain in the custody of the health department. Mallon was eventually released, not by deliberation, but by decree. New York State Health Commissioner Ernst Lederle succeeded in extracting an oath from her that
she would never again work as a cook, and gave orders among mothers and babies and doctors and nurses like to release her back to the general population, with provia destroying angel.” sions for reporting in to the appropriate authorities. Ms. Mallon was re-apprehended and returned to Commissioner Lederle’s imposition of an oath was in North Brother Island, where she would live out the vain. It is difficult to know precisely what Ms. Mallon’s remainder of her life in quarantine under the watchful thoughts were on her release, but it seems clear that she eye of the New York City Department of Health. She died felt herself to be a victim of a conspiracy between her in 1938, but in many ways, her legacy lives on. physicians and the government. In the end, she did not Mr. Finch’s 19th century aphorism, and the exercise accept the health related limitations on her personal of its corollaries that were brought to bear on Mary liberties. Mallon, are not lost on today’s health agencies. The To be fair, it does not appear that she acted with quarantine powers exercised by the government in deliberate disregard for the welfare of others. Indeed, her case remain an issue of contention, but they also accounts suggest that she was very concerned for the remain in effect. In 2019, again in New York, Rockland welfare of the sick that she infected. County officials quarantined the unvacInstead, she acted with wanton disrecinated in a societal case that perhaps gard for the expertise of those responhas uncomfortable parallels to the indisible for the public health. She refused vidual case of Ms. Mallon. to accept that she was the source of Dr. Baker described Ms. Mallon as infection; she felt herself persecuted suffering from “that blind, panicky by sinister powers. She disbelieved the distrust of doctors and all their works lab workers, disbelieved her doctors, which crops up so often.” Like Ms. disbelieved the health department; Mallon, the subculture of vaccine avoidshe felt that she knew better than all ance disbelieves science, disbelieves of the concerned experts put together. physicians, and espouses delusions “She knew she had never had of persecution by a sinister cabal of typhoid fever; she was maniacal in those in power and the medical profesDr. George Soper discovered her integrity,” Dr. Baker wrote, adding sion. Like Ms. Mallon, the subculture the link between typhoid fever that Ms. Mallon was convinced that outbreaks in New York and has been responsible for outbreaks of recommended treatments were a Mary Mallon. disease in areas once thought impervi“pretext for killing her.” In return, Ms. ous to infection. Like Ms. Mallon, this Mallon visited death threats on Dr. Baker, the physician subculture of vaccine avoidance has killed, and will who together with Soper had been charged with the kill again, just by adherents going about the normal requests that led to her quarantine. activities of daily life while unwittingly visiting infection Upon release from her island quarantine, she eventuupon the innocent. ally returned to what she knew: cooking. And by all Yet, as physicians, we must recognize that like Ms. accounts, infecting. And by all accounts, killing. She Mallon, vaccine-avoidant patients deserve our compascontinued in her chosen trade until a chance encounter sion and our respect. To be effective, we must find a that nearly defies belief resulted in what, for Ms. Mallon, way to meet them on their own ground. We must find was the beginning of the end. a way to do better than Soper and Baker, especially in Hearing of an outbreak of typhoid at the Sloane the modern internet-fueled culture of paranoia, slander, Maternity Hospital in New York City, her old perceived and polarization. foe Dr. Baker toured the hospital, even though she was We must find a way to educate and reconcile, because no longer working as a health inspector. What Dr. Baker disinformation is attractive enough that we will eventusays happened next is straight out of a Sherlock Holmes ally fail with condemnation and exile. Perhaps, in the story: “Sure enough, there was Mary earning her living end, that’s the true lesson that Mary Mallon, Josephine in the hospital kitchen and spreading typhoid germs Baker, and George Soper have taught us.
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Mary Mallonâ€™s stool test results, from the New York City archives.
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| CALL TO ACTION |
#ThisIsOurLane Firearm Injury Is a Public Health Crisis
By Glennah Trochet, MD email@example.com
n August 7 2019, Annals of Internal Medicine e-published a call to action for physicians on reducing deaths and injuries from firearms, referencing the infamous tweet from the National Rifle Association (NRA) telling physicians to “stay in their lane” about firearm violence. The original tweet led to a swift response under the “#thisisourlane” hashtag from thousands of medical professionals who take care of the victims of firearms. A similar call to action was published in 2015 and a position paper of the American College of Physicians published in November 2018 prompted the NRA tweet that increased activism among physicians and other health care providers. The latest data on firearm deaths shows that in 2017 there were 39,773 deaths in the United States due to firearms. Sixty percent of those were suicides, and nearly all the rest—37%— were homicides. This is by far the highest rate of deaths due to firearms among high income countries in the world, and it is estimated that there are twice as many injuries as deaths in the United States caused by firearms every year. Based on 2015 data, the U.S. firearm homicide rate is 24.9 times higher than that of other high-income countries and the firearm suicide rate is 9.8 times higher. When all high-income countries are taken together, 84% of all firearms deaths took place in the United States. A staggering 92% of women and 98% of children killed by firearms were in the United States. Although mass shootings account for a very small proportion of deaths by firearms, their high profile causes a profound sense of vulnerability for everyone. Wary of becoming a victim of a seemingly random mass shooting, people tend to curtail their activities. In 2019 alone we have seen multiple killings in churches, schools, stores and malls, as well as here in Northern California at the Gilroy Garlic Festival. The signatories to this call to action are the American 18
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College of Physicians, American Medical Association, American Academy of Family Physicians, American College of Surgeons, American Academy of Pediatrics, American Psychiatric Association, and the American Public Health Association. The consensus among these organizations is that firearm injuries and deaths are a public health crisis that should be treated as such with multifaceted approaches.
Eight Public Policy Recommendations
The call to action included eight public policy recommendations: 1. Comprehensive background checks for all firearm sales, including gun shows and most private sales and transfers, with few if any exceptions. 2. Fund research on the causes and consequences of firearm-related injury and deaths as well as identify, test and implement strategies to reduce these events. (Despite bipartisan agreement that the Centers for Disease Control—which has a responsibility to protect the public health—is not prohibited from funding this research, it has stayed away from the politically charged issue.) 3. Remove access to firearms to domestic violence perpetrators and ensure that those who have been found guilty of this crime are reported to the National Instant Criminal Background Check System. 4. Increase safe storage of firearms, which can reduce accidents and has been shown to reduce suicides. 5. Increase access to mental health services while recognizing that the great majority of people with a mental illness or substance abuse disorder are not violent. In fact, individuals with mental illness are more likely to be the victims, rather than perpetrators, of violent crimes. 6. Enact extreme risk protection orders throughout the nation. These “red flag” laws allow family members or law enforcement to intervene when they observe
Photo credit: Shutterstock.com
Demonstrators gather in front of the White House in 2018, following the shooting at Stoneman Douglas High School in Parkland, Florida, to protest the government’s inaction on gun control.
behavior that could pose a risk to the individual or to others. 7. Physicians must be able to counsel patients appropriately about firearms. Attempts to implement state and federal “gag laws” that prohibit physicians from discussing the patient’s firearm ownership and documenting those discussions should be opposed. 8. Implement laws and regulations that limit access to high-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. The California Medical Asso ciation also advocates for similar policies on firearms violence. Physicians can, as individual constituents, ask their representatives in Congress and in state legislatures to support laws that would reduce the likelihood of firearm injuries. We can also join or donate money
to organizations that advocate for better regulation of firearms, such as the Brady Campaign or the Giffords Law Center to Prevent Gun Violence.
In addition to supporting public policies to reduce firearm injuries and deaths, clinicians can educate themselves and their patients on ways to increase firearm safety when they are in the home. The UC Davis Firearm Injury Prevention program provides information and handouts on their website, What You Can Do (http:// health.ucdavis.edu/what-you-can-do) that can be given to patients. Information for clinicians on how to counsel patients about firearm safety and what questions to ask can also be found on the site. The UC Davis Firearm Injury Prevention program recommends that clinicians ask at-risk patients
about access to firearms and take immediate action if necessary. Patients who are at immediate high risk are those who are expressing suicidal or homicidal ideation. Other risk groups include demographic groups such as children, adolescents, middle-aged and older men for suicide, and adolescent and young men for homicide. In addition, those who have been victims or perpetrators of violence, or those who have impaired judgement whether because of organic causes or due to substance misuse or poorly controlled mental illness are also at-risk individuals. Members of organized medicine, both as medical professionals and as citizens, can do much to mitigate the great amount of damage done by firearms in our country. As so many members of the medical community have eloquently expressed, this is most certainly in our lane. September/October 2019
A Hole H
in the Heart
ey, Doc, leaving early today, are we?” Gloria, the ED head nurse, said. “Yeah, I like losing the scrubs now and then. The wards are quiet and no full moon last night means the loonies aren’t roaming the streets. So, I’m going to spend some time with my family.” My custom since joining the Hospital’s Trauma Team was to do a walk through the ED. Too often I’d left without checking, only to be called back to consult on a problem patient. “Anything cooking?” I asked Gloria. She rose from her desk at the nurses’ station, the Department’s logistic hub––a rectangular arrangement of counters holding computers, keyboards and cubbyholes for forms. An epileptic, industrial-strength printer/ fax machine shook as it spewed document after document to feed a ravenous administrative bureaucracy. An array of twenty examination cubicles, each outfitted with privacy drapes, formed the ED’s outer perimeter. Two rooms, each a fully equipped operating room reserved for the most extreme of emergencies, flanked the ED entrance. “Gloria checked the EMS scanner. You’re good to go, Doc. Have fun. We’ll call if we need you.” My mind now began its shift to a parallel universe, a place with fewer responsibilities, relative calm, laughter, and love. This Saturday afternoon, I might go to the zoo with the kids, or to a movie or maybe just stay home and play games. Editor’s note: This essay is a recollection of a 1981 trauma case Dr. Conti managed while at the UC Davis Medical Center. Nearly forty years later, physicians still experience similar stories over and over again.
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The choices in this universe, inhabited by family and friends, were good, most of the time. In contrast, the choices in the universe I was now leaving were colored by uncertainty, fear, pain, and illness. An invisible presence, the Grim Reaper, accompanied me on my daily By Sebastion Conti, MD firstname.lastname@example.org rounds and into the operating room. He monitored the sand remaining in the hourglass of each patient’s life. Like the Tax Man who expects what is due, the Reaper waits. He knows death is the destination we all share. Some can delay it, but no one’s ever escaped it. I strolled through the exit door into a drama I didn’t know was unfolding. A sixties vintage Chevy, with fender skirts, side pipes, and horn blaring, screeched to a halt at the entrance. The back doors flew open and two gang bangers burst out dragging a third. Their clothes were soaked with blood. One shouted out to a paramedic, “Hey, my homey got capped. You gotta do somethin’, man.” The boy was unconscious, his face pale, his fingers blue. The ED staff rushed out, put him on a gurney, and wheeled past me. He’d been shot in the chest. We lifted the boy onto the OR table and cut off his clothes. I felt a weak pulse. “Can’t get a blood pressure, Doc,” said a nurse. Five bullet entry holes formed a halo around his left chest, blood gushing out with each labored breath. I saw two exit wounds in the back. At times like this, orders were unnecessary. Nurses inserted large bore IV tubing into veins to infuse saline and blood, the ER physician placed an ET tube. I donned a surgical gown and gloves, splashed anti-
| #ThisIsOurLane |
septic onto the boy’s chest, jumped up and straddled his torso for a better position to see and to sew, grabbed a scalpel and opened the left side of his chest. A surgical nurse arrived to assist. We inserted a rib spreader and suctioned blood from the chest. “Oh, Jesus, three holes in his heart,” I said. Incredibly, his heart was still beating. I cupped my hand over the holes to reduce bleeding. I inserted my thumb into the ventricle hole, and my middle and ring fingers into the atrium holes, as one would hold a bowling ball. “Long needle driver, 3.0 Prolene,” I said extending my hand. “Extend the incision,” I said to another surgeon who had just arrived. “I’ll place a purse-string around each finger, then you tie the suture. That’s all we can do.” I struggled against a beating heart in placing the sutures, trying to avoid puncturing my fingers. My heart sank as I placed the last suture––his heart had stopped. We used electrical shock, heart massage, direct drug injections, all to no avail. He was dead. But what the mind knows, the heart sometimes can’t accept. We continued these efforts. When the anesthesiologist said, “Pupils fixed and dilated,” we knew it was time to stop. I removed my gloves and bloodsoaked gown and stared at my street clothes and shoes, also soaked through. I put on another gown and covered my shoes in order to not shock whoever was waiting. We know that death from an injury like this is probable, but it’s impossible to wholly let go of the
notion that perhaps, had something been done differently, the patient might have survived, e.g., if there had been a heart-lung machine available. The most difficult task a surgeon faces is to inform family members that a loved one has died on the operating table. To witness the shock, pain, and sorrow of those who’ve just heard they’ve lost a family member is indescribably sad. It matters not that death resulted because of a gang shooting. Only death matters.
“Oh, Jesus, three holes in his heart.” Incredibly, it was still beating. “The Gomez family is waiting,” Gloria said. “They don’t know.” Through the waiting room door’s window, I saw the boy’s family, huddled together, holding each others’ hands. A parent’s worst fear is to lose a child. I entered, pulled up a chair and sat with them. Their eyes were red and moist, their faces wet with tears. I took the mother’s hands in mine. “I’m sorry, Mrs. Gomez, Victor’s passed away.” Her body shook and she cried. She leaned toward me for support. “No, no no no ..., oh no, Dios mío! No. Not my boy. Mi niño pequeño...” “He was a strong boy, but his injury was too big.” “Why, doctor? Why did God let this happen?” “I don’t know, Mrs. Gomez. I
don’t know.” Then, as if by cue, the hospital Chaplain entered. He embraced each member of the family, speaking words of condolence I had heard too many times. I sat with them, waiting to answer questions. But they asked none. The shock was too intense, the grief too profound. I knew the emotions that would follow––disbelief, anger, sadness. The parents would feel self-reproach and guilt because they didn’t or couldn’t protect their son. The Chaplain led Victor’s family to an adjacent chapel. I remained, my head in my hands, my heart filled with sadness. Tears slid down my cheeks. One never becomes inured to the pain and sorrow death leaves in its wake. Victor, like others before him, and others to follow, would leave a footprint in my heart. I walked back through the ED toward the locker room. “Sorry, Doc, that was a tough one. You did the best you could. It was a lethal injury, Doc. No one could have saved him.” They were right of course. The reason Victor survived his trip to the hospital was that he was young and strong and in perfect health. One bullet in the heart may be survivable, but to survive three is a rarity. I thanked everyone for their efforts and left to shower, to change into clean scrubs and to call home. My family was waiting for me, in that other universe. The sorrow I felt would slowly change to joy, to gladness and most of all to profound relief that they were there for me to love. September/October 2019
| SCIENCE AND TECHNOLOGY |
A Whole New (Virtual) World of Training
Medical Schools Give Simulation a Greater Role By Alex Darwish, MS IV email@example.com
ince the beginning of organized surgical training, a central guiding principle in teaching philosophy has been to “see one, do one, teach one.” This adage describes the often used educational practice of teaching medical trainees to perform procedures by first witnessing the procedure being performed, then performing it independently, and finally teaching it to someone else to solidify understanding. For many medical students, this is the whole appeal of clinical rotations. They offer the opportunity to finally get hands-on experience
and appreciate the real-life use of a vast amount of information that can’t be fully appreciated until it is applied in real clinical practice. But it also raises the fundamental problem of protecting sick patients from potential harm at the hands of inexperienced medical trainees. Additionally, some medical procedures are so rarely encountered in clinical practice that they are difficult for trainees to see and do, let alone teach. So how do we improve this transition point and train physicians better while also prioritizing patient safety? One answer is the increased
Photo courtesy of Arch Virtual
A student practices applying a respirator using Arch Virtual’s Acadicus virtual reality platform. The entire session is recorded and a VR “surgeon” oversees the effort and gives instruction during the procedure.
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use of simulations, including new approaches using virtual reality. Standardized patients are employed at my medical school, California Northstate University, to give medical students practice in skills such as history-taking and physical examination, as well as to learn the nuances of the patientphysician social dynamic and the physician’s role in a multidisciplinary team. Interestingly, there is an element of “see one, do one, teach one” in our institution’s use of this modality: fourth-year students are allowed the opportunity to teach first- and second-year students in these scenarios, representing the last “teach one” element of the principle. Student encounters with standardized patients provide immediate feedback, including suggestions on how to better acquire a valuable history from a patient or take a more complete physical exam. Tasks are well-defined with checklists of critical components that need to be covered during the encounter. Newer forms of simulation-based education also include virtual and augmented reality technology. Virtual reality (VR) offers a fully immersive synthetic environment with many of the same properties of the real world through a
Photo courtesy of Arch Virtual
Virtual reality allows a medical student to practice an intubation and gain more experience before performing the procedure on an actual patient.
device (such as the popular Oculus Go) that tracks the motion and actions of a user wearing a head-mounted display. Augmented reality (AR) is a somewhat different approach that superimposes digital models onto the real world, similar to how some online stores enable you to see how that couch you’re looking at would fit in your living room.
Virtual, Augmented Reality Helps Teach Anatomy Particular interest in these new techniques has come to the teaching of anatomy, which a Johns Hopkins study found has decreased in modern medical curriculum by as much as 55% in the last 50 years. American medical schools have instead devoted more time to problembased learning that stresses self-direction by the student and applied clinical decision making. New systems allow skin to be “peeled” away so students can observe how organs, bones and muscles are placed and see them function. There is growing acceptance among medical schools and students on integrating this technology into their curriculum. A 2017 Australian study randomly distributed 59 students into one of three groups that would learn anatomy after receiving identical lessons using either VR, AR, or on a tablet containing a 3-D model. After a 10-minute lesson on skull anatomy, participants took a corresponding 20-question quiz; the results showed that all three groups performed equally well in both factual and spatial recall questions.
Interestingly, the VR and AR groups had markedly higher levels of engagement by participants, despite this not translating to higher scores on the quiz than 3-D tablet users. Whether the novelty of these newer approaches lead to greater engagement, and if the effect will wane over time, is still an open question. However, the study also noted adverse effects of use of using virtual reality presentations, compared to AR and tablets, with symptoms that included significant headache, dizziness, nausea, disorientation, blurred vision, double vision, and difficulty focusing. Beyond medical school, VR and AR have been useful for learning practical skills used in clinical medicine. Medical simulators allow trainees to play out a number of scenarios, including error-prone situations, and to reflect on their performance without jeopardizing patient safety. After interaction with simulators, trainees often feel more confident in performing the practiced skill on real patients under close supervision. Feedback is critical in this strategy and defects in performance can be addressed with a return to the simulator. Currently, VR simulation can be used as a preoperative exercise using 3-D CT scans from actual patient data. Simulators for procedural training exist for practicing craniofacial reconstructive surgery, breast reconstruction, soft tissue reconstruction, cleft lip/palate repairs, and more. Many simulators provide evaluation metrics that objectively summarize the trainee’s performance. For example, one simulator called AccuTouch Endovascular
Clinical settings are also increasingly adopting VR and AR technology. Novorad’s OpenSight augmented reality system renders patient stuides into 3-D and projects them onto the patient’s body.
System immediately provides the user with an evaluation page that contains data on procedure time, fluoroscopy time, amount of contrast used, images from critical steps in the procedure, and it logs any complications encountered. A Montreal-based company, Ossimtech, has developed a virtual reality simulator called SIM-K that teaches medical students how to perform complex knee replacements. The system includes a series of haptic sensors that provide tactile feedback as it mimics the sound and feel of saws and drills. The company is working on similar technologies for neurosurgery and spine surgery. There are disadvantages to surgical simulators, however, including an absence of teamwork incorporation and questions about the applicability to real patients because of anatomical differences. But simulators can be a cost-effective approach: The cost of establishing a simulation center with one or more simulators is often less than the real-world cost of an instruc24
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tor’s time to teach trainees and the supplies normally needed for training. A laparoscopic simulator made by Immersion Medical was proven in one study to provide a return on investment in approximately six months when considering these cost-saving aspects. The longstanding “do one, see one, teach one” approach still has validity, but technology now offers more dynamic feedback and opportunities to improve at each step of the learning process. More research is needed to compare simulation training with more traditional techniques and to understand how to implement newer technologies like VR and AR into medical training for the best result and to further protect patients from unnecessary exposure to harm. It is clear, however, that the way medical trainees learn will continue to evolve in the coming years and the incorporation of evolving technology will ultimately translate to better patient outcomes.
FRECKLES AND FURY
Some Simulations Don’t Go Quite As Planned…
ome years ago, our School of Medicine at UC Davis began to use paid and trained “standardized patients” to begin to teach our pre-clinical medical students how to do a history and physical. I was asked by the faculty director of this exercise to participate as an observant assessor of the students. I said no, as we had, on our wards and in our clinics, plenty of real patients who were willing and able to interact with students and who had the advantage of actual interlocked history and physical examination findings. The director then asked me how I could make a decision about the value of standardized patients without actually assessing the technique, and he was right to do so. As Sherlock Holmes said to Dr. Watson in Sir Arthur Conan Doyle’s A Scandal in Bohemia, “It is a capital mistake to theorize before one has data.” So I agreed to try it. In the Medical School building itself, away from the hospital, physical examination teaching cubicles were occupied by standardized patents (usually university nonmedical graduate students) who needed the money and were paid to memorize and act out a brief history script and then allow a limited physical exam directed by
that “history.” I came into the cubicle and introduced myself, then sat silent as the medical student, visibly diaphoretic, stood with his eyes fixed downward upon the pages of a list of required history questions on his clip-board prior to beginning the physical exam. The standardized patient, in her early thirties and dressed in shorts and a tank top, was quite an actress and began as she spoke her script to point at herself, looking distressed, and using her arms and fingers to emphasize the sites of her “problems.” She frequently raised and waved her arms above her head, touching her brow while speaking of her suffering. When she did this, I saw freckles in her armpits. I could not contain myself, and so—to his evident relief—I broke into the student’s litany of questions on his “check list.” With the standardized patient’s okay, I took
By Faith T. Fizgerald, MD firstname.lastname@example.org
a good look into her axilla and, running my hand down her right arm, I asked the woman if any other people in her family had freckles in their armpits or small palpable subcutaneous lumps on their arms, as she had. This was almost certainly Von Recklinghausen’s disease and, when she asked what I was looking at, I told her that I thought she might have neurofibromatosis. “What?” she said, pulling her arm away from me. “It’s a genetic thing,” I answered. “How dare you!” she said. “I did not come here to be insulted. There is nothing wrong with me or my family. If you were any kind of real doctor, you should know that my script was of an anxiety attack— and that’s all!” Then, angry, she got up and left the room. I was not subsequently called back by the director to participate in the standardized patient exercises.
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 onetime only or rotating basis. For further information, contact email@example.com.
| VOLUNTEERING |
Not Just Cataracts and Hernias Anymore
SPIRIT Program Offers Wider Range of Care but Still Needs Physician Volunteers
h, how far we have come! In 1995, the Medical Society founded the Sacramento Physicians Initiative to Reach out Innovate and Teach, a program that was (thankfully!) shortened to the acronym, SPIRIT. The SPIRIT program was and still is a simple concept. Uninsured patients in need of non-emergency specialty care are referred to us from local federally qualified health care centers, UC Davis medical student-run clinics and the Sacramento County Healthy Partners program. SPIRIT case managers then match the patients with volunteer specialists who donate consults and outpatient procedures. For many years, the SPIRIT programâ€™s primary activities were almost exclusively cataract and hernia surgeries. While these surgeries are life changing for so many patients, our primary care clinic partners told us they needed access to a wider range of donated services. Unfortunately, there were not enough resources to provide this much-needed care. Fortunately, the health care landscape for the uninsured has changed thanks to the generosity of our SPIRIT partners. The Medical Society is proud to share that all local health systems (Kaiser Permanente, Dignity Health, Sutter Health and UC Davis Health) and many private practice physicians now provide the SPIRIT program with donated specialty consults and procedures. This generosity from the health systems would not be possible without over 100 specialty physicians volunteering their time and skills to take care of this vulnerable population. As a result, SPIRIT patients now have access to colonoscopies and upper endoscopies, ENT consults and surgeries, vision screenings and glasses, orthopedic outpatient surgeries, retinal consults and surgery, pterygium and corneal surgeries, pulmonary function tests and consults, and cardiac clearances for surgery. Along with our traditional methods of scheduling Lindsay Coate is Director of Programs at SSVMS. 26
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By Lindsay Coate firstname.lastname@example.org
patients during normal practice hours, we have also recruited many volunteer physicians, most of whom are recently retired, to see uninsured patients one day a month at the Sacramento County Health Clinic. This has given Sacramento County Healthy Partners patients access to a neurologist, an endocrinologist, gastroenterologists, a rheumatologist, a urologist, and a physical therapist.
We need more dermatology, general surgery, ENT, OBGYN, and orthopedics volunteers. We have dire needs in endocrinology, neurology, rheumatology, and urology. These additions have made a difference to people such as Genoveva B., a 50-year-old woman who was referred to SPIRIT after blood was found in her stool. A donated colonoscopy was performed at Fort Sutter Ambulatory Surgery Center by a volunteer gastroenterologist, and she was diagnosed with colon cancer. She received assistance with her application for full-scope Medi-Cal from the SPIRIT staff and is now on the road to recovery after surgery. The success stories of patients who can now go back to work and take care of their families has been gratifying for SSVMS and our volunteer physicians. However, we are still in need of additional volunteers in the following specialties: dermatology, general surgery, ENT, Ob-Gyn, and orthopedics. We have dire needs in endocrinology, neurology, rheumatology, and urology, as most of our patients have zero access to care. If you are a practicing physician with privileges at multiple ambulatory surgery centers, we need you. If you would like more information about volunteering for SPIRIT or for any of SSVMSâ€™s community programs, please contact me.
Sacramento Physicians Initiative to Reach Out, Innovate and Teach
Improving Access to Healthcare for the Medically Indigent
2019 Services 210 Patients Treated 49 Surgeries 255 Hours Donated $290,023 Donated Care
1995 to Date 53,695 Patients Treated 1,087 Surgeries 43,632 Hours Donated $11,500,000 Donated Care
| VOLUNTEERING |
What to Do in Retirement
Or Whenever You Want to Make a Difference
any physicians retire, have no hobbies or interests and may become problems at home. We used to say in the Air Force when someone retires that they should make every effort to get out of the house during the day. We would say, â€œMarried for better or worse, but not for lunch!â€? There are many volunteer opportunities available to physicians who want to slow down or retire. Volunteering to help staff student-run clinics is not very time consuming, it is rewarding and provides the opportunity to meet and help train the next generation of doctors while also helping to provide health care to the underserved. At the Shifa Clinic where I work, the administrative duties are handled by UC Davis undergraduates, many of whom are interested in pursuing some kind of medical-related profession. Patients are seen by first-
Three generations of the Meyer family in San Quentin, Baja Mexico, on a Flying Samaritans visit to provide free health care.
Sierra Sacramento Valley Medicine
By George Meyer, MD email@example.com
and second-year students from UC Davis, as well as by nursing practitioner and physician assistant students. They are supervised by volunteer physicians who have been given faculty positions at UC Davis in order to cover them for malpractice. Many sub-specialists volunteer at the Sacramento County Clinic on Broadway, coordinated by the SSVMS SPIRIT program (discussed in more detail elsewhere in this issue). I have recently been working a half-day per month seeing gastroenterology consults through SPIRIT. The County of Sacramento provides malpractice coverage. Another not-time-consuming activity would be to volunteer with the SSVMS on one of its committees. The Editorial Committee would be wonderful if you like to write, create poetry, etc. The Public and Environmental Health Committee also meets monthly if you have an interest in that area. You can also volunteer at a Federally Qualified Health Center (FQHC), where you are covered for malpractice by the U.S. Government. If you enjoy travel, I can recommend flying to Baja Mexico with the Flying Samaritans (flyingsamaritans. net). The Mother Lode Chapter is based in Sacramento. This volunteer organization operates free medical clinics in Baja California, Mexico. Physicians, dentists, translators, pilots and support personnel fly or drive to clinics. One weekend per month, we fly to the Baja city of San Quentin in small private aircraft on Fridays, give medical and dental care on Saturdays and fly home on Sunday. Most patients are migrant workers from southern Mexico, many of whom are not covered by the government-run Social Security program that provides health care coverage to employed citizens and their dependents. In the July-August issue of this magazine, Lynn Pesely and I described how the Sacramento Medical Reserve Corps (sacoes.org) is involved in the community and is
Photos courtesy of George Meyers, MD
Children in the road near a hospital in Bwindi, Uganda, where the author volunteered with the Kellermann Foundation. The foundation started a clinic that grew into Bwindi Community Hospital, a 125-bed full-service hospital that is ranked among the best in Uganda.
prepared to help in natural disasters inside and outside of California, including events such as the hurricanes that have hit Louisiana, Mississippi and Texas over the past few years. Sacramento also hosts one of the 42 Disaster Management Assistance Teams (DMAT) nationwide. These teams, which are part of the U.S. Department of Health and Human Servicesâ€™ National Disaster Medical System, consist of a group of professional and paraprofessional medical personnel who provide medical care during public health emergencies or high-profile events deemed National Security Special Events by the Department of Homeland Security. DMAT members include advanced clinicians (nurse practitioners/physician assistants), medical officers, registered nurses, respiratory therapists, paramedics, pharmacists, safety specialists, logistical specialists, information technolo
gists, communication and administrative specialists. DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. The personnel are typically activated for a period of two weeks. If you really like to travel while doing medical work, there are numerous organizations that will help place you in caregiving or teaching assignments. My favorite is Health Volunteers Overseas, a Washington, DC, based volunteer organization that places most medical specialties, physical therapists, nurses, occupational therapists and more (hvousa.org). Whether you are retiring or just looking for stimulation, volunteering is therapeutic, rewarding, and offers the fulfillment of putting your skills to work for those who need health care the most. September/October 2019
Ready for Their Close-Ups SSVMS Physicians Advocate for Patients With Opioid Use Disorder in New TV Spots
Department of Public Health, SSVMS produced two public service announcements (PSA) for the Sacramento Opioid Coalition to help combat the stigma associated with opioid use disorder that creates barriers to those seeking treatment. We recruited three physicians who each play a unique role in patient care in the Sacramento region. Dr. Lee Snook is a pain management physician who treats patients experiencing chronic pain while monitoring them for signs of addiction. Dr. Aimee Moulin is an emergency room physician that does buprenorphine inductions for patients who present to the ER with opioid use disorder. And finally, Dr. Melody Law is an addiction treatment specialist who manages patients
Photo by Mei=Lin Jackson
n 2016, the Medical Society started the RX Safe Physicians program to educate providers regarding safe prescribing, to promote complimentary methods of pain management to physicians and patients and to increase access to naloxone. We have successfully educated hundreds of primary care physicians, promoted the “Got Pain, there is No Magic Pill” campaign to connect patients with non-opioid therapies, and have helped increase the number of x-waivered physicians in our community. Despite these wins, many patients are still not seeking the treatment they need to fight opioid use disorder. One reason for this is the stigma they face in seeking treatment. In conjunction with the Sacramento County
Scan now to see the Sacramento Opioid Coalition PSAs
Melody Law, MD, an addiction medicine specialist and Sacramento County’s deputy public health officer, prepares for her appearance in the Sacramento Opioid Coalition’s public service announcements.
Sierra Sacramento Valley Medicine
Photo by Ken Smith
Dr. Aimee Moulin recorded her segment late in the evening in front of the UC Davis Medical Center emergency room.
version targeted directly to physicians in our community will also appear on social media soon. Physicians and their advocacy for patient wellbeing will be the solution to our nation’s opioid epidemic.
We want to thank Drs. Law, Moulin and Snook for doing a great job!
Contact Lindsay Coate at lcoate@ssvms. org for more information.
Photo by Lindsay Coate
on medication assisted treatment (MAT). They each appear in PSAs that will run a total of more than 3,500 times across the Sacramento region over the next four months. The spots, which started August 12, will appear on 14 different cable channels including news channels such as MSNBC and Fox; sports channels including ESPN, Golf and the NBC Sports Network stations that are home to the Kings, Giants and A’s; and favorites such as Animal Planet, Discovery and the Oprah Winfrey Network The PSAs note that 61 people died from opioid overdoses In 2017 and that hundreds more were hospitalized. Drs. Law, Moulin and Snook help let those struggling with opioid use disorder—and their families— understand that it is a disease and that treatment is available without judgment and with full support. A 15-second version will also appear as a YouTube ad. A longer
Lee Snook, MD, a pain medicine specialist, makes the important point that opioids can have a place in pain management if used properly. In the background is Sierra Sacramento Valley Medicine managing editor Ken Smith, who produced the PSAs.
Waiting Anxious faces fill the By Eric Williams, MD firstname.lastname@example.org
Room where mothers of daughters and Fathers of sons and
Some wait alone making
Husbands of wives wait for
Others to pass the Time and take the fear away
All look up in anticipation as the door Opens Again and
Strangers if not for that strange moment where they share A common fear Generations in attendance lend support
You know when the one behind the door
To each other and the
One on the other side of the door
These are strained reunions
Dead to their presence.
of brothers and sisters
Words like ‘I remember how she/ he...’
Of spouses and ex’s
Faces coming out of that
Followed by nervous and infrequent genuine laughter while
There is peace while they
Again News for Me? They ask with wordless Voices In the hour or two or four you Wait You learn to read the
Good or Bad News
Across the room
You recognize the look And hope that for you the
Cellphones are tapping messages to those
Hopeful smiling emoji will
Receiving encouragement to hang on
Of friends and lovers Wait Here there is no dress code as jeans and ball caps Suits, and slacks Baby carriages and nursing infants are allowed while Waiting
But in truth the wait is an effortless though heavy burden as
One more time the door opens
there is no hunger, or tired or cold while
With the blank face emoji
Someone steps into the room and asks ‘is there anyone here for ...’ Is your wait over.
Sierra Sacramento Valley Medicine
| BOARD BRIEFS |
Board Briefs May 13, 2019 Meeting: THE BOARD: Received an update regarding the SSVMS Joy of Medicine–Sacramento Region Physician Joy Assessment survey results. Approved recommendations in the White Paper, Joy of Medicine: Assessing Physician Wellbeing in the Sacramento Region – Strategies to Promote Physician Wellbeing at the Organization Level that are aimed at promoting physician wellbeing at the medical group/health system level. Approved proposed amendments to the SSVMS Organization Policies.
For Resident Physician Active Membership — Manveer DiltsGarcha, MD; Samantha Edards, MD; William Guthrie, MD; David Hubbard, MD; Yee Lo, MD; Natalia Obzejta, MD; Ashley Rubin, DO; Shasta Rumminger, MD; Collin Shumate, MD; Erica Thomas, MD; Sergey Veretennikov, MD. For Retired Membership — John T. Vallee, MD. For Transfer of Membership — Dave Auluck, MD; Fatima Jafri, MD. Deceased: Jit-Seng Khoo, MD; Jacob Igra, MD; Robert Zeff, MD.
July 8, 2019 For Active Membership — Nathaniel Defelice, MD; Maheer Gandhavadi, MD; Saeid Ghaemmaghami, MD; Scarlett Lu, DO; Kosal Seng, MD; Dharmvir Singh, MD. For Reinstatement to Active Membership — Rajbarinder Hundal, MD; Ryan Spielvogel, MD. For Resident Physician Active Membership — See the list of UC Davis Residents and Fellows approved for Resident Physician Active Membership under New SSVMS Members.
Approved the financial statements ending May 31, 2019. Approved the Restated 1st Quarter Financial Statements Ending March 31, 2019, Investment Reports and Recommendations. Approved appointments and changes to the SSVMS Delegation to the California Medical Association House of Delegates.
APPROVED THE FOLLOWING MEMBERSHIP REPORTS: June 24, 2019 For Active Membership — Sundeep Adusumalli, MD; Shailesh Asaikar, MD; Alexander Chen, MD; Sharad Jain, MD; Jocelyn Kim-Dunlavey, MD; Neil Parikh, MD; Murphy Steiner, MD; An Yen, MD. For Reinstatement to Active Membership — Kayvan Haddadan, MD.
100 Iron Point Circle, Folsom, CA Ideal for medical practice 2100 sq. ft. Rent+CAM charges, $3.00/sq.ft. Contact Tom Lewis at 650-208-8624 or email@example.com •Visible building in attractive office park •Easy access to US-50 •Security & fire systems •Lots of Parking •24/7 access •Built in 2002 •WiFi
•Independently controlled HVAC •Campus fitness center •Attractive landscaping •Building shared with dental practice and financial services company
| NEW MEMBERS |
New SSVMS 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. â€” Carol Kimball, MD, Secretary.
New Active Members
*Physician specialty abbreviated following name. Sundeep Adusumalli, MD, IC, Mercy Medical Group
Katherine Bates, MD, OBG
Trevor Feldman, MD, PD
Shailesh Asaikar, MD, CHN, Child & Adolescent Neurological Consultants
Nima Beheshti, DO, N
Edmund Florendo, MD, AN
Alyssa Bellini, MD, GS
Hee Fong, MD, CD
Gloria Belonwu, AN
Kaitlin Ford, MD, DR
Fatma Berk, MD, NRN
Charles Fredericks, MD, SCC
Kara Blaisdell, MD, IM
Casey French, DO, GS
Shea Boles, MD, EM
Kimia Ganjaei, MD, IM
Sylvia Bowditch, PD
Pranav Garlapati, MD, NPM
Saeid Ghaemmaghami, MD, HOS, Mercy Medical Group
Gregory Brittenham, DO, GS
Maria Albor, MD, IM
Rajbarinder Hundal, MD, CD, Solo Practice
Ian Brooks, MD, AN
Yasmine Gharbaoui, MD, P
Aaron Brown, MD, AN
Bashaer Gheyath, MD, CD
Samantha Brown, MD, EM
Tanvi Ghonasgi, MD, IM
Beatrice Brumley, MD, IM
Mark Gillispie, MD, EM
Nathaniel Calixto, MD, AN
Louise Glaser, MD, PD
Zachary Call, MD, IM
Andrea Gonzalez-Falero, MD, END
Andrei Callejas, MD, GS
Alison Graff, DO, GS
Jorien Campbell, MD
Kimberly Grannis, MD, ORS
Scott Casey, MD, EM
Eric Granowicz, MD, HO
Evan Chang, MD, OPH
Christina Grimsley, MD, GS
Ryan Spielvogel, MD, FP, Sutter Medical Group
Todd Chatlos, MD, N
Bernardo Guevara, MD, IM
Murphy Steiner, MD, OSH, Hand Surgery Associates
Elaine Chau, MD, FP
Ying Guo, MD, IM
Christopher Chen, MD, CD
Petra Hahn, DO, OBG
An Yen, MD, D, Pacific Skin Institute
Henry Chen, MD, MSR
John Hallett, MD, FP
Sarah Chen, MD, GS
John Hanks, MD, OTO
Andrew Chiou, MD, IM
Aaron Hanyu-Deutmeyer, DO, PM
Min Ji Cho, MD, GS
Kaitlyn Hardin, MD, ID
Gary Ciuffetelli, MD, PFP
Matthew Haskins, MD, GS
Clelia Clark, MD, EM
Brandon Hassid, MD, PM
Isaiah Clark, MD, GS
Katherine Hicks, MD, PDO
Jared Clouse, MD, NS
Zachary Hillman, MD, VIR
Arielle Clute, MD, FP
Johnny Hoang, MD, AN
Rebecca Corbett, DO, PCC
Darrell Holmes, MD, GS
Luke Dang, MD, PTH
Leslie Hopper, MD, GS
Manveer Dilts-Garcha, MD
Taylor Howard, MD, OBG
Nam Duy Dao, MD, IM
Adrienne Hoyt-Austin, DO, PD
Daphne Darmawan, MD, PD
Jacqueline Hsieh, MD, IM
Matthew De Niear, MD, OPH
Ling Hsin, MD, PD
Philip DeSouza, MD, OPH
Cecilia Sing-Sing Huang, MD, IM
Alonso Diaz, MD, NEP
Cindy Hudson, MD, OBG
Kathryn DiLosa, MD, VS
Tracey Huey, MD, IM
Jacob Donnelly, DO, PTH
Bethany Hughes, MD, PFP
Kathleen Doyle, MD, GS
William Ip, MD, ORS
Rachel Ekaireb, MD, GS
Laura Jabczenski, DO, EM
Chioma Enweasor, MD
Zachary Jenner, MD, DR
Ozra Eslampanah Nobari, MD, P
Ritika Johal, MD, AN
Emily Evans, MD, EM
Courtney Johnson, DO, GS
Ambarin Faizi, DO, PFP
Omari Johnson, MD, GS
Alexander Chen, MD, IM, Solo Practice Nathaniel Defelice, MD, ID, Pulmonary Med Associates Maheer Gandhavadi, MD, ICE, Mercy Medical Group
Sharad Jain, MD, IM, UC Davis Medical Group Jocelyn Kim-Dunlavey, MD, OPH, Eye Site Sacramento Scarlett Lu, DO, FP, Greehaven Family Practice Neil Parikh, MD, Administrative Medicine, Dignity Health Kosal Seng, MD, PCC, Pulmonary Med Associates Dharmvir Singh, MD, HOS, Mercy Medical Group
New Resident Physician Active Members
UC Davis Medical Center Resident & Fellow Program *Physician specialty abbreviated following name. Mopelola Adeyemo, MD, END Shushmita Ahmed, MD, GS Samer Albahra, MD, PTH Monikankana Alem, MD, FP Farikh Ali, MD, AN Heros Amerkhanian, DO, N Daniel Arkfeld, MD, OTO Emily Armstrong, MD, OPH Neda Arora, DO, FP John Arriola, MD, GS Shanon Astley, MD Dina Attia, MD, AN Jorge Avila, MD, AN Tali Azenkot, MD, IM Michael Baggett, MD, DR Sami Bajwa, MD, N Hussein Baradia, DO, AN Joshua Barber, MD, ORS
Sierra Sacramento Valley Medicine
| NEW MEMBERS |
Michael Jung, MD, APM
Huyen Thi Nguyen, MD, NEP
Richard Teh, DO, RNR
Kunal Kamboj, DO, NMUM
Thomas Nguyen, MD, ORS
Elizabeth Tennant, MD, FP
Alison Kang, MD, DS
Beatrice Nichols, MD, P
Soe Thein, MD, P
Amar Kantipudi, MD, EM
Taylor Nichols, MD, EM
Marcus Theus, MD, EM
Abhinav Katti, DO, N
Karl Nielson, DO, GS
Janese Thompson, MD, OBG
Manmeet Kaur, MD, IM
Dylan Noblett, MD, DR
Olivia Tighe, MD, GS
Judas Kelley, MD, ORS
Kevin Nowrangi, MD, CHP
Sage Timberline, MD, PD
Meghan Kelly, MD, OFA
Edmond Oâ€™Donnell, MD, ORS
Jordan Tordecilla, MD, FP
Matthew Kercher, MD, NS
Caroline Opene, MD, D
Rafael Fajardo, MD, SCC
Roshni Khatiwala, MD, IM
Chidimma Osigwe, MD, PAN
Joel Tourtellotte, MD, PCC
Ravand Khazai, MD, TRS
Kanishka Patel, MD, IM
Trevor Tsay, MD, GS
Travis Kling, MD, EM
Hillary Paulsen, MD, P
Brittni Usera, MD, RO
Jeffrey Zheng-Hsien Ko, MD, GE
Joseph Pearman, MD, IM
Javar Van Buren, MD, PD
Scott Korotkin, MD, FP
Deepthi Penta, MD, AN
Wyatt Voort, MD, ORS
Ellen Kroin, MD, OSH
Donna Pepito, MD, SM
Kylee VanHorn, MD, EM
Stephanie Ya-Wen Kwan, MD, GS
Caitlin Peterman, MD, D
Alexandra Vaughn, MD, D
Austin Kwong, MD, DR
Jameson Petersen, MD, RHU
Brandon Vu, MD, GS
Alexander Ladenheim, MD, PTH
Kristine Phung, MD, IM
Matthew Vuoncino, MD, VS
Linnea Lantz, DO, EM
Jinhua Piao, MD, PCP
Iris Vuong, MD, IM
Jason Lau, MD, PD
Joseph Polio, MD, OFA
Michelle Vy, MD, D
Hai Van Le, MD, OSS
Tali Pomerantz, MD, OBG
Lauren Walden, MD, AN
James Leathers, MD, EM
Ruchi Punatar, MD, PD
Neal Walia, MD, IM
Edward Lee, MD, OPH
Chenghao Qian, MD, IM
Jordan Sueo Foo Tien Wang, MD, PM
Kevin Lee, MD, GS
Yesenia Ramos, MD, IM
Christina Warner, DO, EM
Alexa Li, MD, FP
Jaskiran Ranu, MD, NPM
Stephen Warren, MD, IM
Christine Licata, IM
Amrita Rao, MD, FP
Gabriel Wilds, MD, PM
Xiao Ling, MD, NEP
Mary Rasmussen, MD, PD
Kelsey Wong, DO, IM
Shilpa Lingala, MD, GE
Aaron Reposar, MD, VIR
Carla Wood, DO, N
James Liu, MD, HO
Jesse Roberts, MD, OMO
Alexis Woods, MD, GS
Sirui Liu, MD, FP
Alexis Rosvall, MD, P
Lankai Xu, MD, IM
Ivan Marquez, MD, PD
Lauren Rys, DO, GS
Arthur Yang, MD, FP
Rachel Martino, MD, P
Suzana Saric-Bosanac, MD, D
Jiunn Yap, MD, CD
Zahrah Masheeb, MD, OTO
Kara Schmidt, MD, IM
Kyle Youngflesh, DO, PLM
Namrata Mastey, MD, OBG
Shannon Schroeder, MD, IM
Sanam Zahedi, MD, PS
Genise McAskill, MD, P
Collin Shumate, MD, P
Lida Zeinali, MD,NPM
William McCallum, MD, EM
Ethan Sellers, MD, PLM
Christopher Zimmerman, DO, N
Ellen McCleery, MD, PD
Ivan Shevchyk, MD, EM
Jose Zumba, MD, IM
Jasmine McClendon, MD, P
Averyl Shindruk, MD, EM
Shane McGuire, DO, AN
Tulsi Singh, MD, PMD
Madison McKenney, MD, AR
Matthew Skoblar, DO, APM
Jessie Medina, MD, IM
Daniel Slack, MD, IM
Samantha Edwards, MD
Viviana Mendez, MD, IM
Abigail Smith, MD, AN
William Guthrie, MD
Sam Miotke, MD, SCC
Travis Smith, MD, AR
David Hubbard, MD
Ana Mitchell, MD, DR
Hannah Snitzer, MD, PD
Yee Lo, MD
Anupam Mitra, MD, PTH
Anokh Sohal, DO, P
Natalia Obzejta, MD
Milad Modabber, MD, OPH
Roberto Solis, MD, OTO
Ashley Rubin, DO
Roxana Mohhebali, MD, OBG
Christina Spandler, MD, FP
Shasta Rumminger, MD
Steven Monda, MD, U
Helaine St. Amant, MD, PD
Erica Thomas, MD
Patrick Morency, MD, PD
Matthew Stegman, MD, DR
Sergey Veretennikov, MD
Mark Moubarek, MD, EM
Britta Stjern, MD, OBG
Alyssa Neph, MD, SME
Valerie Stone, MD, EM
Richard Newman, DO, GS
Brian Tanner, MD, EM
Quinn Kwan-Tai Ng, MD, DR
Emmanuel Tavares, MD, U
Methodist Family Medicine Program
Contact SSVMS to Access Your
Member Only Benefits
firstname.lastname@example.org | (916) 452-2671 BENEFIT
Reimbursement Helpline FREE assistance with contracting or reimbursement.
CMA’s Center for Economic Services (CES) www.cmadocs.org/reimbursement-assistance | (888) 401-5911
Legal Services CMA On-Call, Legal Handbook (CPLH) and more…
CMA’s Center for Legal Affairs www.cmadocs.org/legal-resources | (800) 786-4262
Insurance Services Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, etc.
Mercer Health & Benefits Insurance Services LLC www.countycmamemberinsurance.com | (800) 842-3761
Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.
Prudential Travel Accident Policy & AXA Travel Assistance Program www.ssvms.org/Portals/7/Assets/pdf/AXA-travel-accident-policy.pdf
Career Center Member groups receive free basic job postings and access to the Career Center resume bank.
California Physician ™ Career Center www.careers.cmadocs.org
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
CME Certification Services Discounted CME Certification for members.
Institute for Medical Quality (IMQ) www.imq.org
Student Loan Refinancing Members receive a rate discount of 0.25% off the approved loan rate.
Healthcare Messaging Free secure messaging application
HIPAA Compliance Solutions Members receive a discount on the Toolkit.
PrivaPlan Associates, Inc www.privaplan.com
Magazine Subscriptions Members get up to 89% off the cover price of popular magazines.
Subscription Services, Inc www.buymags.com/cma
Confidential Physician Wellness Resources 24-hour confidential assistance hotline is free and will not result in any disciplinary action. Additional Physician wellbeing resources also available through SSVMS’ Joy of Medicine.
Physicians’ Confidential Line (650) 756-7787 www.cmadocs.org/confidential-line www.joyofmedicine.org
Medical Waste Management Save up to 30% on medical waste management and regulatory compliance services.
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
COLA (800) 981-9883
Security Prescription Products RxSecurity Members receive 15% off tamper-resistant security subscription pads. www.rxsecurity.com/cma-order
SSVMS Vetted Vendor Partners SSVMS’ Vetted Vendors are trusted partners of the Medical Society. Each business has gone through an application process and provided multiple physician references that can attest to their satisfaction with the business. Access Vetted Vendors 916-452-2671 or email@example.com. Cooperative of American Physicians (CAP) Medical professional liability protection to over 12,000 of California’s finest physicians.
Sotheby’s International Realty Mela Fratarcangeli is consistently ranked in the top 5% of all real estate agents in the Sacramento Valley serving the buyers and sellers at all levels in the Sacramento Region.
Crumley & Associates Drawing on more than 120 years of experience, Crumley & Associates emphasizes sound financial planning, along with a variety of personal financial services.
The Mortgage Company The Mortgage Company brings a wealth of experience to every purchase and refinance loan, and exceptional concierge level service.
Bank Card USA By eliminating the middleman, Bank Card USA is able to offer special pricing for our members.
JOY of MEDICINE 2019 ANNUAL SUMMIT
The Power of Positive Psychology for Physician Health and Well-Being Liana Lianov, MD, MPH
An innovative leader in lifestyle medicine, Dr. Lianov is a lead faculty member of the American College of Lifestyle Medicine (ACLM) and currently serves as the Chair of the Happiness Science and Positive Health Committee of the ACLM. This session will explore positive psychology interventions for self-care that will enable attendees to develop a personal action plan.
The Art of Medicine and the Mindfulness of Thought
The Simple Thread Woven into Scientific and Spiritual Discovery Daniel McCrimons, MD and Reverend James Trapp, JD This session will focus on how to create a satisfying experience so the patient feels heard and the provider is able to embrace the virtues of the Hippocratic Oath.
Organizational Strategies to Improve Physician Wellness
Panelists representing Mercy Medical Group, Sutter Independent Physicians, Sutter Medical Group, The Permanente Medical Group, UC Davis, and Woodland Medical Group will share their physician wellness strategies, successes and resources.
EMCEE: Rajiv Misquitta, MD Brunch Provided; CME Credits Available Bring your walking shoes for a meditative walk through McKinley Park No Cost for Physicians, Residents & Medical Students
Register At https://tinyurl.com/y5jmxusy
Join other physicians in the region for fellowship and hands-on educational sessions to help you build resilience and bring joy back to your practice of medicine.
8:00 am - 12:00 pm Clunie Community Center McKinley Park, Sacramento Limited Spots: Reservations Required by September 13th RSVP with RSVP@ssvms.org
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Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on Aug 30, 2019
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...