2010 January/February

JANUARY/FEBRUARY 2010 | Volume 16 | Number 1

SCCMA/MCMS LAUNCHES NEW WEBSITE!

Check Your Member Profile • Pay Dues Online Share Messages in the Member Discussion Forum

As a physician, your liability exposure isn’t limited to the practice of medicine.

You also need to consider your risks as a business professional–risks that go unprotected by your medical malpractice coverage.

T

he Santa Clara County Medical Association and Monterey County Medical Society sponsor a high-quality and responsive medical office insurance policy that provides comprehensive business insurance coverage tailored specifically for physicians like you. Only this SCCMA/MCMS sponsored policy offers you well-rounded coverage, the reliability of the SCCMA/MCMS endorsement, specialized expertise and physician-focused service–all at an economical price.

Some of the Important Highlights of this Cost-Effective Insurance Policy: • Coverage to compensate you for lost income to help pay ongoing expenses while your practice is unable to function after a loss–even helping to cover lost profit.

SPONSORED BY:

UNDERWRITTEN BY:

ADMINISTERED BY:

• Pays damages, medical bills, as well as attorneys’ fees and other legal expenses should someone trip and fall or injure themselves while visiting your practice.

• Protects your practice if patient information or

other sensitive data is accidently publicized, stolen or released. Even a nominal technical malfunction could accidentally release protected information, damage your reputation, expose you to lawsuits and other legal complications. Legal defense, assistance to affected individuals and other needed and costly services are included.

Don’t assume the same policy that you automatically renew each year is still the best coverage for your practice. This SCCMA/MCMS sponsored insurance program can make sure that you are not paying more to insure your practice than you need to.

47085 (1/10) ©Seabury & Smith Insurance Program Management 2010 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

For more information or a quote, please call a Marsh Client Service Representative at 800-842-3761, or e-mail CMACounty.Insurance@marsh.com

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Calendar of Events.......................................................................................5 From the Editor’s Desk.................................................................................6 Message From the SCCMA President: Going Green..................................8 SCCMA/MCMS is pleased to roll out an all-new website with marked improvement in functionality and content. Visit the all-new site at www.sccma-mcms.org.

More on page 10

Howard Sutkin, MD, FACS

SCCMA/MCMS Debuts All-New Website!.................................................10 Exploring Career Paths in Medicine.........................................................12

Duy Diao and Michael Chiu

Politics 101..................................................................................................14 Randal Pham, MD, FACS

CME: 59th Annual Yosemite Postgraduate Institute...............................15 A Great Opportunity Missed?....................................................................16 According to surveys, the majority of clients who work with advisors are not aware that income limits associated with the conversion of a traditional IRA to a Roth IRA have been lifted effective January 2010.

More on page 16

Robert M. Cheney, CFA CFP®

Marcus Welby? He’s History.......................................................................18 Ronald J. Glasser, MD

SCCMA Alliance News................................................................................20 Failure to Appropriately Communicate Abnormal Test Results............22 NORCAL Mutual Insurance Company

Focus on Deaf and Hard of Hearing Patients..........................................29 NORCAL Mutual Insurance Company

Coding Q’s...................................................................................................32 Communication breakdowns are at the heart of many medical liability claims. Frequently, when a claim is filed that involves a missed or delayed diagnosis, the plaintiffs have discovered that a critical test result “fell through the cracks.”

Sandie Becker, CMC

MEDICO News ............................................................................................34 Classified Ads..............................................................................................36

More on page 22 PAGE 3 | THE BULLETIN | JANUARY / FEBRUARY 2010

The Santa Clara County Medical Association Officers

AMA Trustee - SCCMA

Councilors

President Howard Sutkin, MD President-Elect Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs William Lewis, MD VP-Member Services Judith Dethlefs, MD VP-Professional Conduct Jim Crotty, MD Secretary Sameer Awsare, MD Treasurer Martin L. Fishman, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Rives Chalmers, MD El Camino Hospital: Open Good Samaritan Hospital: Eleanor Martinez, MD Kaiser Foundation Hospital - San Jose: Efren Rosas, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Saranto, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: Patrick Kearns, MD

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA Delegation Chair Tanya W. Spirtos, MD (District VII)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President-Elect) Randal Pham, MD (Ethnic Member Organization Societies)

Chief Executive Officer

Tanya W. Spirtos, MD (District VII)

William C. Parrish, Jr.

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society of products or services advertised.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Valerie Barnes, MD Ronald Fuerstner, MD David Holley, MD R. Kurt Lofgren, MD James Ramseur, Jr., MD Scott Schneiderman, DO

CMA TRUSTEE – MCMS Valerie Barnes, MD

© Copyright 2009 by the Santa Clara County Medical Association.

PAGE 4 | THE BULLETIN | JANUARY / FEBRUARY 2010

SCCMA / MCMS

calendar of events Please note: All members may attend events held in Monterey and Santa Clara counties, regardless of location of membership. Please call Jean or Jackie to register and for location information, 408/998-8850 or 831/455-1008.

RESCHEDULED FOR MAY 28, 2010 SCCMA: Luncheon With Assemblymember Joe Coto Originally scheduled date: Fri, Feb 19, 2010 | 12:00 PM-2:00 PM

MCMS: What Every Office Manager Should Know About Running a Practice (PRACTICE MANAGERS ONLY) Thu, Apr 1, 2010 | 12:00 PM-2:00 PM A presentation about ARs, collections, and billing for practice managers only. Presented by Frank Navarro, CMA’s Center for Economic Services.

SCCMA’s External Affairs Committee is hosting a luncheon with Assemblymember Joe Coto. Please join us for lunch and discussion.

SCCMA: Luncheon With Congresswoman Zoe Lofgren Fri, Feb 26, 2010 | 12:00 PM-2:00 PM SCCMA’s External Affairs Committee is hosting a luncheon with Congresswoman Zoe Lofgren. Please join us for lunch and discussion.

MCMS: Retirement, Recruiting, Buying, Selling, & Transitioning Your Practice (PHYSICIANS ONLY) Mon, Mar 8, 2010 | 6:00 PM-8:30 PM A presentation for physicians-only by Practice Liability & Consultants.

MCMS: What Every Physician Should Know About Running a Practice (PHYSICIANS ONLY) Thu, Apr 1, 2010 | 6:00 PM-8:30 PM

SCCMA: Retirement, Recruiting, Buying, Selling, & Transitioning Your Practice (PHYSICIANS ONLY) Mon, Mar 15, 2010 | 6:00 PM-8:30 PM

A workshop focusing on telephone techniques, patient relations, and customer service presented by Practice & Liability Consultants.

SCCMA: Luncheon With Assemblymember Jim Beall Fri, Apr 16, 2010 | 12:00 PM-2:00 PM SCCMA’s External Affairs Committee is hosting a luncheon with Assemblymember Jim Beall. Please join us for lunch and discussion.

SCCMA & MCMS: CMA Legislative Day Tues, Apr 27, 2010

A presentation about ARs, collections, and billing for physicians only. Presented by Frank Navarro, CMA’s Center for Economic Services.

MCMS: Diversity in Medical Practices Wed, May 12, 2010 | 10:00 AM-12:00 PM

A web-based presentation by Practice & Liability Consultants.

MCMS: Patient Relations Workshop Fri, Apr 9, 2010 | 9:00 AM-12:00 PM

SCCMA: What Every Physician Should Know About Running a Practice (PHYSICIANS ONLY) Wed, Mar 31, 2010 | 6:00 PM-8:30 PM

A presentation by Practice & Liability Consultants. Part 1 of a 3-part series.

SCCMA & MCMS: 13th Annual California Health Care Leadership Academy, The Era of Health Reform: Harnessing the Currents of Change Location: San Diego Marriott Hotel & Marina Fri, Apr 9-11, 2010

Beyond the Prevention of Harassment and Discrimination A presentation by TPO.

A presentation about ARs, collections, and billing for practice managers only. Presented by Frank Navarro, CMA’s Center for Economic Services.

SCCMA: MBA in 3 Days: Finance Fri, May 7, 2010 | 9:00 AM-12:00 PM

A presentation by TPO.

SCCMA: Diversity in Today’s Medical Practices Wed, Mar 10, 2010 | 12:30 PM-1:30 PM

SCCMA: What Every Office Manager Should Know About Running a Practice (PRACTICE MANAGERS ONLY) Wed, Mar 31, 2010 | 12:00 PM-2:00 PM

A presentation on OSHA compliance by EnviroMerica.

A presentation about ARs, collections, and billing for physicians only. Presented by Frank Navarro, CMA’s Center for Economic Services.

The exciting agenda this year will place major emphases on health information technology, practice management, and leadership development.

A presentation for physicians-only by Practice Liability & Consultants.

MCMS: OSHA Compliance Refresher Thu, Apr 29, 2010 | 12:00 PM-2:00 PM

An exciting day in Sacramento for physicians from throughout the state to visit with their state representatives to discuss health care related issues. Additionally, they normally provide an extensive morning session consisting of various keynote speakers briefing attendees on current legislation being endorsed or opposed by CMA. Will provide a bus to transport everyone together and provide lunch as well. It’s a full day at the capital - but well worth the investment of time!

SCCMA: Mojo Management Webinar Thu, May 13, 2010 | 12:30 PM-1:30 PM SCCMA: MBA in 3 Days: Operations Fri, May 14, 2010 | 9:00 AM-12:00 PM A presentation by Practice & Liability Consultants. Part 2 of a 3-part series.

SCCMA: MBA in 3 Days: HR Management Fri, May 21, 2010 | 9:00 AM-12:00 PM A presentation by Practice & Liability Consultants. Part 3 of a 3-part series.

SCCMA: Luncheon With Assemblymember Joe Coto Fri, May 28, 2010 | 12:00 PM-2:00 PM SCCMA’s External Affairs Committee is hosting a luncheon with Assemblymember Joe Coto. Please join us for lunch and discussion.

SCCMA: Informed Consent and Documentation (PRACTICE MANAGERS ONLY) Thu, Jun 3, 2010 | 12:00 PM-2:00 PM A presentation by Brooke Bledsoe, NORCAL. This section is for office managers only.

SCCMA: Informed Consent and Documentation (PHYSICIANS ONLY) Thu, Jun 3, 2010 | 6:00 PM-8:00 PM A presentation by Brooke Bledsoe, NORCAL. This section is for physicians only.

SCCMA: Annual Awards Banquet & Installation Tues, Jun 8, 2010 | 6:30 PM-9:00 PM Location: The Fairmont, San Jose Don’t miss SCCMA’s Annual Awards Banquet and Installation. Please mark your calendars now! Formal invitations will be mailed in April.

PAGE 5 | THE BULLETIN | JANUARY / FEBRUARY 2010

FROM THE EDITOR’S DESK

Haiti Earthquake: How to Help patients, and leave after just three days. A full account is described here: http://www. cnn.com/2010/OPINION/01/25/doctors. haiti.hardships/index.html.

By Joseph Andresen, MD The devastation, loss of life, and human suffering following Haiti’s catastrophic earthquake is unimaginable.

At this date, more than 200,000 people have died and tens of thousands have been seriously or critically injured. One million people are homeless and hundreds of thousands of children are now without parents.

The account described above prompted me to contact our U.S. State Department and USAID to relate the information provided. It is clear that disaster relief requires much more than medical resources alone. A clear chain of command, vital communications,

For those of us who experienced the 1989 Loma Prieta earthquake that killed 63 people, injured 3,757, and left 12,000 homeless, it is a reminder of how fortunate we were in the San Francisco Bay Area and how important disaster preparedness continues to be.

Early reports from the field give us a glimpse of the challenges facing medical relief teams in Haiti. I received an email from Dean Lorich, MD, FACS, associate director of Orthopedics Trauma Service of New York Presbyterian Hospital.

Within 24 hours after the earthquake, his group put together a 13-member team of surgeons, anesthesiologists, and nurses with a massive amount of surgical supplies all transported to Port-au-Prince by private plane. Upon arrival, the team found that the general hospital was severely damaged, with no running water and limited electricity. They quickly relocated to a community hospital, finding 750 patients waiting and in dire need of care. Working around the clock, they performed 100 operations in the first 72 hours. Twentyfour hours later, a truck bringing additional medical supplies from the airport was hijacked and replacement staff had their flight canceled and could not enter the country as originally planned. With no one in charge and a lack of security and organizational support, this medical team tragically had to abandon their efforts, and

“I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm….” - Hippocratic Oath

(Modern Version) and adequate security are all required to effectively coordinate relief efforts.

Government, military, and experienced relief organizations best handle these efforts. With the aftermath of Haiti’s earthquake, there is a clear need for U.N. authorities to work closely with U.S. military and international security forces.

Establishment of communication links, food and water distribution points, and

Joseph Andresen, MD is the editor of The Bulletin.

He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area. much needed security is an essential first step. This will allow medical resources to get to the thousands who need care most quickly and efficiently.

As Americans involved in this relief effort with our international counterparts, we have much to be proud of. The outpouring of support has been most encouraging, with rapid response in search, rescue, medical assistance, food, water, and financial assistance. We are now hearing the stories of local medical teams returning from Haiti who have provided life-saving care to hundreds of patients. The number of injured requiring treatment for major trauma, amputations, and treatment of sepsis has been an overwhelming experience for those who have been and are on the front lines. Many of our medical organizations, including the American Medical Association (http://www.ama-assn.org/ go/haiti-volunteer) and Doctors Without Borders (http://doctorswithoutborders. org/), continue to actively recruit volunteer physicians and accept donations. Brigg Reilley, an epidemiologist with Doctors Without Borders, gives his view from the field, describing Haiti’s immediate and long-term health needs which continue to evolve during this acute phase. (http:// doctorswithoutborders.org/news/article. cfm?id=4237&cat=voice-from-thefield&ref=home-center-relatedlink)

PAGE 6 | THE BULLETIN | JANUARY / FEBRUARY 2010

As an anesthesiologist currently in practice at Washington Hospital in Fremont and facilities in Palo Alto.

I would like to help in any way that I can. There has been an outpouring of support from our local medical staff with physicians asking how they can help.

Currently, there is a critical need for surgeons, anesthesiologists, obstetricians, and infectious disease specialists.

Volunteer opportunities for physicians can be located through the professional organizations noted above.

Haiti Earthquake: How to Help A list of charitable organizations active in Haiti

Washington Hospital is also supporting the relief effort by providing registered nurses a week of paid leave to go to Haiti for volunteer service. The California Nurses Association (http:// www.calnurses.org/) is underwriting transportation, food, and shelter costs for these volunteers. Contributions to send nurses to Haiti can be made on the following website: www.SendANurse.org.

For most of us, the most immediate, practical, and effective way we can assist the relief effort is to donate to one of the relief organizations noted in the sidebar.

For those interested in helping immediately, simply text “HAITI” to “90999” and a donation of $10 will be given automatically to the Red Cross, to help with relief efforts, charged to your cell phone bill.

Lutheran World Relief, 800/597-5972 Action Against Hunger, 877/777-1420 Medical Teams International, 800/959-4325 American Red Cross, 800/733-2767 Meds and Food for Kids, 314/420-1634 American Jewish World Service, 212/792-2900 Mennonite Central Committee, 888/563-4676 AmeriCares, 800/486-4357 Mercy Corps, 888/256-1900 Beyond Borders, 866/424-8403 Operation Blessing, 800/730-2537 CARE, 800/521-2273 Operation USA, 800/678-7255 CarmaFoundation, carmafoundation.org Oxfam, 800/776-9326 Catholic Relief Services, 800/736-3467 Partners in Health, 617/432-5298 Childcare Worldwide, 800/553-2328 Project HOPE, 800/544-4073 Concern Worldwide, 212/557-8000 Rural Haiti Project, 347/405-5552 Cross International, 800/391-8545 The Salvation Army, 800/725-2769 Direct Relief International, 805/964-4767 Samaritan’s Purse, 828/262-1980 Doctors Without Borders, 888/392-0392 Save the Children, 800/728-3843 Feed My Starving Children, 763/504-2919 UN Central Emergency Response Fund, Food for the Poor, 800/427-9104 cerf.un.org Friends of WFP, 866/929-1694 UNICEF, 800/367-5437 Haiti Children, 877/424-8454 World Concern, 800/755-5022 Haiti Marycare, 203/675-4770 World Hope International, 888/466-4673 Haitian Health Foundation, 860/886-4357 World Relief, 800/535-5433 Hope for Haiti, 239/434-7183 World Vision, 888/511-6548 International Medical Corps, 800/481-4462 International Rescue Committee, 877/733-8433 Yele Haiti, 212/352-0552 International Relief Teams, 619/284-7979

PAGE 7 | THE BULLETIN | JANUARY / FEBRUARY 2010

MESSAGE FROM THE SCCMA PRESIDENT

going green

By Howard Sutkin, MD, FACS President, Santa Clara County Medical Association I usually like to look ahead in life, more than looking back, but lately, I have had a change of heart. The medical association is very interested in local “going green” initiatives. We all know why. Just walk past the trash at any hospital, clinic, or medical facility. With rare exception, it is amazing how much volume of “stuff” is consumed, then trashed. Now consider the amount of energy used to produce these items and to discard them. Most of this energy is in some form of burning fossil fuels.

The large generators, such as hospital systems, are beginning to take notice of this and make changes. I noticed one night, driving to SCCMA headquarters on Empey Way, that the new large parking structure at VMC has a huge array of solar panels on the upper level. What a great place to create a powergenerating station. In the same week, I also noticed my neighbor across the street installing a new rooftop system of panels.

He told me he would no longer have an electric bill and used very little natural gas.

It was time to take some action myself. I interviewed four solar power companies and got quotes for installation at my own home in Los Gatos, which has the pleasure of basking in the sun most of the year without obstruction. The process of getting a quote is not simple, but it is painless. The solar salesperson came over, measured the sun exposure, and analyzed my electric bill. About a week later came a presentation of the recommended systems.

This included the types and number of panels which make sense for the household.

The bottom line is a seemingly accurate estimate of return on investment.

I ended up choosing a 32-panel array of “Sunpower” panels. I also happily picked “Solar Technologies” of Santa Cruz to do the installation. Matt Ledna, their sales rep, was thoroughly knowledgeable, pleasant, accommodating, and prompt in answering all of my questions about how to proceed. Matt informed me about the 10% state rebate, which his company takes off the price, and the 30% federal tax credit, which comes back to me at tax time. These incentives, which may not last forever, make the financial analysis work out to one of the best investments I have seen in years — well over 10%. He also offered to introduce our doctors to the Sunpower Corporation for an additional rebate program available for large non-profits, now offered to SCCMA members in an additional refund direct from the manufacturer — Sunpower, a San Jose-based company

Howard Sutkin, MD is the 20082010 President of the Santa Clara County Medical Association. He is board certified in plastic and reconstructive surgery and is currently practicing in the Los Gatos/San Jose area. with the best reputation for high efficiency panels and inverters.

The installation was done in late December, smooth as silk in three days – ahead of schedule! The electricians did a great job and beat my expectations for neat and professional placement of all the wiring and equipment.

So now, even on some of our cloudy weather days, I make more electricity during the day than I use. In the summer, when the days get long, I will really rack-up the kilowatts. I get a thrill in watching the meter run backwards and have already seen a huge reduction in my power bill. I can only imagine that as the trend for solar electric home generation takes off in our community, it will help to lessen our geo-political problems as well. Yes, I love looking at my meter going backwards, and looking back on my decision to get involved in going green — a real slam-dunk decision and process.

If you have considered following in my tracks, please call Matt Ledna and take advantage of the special pricing.

There is a link on the SCCMA website to get started.

PAGE 8 | THE BULLETIN | JANUARY / FEBRUARY 2010

THE PLANET’S MOST POWERFUL SOLAR™

Call: 877-SPWR-4-YOU To start saving today

Introducing the Santa Clara County Medical Association Solar Program As a member of SCCMA, you can receive an ADDITIONAL rebate of up to $2000 on the purchase of a SunPower system.

Sign up for a free solar evaluation by April 30, 2010 to lock down this special offer.

This rebate of $0.40 per watt (up to $2000) can be added to other Federal, state and local rebates which could save you up to 50% off the total cost of your system.

The Santa Clara County Medical Association (SCCMA) wants to help you generate clean power for your home so you can reduce your electricity bill while helping to reduce greenhouse gas emissions.

As part of SCCMA’s commitment to build a clean energy future, the TM Association has partnered with SunPower Corporation to provide an exclusive program to help you go solar TODAY. The Santa Clara County Medical Association Solar Program provides members with an additional discount on the purchase of a SunPower home solar system. With the 30% federal investment tax credit combined with state and local rebates, you could save up to 50% off the total cost of your system.

“ I love having a $5.80 electrical bill every month!”

Sueling Cho Los Gatos Homeowner

MONTHLY ELECTRIC BILLS

$350

$350 $300 $250 $200

And, with the wide range of flexible financing options offered by SunPower, you can start saving money from day one.

The time for solar is now. Take advantage of this exclusive program for SCCMA members and join the solar revolution today.

Visit www.sunpowercorp.com/asp/SCCMA to sign up for a free solar evaluation.

$150

$5.80 Before SunPower

$100 $50

With SunPower

Find out how much you can save TODAY. Visit us online at: www.sunpowercorp.com/asp/SCCMA Or call: 877-SPWR-4-YOU 1-877-779-7496

PAGE 9 | THE BULLETIN | JANUARY / FEBRUARY 2010

www.sccma-mcms.org

SCCMA/MCMS DEBUTS ALL-NEW WEBSITE! Your new first-stop for all things about your medical profession!

SCCMA/MCMS is pleased to roll out an all-new website with marked improvement in functionality and content. The following are a few attributes of the all-new www.sccma-mcms.org.

For assistance with your user name and password, please contact SCCMA/MCMS at 408/998-8850 or 831/455-1008.

Step 4: Enter your password.

Enhanced Physician Finder

Step 5: Make changes/edits to your profile.

The SCCMA/MCMS pictorial membership directory is online. This online referral system provides you and the public with the most up-to-date member profile information. Our online Physician Finder also includes expanded member information including languages spoken, acceptance of new patients, acceptance of Medicare, etc. Member physicians will be able to access information on the number and types of referrals that are being generated from both the SCCMA/MCMS staff and from the public website.

Step 6: Click on Save Changes.

Member Profile Maintenance Our new Members Only area will enable you to securely view and edit your profile information with ease. When you submit your change request, the information is electronically imported back into our database after review by our staff, reducing data entry errors and processing time.

Please check your member profile online to verify that the information is accurate. If any revisions are needed to your member profile, please make the changes online and select the appropriate box at the bottom to Save Changes. Once you Save Changes our system will be updated (after SCCMA/MCMS staff internally accepts/approves the edits made). This database contains the same information as your professional member profile that is printed in the hard-copy membership directory.

Renew/Pay Member Dues Online Under the Quick Links, click on Members Only – Pay Dues Online. Then follow the same steps outlined above to the Members Only login page.

Physician Member Discussion Forum The Members Only area will also host a physician discussion forum, providing members with a platform to open new doors for collaboration and communication. This online forum will provide a link to easily connect to your physician community and talk to other members about business or planning issues of concern.

Get connected today!

Current News SCCMA/MCMS will keep you up-to-date on current news with links to in-depth coverage and resources.

The Bulletin Magazine You will find current and archived issues of The Bulletin online.

Classified Ads

Step 1: Go to our homepage at www.sccma-mcms.org.

Use classified ads to find or advertise for office space, practices for sale, medical equipment, MD employment opportunities, and much more.

Step 2: Under the Quick Links, click on Members Only –

Reimbursement Advocacy

To make changes to your member profile:

Verify Your Member Profile.

Step 3: Log in with your email address. (To begin the process, a temporary password will be emailed to each member.

Members will then have the capability to determine their own

You can access resources developed by SCCMA/MCMS to assist members with reimbursement-related issues. Also, download current and past issues of the Reimbursement & Coding Newsletter.

permanent password. If SCCMA/MCMS does not currently have your email address, please send to pjensen@sccma.org.)

PAGE 10 | THE BULLETIN | JANUARY / FEBRUARY 2010

Member Benefits and Services Our new site contains the latest information and discounts on your member benefits and services.

Calendar of Events Stay up to date on current events, seminars, webinars, etc. offered by SCCMA/MCMS.

Legislative Advocacy Visit the site to stay current on SCCMA/MCMS/CMA legislative advocacy news and activities.

Apply Online Encourage your non-member colleagues to join SCCMA/MCMS online.

It takes only a few minutes to apply via the online application.

Advertising Opportunities Consider whether an ad in The Bulletin or annual Membership Directory might enhance your practice’s marketing program. Receive a 25% member discount off the (downloadable) rates for display ads and 50% discount for classified ads.

www.sccma-mcms.org Front Page: SCCMA/MCMS is pleased to roll out an all-new website with marked improvement in functionality and content at www.sccma-mcms.org.

The new website is still a work in progress. We will continue to improve the website over time, adding more content and practice management materials (i.e.

CME events, etc.). If you have any other suggestions for what you would like to see on YOUR website, please send them to any staff member at SCCMA/MCMS. Our site was designed and implemented by 1027 Design. 1027 Design is an nine-year-old graphic and web design firm based in Redding, California. They specialize in database-related projects such as catalogs, directories, and e-commerce websites. View samples of their work online at http://www.1027design.com, or call them at 530/941-4706. www.sccma-mcms.org Find a Physician Page: The SCCMA/MCMS pictorial membership directory is online. This online referral system provides you and the public with the most up-to-date member profile information.

PAGE 11 | THE BULLETIN | JANUARY / FEBRUARY 2010

SCCMA HIGH SCHOOL OUTREACH PROGRAM

Exploring Career Paths in Medicine A high school outreach program developed by SCCMA student members from Stanford Medical School.

By Duy Diao and Michael Chiu, SCCMA student members, Stanford Medical School

provided exciting anecdotes regarding the daily activities of a diagnostic radiologist and nurse practitioner. The morning presentations were concluded by Dr. Martin Fishman, who illuminated the complexity and intricacy of visual system to the students. Following the presentations, the students were led by the physicians on a tour of the Regional Medical Center, where they visited and learned about the cardiac catheter laboratory, nuclear medicine department, x-ray and vascular laboratory, and the electrocardiogram department.

On November 14, 2009, SCCMA staff and physician members, Stanford medical students, Alliance members, and The Health Trust put on the second-ever “A Day in Medicine” event at the Regional Medical Center of San Jose. This was an opportunity for aspiring high school students to explore a career in health care through physicians’ presentations and interactive activities. Spearheaded by a group of medical After lunch, the high school students students at Stanford School of Medicine, the Thirty-six students from participated in three stations of interactive event received generous support from the various San Jose high activities. They took turns learning how to Santa Clara County Medical Association and work with microscopes, read chest X-rays, Alliance, American Medical Association, schools attended the and take vital signs. The event ended on a and The Health Trust. Thirty-six students event for what turned out high note with a vast majority of the students from various San Jose high schools, including expressing deepened interest in medicine and Andrew Hill, Evergreen Valley, Willow Glen, to be a fun-filled day.

Milpitas, Independence, Live Oak, and Leland wishes to participate in future events. high schools, attended the event for what A special thanks to Drs. Bhatnagar, turned out to be a fun-filled day.

Fishman, Rao, Silberstein, Sutkin, and Ms. Ketner for being The morning started with back-to-back presentations from Drs. Madhur Bhatnagar and Sarala Rao, who introduced their audience to the exciting fields of obstetrics/gynecology and pathology. Dr. Howard Sutkin followed with an electrifying PowerPoint presentation on painstaking procedures in plastic surgery. Dr. Richard Silberstein and Ms. Karen Ketner then

such wonderful speakers at the event, and to Drs. Burbano and Balakrishnan for arranging the tour at Regional Medical Center.

Thank you to The Health Trust for co-sponsoring the day; Stanford medical students and Alliance members for volunteering their time; and Jean Cassetta and Jacquelyn Mentz for doing all the organizational work to make the event possible!

Martin Fishman, MD provides classroom instruction to the students, introducing them to his specialty of ophthalmology.

Howard Sutkin, MD gives a presentation on plastic, cosmetic, reconstructive, and hand surgery.

PAGE 12 | THE BULLETIN | JANUARY / FEBRUARY 2010

SCCMA member medical students show the high school students how to check their vitals.

Medical student Michael Chiu instructs the students on how to read x-rays.

Thank you to the mentors for sharing their perspective about the practice of medicine. L to R: Howard Sutkin, MD; Karen Ketner, NP; Richard Silberstein, MD; Martin Fishman, MD; Madhur Bhatnagar, MD; and Sarala Rao, MD.

One of the highlights of the day was the hands-on experience of looking for different tissue cells under a microscope.

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LEGISLATIVE ADVOCACY

POLITICS 101 Highlights From the Ethnic Physician Leadership Summit Politics 101 Workshop

By Randal Pham, MD, FACS During the Politics 101 workshop at the Ethnic Physician Leadership Summit, physician attendees were asked to sit back and think of themselves as patients sitting in a doctor’s office. What would they want from their doctors? How would they want to be treated? What would they expect from their health providers as they are empowered with the tools to effect health care reforms? It was within this framework that I defined public policy and discussed how they can participate in the public policy process.

The results of a 2009 public policy survey conducted by the Network of Ethnic Physician Organizations, a consortium of 41 ethnic physician organizations, was presented. One hundred and one physicians responded to the survey. The survey revealed that access to health care is the number-one concern to both ethnic and non-ethnic physicians.

Health care reform was ranked second by the ethnic physicians, whereas health and health care disparities were second for the non-ethnic physicians. Other issues of concern were cultural and linguistic competency, workforce diversity, obesity prevention, and physician workforce. Most responders came from two counties in California—Alameda and Los Angeles— but every county in California was represented. This survey was used to help prioritize public policies that are pertinent to physicians of color.

I introduced the audience to the Ethnic Medical Organization Section (EMOS) of the California Medical Association (CMA). In 1997, the California Medical Association established EMOS as a section to represent the ethnic physicians who are members of CMA. EMOS is dedicated to representing the unique perspective of physicians of

color and to facilitating communication and participation between physicians of the diverse ethnic groups in California.

EMOS also provides a forum with CMA through which to resolve the unique concerns facing communities of color, promote nondiscrimination at all levels of medicine, and promote quality and culturally sensitive medical care. EMOS as an organization is represented in both the CMA House of Delegates and the CMA Board of Trustees to effect change within the house of medicine that benefits physicians of color.

During the workshop, I also described the process through which an issue of concern to ethnic physicians can be conceived and turned into concrete change in the form of legislation or legal action, as in the case of the injunction by a federal judge to stop the 10% Medi-Cal cut in 2008. I urged ethnic physicians and non-ethnic physicians who are interested in serving the ethnic communities to join EMOS and participate in the Annual Legislative Briefing, the CMA Legislative Day, and the NEPO/EMOS Legislative Day. Tom Riley, director of Government Relations of the California Academy of Family Physicians, also pointed out that we are living in a very exciting time. He stated that in his 27 years as a lobbyist, he has never before encountered an opportunity to effect change in health care of this magnitude.

Mr. Riley reported that, based on a survey he conducted, the public perceives the U.S. health care system as an automobile that is “very advanced,” “very expensive,” “not everybody can use it,” with “lots of moving parts,” and “if you get in a wreck, you die.”

According to the public, the U.S. health care system is inaccessible, unsustainable, and of dubious quality. These are the

Randal Pham, MD, FACS is an oculoplastic surgeon practicing in San Jose and is the chair of the Ethnic Medical Organization Section (EMOS) of the California Medical Association. He is also a member of the Vietnamese Physician Association of Northern California. reasons used by various groups in Washington to justify sweeping reforms of the health care system.

Given the size and complexity of HR 3200, Mr. Riley suggested that the attendees pick three things from HR 3200 that they think are of utmost importance and use advocacy strategies to voice their concerns. Mr. Riley highlighted the CMA’s support for coverage expansions, insurance market reforms, nearly $400 billion in physician payment fixes, and elimination of the current sustainable growth rate formula and Medi-Cal rate increase. He also reasserted the CMA’s opposition to reduced payment for imaging services, the ban on physician-owned hospitals, provisions allowing nurse practitioners to run medical homes, and regulations forcing physicians to accept a public plan.

Attendees were urged to be actively involved by contacting and maintaining relations with their senators and representatives in Congress.

This article originally appeared in San Francisco Medicine, the journal of the San Francisco Medical Society. Visit them online at www.sfms.org.

PAGE 14 | THE BULLETIN | JANUARY / FEBRUARY 2010

59th Annual Yosemite Postgraduate Institute For Primary Care Physicians

CONTINUING MEDICAL EDUCATION COURSE ANNOUNCEMENT

Yosemite Lodge, Yosemite National Park March 26-28, 2010 $375 Physicians; $300 Allied Health Professionals (RN, NP, PA); $100 Medical students, interns or residents Up to 16 hours, Category 1 and Prescribe Credit

TOPICS INCLUDE: Wilderness Medicine, Travel Medicine, Immunizations, Cardiology, Adolescent Care, Allergy, Chronic Cough, Diabetes MORE INFORMATION: Fresno-Madera Medical Society; P.O. Box 28337; Fresno, CA 93729-8337 (559) 224-4224 ext. 118 • FAX: (559) 224-0276 • csrau@fmms.org • www.fmms.org PAGE 15 | THE BULLETIN | JANUARY / FEBRUARY 2010

financial planning

a great opportunity missed?

By Robert M. Cheney, CFA, CFP® Two recent surveys have come to my attention that illustrate that investors are not learning from their financial advisors about a significant opportunity to convert into Roth IRAs. According to both surveys, the majority of clients who work with advisors are not aware that income limits associated with the conversion of a traditional IRA to a Roth IRA have been lifted effective January 2010.

From August 14 to 28, Fidelity Investments surveyed 800 retirement plan owners with a household income of $100,000 or more, and of those working with financial advisors, a whopping 83% responded that they had no clue that the income limits on traditional-to-Roth IRA conversions were lifted on January 1.

In another survey, by Financial Planning, On Wall Street, and Bank Investment Consultant magazines, 3,715 financial advisors surveyed across large brokerage firms, independent firms, and banks reported that only 42% of their clients were aware of changes affecting Roth IRAs this year.

These changes in the rules governing Roth IRAs could significantly help doctors – if they only knew about them.

Financial advisors generally seem to be doing a poor job of educating their clients about this opportunity. However, I have been speaking with doctor clients

Meeting next week! re: ROTH IRA! Don’t Miss it! about this opportunity since the rules were enacted three years ago.

As of January 1, doctors earning a modified gross income of over $100,000 will finally be able to convert any amount of assets in their traditional IRAs to Roth IRAs. Investors in Roth IRAs pay income tax on the money they invest now and withdraw the funds tax-free in retirement, the reverse of traditional IRAs. Consider making an IRA contribution for you and your spouse in 2010. You can also use Rollover IRAs (from old 401(k), 403(b), or 457(b) accounts). Aim to convert those IRAs to Roth IRAs in 2010, with advice from a capable advisor,

and you even have the opportunity to delay payment of the income taxes on the conversion to half the taxes in 2011 and half in 2012.

Roth IRA funds can then grow tax-deferred and distribute tax-free (when five years have elapsed since the first contribution and you are 59 1/2). Roth IRA holders should be poised to get longterm tax-free appreciation from the stock market, and if we believe income tax rates will increase in the future, then these Roth IRA accounts will be particularly valuable. This taxfree nest egg can supplement your tax-deferred retirement funds at work.

These conversion strategies give doctors flexibility and should help them accumulate more retirement savings. Having both pre-tax retirement savings accounts at work along with personal taxfree Roth savings accounts will help you efficiently reach financial independence and give you flexibility to minimize income taxes, while you take withdrawals during retirement.

Robert M. Cheney, CFA, CFP®, is a wealth advisor and founder of Westridge Wealth Strategies. He helps doctors from his offices in Portola Valley and Palo Alto. He was named to Medical Economics magazine’s 2008-2009 list of “150 Best Financial Advisers to Doctors.”

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13th ANNUAL CALIFORNIA HEALTH CARE The Era of Health Reform: Harnessing the Currents of Change April 9-11, 2010 • • • •

San Diego Marriott Hotel & Marina

Hospital-Physician Alignment and New Models of Practice Health System Reform: Then and Now Leadership in a New Health Care Era and more...

New for 2010: Academy Curricular Tracks • Health Information Technology • Practice Management • Leadership Development

Register by March 9th

TO REGISTER - call 800.795.2262 or visit our website at caleadershipacademy.com Continuing medical education: The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical Association designates this educational activity for a maximum of 18.25 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.

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HEALTH CARE REFORM

MARCUS WELBY? He’s History

By Ronald J. Glasser, MD [Note: Originally published in the Sunday, May 31, 2009, edition of The Washington Post and August 2009 issue of San Diego Physician, and reprinted here with permission from the author.]

A few decades ago, the biggest problem in medicine was diagnosis. Is that a heart attack or heartburn? The beginnings of dementia or a stroke? Is the tumor benign or malignant? Medical technology has changed all that. The biggest problem in medicine today is not determining what’s wrong with you. It’s knowing whom to call at 2:00 A.M. — other than 911 — when something happens. And the nasty little secret is not that your doctor is no longer available, but that he or she is no longer in charge.

Of the 15,000 students who will graduate from medical

school this year — and the roughly 8,000 physicians and surgeons who will finish their specialty training — more than 93% will become employees of large clinics, managed-care companies, or hospital systems.

These physicians, as I have seen in my own practice in Minneapolis, are no longer patient advocates. In many ways, they’ve abandoned the patient to the work rules of health plans and the professional demands of managed care. The Hippocratic Oath has been discarded, and the Golden Rule has become: He who has the gold sets the rules.

What this means is that the care you get — and how long you get it — is only the care your health plan will reimburse your doctor for. You can see your psychiatrist or psychologist for five visits; you can stay in the hospital for 48 hours following a hip replacement, or three days after a radical prostatectomy. Simple mastectomies go home the same day, and gallbladder removals as soon as they wake up from the anesthesia.

If the drug prescribed is not on your health plan’s list, then your doctor will have to prescribe an approved alternative that may not be as effective.

This kind of care is simply unsustainable. It’s not just the enormous amount of money we already spend on health care or the fact that 45-million Americans are uninsured. America is also graying. By

2015, there will be more 80-year-olds than children under eight, and the elderly need more — and more personalized — care.

People respond differently to treatment, and it must be tailored to the individual patient.

Our current depersonalized, diseasebased system is not only dangerous, but also dysfunctional. And any dysfunctional system will eventually fail. It happened to the financial system, and it will happen in medicine.

From the end of World War II until the mid-1980s, the average medical or surgical group in the United States was made up of three to five physicians.

They ran their practice as a privately held company, treating patients, sending out the bills, setting fees, and organizing night-call and weekend coverage while deciding how much charity care they would also provide.

The focus was on maintaining good relationships with patients. Doctors cultivated a trusted bedside manner to maintain referrals and their colleagues’ respect. The physicians in a small practice knew one another’s patients. When someone called after hours, the answering physician would be able to respond to any questions and give realistic suggestions.

I care for a number of spina bifida patients, along with another physician.

These children have complex problems that include a malfunctioning central nervous system, orthopedic problems, difficulty breathing, and recurrent bladder infections.

If I didn’t know these patients, all I could do, if they called after hours, would be to send them to the nearest emergency room, where they would sit for hours while someone else, who didn’t know them, tried to figure out what was wrong.

But personal knowledge and concern have evaporated in the world of

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employee-physicians, replaced by cookiecutter, best-practice guidelines and rules on prescribing drugs, acceptable lengths of hospital stays, and the number of clinic patients a doctor must see per hour.

patient apart from that person’s array of symptoms.

And why not? Everyone in medicine knows that these are no longer the physician’s patients. They belong to the insurance companies, the health plans, the hospitals. With that understanding comes personal indifference and professional exhaustion. Today, it’s the rare physician who gives a patient his or her private office phone number, something that was almost universal when I first went into practice. Nowadays, if you want to talk to your doctor, you go through the office coordinator or the nurse associate.

The new tsunami in employed physicians has also led to something quite new in the medical profession — the parttime doctor. According to a recent survey of one of Minneapolis’s largest medical clinics, more than 50% of the doctors in the pediatrics and family practice departments and more than 70% in the OB/GYN department were working part-time.

This is great for the employer, who doesn’t have to provide retirement or health care benefits. But as a medical organization, you do best not to mention your parttimers to the patients. When I talk to one of these physicians, I’m reminded of what a professor of mine at Johns Hopkins medical school in the 1960s said when one student complained about having to be on the wards every other night. The professor offered a quote he told us was from the pianist Arthur Rubinstein: “When I don’t practice one day, I can tell the difference. When I don’t practice two days, my wife can tell the difference. When I don’t practice three days, anyone can tell the difference.”

Thank goodness for technology, which has saved both patients and medicine. MRIs, CAT scans, ultrasounds, pulmonary function tests, angiography, PSA testing, mammograms, molecular genetics, needle biopsy specimens — all these have reduced the chance of error.

But they also offer professional cover to physicians who know little about a given

Why have we witnessed a shift from independent medical practitioner to employee? The accepted reason is the steady growth of managed health care since the late 1970s. Thousands of small-group practices, faced with one or two dominant health plans in a city or geographic area, have been forced to merge to cut better deals on reimbursements. But the shift also appears to be generational. Consciously or unconsciously, we have raised a generation that views the medical profession in economic terms, as a career rather than as a calling.

Not long ago, a senior member of one of the Twin Cities’ largest gastroenterology groups confided to me that no one in the group over the age of 55 could tolerate being part of the search committee hiring new physicians. “It isn’t like it used to be when you and I were looking to be hired a few decades ago,” he said. “We were dutiful and respectful and excited to even be offered a job …. Now, it’s, ‘When will I be completely vested in the retirement plan?’ ‘I can’t work a full day on Friday because the kids play football or soccer on Friday night.’ ‘I don’t want to be on call more than twice a month. And if I do work here, I would like a signing bonus to cover the expenses to move here and the time it would take me to get up to speed.’”

Similarly, Claus Pierach, a professor of medicine who serves on the admissions committee at the University of Minnesota Medical School, recently told me that the committee had begun to notice something new a few years ago. When asked, “Why do you want to be a doctor?,” most applicants still answered as expected, “Because I want to help people.” But every so often, a candidate would reply that the reason was “job security.”

At first, the committee bristled at this answer. But now, members have grown used to hearing it. It is a frequent and unembarrassed response, usually accompanied by the stated desire to go into one of the more lucrative procedureor diagnostic-based areas of medicine: radiology, dermatology, orthopedics, or

cardiology. A good income and more desirable lifestyle matter more than the type of patient the doctor might see. Taking care of the needy is no longer on anyone’s radar screen. When the administration of a large Minneapolis medical clinic surveyed its 600 doctors this year about whether they’d be willing to work more hours, most said no.

When asked whether they would work more hours for more pay, they still said no.

One result of this new attitude is that fellowship slots in the country’s leading geriatric training programs are increasingly going unfilled, and some of these programs are closing. U.S. medical school deans admit that students no longer plan to go into such primary-care specialties as pediatrics or family practice and are not interested in caring for the elderly because the major insurers won’t pay for the personal involvement and time that primary-care specialties demand.

Troublingly, medical school professors have helped push the shift to physicians as employees. They’ve dismissed the concept of a small-group practice as unworkable. On the wards and in the clinics, they emphasize the “team player.”

Medical schools now have mandatory courses on getting along in large-group practices. Individual or small practices are dismissed as too complicated and too expensive to run. Large-group-, clinic-, or hospital-based employment is presented as the only realistic post-graduate option.

Perhaps we can’t go back to the two- or four-physician group practice. But medical school faculties can quit carrying the water for the managed-care companies and the large hospital systems. Our current medical system is out of whack. And those of us who see the edge of the cliff approaching should begin to warn publicly that medicine cannot survive if its real value — its capacity both to comfort and to heal — is replaced only by the superficial value of price.

About the Author: Dr. Glasser practices nephrology and is writing a book on medicine and the baby-boom generation. He can be reached at ronglasser@earthlink.net.

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SCCMA Alliance

SCCMA Alliance news (The Santa Clara County Medical Association Alliance is the philanthropic and volunteer arm of SCCMA that consists of physicians, physician spouses, students in training, and friends of medicine. Bettering the health in Santa Clara County is the main focus of the Alliance. In collaboration with other community groups, the Alliance provides health education, underwriting of projects, and legislative support for medical issues.

To join, please visit the website at www.sccmaa.org. You will also find the most current updates and contact information on that site.)

The annual Holiday Luncheon was held on December 14 and featured a slide show (prepared by Mary Hayashi and Debbi Ricks) that depicted 75 years of SCCMA Alliance history. Mary Hayashi and Jacqueline Mentz presented a book they prepared which provides photos and text, also representing the history.

(The book is available online through the website.) In honor of the anniversary, vintage hats and gloves were worn to the luncheon! In January, members and family members attended the Star Trek Exhibit hosted by the Tech Museum of Innovation.

A festive dinner followed at a local San Jose restaurant.

Basket Program; distribution of hundreds of copies of nutritionally-balanced cookbooks to families in the Gardner Family Services program; legislative updates provided by Meg Giberson regarding current health initiatives; and support of medical and political speakers at the SCCMA office.

•

“Dining Out for Life” (AIDS fundraiser) on April 29.

•

“Not Even for a Minute” – a campaign to display posters in grocery stores which would remind parents of the dangers of leaving children unsupervised in cars with windows closed.

•

Tired Cupid Coffee on February 15, 2010 (open to all members). Please check the website for details.

Upcoming Events: Health projects for the upcoming year include the following: •

“Loaves and Fishes” – the assembling of food baskets to support individuals and families living with HIV.

Details are available online at www.sccmaa.org.

Ongoing volunteer activities have included Alliance volunteers at the Food

Holiday Luncheon: Lois Hanson, Siggie Stillman, Mary Hayashi

Star Trek Exhibit: L-R: Suzanne Jackson, Siggie Stillman, Kathleen Miller, Carolyn Miller, Heather Goodman. Live long and prosper!

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Dinner at Il Fornaio: Front to Back: Steve Jackson, Siggie Stillman, Phil Stillman, Carolyn Miller, Courtney Miller, Suzanne Jackson, Kathleen Miller, Heather Goodman, Roger Hayashi, Mary Hayashi

Holiday Luncheon: Pat Baker, Kathleen Miller, Mila Mitchell

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RISK MANAGEMENT

Failure to Appropriately Communicate Abnormal Test Results and/or inadequate documentation of the communication of test results.

By NORCAL Mutual Insurance Company

Introduction Communication breakdowns are at the heart of many medical liability claims. Frequently, when a claim is filed that involves a missed or delayed diagnosis, the plaintiffs have discovered that a critical test result “fell through the cracks.” In some cases, test results were never sent to the health care provider who was in the best position to follow up; in others, the results were communicated to that physician, but he assumed that someone else would follow up. All of the claims reviewed in this article were settled because of inadequate communication

This article provides strategies for ensuring the timely and accurate communication of test results to other providers and to patients.

Case Study #1 Allegation: Failure to appropriately address the patient’s carotid artery stenosis resulted in the patient’s massive stroke and complete disability.

On May 21, 2005, a 70-­year-­old man with an extensive medication list and a medical history that included smoking, hypertension, diabetes, high cholesterol, and bilateral carotid endarterectomy was transported, via ambulance, to the emergency department (ED).

In the initial nursing assessment, the patient complained of fatigue, weakness, paresthesia, difficulty standing/walking, and impaired speech for the previous 48 to 72 hours.

Diagnostic imaging and labs were

ordered. He was started on Plavix and admitted to the attending physician’s care with a diagnosis of cardiovascular acci­ dent (CVA), focal neurological deficit, and right leg weakness. The patient’s primary care physician (PCP) was informed of the patient’s status via telephone shortly after the assessment.

The next morning, the patient was seen by a neurologist, who ordered an MRI and a bilateral carotid ultrasound. It was the hospital’s policy to report test results to the attending physician, rather than the physician who ordered the test. Thus, the neurologist did not feel responsible for following up on the tests and would not have expected to receive the results. The neu­rologist’s consult note was sent to the PCP, but it did not mention the carotid ultrasound.

The attending physician saw the patient for the first and only time that afternoon. He reported that the patient was stable and would probably be discharged later in the day. His discharge plan caused the patient to be labeled a “short stay” patient (a patient discharged within 24 hours of admission). By hospital policy, attending physicians did not have to dictate a discharge summary for short­stay patients. Although the patient had by this time undergone the MRI and ultrasound, there was no mention of them in the attending physi­ cian’s notes. The attending physician did not follow up on the results of the MRI or ultrasound.

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The ultrasound showed critical (80% to 99%) stenosis of the left internal carotid artery and severe (60% to 79%) stenosis of the right internal carotid artery. The nursing notes made that day documented that the vascular lab physician had reported the ultra­sound results to a nurse. The nurse later stated that she had subsequently and erroneously told a physician’s assistant (PA) that the carotid ultrasound showed 80% to 89 % stenosis of the left internal carotid artery.

It was the PA’s standard practice to convey test results to the attending physician, but in this case the PA did not recall doing so, nor was the communication documented. Even if he had communicated with the attending physician, the information would have been wrong.

Upon the attending physician’s telephone order, the patient was discharged at 5:00 p.m. on May 22. The vas­cular lab physician dictated the ultrasound report on May 24 and digitally signed it on May 25. The ultrasound report was not sent to the PCP. The attending physician remem­bered talking to the PCP shortly after the patient’s hospitalization, but did not recall whether he was aware of, or mentioned, the results of the ultrasound. Neither the attending physician nor the PCP documented anything about this conversation.

On May 26, the patient followed up with his PCP. The PCP noted that the patient reported having been hospitalized for a stroke, but had no complaints and no sequelae at the present time. A month later, the PCP saw the patient for low back pain.

The patient was very confused and told the PCP that he had to refer to the newspaper to determine the day and date. The PCP planned to review the patient’s hospital records from the recent hospital admission and told the patient to return to his office in two weeks.

Do You Have an Effective “Tickler System?”

As many of the cases reviewed for this article suggest, a physician’s or entity’s lack of a test result follow­-up system or “tickler system” can lead to failures and delays in diagnosis and treatment. Evidence of absent or poor follow­-up systems can be used to support negligence allegations and to shed a generally negative light on the defendant physician during malpractice litigation. There are a variety of ways to ensure that patients and their physicians receive test results in a timely fashion. The risk management recommendations below can serve as a framework to create a follow-­up system that is adapted to a particular practice: 1. Utilize the tracking and follow-up capabilities in an electronic medical record system to their full capacities.

2. For manual tracking, consider implementing the following: • When ordering tests, tell patients approximately how long it will take to obtain results and advise them to call by an appropriate date if they have not been advised of the results.

–– Requesting the patient’s involvement in follow up should enhance, not replace, an office “tickler system.”

• Place copies of all ordered tests/consults in a designated file.

• Monitor this file regularly to ensure that all ordered tests and consultations have been completed and that you have received the results.

–– Contact patients and/or consultants and/or the facility conducting the test to determine the reason for delayed tests or missing test results.

–– Utilize a tracking mechanism to compare ordered tests and consults with the corresponding results/reports.

• When results and consultation reports are received (by mail, fax, email, etc.) by your staff, make sure they route the results or reports, with the patient’s record, to a designated location for your review.

• Once you have seen and initialed a report or the results of a test, indicate the necessary follow-up by documenting the need in the patient’s record.

• Ensure that the patient has received all test results and recommendations for follow-up.

• Document patient notification of test findings and any recommendations for further testing or treatment.

• Document communication you have with consultants (ordering physicians) regarding test and study results.

3. Develop policies and procedures that outline processes for your office to: • Report urgent information to you • Process phoned-in lab results • Communicate all test results to patients • Document test communications 4. Do not delegate review of test result reports. These should be reviewed by the provider who ordered the tests or on whose patients the tests were ordered.

• Medical assistants may not review test results and may not post results in the medical record until authenticated by the practitioner.

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Failure to Appropriately Communicate Abnormal Test Results, from page 23 The PCP did not follow through with the review, and the patient did not return.

Two months after the patient’s last visit with the PCP, he was again transported, via ambulance, to the ED. The patient reported that he had woken up that morning with right­-side weakness and difficulty speaking. The patient was admitted to the telemetry unit, where he was evaluated for a CVA. An MRI revealed an evolving CVA, and a carotid ultrasound revealed severe stenosis. He was ultimately discharged from the hospital to a nursing home, completely disabled and requiring 24-­hour custodial care. He could not perform any normal activities of daily living, was incontinent, could not walk, and was unable to communicate meaningfully.

The patient and his family filed a medical liability lawsuit, which focused on the failure of his health care providers to discover and appropriately act on the May 22 carotid ultrasound results.

Discussion: This is a case in which substandard medical decision making was compounded by poor communication among providers and inadequate hospital documenta­t ion and communication protocols. That the patient was designated as a “short stay” patient was a primary problem in this case. The plaintiff alleged, and his experts testified, that the standard of care required that the patient be hospitalized for at least 48 hours, be seen by a vascular surgeon, and possibly undergo surgery prior to discharge.

Separate from the “short stay” issue was the issue of the May 22 ultrasound result. Even though the patient’s condition was potentially life threatening, the vascular lab physician chose to communicate his findings through a nurse, instead of going directly to the

ordering or attending physician. Because he did not ask the nurse to repeat back the results, he did not know if the nurse had understood him or whether she would be able to accurately convey the results to the attending physician. The nursing notes contained the only evidence of the ultrasound results being communicated, and that communication was inaccurate.

Another major problem in this case was lack of docu­mentation.

Specific memories about the patient’s hospitalization had faded by the time the lawsuit was filed, thus the defendants had little evidence to defend against the allegation of inaction.

Finally, there were no discharge and hand­off systems in place for any of the patient’s health care providers to follow up on test results: the attending physician and neurologist never obtained the results of the ultrasound or the MRI, the PCP never requested the patient’s hospitalization records, and the hospital did not send the patient’s records and test results to the PCP. Risk Management Recommendations – Follow­-up Between Providers 1. Follow up on all of the results of tests and studies that you order.

•

Have a system in place that tracks the tests that you have ordered.

•

When you receive test results, communicate them to the ordering physician or the physician who is coordinating the patient’s care, as well as the patient’s PCP.

•

Do not depend exclusively on another provider to report results to you — have a system that alerts you when results are late, so you can proactively seek out and obtain the results.

•

Document your follow­-up and tracking of these results.

2. When you or your staff relay test results over the telephone, have the recipient of the information read the information back to confirm accuracy.

•

Document to whom the information was given, the date, the time, and that read-­back was done.

•

Document the date and time that the information was communicated to the ordering or consulting physician.

3. If you receive test results over the telephone, read the information back to confirm accuracy.

•

Document the test results in the patient’s medical record.

•

If the ordering physician is not mentioned, ask who it is.

4. If one of your patients is hospitalized, obtain the patient’s records from the hospital after discharge.

5. If the results of a test are abnormal, determine which provider is going to coordinate further testing and treatment. Document the communication with the provider and document the provider’s agreement to follow up with further testing and treatment.

6. Document this determination in the record and note the proposed plan, for example, “patient to be scheduled for MRI by Dr. XYZ.”

Case Study #2 Allegation: Failure to follow up on a pathology report positive for left branchial (cleft) carcinoma resulted in a 19­- month delay in diagnosis and in the patient’s diminished life expectancy.

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The patient, a 55-­year-­old woman, presented to an otolaryngologist in September 2000. She had been referred by her PCP. The patient had a painful lump on her neck that had not responded to the antibiotics prescribed by the PCP. The otolaryngologist believed that the lump was a branchial cleft cyst. He performed a fine needle aspiration and sent it to pathology.

The pathologist found amorphous debris with benign mature lymphocytes.

The otolaryngologist sent a consultation report to the PCP, relaying the information that the lump was benign.

In view of the negative fine needle findings plus the symptoms of tenderness, the otolaryngologist felt that the lump was an inflammatory node rather than a malignancy. He recommended reevaluation of the patient in one month. When the patient returned to the otolaryngologist one month later, the mass in her neck had increased in size. At this point, the otolaryngologist decided to do a surgical biopsy.

In December 2000, the otolaryngologist excised the cyst. He also removed what he thought was one small node. He thought the tissue looked benign.

The pathologist’s diagnosis, however, was metastatic squamous cell carcinoma present in six lymph nodes and squamous cell carcinoma and carcinoma in situ arising in the branchial cyst. The pathology report was sent to the otolaryngologist, but it was inadvertently filed without him seeing it. A copy of the report was also sent to the patient’s PCP. Assuming the otolaryn­gologist would follow up, however, the PCP signed the report and it was filed.

No one informed the patient of her cancer diagnosis.

The otolaryngologist had no office policy in place that would ensure that he reviewed and signed off on reports that came into his office. The pathologist later testified

that in addition to sending his report to the otolaryngologist, he left a message for the otolaryngologist, but the pathologist did not document the call. The otolaryngologist did not receive the pathologist’s message and did not follow up on the pathology results.

The patient returned to the otolaryngologist and her PCP on numerous occasions post­operatively, but the biopsy results were never discussed.

In 2003, the patient moved and switched health care providers. In June 2003, she saw a surgeon for lower back pain. Having obtained the patient’s records from her former PCP, the surgeon saw the pathology report and told the patient that she had been diagnosed with squamous cell carcinoma in 2000. The surgeon noted a swelling in the left side of the patient’s neck. He ordered a CT scan. The radiologist reported cervical adenopathy, the largest of which (12 millimeters in diameter) appeared to correspond to the palpable mass extending deep to the sternocleidomastoid. The radiologist was concerned that the mass might be malignant. A PET scan showed activity in the left base of the tongue and left neck. A biopsy of the left tongue base with left modified radical neck dissection was recommended, followed by radiation therapy and chemotherapy.

In August 2003, the patient underwent a triple endoscopy with biopsies of the left base of the tongue and a left modified radical neck dissection. She was diagnosed with malignant neoplasm of the left base of the tongue, staged at T2 N2A MO. Because the tumor was 4 centimeters in size, it bordered on a T3. Using the American Joint Commission on Cancer (AJCC) tumor stage grouping, the patient

against the otolaryngologist and her former PCP. Discussion The patient’s medical liability claim focused on the otolaryngologist’s failure to act on the results of the pathology report revealing cancer. The patient’s PCP was also faulted for failing to address the patient’s cancer diagnosis with the patient. The medical literature sup­ ported the plaintiff’s allegation that the 19­-month delay in diagnosis diminished her prognosis.

Risk Management Recommendations Have an office protocol in place for ensuring that you review consultant reports.

1. Have a tickler system in place to ensure that the results of ordered tests are received and that the patient is informed of test results.

2. When a consultant discovers and reports a signifi­cant health care issue that demands follow­-up and treatment, determine whether you, the consultant, or a different physician will coordinate the follow-­up and treatment. Confirm that the patient has been informed of her diagnosis and who will be coordinating care.

3. Document conversations with consultants, referring physicians, and patients.

4. Before discharging a patient from care, determine whether there are any outstanding test results or consultant reports that have not been discussed with the patient; obtain them before the patient’s last appointment; and then discuss them with the patient.

was a stage IVA. She underwent radiation and chemother­apy and was cancer-free when she filed her medical liability claims

PAGE 25 | THE BULLETIN | JANUARY / FEBRUARY 2010

Failure to Appropriately Communicate Abnormal Test Results, from page 25 Case Study #3 Allegation: The patient’s urologist failed to follow up with appropriate care and treatment after the patient’s radical retropubic prostatectomy. The delay in treat­ment resulted in metastasized cancer, more painful treatment, and a decreased life expectancy.

In April 2003, the patient’s PCP referred him to an urologist because of an abnormal PSA test result. A month later, the urologist examined the patient and recommended a needle biopsy of the prostate to determine if cancer was present.

The pathologist interpreting the tissue found that there was adenocarcinoma present in the tissue sample from the left lobe of the patient’s prostate. He rated the Gleason’s score as a 6 (a very positive prognosis). The urologist recommended a rad­ical prostatectomy (surgical removal of the prostate that has a 70% cure rate) as treatment. After consid­ering the risks, benefits, and alternatives, the patient agreed to have the surgery.

The urologist performed the radical prostatectomy in August 2003.

Pathology confirmed that there was ade­ nocarcinoma present in the prostate.

During the following year, the urologist’s office mailed PSA test orders to the patient, and the patient underwent testing, four times. His results were: 0.1, 0.3, 1.1, and finally 4.5. After the fourth test, the urologist’s office had no fur­t her contact with the patient.

According to experts, the first three test results could have been interpreted as normal in a patient who had not undergone a radical prostatectomy. In this patient, however, the PSA results indicated that the patient had a recurrence of prostate cancer.

Studies have shown that if hormone therapy is started before the PSA reaches 0.5, patients have an 85­% chance of 12­-year survival.

If patients are started on radiation therapy before the PSA reaches 1.5, studies indicate

that patients have a 70% chance of 15­-year survival.

During the time that he was treating the patient, the urologist’s policy was to review PSA tests as they arrived and then route them to his back office staff for filing. It was not his policy to review the tests in reference to the patient’s medical record. There was some indication that during this period the urologist may not have been reviewing the results at all before they were filed. There was no indication in the patient’s record that the urologist had noticed the recurrence of cancer or had contacted the patient or his PCP with any of the PSA test results.

Approximately twenty months after the patient’s fourth PSA test, a different provider ordered a routine PSA test. The result was 87.6, which is extremely high. A bone scan was done, revealing a finding in the hip that was suspicious for metastatic disease. The patient was referred to a cancer center where he started radia­t ion treatment; but at that point, his long-­term survival rate had dropped to well below 50%.

The patient filed a medical liability lawsuit against his PCP, the urologist, and the hospital.

Discussion The urologist’s practice of either reviewing reports without reference to the patient’s medical record or having reports filed in the patient’s medical record without reviewing them resulted in the urologist’s failure to observe the patient’s rising PSA level. The medical lit­erature supported the plaintiff’s allegation that the delay in diagnosis and treatment of the cancer reoccur­rence decreased his chance of long­term survival.

Risk Management Recommendations – Communicating Test Results to Patients Providers are encouraged to evaluate their current patient communication systems and determine whether they are designed to both ensure optimal test result communication and effectively communi­cate results. Consider the following questions during this evaluation: 1. Are all test results communicated to patients? Or just those with clinically pertinent findings?

• Are patients familiar with your process, and do they know whether to expect to be contacted with results?

2. If they are not aware of office policy and don’t receive test results, patients may assume that a test result is negative.

3. Is the patient informed as to how long it will take to obtain results, and is she told to follow up if she has not been informed of the results within a specified period of time?

4. To ensure a timely and efficient follow-up, is there a specific policy and protocol for handling test results requiring further follow-up?

5. When a consultant fails to forward a test result or consultation report to you, is your patient contacted to find out if she received recommended testing?

• Patients do not always understand the urgency of completing followup studies and treatment, and they may unknowingly delay undergoing tests. A follow-up telephone call can help to remind patients of the importance of the needed care.

PAGE 26 | THE BULLETIN | JANUARY / FEBRUARY 2010

6. Is the significance of test results being discussed with patients?

in the patient’s record to indicate that the information had been communicated.

7. Are discussions with patients and consultants being documented in the patient’s medical record?

The ED physician referred the patient to his PCP to continue work­up for his left groin pain. The ED physician prepared a written consultation note follow­ing his evaluation of the patient. His note was sent to the PCP.

Case Study #4 Allegation: Defendants negligently failed to follow up on chest x­- rays and a CT scan, resulting in delayed lung cancer diagnosis and decreased life expectancy.

On July 1, 2006, the patient, a 45-­year­- old man with a history of thyroid cancer, presented to the ED com­plaining of excruciating groin pain. He was evaluated by the ED physician, who ordered a chest x-­ray and a CT scan of the abdomen and pelvis. Radiologist #1 reported that the chest x-­ray showed a 3­4 millimeter nodular opacity in the left upper lobe of the lung, which he thought might be a small granuloma. He recommended interval follow-­up with a plain film or a CT scan.

His report on the chest x­- ray was neither sent to, nor requested by, any other physician.

The CT scan of the abdomen and pelvis was inter­preted by radiologist #2. She noted a 0.9 centimeter pulmonary nodule in the left lower lobe of the lung.

She recommended dedicated axial imaging of the chest for further evaluation.

It was radiologist #2’s custom and practice to interpret the film, dictate her report, and describe her complete findings to the ordering physician over the telephone.

The typewritten report was normally transmitted to the ordering physician within 72 hours. Radiologist #2 had no specific memory of communicating with the ED physician who had ordered the studies, and the ED physician had no recollection of receiving the information. There was nothing

In his report, the ED physician did not mention the abnormal­ities seen on either the chest x­ray or the CT scan. There was no indication in the ED physician’s report that the patient was informed of the findings.

The patient was seen by his PCP on July 3. The PCP’s assessment was that the patient had musculoskeletal pain secondary to scoliosis. He ordered a lumbar spine MRI and referred the patient to a neurosurgeon. The patient’s lumbar spine MRI showed a prominent abnormality at the L1 level, which later proved to be an extruded disk. He was referred to a surgeon, who performed a bilateral laminotomy, microdissection, and extensive lumbar discectomy on July 10.

Preoperatively, the surgeon ordered a chest x-­ray. Radiologist #3 noted a faint nodular density in the left upper lobe of the lung, which he thought appeared slightly more prominent than it did on the prior chest x-­ray of July 1.

Radiologist #3’s interpretation was that the abnormality could represent a pleural plaque or an artifact. He recommended consideration of a follow­-up CT scan.

Although a copy of radiologist #3’s report was not sent to the PCP, radiologist #3 called the PCP to discuss the findings. According to the PCP, radiologist #3 downplayed the findings and did not specifically urge the PCP to order a follow­up CT of the left lung. Neither the PCP nor radiologist #3 documented their conversations about the upper lobe density.

After speaking with radiologist #3, the PCP logged onto the radiology department’s website. He brought up the patient’s July 1 chest x­- ray, but could not see any irregularities. After looking at the chest x­- ray, he wondered if the July 1 abdominal CT would have any lung images, so he tried to access those images, but he had trouble manipulating the icons. He was, however, able to access the abdominal CT report. Because much of the upper lobe overlaps the lower lobe, the PCP assumed that the nodule mentioned in the CT report was the upper lobe density that radiologist #3 had told him was equivocal.

The PCP saw the patient in the hospital on July 11. The PCP told the patient that he had a small spot on his lung and recommended following up on it after he had recovered fully from the back surgery.

The PCP had planned to get the x­- ray and CT scan reports later, but he subsequently forgot about them. He also failed to mention the lung density in his discharge summary for the back surgery admission.

Over the next two years, the PCP continued to follow the patient off and on for various complaints. In February 2008, the patient started complaining of chest tighten­ing that waxed and waned, difficulty breathing, and persistent left arm pain unrelated to exertion. The PCP recommended an EKG and a stress test.

Both came back normal.

On April 2, 2008, the patient underwent a CT coronary calcium study.

The study was interpreted by radiologist #2, who had interpreted the 2006 CT scan.

Radiologist #2 identified a pulmonary mass with some spiculation in the left lower lobe, which had increased in size com­ pared to the study of July 1, 2006, and now measured 1.8 x 1.3 centimeters. Radiologist #2 again recommended dedicated imaging of the chest. She further noted that

PAGE 27 | THE BULLETIN | JANUARY / FEBRUARY 2010

Failure to Appropriately Communicate Abnormal Test Results, from page 27 given the increase in size, the mass was concerning for primary malignancy.

On April 10, the patient had a CT scan of the chest. The CT scan revealed a solitary left lower lobe circum­scribed mass with some spiculation. A fine needle aspiration revealed rare atypical cells, suspicious for non­small cell carcinoma.

The patient underwent a lobectomy on April 20. A pathology report identified a moderately differentiated adenocarcinoma measuring 1.4 centimeters. Three of 16 lymph nodes were positive, with the largest metastatic focus measuring one centimeter. The tumor invaded the bronchial wall, the surrounding bronchial cartilage, and the wall of the large artery, but tumor was not present in the lumen of the artery. The patient’s cancer was staged as IIIA. The patient started chemotherapy, but during chemotherapy, his cancer continued to metastasize.

The plaintiff sued his PCP, the hospital, and all the providers who had treated him during his July 2006 ED visit and his back surgery hospitalization. At the time that the lawsuit was filed, the patient had a prob­able life expectancy of less than six months.

Discussion This was a complex claim with numerous defendants and very little documentation. The claim was further complicated by the fact that the hospital was transi­t ioning to an electronic medical record system. Unfortunately, the PCP was unable to fully access patient information on the new system, and this diffi­culty contributed to his failure to adequately follow up on the July 2006 chest x-­ray and CT scan results.

Plaintiff’s Arguments Plaintiff’s counsel focused on a number of issues asso­ciated with failure to

timely diagnose the patient’s lung cancer.

The attorney made the following points to support allegations that the patient’s treatment was below the standard of care:

•

Ascertain which studies have been ordered during a patient’s hospitalization and include significant find­ings in the discharge summary.

•

•

When a patient has a pre-­existing condition that exposes him to a particular health risk, vigilantly fol­low up on tests or symptoms that may signal that the risk has become reality.

In light of the patient’s history of thyroid cancer, the PCP should have been more vigilant in following up on the findings in the radiological studies obtained in July 2006. It is well known in the medical com­munity that the lung is one of the most common sites for thyroid cancer metastases.

•

The PCP had access to the entire record of the patient’s July 1, 2006 ED visit, but failed to follow up on the chest x-­ray or CT scan.

•

The hospital failed to forward any of the diagnostic reports to the PCP or the ordering physicians.

•

Interpreting radiologists #1 and #2 did not personally report suspicious findings to the ordering physician.

•

The ED physician did not follow up on the results of the chest x-­ray or CT scans; he did not inform the patient or his PCP of the results and did not mention the studies in his discharge summary.

Conclusion As these case studies have shown, most adverse events come about through a combination of individual provider errors and system errors. Ambiguity about roles and responsibilities among members of a patient care team and inadequate protocols and procedures can lead to abnormal test results “falling through the cracks.” By implementing the strategies suggested in this article, health care providers can increase the probability that critical reports will be received and reviewed by the appropriate parties, so that timely diagnosis and treatment can take place.

This article is reprinted with the permission of NORCAL Mutual Insurance Company [Note: Originally published in the May 2009 edition of Claims RX.”]

Causation It was determined that the patient most likely had stage 1 cancer when he had the CT scan in 2006. Therefore, at that time, he probably had a 5-­year cure rate of 55% to 60%. At the time he was diag­nosed 22 months later, the rate had diminished to 20%. In other words, the patient’s cancer went from curable to incurable.

Risk Management Recommendations •

If there is some aspect of an electronic medical record that makes it difficult or impossible to obtain patient records, request assistance with the electronic record, or request hard copies of the reports.

PAGE 28 | THE BULLETIN | JANUARY / FEBRUARY 2010

risk management

Focus on Deaf and Hard of Hearing Patients

By NORCAL Mutual Insurance Company Communicating test results and treatment options can be particularly challenging if a patient is deaf or hard of hearing. Approximately 9% of the U.S. population is deaf or hard of hearing, making it the most common permanent physical disability.1 Consequently, providers should be prepared to adequately communicate with these patients.

Federal law (e.g., the Americans with Disabilities Act [ADA]) and state laws prohibit discrimination against the disabled. For a deaf or hard of hearing person, you must provide a means of communication comparable to what a hearing person receives. The ADA, however, does not necessarily mandate providing a sign language interpreter for deaf and hard of hearing patients, so long as effective communication is achieved. (Studies show, however, that deaf and hard of hearing patients who have access to an interpreter are more satisfied with care, more compliant, and more engaged in their health maintenance.)1,2 According to the ADA, a health care provider is not required to

provide an interpreter if doing so would fundamentally change the nature of the physician’s practice or pose an “undue burden.” (Paying for an interpreter or other form of communication is the provider’s responsibility.) The ADA does allow a provider to use an alternative “auxiliary aid” to accomplish communication. A comprehensive list of appropriate auxiliary aids and services for deaf and hard of hearing patients is in the ADA regulations.

It includes: qualified interpreters, note­ -takers, computer­-aided transcription services, written materials, telephone handset amplifiers, assistive listening devices, assistive listening systems, telephones compatible with hearing aids, closed­- caption decoders, open- and closedcaptioning, telecommunication devices for deaf person (TDDs), and videotext displays.3

that the cost of providing an interpreter was not an appropriate basis for a private practice physician to refuse providing a sign language interpreter for his deaf patient. The jury also returned a punitive damages verdict against the physician.5 Under the ADA, the provider, not the patient, is the ultimate decision maker regarding the use of an interpreter.

However, when a patient requests an interpreter, the provider should make that request a primary consideration.

Other important issues to consider are the length and complexity of the planned communication. For example, if the patient is undergoing a complex battery of tests, an interpreter will probably be necessary to explain the results of those tests. But if the patient is coming to the office for a routine blood pressure, weight check, or blood test, effective

Providers who feel that an interpreter would pose an undue financial burden and that another form of communication would result in effective communication should bring the available alternatives to the attention of the patient, who may not be aware of their availability.4 It should be noted that a New Jersey court recently found

PAGE 29 | THE BULLETIN | JANUARY / FEBRUARY 2010

Focus on Deaf and Hard of Hearing Patients, from page 29 communication could probably be accomplished with note taking.

If the patient insists on an interpreter, but the provider does not believe it is necessary; or the patient refuses to go forward with an interpreter that has been provided to him; or the patient refuses an interpreter (possibly because of the private or embarrassing nature of a condition) when one is clearly necessary; insureds should contact the NORCAL Risk Management Department or a health care law attorney before continuing care.2,4 More information about antidiscrimination law requirements for providing interpreters to hearing disabled patients can be found in the California Medical Association (CMA) ON­- Call Document #802: “Sign Language Interpreters,” which can be accessed on the CMA website at www.cmanet. org (accessed 2/19/2009). Information specific to hospitals and deaf and hard of hearing patients can be accessed on the United States Department of Justice (DOJ) website at: www.ada.gov/ hospcombr. htm (accessed 4/3/2009). The DOJ also maintains a hotline for ADA issues. Hotline information can be accessed at: www.ada. gov/infoline.htm (accessed 4/3/2009).

Although laws treat limited English proficiency and hearing disabilities differently, patients with these issues can present the same communication challenges to providers. Information about the legal requirements for providing interpreters to patients with limited English proficiency can be found in CMA ON-Call Document #813: “Language Interpreters.”

Finding a Sign Language Interpreter: Registry for Interpreters for the Deaf The Registry for Interpreters for the Deaf (RID) maintains a list of certified interpreters on its website (www. rid.org). Local and state agencies working with people who are deaf and hard of hearing can also provide information on appropriate interpreter referral agencies.

Often, a deaf or hard of hearing patient will be the best resource for accessing a sign language interpreter who is accustomed to interpreting in a medical setting.

Risk Management Recommendations •

•

Ask the patient which method of communication is preferred and with whom they prefer to work.

Accommodate the patient’s request when appropriate.

Be familiar enough with federal and state antidiscrimination laws to know when it is necessary to provide a hearing disabled patient with an interpreter.

•

Create policies and procedures that address the provision of interpreters to hearing disabled patients.

•

Teach front office staff to determine when a patient is hearing disabled and to make arrangements for an interpreter or some other auxiliary aid prior to the patient’s appointment.

•

contact list of qualified sign language interpreters.

•

Document the method of communication requested and the name of the interpreter, if one is used.

•

If the patient requests a method of communication that cannot be accommodated, or if the patient requests a family member or friend for interpretation, make a notation in the chart describing the circumstances.

Notes 1. Harmer L, Healthcare delivery and deaf people: practice, problems and recommendations for change. Journal of Deaf Studies and Deaf Education 1999;4:73­110.

2. CMA ON-Call Document #802: “Sign Language Interpreters.”

Available on the CMA website at www.cmanet.org (accessed 2/19/2009).

3. 28 C.F.R. 36.303(b)(1).

4. Americans with Disabilities Act and Hearing Interpreters. Available on the AMA website at: www.ama­assn. org/ama/pub/physician­resources/ legal­topics/regulatory­compliance­ topics/the­americans­disabilities­act­ hearing­interpreters.shtml (accessed 3/22/2009).

5.

Be prepared to contact a sign language interpreter when needed — keep a

PAGE 30 | THE BULLETIN | JANUARY / FEBRUARY 2010

In the Courts. By Amy Lynn Sorrel, Posted Jan. 5, 2009. Available on the AMA website at: www.ama­assn.org/ amednews/2009/01/05/prca0105.htm (accessed 3/4/2009).

Antibacterial Soaps May Be Harmful to Your Health and the Environment Triclosan persists

Avoid Triclosan Containing Products

in the environment,

What is triclosan?

and contributes to

Triclosan is a synthetic compound used ed as an antibacterial/anti-fungal agent in a growing number of consumer products such as hand-soaps, laundry-detergents, and all-purpose cleaners.

the growing problem of bacterial resistance

Why be concerned about triclosan?

to antibiotics.

• Triclosan is a registered pesticide now found •

widespread in our environment.

A As a result of extensive human use, triclosan and other antibacterial chemicals have been found in water bodies, including o the San Francisco Bay. Studies demonstrate that it is toxic to marine life.

• Triclosan has been found in human blood, urine and breast milk, however, the impact of its use on human health are unknown.

Why are triclosan-free products better?

CO

M U N T Y E DI C A

Use plain soap and warm water, with vigorous scrubbing for 15-20 seconds, to fight germs on the hands.

L

ASS

What can I do? Read the label!

O C I A TI O N

S A N T A CL A RA

According to the Center for Disease Control and the American Medical A Association, there is no demonstrated benefit of Triclosan containing soaps Ass over ove plain hand soap in protecting people from germs.

CAL

Use alternative products: • Pure glycerin, castile or vegetable-based soap • Hand-sanitizing gels with at least 60% alcohol or peroxide base • Less toxic products without synthetic perfumes, dyes or synthetic petroleum compounds

IF O R NIA

To learn more and find alternative products, visit:

Environmental Services A Certified Green Business

Pollution Prevention

www.thegreenguide.com www.foodandwaterwatch.org/water/ www.greenhome.com/

www.greenseal.org/ www.goodguide.com www.ewg.org/node/26861 Approved by the Director of Environmental Services Printed on recycled paper. 1009/Q500/JY/RB

PAGE 31 | THE BULLETIN | JANUARY / FEBRUARY 2010

coding and reimbursement

coding q’s

by Sandie Becker, CMC, SCCMA/MCMS Coding & Reimbursement Specialist Q: Can I bill for a hospital death summary, if I am not present in the hospital at the time of the patient’s death? If so, what would be the CPT code to report?

A: The hospital discharge services codes may be used to report discharge services to patients who die during the hospital stay. The attending physician may be needed to perform the final examination of the patient (to pronounce the patient’s death), discuss the hospital stay with family members or others, and prepare the discharge records (such as the discharge summary for the hospital record). However, if the physician is not the discharging physician, there is no CPT code for reviewing the patient’s medical record or selecting and preparing the death summary. The selection of the appropriate hospital discharge services code (99238 or 99239) is based on the unit/floor time, which includes establishing and/or reviewing the patient’s chart, examining the patient, writing notes, and communicating with other professionals and the patient’s family. It is important to note, therefore, that there must be unit/ floor time, ie, completion of forms/records in the medical records department.

Q: What CPT codes should we use when billing a private payer for home health certification and recertification services?

A: CPT does not include codes for certification and recertification of home

health services. G0179 (recertification) and G0180 (certification) was created specifically for billing Medicare-covered home health services provided as part of a home health care plan, including physicians’ contacts with the home health agency and review of patient status reports.

Some private payers may cover similar services using these codes; others may consider them to be part of care plan oversight, which is billed with CPT codes 99374-99375.

Q: The issue of when to bill a problem-oriented evaluation and management (E/M) service with a preventive medicine service is confusing. If chronic problems are stable, should we charge for both services?

A: It depends on the amount of work necessary to determine whether the chronic problems are stable and whether current management should be continued or adjusted. Preventive services were not valued to include significant physician work related to management of chronic conditions (or acute problems that require the key components of a problem-oriented encounter), so you shouldn’t automatically discount this work. One approach is to consider whether the patient would have presented for evaluation of current medical conditions if he or she had not been coming

For coding questions and reimbursement issues, contact Sandie @ 408/9988850 or MCMS 831/455-1008 or email sandie@ sccma.org.

in for the preventive visit. If the answer is yes and the details of the encounter are properly documented, then you should report both E/M codes. If the answer is no, you should only report the preventive service.

Billing Tip: Do you often find when you bill out for multiple units, for follow-up hospital visits using the same code, you only get paid for one?

It is not uncommon for payers to overlook multiple units in block 24G and end up paying providers for only one visit! Now, billers have to resubmit the claim for the other visits that were not paid, therefore delaying the providers’ correct reimbursement due! It wastes time and slows the production of cash flow! While it may seem like a hassle billing hospital visits one-day-at-a -time on the CMS-1500 form, on the initial claim, you increase the likelihood of providers getting paid correctly the first time around.

Would you like to receive updated coding & reimbursement news by email? If so, please call the SCCMA/MCMS office to provide your email address at: 408/998-8850 ext. 3007 or email: sandie@sccma. org. You may also visit our website at: www.sccma-mcms.org.

PAGE 32 | THE BULLETIN | JANUARY / FEBRUARY 2010

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PAGE 33 | THE BULLETIN | JANUARY / FEBRUARY 2010

MEDICO NEWS

MEDICONEWS DMHC Finalizes Timely Access Regulations The California Department of Managed Health Care (DMHC) recently finalized regulations that require HMO patients to be seen in a timely manner. The primary intent of these regulations, and the underlying legislation, is to require HMOs to ensure that their networks of providers have the capacity and availability to provide care to enrollees within certain time frames for various levels of care.

As you may recall, CMA supported the underlying legislation, AB 2179, which was signed into law in 2002 and directed the state to develop regulations to ensure that HMO enrollees have timely access to health care services. CMA supported that legislation because it promised to improve the adequacy of provider networks.

The regulatory effort to implement AB 2179 has taken eight years to complete, during which time we have seen at least a dozen proposals from DMHC. Over the last year, CMA obtained several concessions from DMHC to address our major concerns with these regulations, such as: • a provision that allows a patient’s wait time to be extended if the physician has determined that delay will not have a detrimental impact on the patient’s health; • a “provider’s bill of rights” that requires HMOs to provide physicians with advance notice of any contractual changes and the right to negotiate those changes; • a provision stating that these regulations do not create additional physician liability; • a requirement that HMOs demonstrate they have an adequate physician network before implementing the regulation.

“We are hopeful that these new regulations will work as intended,” says CMA President Brennan Cassidy, MD. “As doctors,

our No. 1 priority is our patients. We want to be sure that HMOs meet these requirements without forcing doctors to shorten patient visits or meet unrealistic quotas that would comprise the quality of care.”

Both the regulations and the underlying law impose requirements on HMOs, not physicians. However, to comply with the regulations, HMOs will very likely pass on these requirements contractually to physicians and other providers. This in turn may require modification of existing physician office procedures to comply with the additional scheduling or reporting requirements.

As part of the regulations, HMOs are required to meet the minimum physician-to-patient ratios established in the Knox-Keene Act. The Knox Keene Act already requires HMOs to maintain provider networks with certain ratios of physicians to enrollees, but very little recent information on network adequacy is available because the state does not regularly monitor compliance.

HMOs still need to develop the contractual amendments necessary to comply with these regulations, so there will not be a full picture of what physicians need to know regarding contracting or implementation for some time. HMOs have until October 17, 2010, to file a compliance plan with DMHC, by which point we should have a more fully developed picture of what physicians need to know and do. CMA will be in contact with HMOs during this process to provide physician perspective. HMOs must fully comply with the regulations by January 17, 2011.

For more information on these regulations, see the newly updated ON-Call document #1005, “Access to Physicians.” ONCall documents are available free to members at http://www.cmanet. org/member.

(CMA Alert, January 25, 2010 issue)

CMA CEO Alfred Gilchrist Steps Down Alfred Gilchrist has resigned as CEO of the California Medical Association to return to Colorado. Gilchrist submitted his letter of resignation in January, citing personal and professional reasons for accepting an offer from the Colorado

Medical Society to return to his former capacity as CEO there.

Alfred has made clear that all the factors related to his decision are external to CMA and that he hopes and expects to work with CMA on many issues on the national stage in the future.

He praises CMA for its rich history of accomplishment, as well as its regard in legislative, legal, and advocacy arenas.

Dustin Corcoran, CMA’s deputy CEO and former vice president of government relations, has been appointed as the new chief executive officer of CMA.

PAGE 34 | THE BULLETIN | JANUARY / FEBRUARY 2010

MEDICO NEWS

Fate of Health Reform Uncertain

The nature and outcome of health reform was thrown into turmoil last month with the election of Massachusetts Republican Scott Brown to fill the Senate seat of the departed Ted Kennedy, longtime liberal lion of the U.S. Senate. Brown is the 41st Republican Senator, depriving Democrats of their filibuster-proof majority.

It is difficult to overstate the impact that this one election has on health reform. Up until now, discussions were taking place entirely between House and Senate Democrats with virtually no Republican involvement. With Brown’s election, Republicans now have the ability to stop the current version of health reform in Congress, unless Democrats pursue one of several unpalatable and unpopular alternatives to avoid the Senate. (For more details, see http://www.cmanet.org/healthreform.)

The ultimate impact of the new paradigm in Washington is as of yet uncertain. While the slowed pace may present an opportunity for CMA to fight for our priority issues, the retrenching may also cost us some of the provisions in the health reform proposals for which we successfully fought. We will know more about the plans of congressional leaders and the Obama Administration in the days to come, as they figure out their response.

Bottom line: any health reform legislation that makes it to the President’s desk will very likely be either markedly scaled down from the House or Senate bills, or a combined proposal.

Regardless of the new direction reform efforts may take, CMA remains committed to expanding meaningful access to care, while preserving and protecting the doctor-patient relationship.

(CMA Alert, January 25, 2010 issue)

Federal Officials Announce Meaningful Use Criteria Federal health officials, in late December, released proposed standards for the use and certification of electronic health records. As you know, Medicare and Medi-Cal physicians who demonstrate “meaningful use” of certified electronic health records (EHR) will qualify for incentive payments under the 2009 federal economic stimulus package.

The meaningful use definition proposed by the Centers for Medicare & Medicaid Services (CMS) sets forth the basic guidelines physicians must follow in order to receive Medicare incentive payments. Among other things, it lays out which quality measures physicians will have to report and which functions (computerized physician order entry, for example) physicians will have to use. CMS’s proposal would phase-in

meaningful use requirements in three stages between now and 2013.

This definition only applies to Medicare. States will be allowed to create their own definitions. One of CMA’s concerns regarding meaningful use is that this could cause confusion and administrative difficulty for physicians, particularly in a group setting where different physicians may qualify under different programs.

CMS has acknowledged this problem, and has expressed in the proposed rule a strong preference for states’ definitions to be the same or very similar to the federal definition. States that plan to use an alternate definition must get approval from the Federal Secretary of Health and Human Services.

CMA has prepared a summary of the proposed definition and will be submitting

comments during the 60-day comment period. The final definition should be released in late February or early March and will become effective 60 days after release.

The Office of the National Coordinator for Health IT (ONCHIT) has released a related set of proposed certification standards for EHR technology.

ONCHIT’s interim final rule outlines the technical standards and features that EHR systems must include to receive certification for meaningful use. The EHR certification standards will also be open for comment for 60 days after publication in the Federal Register on January 13. The standards will take effect 30 days after the final rule is published.

Contact: David Ford, 916/444-5532 or dford@cmanet.org.

(CMA Alert, January 12, 2010 issue)

CMA Updates Medicare Consultation Code Billing Guide Medicare is no longer recognizing inpatient and outpatient consultation codes. Effective January 1, physicians must instead bill using E&M codes from the Office and Other Outpatient Services, Initial Hospital Care, and Initial Nursing Facility sections of the 2010 CPT. CMA has updated its consultation code billing guide to provide some additional clarity on this understandably confusing and complex issue. Since final adoption of the rule, we have received additional information. Please discard any previous version that you may have downloaded, and download the new file at http://www.cmanet.org. You may also request a hard copy by

contacting our Member Help Center at 800/786-4CMA (4262) or memberservice@cmanet.org.

CMA is also surveying major payors in California to find out which ones will be changing their own payment policies as a result of this change. The data that we have gathered, thus far, is available to members-only at http://www.cmanet.org. The chart will be updated regularly as new information becomes available.

If you have any additional questions about these new rules, please do not hesitate to call Sandie Becker, SCCMA/MCMS Reimbursement Specialist at 408/998-8850 or 831/455-1008.

PAGE 35 | THE BULLETIN | JANUARY / FEBRUARY 2010

(CMA Alert, January 25, 2010 issue)

CLASSIFIED ADS office space for rent/lease TWO UNITS AVAILABLE IN PRESTIGIOUS BUILDING • BY REGIONAL MEDICAL CENTER One has 1,200 sq. ft., at 244 North Jackson, with a big waiting room, spacious reception and secretarial area, with possible four examining rooms and private doctor’s consultation room, two bathrooms, carpet recently changed. Building has elevator, Quest Laboratories and xrays in the premises, and pharmacy on the corner of Montpelier for the convenience of your patients. Asking $2,400 per month, no triple net.

MEDICAL OFFICE FOR LEASE/ SUBLEASE/SALE

MEDICAL OFFICE TO SHARE • SUNNYVALE

Office in close proximity to O’Connor Hospital for lease/sublease/sale. Please call 408/923-8098 for more information.

One exam room plus one large office, shared waiting room and front office.

Newly built, 1,280 sq. ft. Call 408/4381593.

MEDICAL OFFICE SPACE AVAILABLE • ACROSS FROM O’CONNOR HOSPITAL

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE

Class A medical office space located across from O’Connor Hospital. Various suite sizes ranging from 1,650–3,800 sq. ft. Suites are built out with exam rooms and sinks, waiting room area, reception, restrooms, and private offices. Call brokers for more information and to tour: Alice Teng, 408/282-3808, or Patrice Delorey, 408/282-3848.

Available to share with prominent aesthetic dermatologist. This upscale office has seven exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

The second one has 1,456 sq. ft. on the first floor, with a spacious waiting room and reception area, two bathrooms, with five examining rooms and consultation room. There is an area which was used for a full laboratory. The lease is not NNN. Please call Dr. Miranda about both units at 408/923-0257 for details.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

MEDICAL SUITES • LOS GATOS – SARATOGA

OFFICE SPACE FOR LEASE • SAN JOSE

Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking.

Located next door to El Camino Los Gatos Hospital. Both units currently available.

Call 408/355-1519.

600–1,900 sq. ft. in West Valley Medical Building, second floor, elevator, separate entrance. Call Helen at 408/243-6911.

FOR LEASE IN SUNNYVALE On Remington and El Camino Real. Behind In & Out. 828 sq. ft. in an established medical/dental building. Move-in condition five rooms and reception. Was leased by Chiropractor for 10 years. Existing tenants are five dentists and one accupuncturist. Call Dr. Advani at 408/204-5050.

Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.

MEDICAL SUITES • GILROY

OFFICE SPACE FOR SUBLEASE • MTN VIEW Two exam rooms and one doctor’s office, five days a week, shared waiting room, in Mountain View, on South Drive. Call 650/967-7471.

OFFICE EXAM ROOMS TO LEASE Two nice and large exam rooms (dedicated), shared waiting room. Available five days a week, 2585 Samaritan Drive, San Jose. Please call 408/356-7788 for more information.

PAGE 36 | THE BULLETIN | JANUARY / FEBRUARY 2010

ATHERTON SQUARE MEDICAL/ DENTAL BUILDING A newly upgraded Class A building offers a variety of spaces from 1,166 sq. ft. and up for medical/dental use at 3301-3351 El Camino Real, Atherton. Tenant improvement allowances available to design suite to meet your needs. Excellent onsite parking, close to Stanford and Sequoia. Trask Leonard, Bayside Realty Partners, 650/282-4620 or Alice Teng, Colliers, 408/282-3808.

PRIVATE PRACTICE/ OFFICE for sale

Pajaro Dunes

PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families

PRIVATE PRACTICE FOR SALE Available immediately. Urgent Care/Family Practice in West Valley area. Established 30 years, $0 down. Contact Helen at 408/4763450.

EMPLOYMENT OPPORTUNITY

Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

OCEAN FRONT CONDO ON KONA COAST Beautiful setting on the big island of Hawaii. Sleeps four. Great views. Call 408/354-3253 for more info.

Rental Agent Pajaro Dunes Company 1-800-564-1771

FOR SALE

OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

condo/COTTAGE rentals

Owners Bill & Debbi Ricks 408-354-5613

WANTED

BEAUTIFUL HAWAIIAN CONDO

PEDIATRIC PRACTICE

Poipu Beach, Kauai. Lovely 2 BR/2 BA condo, across street from ocean. Recently remodeled bathroom and kitchen with granite countertops, new carpeting throughout. Three lanais with ocean and mountain views, and the tropical gardens which make the Nihi Kai complex so special. Price reduced to $785,000. Call 650/949-3353.

Will buy Pediatric practice in South Bay. Call 408/455-2959.

FOR SALE! BURAGO & MAISTO AUTOMOBILES! Die Cast Metal - 1:18 Scale - Special Edition. Great for gift giving, or the serious collector. Sealed, never opened, excellent condition. Dated from 1936 to 1996. Both domestic and foreign. 14 autos total. Purchase price: $30.00 each! Models include: Cadillac Eldorado Barritz, Corvette ZR1, Dodge Viper, Ford GT90, Mustang Mach III, Porsche 911 Speedster, Porsche Carrerra Cabriolet, Porsche Boxster, Mercedez Benz 500K Roadster, Mercedes Benz 190 SL, Mercedes Benz 300 S, Lamborghini Jota, Jaguar XJ220, and Ferrari F-50. Purchase price: $30 each. Call Lee at 408/866-0558.

MEDICAL BILLING PHYSICIAN NETWORK • MEDICAL BILLING AND CONSULTING SERVICES Over 18 years of experience managing medical and specialty billing; customized to fit the needs of your practice. Services include, but are not limited to, full medical billing (including patient statements), coding, authorization, insurance eligibility, monthly summaries, and financial counseling. Call us today and allow our professionals to reduce the frustration and time consumed processing medical claims and account follow-up, so you can focus your valuable time on patient care. Office: 408/998-8537, Email: physnet@sonic.net.

PAGE 37 | THE BULLETIN | JANUARY / FEBRUARY 2010

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When was the last time a doctor came to YOU?

At California Pacific Medical Center’s Atrial Fibrillation and Arrhythmia Center we are committed to a comprehensive team approach in treating your patient. Whether a patient is having debilitating palpitations, recurrent syncope or severe heart failure, sensitive and difficult challenges await – for them and their family.

We are Andrea Natale, M.D., Steven Hao, M.D. and Richard Hongo, M.D., electrophysiologists who specialize in complex ablation procedures.

In fact, we have the highest atrial fibrillation ablation volume on the West Coast; last year, we performed over 450 procedures. We would like make an appointment to see you in your office.

The Atrial Fibrillation and Arrhythmia Center offers:

Why?

•

Board certified, fellowship trained cardiac electrophysiology specialists

We’d like the opportunity to acquaint you with our facilities, staff and equipment – including

•

State of the art technology and facilities for the treatment of arrhythmias•

•

Nationally and internationally recognized expertise in complex ablations, providing care for patients and education for physicians throughout the world

•

In 2008, HealthGrades® ranked California Pacific “Best in the San Francisco Area for Cardiology and Overall Cardiac Services”

•

Dedicated arrhythmia nurse and nurse practitioner to provide continuity from the consultation through the procedure to follow ups

California Pacific’s new Stereotaxis lab. We’d also like to help familiarize you with referral indicators for your patients with arrhythmias, particularly atrial fibrillation.

Let’s schedule an appointment for a visit to your office: 415-600-7459

www.cpmc.org/services/heart

BULLETIN THE

Address service requested

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way, San Jose, CA 95128-4705

PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503

Does Your Insurance Company Have the Strength to Endure?

Strength and flexibility. That’s what your practice needs to thrive during challenging economic times. NORCAL Mutual Insurance Company has received an “A” (Excellent) financial rating from A.M. Best, the leading provider of insurance industry ratings, for the past quarter century.

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Our financial stability has allowed us to declare more than $386 million in dividends to our policyholders.

Visit www.norcalmutual.com today, or call 800.652.1051.

NORCAL Mutual is proud to be endorsed by the Santa Clara County Medical Association and the Monterey County Medical Society as the preferred professional liability insurer for their members.