2022 - Jul/Aug - SSV Medicine

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Sierra Sacramento Valley Serving the counties of El Dorado, Sacramento and Yolo

July/August 2022

“We want to make sure that California’s finest physicians are properly protected.”

A Team Approach to Medical Malpractice Coverage is a Winning Approach for Physicians More than 12,000 physicians rely on the Cooperative of American Physicians (CAP) to protect their practices every day.

Sarah E. Scher, JD Chief Executive Officer

Physician-founded and physician-governed, CAP provides superior medical malpractice coverage and solutions to help California physicians realize professional and personal success. CAP members also receive risk management services, claims support and a dedicated in-house defense firm, practice management resources, and so much more. Find out what makes CAP different.



Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.




Preventive Medicine for Gun Violence

Maggie Parsons, MD

Lindsay Coate, SSVMS Vice President, Strategic Operations


Paul Reynolds, MD



SSVMS Goes to D.C. to Advocate for Reforms

Aileen Wetzel, Executive Director


Saving Energy, Saving Ourselves Caroline Giroux, MD

A New Era for MICRA



Mourning in America

Megan Babb, DO


High Adventure

Michael J. Schermer, MD


Join the Fight Against Underage Vaping Rachel Caynak, MD and Elisa Tong, MD

A Thousand Chances to Save a Life


Board Briefs


New SSVMS Members

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. 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.




Eric Williams, MD Visit Our Medical History Museum 5380 Elvas Ave. Sacramento The SSVMS Museum of Medical History is currently open Tuesdays and Thursdays by appointment. Visit ssvms.org/museum. VOLUME 73/NUMBER 4

Cover photo: Storm clouds loom as a tornado touches down in Texas.

Photo by David Evans, MD

Official publication of the Sierra Sacramento Valley Medical Society

5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx

July/August 2022


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.

2022 Officers & Board of Directors

Paul Reynolds, MD, President J. Bianca Roberts, MD, President-Elect Carol Burch, MD, Immediate Past President District 1 Jonathan Breslau, MD District 2 Adam Dougherty, MD Judith Mikacich, MD Susan Murin, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD

District 4 Shideh Chinichian, MD District 5 Christina Bilyeu, MD John Coburn, MD Farzam Gorouhi, MD Roderick Vitangcol, MD District 6 Marcia Gollober, MD

2022 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Anand Mehta, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD

District 1 Alternate Tanuja Raju, MD District 2 Alternate Janine Bera, MD District 3 Alternate Toussaint Mears-Clark, MD District 4 Alternate Shideh Chinichian, MD District 5 Alternate Joanna Finn, MD District 6 Alternate Natasha Bir, MD

At-Large Delegates R. Adams Jacobs, MD Barbara Arnold, MD Megan Babb, DO Jonathan Breslau, MD Carol Burch, MD Amber Chatwin, MD Angelina Crans Yoon, MD Mark Drabkin, MD Rachel Ekaireb, MD Gordon Garcia, MD Ann Gerhardt, MD Farzam Gorouhi, MD Richard Jones, MD Steven Kmucha, MD Sam Lam, MD

Charles McDonnell, MD Leena Mehta, MD Sandra Mendez, MD Taylor Nichols, MD Tom Ormiston, MD Sen. Richard Pan, MD Neil Parikh, MD Hunter Pattison, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD Ajay Singh, MD Lee Snook, MD Tom Valdez, MD John Wiesenfarth, MD

At-Large Alternates Brea Bondi-Boyd, MD Christine Braid, DO Lucy Douglass, MD Karen Hopp, MD Arthur Jey, MD Justin Kohl, MD Vong Lee, MD

Scarlet Lu, MD Derek Marsee, MD Taylor Nichols, MD Ashley Rubin, DO Alex Schmalz, MD Ashley Sens, MD Asmaneh Yamagata, MD

CMA Trustees, District XI

Adam Dougherty, MD

AMA Delegation Barbara Arnold, MD

Editorial Committee

Robert Oldham, MD Margaret Parsons, MD Sandra Mendez, MD

Megan Babb, DO Sean Deane, MD Caroline Giroux, MD Robert LaPerriere, MD Karen Poirier-Brode, MD

Gerald Rogan, MD Kayla Umemoto, MS II Michelle Ann Wan, MS III Lee Welter, MD Eric Williams, MD

Executive Director Managing Editor

Aileen Wetzel Ken Smith


Sierra Sacramento Valley Medicine


Listen and subscribe to Joy of Medicine - On Call on your favorite Podcast App or visit joyofmedicine.org

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2022 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.


Paul Reynolds, MD

Caroline Giroux, MD


Maggie Parsons, MD

Gun violence is at an epidemic level in this country, but physicians can play a key role in prevention. Asking the right questions, as you would with any health condition, can save a life.


Energy is all around us, some good, some bad. Conserving energy so you can focus it where it is really needed can help you and your patients be happier. And keep an eye out for those energy vampires.

mepmd92@me.com A decades-long battle to update MICRA recently ended with a historic compromise. Dr. Parsons provides a brief history of the 50-year-old law and explains why it's still central to every physician's practice.

Megan Babb, DO

Michael J. Schermer, MD

Rachel Caynak, MD

Overturning Roe v. Wade is more than an assault on a woman's right to choose. Roe also protected a woman's health, her future and the right to life, liberty and the pursuit of happiness, Dr. Babb says.

Dr. Schermer takes us on his trek to Everest Base Camp at 17,500 feet. Fulfilling a long-held dream at age 78, he shares the sights and experiences that can be found nowhere else in the world.

As many as one in five teens have tried vaping, often lured by sweet or fruity flavors. Over 125 California cities and counties restrict the sale of flavored tobacco, but more can be done.

Lindsay Coate

Eric Williams, MD

In conjunction with the Sacramento County Opioid Coalition, SSVMS is distributing 1,000 Narcan kits throughout the community to help prevent fentanyl ingestion, treat overdoses and save lives.

Dr. Williams closes this issue with a poem that reminds us that even after the stormiest and most difficult of days, a magnificent sunset can await. Each is unique, reflecting one moment in time.






Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ssvms.org.

July/August 2022



Preventive Medicine for Gun Violence O

n an almost daily basis, we see the devastation caused by gun violence. As one heart-wrenching event occurs, such as the murder of 19 children and two teachers in Uvalde, Texas, others that equally have shocked us seem pushed back into history. This year, Sacramento experienced one of the nation’s largest mass shootings with the deaths of six people in a downtown gun battle and the unthinkable killing by a father of his children and a social worker at a local church. Firearms have taken more American lives since 1975 than World War II, World War I — in fact, more lives than in all the wars the United States has participated in since the American Revolution combined. Gun violence, which also includes suicide, has been declared one of the leading causes of death in this country and a public health crisis by the American Medical Association and the California Medical Association. Physicans, of course, are the ones who often see the immediate and gruesome results of gun violence. It is a plague that has swept our country, state and neighborhoods, and many of us have been touched personally by it through knowing someone who was injured or killed by a gun or who used a firearm kept for “protection” as the instrument of choice for suicide. But just like any other public health crisis, the key to reducing death and injury is an aggressive prevention effort. “I dropped off my almost 10-year-old son at school today and couldn't help but think about those babies who were the same age as mine who were also dropped off and never came home,” one SSVMS board member recently said. No parent should ever have to worry whether their child will finish the school day alive. In 2019, Assembly Bill 521 authorized funding for the California Firearm Research Center at UC Davis, which has spurred the formation of the BulletPoints Project. BulletPoints has a wealth of resources available to help clinicians combat gun violence through being 4

Sierra Sacramento Valley Medicine

By Paul Reynolds, MD paul.d.reynolds@kp.org

more aware of the risk factors among patients and those associated with them. For example, the BulletPoints website notes that one of the most effective ways to reduce suicide risk is to put time and distance between the at-risk person and lethal means. It encourages clinicians to counsel patients with risk factors for suicide about reducing firearm access and choose appropriate interventions based on the level of risk and the ability of the patient to collaborate. Reducing lethal means through an intervention makes it less likely that a suicide attempt will be fatal, especially because most suicidal crises are temporary and many attempts happen with relatively little planning. Although cases usually don’t make the front page, domestic violence victims are among the most frequent victims of gun violence. According to BulletPoints, more than 10 million women and men each year — equivalent to 20 people per minute — are physically abused by an intimate partner in the United States. Nearly one in four women and one in seven men will experience severe physical violence at the hands of an intimate partner in their lifetimes, and a gun makes it much more likely that violence will turn deadly. What can you do to possibly save a life? The U.S. Preventive Services Task Force recommends that clinicians screen all women of reproductive age for intimate partner violence and clinicians should be prepared to discuss protective orders and the importance of removing a firearm from a violent situation. These are difficult conversations but ones that need to be had. The mass shootings that have become an almost daily — and sometimes twice daily — occurrence that get the most attention in the news are actually just a small fraction of the death and injury related to firearms in America. BulletPoints notes that, on average, they account for less than one percent of annual firearm deaths in the country.

There is a common perception that most mass shooters are mentally ill, but the reality is that the large majority of them have have not been diagnosed with a mental illness and are not legally prohibited from owning firearms. As a result, mental health intervention to prevent these horrifying episodes will likely have little effect since potential perpetrators often do not meet criteria for involuntary psychiatric commitment or for firearm prohibitions. What you can also do is be aware of the various types of civil orders that can protect patients and lessen the chance of an injury or fatality. Even though as a clinician you cannot petition for protective orders on behalf of patients, you can make them aware of the array of orders available and be ready to discuss options as clinically indicated. Patients who express concern about the violence potential of a family member or intimate partner need to understand that a domestic violence restraining order may be available to them. California’s red flag laws can take guns out of the hands of those who make threats, such as on social media or to another person, of a mass shooting or other violent act. If you are a mental health or emergency clinician, a mental health hold may be

appropriate although it does not necessarily result in that person being prohibited from owning a firearm. SSVMS encourages all physicians and medical professionals to review the resources available to them, including BulletPoints (bulletpointsproject.org), to better understand how to take preventative steps that could save a life without that person ever needing an emergency room team to use all their skills to address a catastrophic and unnecessary injury. The AMA has also developed resources to help physicians address firearm injuries, including a continuing medical education module designed to assist physicians in recognizing risk factors and effectively communicating with patients to reduce the risk of firearm injury and death. Asking the right questions, just as we would discuss habits that might increase the chance of diabetes or cancer, to understand the risks our patients face from guns in their households or threats from others in their lives must become part of our care routines. We are healers, but we are also advocates of preventive medicine and the best way to reduce the impact of a firearm attack, a suicide attempt using a gun, or the injuries (especially to children) incurred through gun accidents is to do all we can to make sure they never happen.

July/August 2022



SSVMS Goes to D.C. to Advocate for Reforms Medicare, COVID Help Are Top Priorities


SVMS had fantastic participation at CMA’s 48th Annual Legislative Advocacy Day at the state Capitol, as our president Dr. Paul Reynolds wrote in our previous issue, but we are also making our presence known at the U.S. Capitol in Washington, D.C. We joined business leaders from our region on the Sacramento Metropolitan Chamber of Commerce’s annual Cap-to-Cap trip April 29 through May 4. Physician leaders and staff from SSVMS met with local congressional representatives, including Rep. Doris Matsui and Rep. Ami Bera, staff members from President Joe Biden’s office and staff from key congressional committees. SSVMS made its position on several priority issues known in the halls of Congress and with the president’s health care team. We addressed the significant challenges physician practices are facing because of the COVID pandemic and the Medicare fee schedule, which currently pays 20% less than it costs physicians to run their practices. If Medicare had offered annual payment adjustments to physicians as it has for other providers, this gap would not exist. In fact, Medicare rates for physicians have only increased by 7% since 2001 despite a 40% jump in the consumer price index. We also made a strong case to delay the phased implementation of the Medicare sequestration cuts that would be devastating financially and cause further stress that will lead some doctors to retire or stop seeing Medicare patients. Physician burnout is being driven by revenue losses, pandemic-related increases in costs and massive health care staffing shortages. Nurses are in particularly short supply and have seen their salaries nearly double, compounding staffing issues. A recent CMA survey found that 54% of physicians who responded say they have not been able to return to prepandemic staffing levels, which means fewer hours for patients to have access to the services they need. This is not a case of waste in health care spend6

Sierra Sacramento Valley Medicine

By Aileen Wetzel awetzel@ssvms.org

ing. Physicians in Northern California are the most efficient in the nation and rank among the lowest in spending, but providers are seeing worsening patient health conditions and an increase in mental health and substance abuse issues as collateral damage from the pandemic. We are asking Congress to release remaining dollars from the Provider Relief Fund, which has helped health care providers remain financially viable during these unprecedented times, immediately to provide much-needed support.

The Medicare fee schedule pays 20% less than it costs physicians to run their practices. One side effect of the pandemic was an expansion of telehealth that was, it seems, welcomed by patients who saw it as a convenient and effective way to meet with doctors across a wide variety of specialties. We believe Congress and regulators should recognize this reality and extend the current telehealth waivers beyond the public health emergency and make them permanent fee-for-service elements of Medicare and Medicare Advantage. We were also very pleased at the interest in the need for workforce development in health care. There is an understanding in Washington that there will be a tremendous need for health care providers and that it is essential that health care regulations encourage young people, rather than discourage them, from becoming physicans. These are just some of the issues that arose during the trip. On behalf of all of us at SSVMS, I want to thank SSVMS leaders Paul Reynolds, MD and Carol Burch, MD for taking the time and effort to make the trip to D.C. We’re proud that we can bring your voice to Washington and work to make progress on the issues that directly affect your practice.

Closer to home + enhanced referrals = easier access to world-class care Payam Saadai, M.D., Assistant Professor, Department of Surgery Specialties: Pediatric Surgery, Colorectal Surgery, Fetal Surgery, Minimally Invasive Surgery

UC Davis Health offers nationally ranked expertise — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley. Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care. Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals.

Our liaisons can also help to: ■

Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, symposiums, etc.

Reach out to your local Physician Referral Liaison today:

Tracy Bayne | 916-916-281-8734 thbayne@ucdavis.edu

referrals.ucdavis.edu July/August 2022


Saving Energy, Saving Ourselves

Beware of Energy Vampires Who Want to Steal Yours


hen I was in high school, two of my favorite topics were physics and chemistry. “Nothing is lost, nothing is created, everything is transformed.” This law was a common denominator of these fields and probably so many others. Looking at every material entity as a mass of potential energy was intriguing, comforting and exciting. Realizing that potential energy could transform into kinetic energy as the mass started to move just sounded magical. And wait until it’s winter and static electricity creates lightning in your bedsheets! Because energy feels uncapturable, intangible, mysterious, our civilizations yearn for and obsess about impermanent illusions to override its perceived omnipotence. Time, money, status become proxy for that energy. And energy, this pure reality, becomes strangely relegated to the realm of the esoteric, the paranormal, the woo-woo. But I could never deny its power or influence. It remained real for me, even if I could not quickly pinpoint its role as I experienced an interaction or a phenomenon leaving me either confused, drained, depressed, or on the other hand, ecstatic, hopeful, creative. Depending on the direction of the flow of energy, I would be either depleted or replenished. I preferred plays to movies because of the palpable energy of the characters in real time. Slowly, this silent, invisible soul mate from physics made its way back into my vocabulary. Feeling constantly exhausted from raising three sons who were all spirited, I openly envied their energy level. One day, I told my then-toddler first-born, “I wish I had half of your energy!” He looked at me, bemused. At some point, I nicknamed him my “energy bar.” He seemed to like it. Bonding strengthened, energy in me was accessed more. Later on, with two younger brothers at his side, they all seemed to get it whenever I said, “OK, now time for quiet play or reading. Mama needs to lie down for a 8

Sierra Sacramento Valley Medicine

By Caroline Giroux, MD cgiroux@ucdavis.edu

few minutes, I must recharge my batteries.” I started listening more carefully to others using similar language. If they said “energy” beyond the DSM diagnostic parameter for depression or mania, I paid close attention. A psychologist referred to the distress of a patient we had in common: “He was there energetically,” she said, referring to his morbid mental state or emotional experience that was not yet following the rational mind that could not make sense of his self-destructive impulses. A relative, commiserating, said of an obsessive, antagonistic person, “He’s such bad energy.” I could validate her perception. “I like her energy,” a spirited colleague would say. I wanted to be an energy generator, too. I strived to be a solar panel of ideas, a windmill dancing all year round to lift the mood of the world, to contribute to the elevation of consciousness. But I was still far from channeling my source. I didn’t realize how hard I was fighting the negative energies or energy vampires around me. It took me a while to understand that certain colors (black) or shapes (tall, vertical) in heavy furniture or appliances would drain me, that certain people made me feel like a nothing after a sterile debate of ideas. The flow of energy got stuck and I was using what I had left to protect myself or to try to change the negative energy. But energy can’t be fought, it can only be moved around. At some point, I realized this so I decided to receive it, to make room for it, to use it to optimize my physical environment and my emotional and spiritual health. Even words carry a vibration (or energy) and it is important to wisely select high-frequency words that brighten up our mood, such as love, joy, gratitude. I knew which things or colors to look at, music to listen to or nutrients to eat to give me a boost of energy. I also knew what took energy away. I tried to do more of the former, less of the latter rather than trying to change

what I couldn’t: other people’s tastes or ideas of me, choice of words, or repressed energy. Over the years I have become interested in chakras, the energy centers in our body. It is a framework that can find its equivalent in the endocrine glands as studied in Western medicine. “The chakra system is one of the metaphors Eastern philosophy uses for the concept of alignment,” explains Michele DiPietro of Kennesaw State University. It is simply a different language, and I think we need to be fluent in as many frameworks as possible. I learned about and applied the concept of chi, or prana, the life force that flows through the body along thousands of channels termed nadis and it made sense. For instance, I evolved from a more intuitive decorating style to intentionally incorporating more feng-shui principles like using mirrors in strategic locations to increase the perception of space (or abolishing tall, black fans!). I even saw why where people sit during therapy can have an impact. I attended a CME event for women physicians at Mount Shasta last year. One of the leaders of the event said there was a “powerful energy” there. Mount Shasta is considered the root chakra of the planet by many; I must admit I didn’t quite feel it, even though as a highly sensitive person I am quite attuned to shifts of energies, especially between human beings, as I can read quickly the emotional temperature in situations. But that got me interested and I decided to pay more attention to how environment affected me. Later, I traveled to Kauai and learned that all the Hawaiian islands are also associated with a particular chakra. Kauai is associated with the third eye, or the pineal gland, which is related to clarity, intuition, imagination. Without knowing this, I had selected this island

with the intention of letting my deep knowing guide me because I was facing various impasses and was hoping to see more clearly in my life. At one point, full of deep disappointment from having to turn back after finding out reservations were needed to hike the Napali Coast, I ended up discovering a dry cave. As I walked in, I could feel the energy, or its shift. Something was noticeable in the air, and it was not anything I could measure with my five usual senses. It was a powerful experience to be in the dark, peaceful womb of the earth. It accentuated my fascination for the concept of energy. Sending someone “good vibes” is holding them in our heart energetically. Choosing to believe that such intangibles exist and can have some impact may affect our work as clinicians in a good way. I think countertransference while working with our patients could be translated into various energies as well: do we feel restless (energy spinning wheels), heavy (stuck energy, as in depression), light and ecstatic (sense of aliveness from unblocking energy)? Paying attention to that might allow us to more effectively protect or conserve our energies through detachment and compassion rather than empathy, which is draining. Setting boundaries would also prevent the absorption of negative energies from others. An encounter in Kauai with several hungry and perseverant turtles gave me the great gift of a metaphor. I needed to emulate the nurturing, vegetation-covered rock they were trying to feed off of before they were swept away by relentless waves. When I returned home, I integrated the concept of energy conservation more solidly by no longer squandering energy on dead-end debates as I protect the turtles in my life. I could not have effectively preserved my enerJuly/August 2022


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Sierra Sacramento Valley Medicine

gies without self-awareness and a commitment to myself. I had often felt angry at others who drained me, but I realized I was more to blame because what I had done was let them cut the flow of my own energy. Energy is always inside of us. No one can really steal it. And even if one could, what really belongs to us always finds its way back to us, as the saying goes… Learning to connect with our source of power is important to feel alive in our work. Then, in order to communicate this aliveness to others, we must be fully present. Using our soothing, nurturing voice, reassuring and poised body language, and even a good dose of laughter can all help others access their own energy. Think about the mirror-neuron theory, or how we get “energized” or inspired by seeing people expressing their most authentic selves. The harmony we witness in the effortlessness of living according to one’s core values is contagious and the resonance it elicits can make us channel our positive energies for the greater good. Then, at the end of this tangible, material life, it might be a good idea to remember that nothing is lost. That we transform throughout our lifetime and beyond it as we step into what seems to be a white light of unconditional love, acceptance, and collective soul. That the energy of a person we love, but is no longer, cannot go very far; it always finds its way as a spiritual legacy landing in our hearts forever, keeping our own source of energy within reach, until we do the same to others.


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A New Era for MICRA

Understanding the Latest Chapter of California's Landmark Malpractice Law Takes Revisiting the Original Story


he recent deal updating California’s landmark Medical Injury Compensation Reform Act — better known as MICRA — is a historic agreement that fairly compensates injured patients while also maintaining limits that will continue to enable health care providers to operate their practices with confidence and a focus on care. It also staves off what would have undoubtedly been an expensive campaign against an initiative that, even if defeated this year, would likely have come back in some form in the next election cycle. It was time to negotiate to protect physicians and patients — basically, to protect health care in California. It was important during negotiations to keep the protections and framework that affect us every day in our practices. MICRA predates most of our practicing members, and it’s sobering to realize how many of today’s practicing physicians don’t really know much about it with the shift from private practice to medical groups. For nearly 50 years, MICRA has protected access to care and kept already high health costs from going higher. MICRA is the result of physicians — and many of their spouses, who occupied the front of Gov. Jerry Brown’s office for a couple days during his first stint as governor — who stood up against a growing number of frivolous malpractice lawsuits. These lawsuits were making malpractice insurance unaffordable in California and threatened physicians’ ability to practice. In those days, legislators from opposite sides of the aisle not only talked with each other, they were known to sometimes eat and drink together as well. Through bipartisan action, MICRA was passed after legislative leaders came together to address the alarming number of lawsuits and correlating increase in malpractice premiums that were threatening the ability of physicians to provide health care in California. (Historical footnote: an update to the agreement became known 12

Sierra Sacramento Valley Medicine

By Maggie Parsons, MD mepmd92@me.com

as the “Napkin Deal” because it was sketched out on a napkin and subsequently framed on the wall at Frank Fat’s restaurant on L Street.) Through the original legislation and the Napkin Deal, MICRA set a cap of $250,000 on non-economic — or pain and suffering — damages but allowed patients to recover unlimited economic damages for items such as medical care and lost wages. Punitive damages are also allowed in cases of gross negligence. Attorney fees were also capped to ensure patients would receive adequate compensation in cases of malpractice and that most of the award would not go to lawyers taking the case on a contingency basis. The ongoing battle to save MICRA from “reform” has taken place over decades. In 2014, Proposition 46 would have raised the cap on non-economic damages from $250,000 to $1 million, and the supporters threw in a provision requiring drug and alcohol testing of doctors to make it attractive to voters. The initiative lost by a resounding margin of more than two to one. The long-awaited compromise recently reached between doctors, consumer attorneys, hospitals, clinics, malpractice insurers and other health care providers provides a reasonable and acceptable update. AB 35 was swiftly enacted once sponsors pulled the initiative and has been signed into law by the governor. Under the new law, the cap on non-economic damages will increase from $250,000 to $350,000 in 2023 and then incrementally to $750,000 over the next 10 years. At that point, it will continue to increase by 2% each year for inflation. The limit in wrongful death cases will go from $500,000 to $1 million in the same 10-year period with the same subsequent 2% increase. MICRA, even in its new form, still has far-reaching consequences for any practicing physician. It has kept — and will continue to keep — malpractice insurance rates in California among the lowest in the nation, saving

The protections from frivolous lawsuits under MICRA save physicians thousands of dollars in malpractice insurance premiums each year. health systems millions of dollars each year and individual physicians thousands of dollars annually, if not tens of thousands. CMA estimated that if the proposed initiative had passed, malpractice premiums would likely have tripled almost immediately. Under our compromise, some insurers say they won’t increase premiums and stunningly, it could take 40 years for premiums to increase to the level the proposed initiative would have triggered. Without MICRA, the practice of medicine would take on a far more defensive tone, with providers ordering tests and procedures at significant expense to protect themselves rather than focusing on the care for their patients. Some community clinics could not function without MICRA (due to increases in the cost of providing care and skyrocketing malpractice premiums), significantly reducing access to care for Medi-Cal patients and those who are most vulnerable. MICRA, both in its original and now “2.0” form, was the result

of compromise and as with any compromise no one will consider it perfect. But as humans, neither are we, and that’s why MICRA is so important to the practice of medicine in California. We all know that medicine is as much an art as it is a science, and because we’re human there are times that our best efforts might not produce the outcomes we hope for or expect. MICRA was put in place to keep lawyers from exploiting those nuanced situations while making sure that cases of gross negligence are dealt with accordingly. MICRA has worked for decades and will continue to ensure Californians have access to care as it helps to reduce health care costs. Importantly, the legislation has included the ability for physicians to express empathy and talk about what happened when things do not go as expected or planned. The ability to talk with patients and their families is so important to them and to the physician that has cared for them. Prior to this legislation, physicians were usually

advised to not talk with the other party. Conversation will allow for understanding and an opportunity for emotional healing, and now can occur without being part of discovery if a case proceeds. Also, the new law keeps MICRA’s “guardrails” that protect fair process and sets attorney fee schedules. One sign of MICRA’s success is how it has been taken for granted and, unfortunately, many of our younger physicians are barely aware of MICRA and how their predecessors have fought to preserve it for decades. I think every student should learn about MICRA in medical school so they can better understand the impact this law has had in providing them with a future in medicine in California and how important it is to protect it from any future challenges that it may face in the electoral or legislative arena. The negotiating team and CMA’s Board of Trustees believe this agreement between factions that have fought each other for decades will bring an extended period of peace and takes a major concern for physicians off the table so that we can focus even more on providing the best care to Californians. MICRA has been repeatedly attacked over the years by opponents who felt it was necessary to bring down MICRA in order to attack similar laws in other states, meaning the effect of this compromise reaches far beyond California’s borders. Still, it is essential for all of us in the health care profession — physicians, dentists, nurses, community clinics, hospital systems and more — to understand how MICRA has preserved the practice of medicine in our state and be diligent in its protection so that we can continue to make the best health care accessible and affordable for Californians. July/August 2022



Mourning in America

By Megan Babb, DO ssvmedicine@ssvms.org

Roe Protected Women's Health and Futures, Not Just Choice


henever I get gloomy thinking about the current state of America, I am reminded of the hope that exists at the center of its established principles. Seeping deep into the roots of our Constitution, the fundamental rights to life, liberty and freedom emerge. No matter how tumultuous the state of our country can become when authoritarianism raises its ugly head or ignorance produces actions contrary to those principles, there is something profoundly inspiring around this universal truth. Perhaps this inspiration comes from knowing we all have the right to heroically challenge the status quo in order to effect changes in unjust policies and systems. Perhaps it is simply the existence of the opportunity to pursue a better tomorrow. Regardless of its source, its causation matters far less than its sheer existence because inspiration, even in its simplest state, means we will always have the fundamental right to pursue truth. Like other millennials, I wasn’t alive when Roe v. Wade made its way to the Supreme Court. For me, the legalization of abortion seemed redundant. But with the Supreme Court overturning this landmark decision, I have realized that I was naive to assume that a woman’s right to full agency over her body, independent of any external factor, already comfortably coexisted under the blanket of protection given by the fundamental rights established by the Constitution. I have also realized that the precedent set forth by Roe wasn’t just about protecting her right, and ours, to choose. It was much more than that. It was to safeguard a woman’s health, liberty, and ability to pursue happiness the same as men. I have been a physician for over a decade now. The truths that I have come to learn have been a long time in the making. To practice medicine in America is to practice the principles of the Biomedical Model, in


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which health is singularly defined as the absence of disease. But without a mechanism that supports and encourages constant introspection of its strengths and flaws, America's adaptation of the Biomedical Model has led to an unhealthy imparted privilege that has allowed the American health care system to arrogantly evade responsibility for the disparities and inequities it has had a hand in creating. Even though the intention of this model is to seek truth rooted in objectivity, it is incapable of holding itself to the same objective standards needed to address the prejudices driving this duality. Its inability to remain congruent has led to a failure to protect humanity from the political construct of biopower, or the use of political power to assert control over the female body. In the pursuit of health for all, congruence in the actions of those making decisions matters most. Unfortunately, what we have seen is the opposite with contradictory policies and beliefs that have and will continue to mean that hundreds of thousands of people will die unnecessarily. And now, by removing a woman’s right to choose, we will continue to watch this number grow. Undoubtedly this will also mean that it will occur disproportionately to women of color. Politicians who try to frame their decisions as based on what is best for the health and wellbeing of their constituents conveniently leave physicians out of the conversation. This is by design, so that when the subjective views held by politicians with an agenda are contrary to the truth those with the greatest level of expertise have no opportunity to stand in opposition. The decision to overturn Roe v. Wade is more about the authority to assert power over the female body by mainly heterosexual, cisgendered, Christian, white males than it is about protecting a fetus. In a state like California where efforts are made to

CMA said the Supreme Court has rolled back the fundamental rights of Americans to receive evidence-based reproductive health care and as a result has put the lives and welfare of millions of women at risk. put the needs of women first, objective data emerges proving why this is an effective strategy. Ranked in the top three states in the nation for women’s employment rates and earnings, it is no wonder that California also ranks number one in the nation for lowest rate of maternal and fetal mortality. This is not by chance. This is the result of a deliberate effort. In contrast, Louisiana is home to the second worst

paying for unwanted pregnancies on the state’s taxpayers will only grow greater. Ironically, while McCormick believes that he and the government should dictate what a woman does with her body, he certainly is quick to take objection against biopower when it doesn’t suit his subjective religious beliefs. In July of 2020, as COVID continued to spread across the country, he spouted anti-mask, anti-vaccine

While politicians stand to make decisions about the health and wellbeing of its constituents, physicians and their professional expertise have been left out of the conversation. infant mortality rate in the country and is one of only eight states where nearly 80% of unplanned pregnancies are paid through Medicaid services supported by taxpayers. Earlier this year, State Representative Danny McCormick introduced the Abolition of Abortion in Louisiana Act of 2022 and argued that the state’s moral obligation to an unborn fetus trumps the moral obligation it has in allowing women full agency over their reproductive organs. This means that the burden of

rhetoric and claimed the government has no jurisdiction in controlling a person’s body. “Your body is your own property,” he said. “If the government has the power to force you to wear a mask, they can force you to stick a needle in your arm against your will. They could put a microchip in you. They can even make you take the mark. After all, it's for the greater good.” What he fails to recognize, of course, is that mask mandates help the collective thrive while

July/August 2022


denying women access to abortive services does the opposite. I need not point out the hypocrisy wrapped up in his 90-second rant. Rep. McCormick also isn’t in any hurry to improve the outcome of life once these infants exit the womb. Just one month ago he wrote another bill that would loosen the regulations on gun control, making it easier to obtain and carry a firearm. That’s been a common thread, that those who are most vocal about being pro-life adamantly oppose any reforms that would restrict access to firearms or impose gun control laws. Even despite the vile acts in Uvalde, Texas that led to the brutal murder of 19 children and two adults, he still pushed his bill forward. While Rep. McCormick is given a platform to speak untruths that have directly resulted in the deaths of Americans, it is not hard to wonder how our health care system is reacting. A review of McCormick’s campaign contributions shows that Blue Shield/Blue Cross of Louisiana contributed to his campaign the maximum

CMA called overturning Roe v. Wade “a direct attack on the practice of medicine.” funding amount allowed by law. How does any individual stand a chance when the systems integral to maintaining the infrastructure of health care in America are taking stands to support those who actively oppose the health and wellbeing of the collective? Research has concluded time and again that a woman’s access to abortive services improves the health outcomes for her and the children she has chosen to have. In response to the decision, the California Medical Association has issued a statement stating, “Today the U.S. Supreme Court has rolled back the fundamental rights of Americans to receive evidencebased reproductive health care, and in doing so has put the lives and welfare of millions of women at risk. The California Medical Association has long advocated for unencumbered access to reproductive health services and strongly believes that all personal medical decisions — including those around abortion — should be made by patients in consultation with their health care providers.” It called overturning Roe v. Wade “a direct attack on the practice of medicine.”


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It is also another step backward for health equity. Restrictive laws banning abortion will have a disproportionate impact on our marginalized communities, especially those living in southern states. Black individuals who already suffer the effects of rampant racism in medicine will only suffer more. Despite mounds of evidence to support this, medicine and those practicing it still fail to acknowledge this truth. The intersectionality of how care is given to women will simply mean that the outcomes on Black women and their babies will be worse than those who are white. This is a hard stop. A study done in 2000 by Planned Parenthood in association with the National Center for Health Statistics found that “compared to states that support women’s health, states that oppose safe and legal abortion spend far less money per child on a range of services such as foster care, education, welfare, and the adoption of children who have physical and mental disabilities.” The reasoning for this is simple: When the political body supports women, infrastructure is created to support their wellbeing as well as the wellbeing of their children. Again, I turn to the state of California as proof of this. As a physician, I swore an oath to remain objective in the pursuit of an individual’s right to health. Since we all have taken that oath, doesn’t the physician collective as a whole have a responsibility to set aside personal opinions and stand openly in opposition to policies — and the individuals in power supporting them for that matter — that we know cause irreparable harm? The actions of people like McCormick and even women such as Alabama Gov. Kay Ivey, who signed one of the most stringent abortion laws in the nation, tell us that they care far less about the welfare of human life and more about the power to control a woman’s body, all while they conveniently cry constitutional infringement when it comes to their own. The Supreme Court, the highest tribunal in America, established to ensure that all people in this nation are promised equal justice of the law, especially when a state is incapable of doing so, just worsened a nation. Because, truth be told, the safeguards set in place by this historical precedent promising the female a better future have been ripped out from under her feet. So let it be known that from this day forward, as a result of this, women will die. The science is irrefutable.


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High Adventure

A 78-Year-Old Sacramento Ophthalmologist Treks to Everest Base Camp to Fulfill a Long-Held Dream


t is March 31, 2022 and the internet is spotty in the Khumbu, a region on the Nepalese side of the Himalayas. I’m a 78-year-old ophthalmologist from Sacramento, here to fill a bucket list item of visiting Everest base camp. On the first day of trekking we went from Lukla at 9,317 feet to Monjo, elevation 9,301. That’s a net elevation gain of minus 16 feet over a six-hour period. The key word is net; there was a lot of up and down. We descended to the river at the floor of the valley several times, crossed over a very cool suspension bridge and then hiked back up the valley wall on the other side. Even though I have still not seen the Himalayas, the hike was gorgeous with waterfalls, blooming trees, white water and beautiful rock formations. Along the way, we shared the trail with a few other trekkers, some porters carrying heavy loads and lots of pack animals, mules, horses, dzos (a cross between a cow and a yak), and a few very lazy dogs. Five of the 18 members of our International Mountain Guides (IMG) Team One are planning to summit Everest (29,029 feet), the rest, including me, will stop at Everest Base Camp (EBC, 17,500 feet) and of those three will climb a nearby mountain named Loboche (20,161 feet). I’m the oldest in a roster that includes two women about 50, a female ER doc from Indiana, a nurse of about 60 from East Sacramento, another nurse from eastern Washington, a retired female surgeon from Virginia and others. Everyone is on their best behavior, so far, at least. The only inanimate thing I miss is my electric blanket.

April 2: Namche Bazar, 11,283 Feet My personal guide Mingma calls Namche Bazar “Sherpa New York.” Mingma is 42 years old has a 23-year-old assistant named Dawa. These Sherpas


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By Michael J. Schermer, MD mjsmd1943@gmail.com

cannot do enough for me; Dawa even ties my boot laces. Mingma speaks passable English and has 25 years of experience in the Khumbu. As a child, he attended one of the schools founded by Sir Edmund Hillary and met him several times. My jaw dropped just a few steps past the entrance to Sargarmatha National Park when I saw the sacred mountain they call Khumbi Yul Lha (18,909 feet). One of two sacred mountains where climbing is forbidden, we saw the other, Tubuche (21,458), after crossing a very high suspension bridge. I got my first view of Everest today during a rest day from a spectacular viewpoint near Namche Bazarat at 11,283 feet. From here the mountain is unimpressive but recognizable by the clouds that blow off the peak almost all the time as the summit extends up into the jet stream. Tomorrow, I trek to Khunde, where I will visit the Hillary Hospital and spend the night.

April 5: Khunde, 12,600 Feet I met a young Australian man named Steve in the quiet, peaceful village of Khunde who had just climbed a difficult nearby peak called Kayjo Ri. He was wind burned, dirty, fatigued, and still high on this accomplishment. His joy was infectious. We were in a cozy common room with a stove in the middle. The proprietor fired this up with dried yak dung collected last summer. The hospital in Khunde is very basic. A young female doctor there showed me around. My sense is that the one doctor is pretty much the entire staff; she is doctor, nurse, pharmacist, X-ray tech and lab tech all rolled into one. Her quarters are on the hospital grounds, she is on call 24/7 except on the rare occasions when a relief doctor shows up. There was an office/exam room and seven inpatient rooms, none of which were occupied or heated. Each

Dr. Schermer crosses the Hillary suspension bridge, one of many at the beginning of the trek. room is semi-private because there is always a friend or relative with the patient. The delivery room features an incubator and delivery table with stirrups. All of the prescription drugs are kept in cardboard boxes that line the shelves of a small room. Most importantly, a helipad is located on the hospital grounds. I was happy to see a slit lamp, a set of trial lenses and a lensometer. The lensometer is used only when they have a cataract camp held every two to three years. I don’t think the trial lenses are used at all. Very near Khunde is the most beautiful spot on earth. I know this should be qualified, so here goes: it is by far the most beautiful, breathtaking, jaw-dropping and tearproducing spot I have ever seen. The Hillary Memorial Lookout at 13,000 feet provides terrific views in all directions of spectacular mountains including Everest. I’ll be flabbergasted if anything ahead of me tops this place. It should be on everyone’s bucket list.

April 8: Phereche, 13,958 Feet I was able to join the second IMG team for a Ve Ja Guru ceremony with Nawag Pal Ju, the 78-yearold Lama at the Pangboche monastery. The 13 of us removed our shoes and hats, sat cross legged on the floor at the perimeter of the small, highly decorated room facing some sort of altar. The table in front of the altar was covered with a cloth featuring colorful cartoon characters and was crowded with small brass bowls, pitchers and assorted items including, believe it or not, two soft drink bottles and a few small cartons of cookies. Mingma immediately began braiding thin red twine into four-inch segments that were attached to a long yellow twine. White linen scarves were passed out to all of us. Few words were said, everyone was most respect-

ful and attentive. Somehow, we got the message to insert a donation in these scarfs then return them. The bearded Lama sat in the corner wearing maroon robes and a matching knit cap. He chanted in the Tibetan language for a few minutes then we were signaled, one at a time, to approach him and bow. With our heads bowed and our hands held in the prayer position, he tied the yellow twine around our necks and placed the white scarf over this. Next there was a gentle tap on the bowed head with some sort of a clapper wrapped in yellow cloth. I had read that peacock feathers were prized in the Buddhist community because a peacock can safely eat a poisonous snake, so I got a few on Amazon before leaving home. Mingma told me to give one of the feathers to the Lama when I was called for my head tap. I got no reaction from the holy man, but when the others left the small room I was signaled to stay. That was a lucky break, because two young Sherpas came into the room. These two men were planning to summit Everest, so a special ceremony had been planned for them This time the Lama put on his reading glasses and began chanting from a stack of rectangular parchment papers each about 15 inches by five inches. When he finished one side of the page he adroitly flipped over to the other. The coolest thing was that he replaced his knit cap with his large double curved maroon and gold Lama hat from a special case. Each person in the room bowed and approached the Lama who first tapped a small brass decorated pitcher against the head of the supplicant then poured a small amount of liquid from the pitcher into our cupped hands. This was slurped up and the remainder rubbed into the face. I waited my turn never knowing if it was July/August 2022


appropriate for me to participate, but each time I was encouraged to do so. I later learned that one pitcher contained water and the other local beer. All the while the chanting continued. At a few points, the Lama rang a bell and twirled a two-sided handheld drum. A bowl of uncooked rice was passed around. When I saw the others take some, I did the same. When they tossed the rice into the air so did I. A few times the Lama, without taking his eyes from the pages, tossed rice in the direction of each person in the room. This went on for over an hour. The chanting in Tibetan was reminiscent of Torah reading. At the end, each climber received a special necklace with a small, laminated picture of a god attached. These necklaces, called “Sungde,” are to be worn constantly until the journey at hand is completed.

April 13: Lobuche, 16,340 Feet

April 14: Gorakshep, 16,942 Feet

Yesterday I arrived at Lobuche Base Camp, a small, very wellequipped tent camp set up by International Mountain Guides. When I unpacked for the umpteenth time I could not find my pee bottle, so I checked and double-checked, but no luck. When this was reported to Mingma he too checked, but without success. I figured I could use an empty Pringles can as a last resort. Not a happy thought, but better than the battle to exit the tent on a cold, dark night. Lo and behold at dinner, Dawa showed up with the bottle. I could have kissed him. He went all the way back to Thukla to retrieve it. That was a four mile round trip with 1,400 feet of elevation, and he did it with a smile. No leaky Pringles cylinder for me.

My itinerary had me spending the night about halfway to EBC at Gorakshep. This was an elevation gain of only 732 feet. As always, I put myself in Mingma’s hands. Hydration is critical at altitude. I have been forcing myself to drink and on the trail my average is one liter per hour. I was expecting a short trek, but this turned out to be six and a half hours. We had only three liters of water between the three of us. Unaware of this problem, I drank water at my normal rate. Looking back, we should have purchased more water in Loboche Village, about a half hour from our starting point. About three hours into the trek, Mingma notified me that we were down to half a liter between the three of us. Dawa has conditioned himself to the point where he drank nothing for the full six and a half hours while Mingma had only a few sips. A 6 1/2-hour trek for me is like a 90-minute hike for my Sherpa guides. Mingma tried to reach Pasang, our young porter who almost always races ahead to our destinations. Pasang could backtrack down to us with more water. Unfortunately, he could not be reached so Mingma decided to go the last mile and a half to Gorakshep and then return to us with a water supply. I took only sips of the remaining precious water as we moved slowly along the trail. Soon, Dawa phoned Mingma to find that he was already heading back to us. I decided to stay put until he arrived. About 15 minutes later, when Dawa spotted Mingma on the

Recollections Recollections of of How How Teaching Teaching and and Learning Learning Were Were Upended Upended in in 2020 2020

Above: The view at Lobuche Base Camp, altitude 16,210 feet. Opposite page: Dr. Schermer at the breathtaking Hillary Memorial Lookout. 20

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literally had my back; he clung to my parka as we climbed. These three did not pull or push me up, I had the energy for that. They were there for much-needed stability.

April 15: Everest Base Camp, 17,500 Feet

trail I finished the last of the water. Upon his arrival, I gulped down half a liter. By now the sun was setting, but we still had that last mile and a half at about 16,500 feet. I put on my heavy parka and ski gloves just as the wind kicked up and sleet began to fall. We made it to Gorakshep just before dark. The next day I successfully climbed Kala Pathar (18,209 feet). I think my time of 4 hours and 6 minutes will stand as the slowest ascent in modern times. This mountain is popular with trekkers because it offers the best views of Everest, the ugly duckling among the many beautiful snow-covered pyramidal peaks in this part of the Himalayas. It is dark, rounded and without snow. The main redeeming feature is the almost constant cloud that hides its peak. I was driven to reach the top of Kala Pathar, so with plenty of water, on we went. Near the summit, there is a perilous boulder field, kind of like at the top of Pyramid Peak near Lake Tahoe. The difference is that Kala Pathar is almost two miles higher and on this day the wind was terrific. I made it through the boulders only because Dawa held my right hand and Pasang my left. Mingma

Base camp is huge and cold. It must extend for a mile. There are literally hundreds of tents. Each climbing group is a little community. The IMG compound has a dining tent, communications tent, toilet tents, electricity for charging devices, hot water and even a shower facility. The groups here are from all over the world. Beautiful peaks surround it on three sides. The famous Khumbu icefall is easily visible. This morning we saw a distant avalanche that looked like a cloud of white dust. Some of my wife Shelly’s ashes have been with me from the beginning in a special belt that I wear. My goal was to ask one of the Everest climbers to spread them at the summit, but Ang Jangbu, the senior guide, told me it was a bad idea. He said a small altar, called a Pooja, set up at the IMG camp, is considered higher than Everest to the Buddhists. This stone Pooja was decorated with prayer flags and offerings that were mostly bottles of soft drinks and a can of beer. Eleven days ago, back in Namche Bazar, I was advised to buy a can of San Miguel beer because as the trek progresses, the cost of everything escalates. After Namche I completely lost interest in alcohol, so every time I packed and unpacked that can I considered giving it away, but Pasong was schlepping it, so it stayed in my duffel. Now I placed it as an offering on the IMG Pooja, then I closed my eyes and opened the packet of ashes. George Mallory, in 1923, when asked why he wanted to climb Mt. Everest, answered more than just, “Because it’s there.” He said, “Because it’s there… Everest is the highest mountain in the world, and no man has reached its summit. Its existence is a challenge. The answer is instinctive, a part I suppose, of man’s desire to conquer the universe.” I am not about to conquer the universe, but I did conquer Everest Base Camp. It was an adventure, a challenge, and the fulfillment of a long-held dream. This article is excerpted from Dr. Schermer's trek blog. To read the entire blog, visit https://bit.ly/EBC2022blog. For more pictures, visit https://bit.ly/EBC2022pics. July/August 2022



Join the Fight Against Underage Vaping “N

o, I don’t smoke. I just vape.” For pediatricians, this response is all too familiar from our adolescent patients during routine health maintenance visits. We are currently in an epidemic of teen vaping, with as many as one in five teens saying they have used e-cigarettes. The 2019-2020 California Student Tobacco Survey revealed 96% of high schoolers in California who vape use flavored vape products. Candy-flavored tobacco and nicotine products can lead to addiction and hook customers for a lifetime. Opya Half Page Ad_Print.pdf 1 6/1/22 6:27 PM E-cigarette use in teens can have significant detrimen-

By Rachel Caynak, MD racaynak@ucdavis.edu

tal effects to their health, prime the developing brain for future addiction and increase the likelihood that they will use traditional cigarettes later in life. Ninety percent of adult smokers smoked their first cigarette before the age of 18, and more than one half of young adults who smoke daily started smoking between ages 6 to 12. Fruit and candy flavors like bubble gum, blue raspberry and root beer have been used in vape pens and electronic cigarettes, making them more attractive to underage users. Colorful and convenient packaging work to glamorize nicotine use. Moreover, while flavorings may seem innocuous, some flavoring chemicals

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As many as one in five teens say they have used e-cigarettes. Some flavoring chemicals have been found to be toxic and damage lungs. have been found to be toxic, damaging cells in the airways and lungs. Menthol is a common flavor that makes it easier to start, harder to quit and increases the risk of harm. Big Tobacco’s years of targeted marketing has resulted in significant health disparities for African Americans and many other groups. The U.S. Food and Drug Administration’s recent ruling to take menthol out of cigarettes has been years overdue. What’s even worse is these new products with nicotine salts, which are more bioabsorbable and can contain as much nicotine as a pack of 20 cigarettes, amplifying the opportunity for addiction and disease. Vaping is associated with up to a seven-fold increase in getting COVID. New disease epidemics like EVALI are still sickening young people locally during COVID. How do we keep these dangerous products out of the hands of children? Limiting the retail sale of flavored tobacco products is one first step to reduce access. Addiction among children and young adults

will decrease when tobacco tastes and smells like tobacco. A study of children and young adults in Texas in 2017 revealed 75% of flavored tobacco users reported they would no longer use the product if it wasn’t flavored. California has a state law restricting the sale of flavored tobacco products, including menthol, but it has been on hold. In August 2020, California passed Senate Bill 793, with bipartisan support, to prohibit the sale of flavored tobacco products. The tobacco industry spent over $20 million to place a referendum on SB 793, and the law’s implementation has been on hold pending the outcome of a vote by Californians on the November 2022 ballot. At the local level, over 125 cities and counties in California have passed restrictions on the sale of flavored tobacco products. The City of Sacramento has had a policy since 2020 and unincorporated Sacramento County will implement a similar policy in July 2022. Several

other cities in the Sacramento region have been actively considering policies. Local physicians who work at UC Davis Health have joined public health groups to help educate policymakers and the community. The Sacramento Sierra Valley Medical Society and its Public and Environmental Health Committee have helped with local education and support, consistent with the California Medical Association’s official position. There are several ways for SSVMS physicians to get involved and make a difference. One way to become more active in the campaign is to contact the Greater Sacramento Smoke & Tobacco Free Coalition at greatersacstfcoalition@ gmail.com or call (916) 875-5869 about opportunities to join upcoming policy meetings and a speakers’ bureau training. Patients who smoke or vape can be referred to Kick It California (www.kickitca.org), previously the California Smokers’ Helpline, for free help to quit. The UC Quits series also offers free, brief tobacco treatment training modules worth up to 3.0 CME credits at www.cmecalifornia.com. More information can be found at the California Tobacco Control Program’s public website at www.undo.org. When Big Tobacco wins, our children and communities lose. As physicians, we can help the next generation from suffering through more tobacco epidemics. Dr. Elisa Tong contributed to this article. The opinions expressed are those of Drs. Caynak and Tong and not of the University of California.

July/August 2022



A Thousand Chances to Save a Life SSVMS, Sacramento County Opioid Coalition Distributing 1,000 Narcan Kits Into the Community


ver the last several years, the Sacramento County Opioid Coalition, run through SSVMS, has benefited from participating in the AmeriCorps VISTA program. Our current AmeriCorps Vista volunteer, Lauren Werner, has taken on our Narcan distribution project, which has the goal of distributing 1,000 Narcan kits into the community accompanied by the training needed for their proper use. The focus is on youth prevention and harm reduction, and we’re taking our kits and information to where they are needed most including raves, community wellness events, church-sponsored gatherings, and more. In just five months, Lauren has given 142 presentations, either in-person or over Zoom, with an emphasis on at-risk populations such as LGBTIQ+ and at venues ranging from local bars to high schools. Narcan can provide an almost immediate reversal of the effects of opioid overdose. Through the Opioid Coalition, we are distributing kits that include Narcan (two 4 mg doses of naloxone), fentanyl test strips, a CPR

The Sacramento County Opioid Coalition's Narcan kit includes tools to treat and prevent overdoses. Right, the Coalition's quick start Narcan guide. 24

Sierra Sacramento Valley Medicine

By Lindsay Coate lcoatef@ssvms.org

face mask, key chains, alcohol swabs and even lip balm with a “safe and serene vanilla bean” flavor. Part of the outreach includes educating kids and their parents about the dangers of fentanyl. Sacramento, like other areas of the country, has experienced a wave of unintentional overdoses because 98% of the most common street pills tested are fake and found to contain fentanyl. We are reducing the stigma associated with harm reduction strategies by focusing on the fact that Narcan and fentanyl test strips will save lives. We are also educating people about California's Good Samaritan law, which says that a person who seeks, in good faith, medical assistance during an overdose or assists someone who is experiencing an overdose will not be charged with a crime. Lauren, a graduate of Humboldt State University with a degree in international studies, will be with us for a year to work on the project. She is one of many VISTA volunteers recruited by The Center for Health Leadership and Practice at the Public Health Institute for a one-year commitment to serve in local opioid safety coalitions across California. The Sacramento County Opioid Coalition includes health care professionals, community-based organizations, law enforcement, county agencies, and concerned citizens determined to turn the tide of our local opioid epidemic. It is committed to preventing overdoses and saving lives by expanding treatment access, promoting safe disposal, encouraging early intervention and treatment, and public education and media outreach. Watching up-and-coming professionals like Lauren and our previous VISTA volunteers educate our community has been a joy and we look forward to recruiting new AmeriCorps VISTA volunteers for the foreseeable future. Lauren and the Opioid Coalition will be making appearances throughout the Sacramento area, often several times each week, through early 2023.

QUICK START GUIDE HOWNASAL TO USESPRAY NARCAN Use NARCAN Nasal Spray (naloxone hydrochloride) for known or suspected opioid overdose in adults or children. Naloxone does not produce effects on those without opioids in their system. It is safe to administer Narcan regardless of knowing if there is an occurring opioid overdose. *Important: Do not remove or test the Narcan Nasal Spray until ready to use. For additional information, please visit: www.narcan.com


Look for any of the following signs


Check responsiveness


Call 911 and give Naloxone


Perform rescue breathing

Breathing is shallow, gurgling, or stopped Lips, face, and fingernails look blue or grey and skin is pale

No response when you rub your knuckles firmly on their sternum or when you yell their name Hold the tip of the Narcan about 1 inch inside one nostril and then press the plunger to spray entire contents If no response after 2-3 minutes, be prepared to give a repeat dose in the the other nostril

Follow 911 dispatcher instructions and continue rescue breathing and/or chest compressions until the individual wakes up or emergency medical services arrives For rescue breathing, check airway, tilt the head, lift the chin, pinch the nose, and start with 2 breaths then give 1 breath every 5 seconds If the person wakes up, they may present disoriented or confused Reassure them that help is on the way and wait with them until emergency medical services arrive July/August 2022



Board Briefs May 9, 2022 THE BOARD: Received a report from Andrea Linder, Director of Business Development, ProAssurance-NORCAL Group Professional Liability Insurance, a SSVMS Business Partner and Sponsor. Received a presentation from 11th District CMA Trustees Drs. Adam Dougherty and Margaret Parsons regarding the agreement between Californians Allied for Patient Protection and the plaintiffs’ attorneys to modernize and update the Medical Injury Compensation Reform Act (MICRA).

Approved the 1st Quarter 2022 Financial Statements. Approved the 2022 Nominating Committee. Approved the May 9, 2022 Membership Report as follows: For Active Membership — Derek I. Brink, DO; Jerrell S. Brown, MD; Camilo E. Cano Portillo, MD; Alexandra Chesnokova, MD; Sarah H. Ching, DO; Matthew A. Cummins, MD; Rosa Farrer-O’Bryant, MD; Sherri L. Kappler, MD; Harshal D. Kirane, MD; Janine B. Lee,

Retinal Consultants Medical Group welcomes

T h e P h ys i c i ans an d st aff a t R e t in a l Cons ul tan ts Me d i cal G ro u p ar e e x c i t e d to an no un c e th a t D r . C a m e r o n P o le wi l l b e j oi n i n g o ur pr ac tic e i n Aug u st!

Please j oin us in welco mi ng him!

Cameron Pole, MD Re t i na S p e c i a l i st

v i si t u s o nl i ne at w w w .r e t i nal m d . c o m


Sierra Sacramento Valley Medicine


MD; William Massey, MD; Masaru H. Oshita, MD; Ravneet Riar, MD; Matthew J. Storment, MD; William S. Tanner, MD; Yolanda S. Tejeda, MD; Daniel Tupy MD; Mariel M. Velez, MD; Barry K. Young, MD.

For Transfer of Membership — Rostam Bakhtari, MD (to Placer-Nevada); Richard A. Bermudes, MD (to Marin); Arthur R. Jey, MD (to Placer-Nevada); Susana Torres, MD (to Monterey).

For Reinstatement to Active Membership Following Payment of Dues — Nathan H. Allen, MD; Suzanne J. Stewart, MD.

For Termination of Membership (nonrenewal of medical license) — Katherine B. Lee, MD; Elaine M. Oliveira, MD; Tooba Rehman Jahangir, MD.

For Multiple Membership — Colleen Townsend, MD.

Deceased — J. Willison Allen, MD (4/5/22)

For Resignation (moved out of state) — Julia M. Graham, MD; Nisha Hariharan, MD; Brandon Vu, MD.

New SSVMS Members The following applications have been approved by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Adam Dougherty, MD, Secretary.

New Active Members *Physician specialty abbreviated following name.

Omnia D. Awad, MD, OPH, The Permanente Medical Group Hannah M. Bechtold, MD, AN, UC Davis Health Samhita H. Bhargava, MD, PD, UC Davis Health David M. Brandman, MD, NS, UC Davis Health Anjali J. Cera, MD, NPM, UC Davis Health Tatiana Chadid Santamaria, MD, HOS, Mercy Medical Group Valerie D. Curtis, MD, HOS, Sutter Medical Group Emmanuel S. De Jesus, MD, IM, Sutter Medical Group Timothy M. Dempsey, MD, EM, UC Davis Health Diana L. Dremsa, MD, PMD, UC Davis Health Nancy O. Ekeke, MD, IM, The Permanente Medical Group Cameron E. Gaskill, MD, SO, UC Davis Health Raymond Gong, MD, PTH, UC Davis Health Daniel C. Herman, MD, PM, UC Davis Medical Group-Davis Alejandro Jimenez, MD, IM, UC Davis Medical Group-Midtown

Satinderpal S. Khera, MD, R, The Permanente Medical Group Rajbinder K. Mann, MD, FP, The Permanente Medical Group Angel M. Mendoza-Gonzalez, MD, IM, The Permanente Medical Group Phillip M. Murray, MD, P , UC Davis Health Minhthao T. Nguyen, DO, END, UC Davis Health Na'amah Razon, MD, FP, UC Davis Health Amadeo D. Rivera, Jr., MD, IM, The Permanente Medical Group Richard A. Ruben, MD, FP, Mercy Medical Group David E. Sahar, MD, PS, UC Davis Health Joshua I. Santos, MD, PUD, UC Davis Health Kurt Swartout, MD, IM, Mercy Medical Group Peter A. Than, MD, GS, UC Davis Health Sophia A. Traven, MD, ORS, UC Davis Health Jennifer R. Urban, MD, D, Sutter Medical Group Amanda T. Whitaker, MD, ORS, UC Davis Health Shaina M. Willen, MD, PD, UC Davis Health

July/August 2022



Woven Every day, when time permits I marvel at the spectacle of a new sunset. Each different — every time Ever changing — every time Alluring — every time Affected by pleasant breezes Affected by darkened clouds Affected by the heat, the blazing blindness of the sunlight of that day, that month, year, time So wonderfully different and captivating each day So affected by events and by time This morning, I witnessed a new sunrise It too was mesmerizing and I wondered At how our interwoven lives create a sunset before we sleep With deep, cheerful and pretty pinks and yellows swaths Hues of bright orange and heavy angry reds laced with deep bruises of purple and of pain Trailing into greys and black before the sunrise All within the same woven sky — Eric Williams, MD


Sierra Sacramento Valley Medicine

Closer to home + enhanced referrals = easier access to world-class care Payam Saadai, M.D., Assistant Professor, Department of Surgery Specialties: Pediatric Surgery, Colorectal Surgery, Fetal Surgery, Minimally Invasive Surgery

UC Davis Health offers nationally ranked expertise — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley. Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care. Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals.

Our liaisons can also help to: ■

Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, symposiums, etc.

Reach out to your local Physician Referral Liaison today:

Tracy Bayne | 916-916-281-8734 thbayne@ucdavis.edu


You’ve worked hard to achieve success. You deserve financial advisors who work as hard for you. As an Ameriprise private wealth advisory practice, we have the qualifications and experience to help navigate your complex financial needs. Whether it’s investment management, tax strategies or legacy planning, we can work with you to grow and preserve what you’ve worked so hard to achieve. Call us today and discover the personal service you deserve.

Douglas A. Crumley Jr. CFP®, CRPC®, APMA®, CKA® CERTIFIED FINANCIAL PLANNER™ practitioner Private Wealth Advisor Business Financial Advisor Crumley & Associates A private wealth advisory practice of Ameriprise Financial Services, LLC 7956 California Ave, Fair Oaks, CA 95628 916.638.4600 | dougcrumleyjr.com douglas.2.crumley@ampf.com Crumley & Associates will donate $100 to the Joy of Medicine program for each SSVMS physician member who engages in financial planning.

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