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www.escambiacms.org SEPTEMBER/OCTOBER 2013 VOLUME 43, NO. 5

Upcoming Events September 29 Women in Medicine 11:00 am | Location: Hemingway’s Bimini Bar Sponsors: Baptist Healthcare | Danna Gracey Insurance | Emerald Coast Hospice | Fisher Brown Bottrell Insurance | Safe Harbor Tax Advisory LLC October 8 Pensacola Yacht Club 5:30 pm General Membership Meeting | Topic: Asset Protection/Wealth Management | Speaker: Jason Dyken, M.D. Sponsors: MAG Mutual Insurance & McMahon & Hadder Insurance RSVP: 478-0706 info@escambiacms.org

Founded in 1873

BULLETIN SAVE THE DATE:

2014 ECMS INAUGURAL BALL

Saturday, January 25, 2014 President-Elect Susan Laenger, M.D. Hilton Pensacola Beach

During the weekend of July 26th - July 28th the Escambia County Medical Society, Inc. [ECMS] took seven delegates to the Annual Florida Medical Association Meeting. The delegates included ECMS President Dr. Wendy Osban, ECMS President-Elect Dr. Susan Laenger, ECMS Vice-President Dr. Christopher Burton, ECMS Secretary/ Treasurer Dr. Brian Kirby, ECMS Member at Large Dr. Tom Westbrook, ECMS Liason and the Director of the Health Department in Escambia County Dr. John Lanza, and Santa Rosa County representative Dr. Eduardo Puente. ECMS submitted a resolution brought forth by member Dr. David Turner and it was met with overwhelming approval. This resolution addressed placing a limit on the amount of time a physician remains responsible and liable for a patient who has not been seen in many years. Right now there is NO time limit, and all Florida physicians are responsible for test results on all patients they have ever seen, unless the relationship was specifically terminated. To better understand the context of this resolution, here is an example: if a patient that you have not seen in many years goes to the ER and complains of a breast mass, the ER provider could potentially put your name on the mammogram order and you would be responsible for ensuring the patient went through the appropriate work up including potential breast biopsy. This would be true even though you have no current information on the patient. Friday was filled with meetings including opportunities for FMA delegates to receive free state mandated CME. Dr. Osban concluded her yearlong FMA Physician Leadership Academy Training and graduated Saturday. “The Leadership Academy was a 10 month program that strengthened my leadership skills and gave me the opportunity

to network and exchange ideas with other young physicians in the state. It was an invaluable experience and the curriculum included: Wendy Osban, D.O. Building Culture and Talent, Self and Relationship Mastery, Thinking and Leading Strategically, and Effective Presentation Skills,” said Dr. Osban. Dr. Burton chaired the Young Physicians Section and spoke at the Physician Leadership Academy training and to the Residents and Fellows Section. The lecture to the residents, fellows and medical students was in conjunction with Chris Cupoli, Director of the Executive Education program at University of Florida and focused on developing leadership skills and the importance of mentoring to young physicians. “It is a pleasure working with the young physicians of Florida to improve their leadership skills. The practice of medicine is changing, and we need to be prepared to change with it. Our role as leaders in healthcare teams requires new skills that are not taught in medical school and at times have nothing to do directly with patient care. We are lucky to have several physicians locally who not only have gone through the training to succeed as leaders but who are also willing to share that knowledge and mentor others. Whether you still consider yourself a young physician or not, everyone needs to consider how they will face the new realities of healthcare. By participating in the county medical society and the FMA, you can access resources that you will need to be successful,” said Dr. Burton. Friday evening delegates from ECMS, continued on page 3


E.C.M.S. Bulletin

The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/Feb, Mar/Apr, May/ Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.

Vision for the Bulletin:

路 Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond. 路 A powerful instrument to attract and induct members to organized medicine. Views and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the directors, staff or advertisers. Editors: Brian Kirby, M.D. Erica Huffman, Executive Director

Ad placement Contact Erica Huffman at 478-0706 Ad rates 1/2 page: $300 路 1/4 page: $150 路 1/8 page: $100

2013 ECMS officers President - Wendy Osban, D.O. President-Elect - Susan Laenger, M.D. Vice President - Christopher Burton, M.D. Secretary/Treasure - Brian Kirby, M.D.

Contents Page 3 - New Members/ ECMS Young Physicians Section Page 4 - 2013 FMA Annual Meeting Page 5 - Remembering William Bell Page 6-7 - Diagnosis and Treatment of Acute Pulmonary Embolism Page 8 - Tracking & Follow-up of Test Results Page 10 - In the Community News


Membership New Members Jacque LeBeau, M.D. Facial Plastic and Reconstructive Surgery The LeBeau Clinic 1020 North Palafox Street Pensacola, Florida 32501 (P) 850-308-1738 (F) 850-308-5420 Jonathan Leibig, M.D. Flight Surgery/Aviation Medicine NASWF Naval Branch Health Clinic 7119 Langley Street Milton, Florida 32570 (P) 850-623-7151 Scott Moore, M.D. Family Medicine Century Medical Center P.O. Box 1164 Century, Florida 32535 (P) 850-256-5314 (F) 850-352-2488 Dina Navarro, D.O. OB/GYN Sacred Heart Medical Group 3754 Highway 90 Suite 220 Pace, Florida 32571 (P) 850-416-5050 (F) 850-4165022

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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Elisabeth Tucker, M.D. OB/GYN Ladies First 2510 North 12th Avenue Pensacola Florida, 32503 (P) 850-432-7310 (F) 850-432-7320 James Ward, Jr., M.D. Cardiology Sacred Heart Health System 5151 North 9th Avenue Pensacola, Florida 32504 (P) 850-416-4008 (F) 850-416-6119 News Dr. Ken Garrett is now practicing with the Gulf Coast Pain Institute. 4724 North Davis Highway. (P) 850-484-4080 (F) 850-484-8801 Dr. Eduardo Puente has closed his office as of 8/14/2013. All medical records have been given to Baptist Medical Group Urology; M. Elizabeth Cruit, M.D. and Charles Yowell, M.D. (P) 850-437-8711

continued from page 1

Bays Medical Society (Bays CMS), Capitol Medical Society (Capitol CMS) and Duval Medical Society gathered for dinner and a chance to discuss issues directly affecting the Northwest Florida region. The physicians and executive directors had the opportunity to share ideas on how to add even more value to their members. The group also collaborated on ideas for future CME and networking events for the physicians in panhandle. Saturday’s meetings started early with a 6:00AM Northwest Florida Caucus Meeting where the delegates from ECMS, Bays CMS, and Capitol CMS discussed and debated details of the resolutions brought forth in the FMA Handbook. Immediately following all delegates from each medical society gathered for the House of Delegates Opening Session where elections were discussed and running candidates gave speeches. We concluded the day with the Reference Committee Meetings where resolutions were heard. We asked Dr. Laenger what she thought about attending the FMA Annual Meeting and this is what she had to say: “Some of you may still be asking why you should continue to belong to the Escambia County medical Society. I will tell you why: so you can become more involved and become a delegate to the FMA meeting. I just returned and it was incredibly exciting and informative. How many of you know that there are now Doctors of Nursing? The traditional nurse practitioner training is a master’s degree. Now you can attain a PhD in nursing. No doubt this will confuse patients. Resolutions have been brought to the

House of Delegates addressing the need for clarification, so that patients are informed that the doctor of nursing is neither a medical doctor nor a doctor of osteopathic medicine. We already have patients that are confused seeing nurse practitioners and physician assistants. Can you imagine how much worse this will become? There was a resolution brought forth that suggested that the FMA support legislation that would limit sales of tobacco products in pharmacies. This is already law in San Francisco. An excellent idea was brought forward, that since pharmacies are getting into healthcare delivery, perhaps legislation should be sought to limit tobacco products being sold where primary care is being practiced. Isn’t it hypocritical that a nurse practitioner in a minute clinic could treat your COPD exacerbation and then you could turn around and purchase a pack of cigarettes along with your antibiotics? Do you have an opinion on NICA fees? How about limiting futile care at the end of life? How do you feel regarding the possibility of medical marijuana in the state of Florida? If you have an opinion regarding these issues, then you really should become more involved in organized medicine in order to ensure that your voice is heard at the state level.” If you would like more information about how you may become more involved in organized medicine at the local level please contact the ECMS Board or Executive Director Erica Huffman.


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Announcements 2013 FMA Annual Meeting

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

The following ECMS physicians have been named to a 2013-2014 Florida Medical Association council • •

Dr. Wendy Osban, ECMS President has been named to the 2013-2014 Council on Healthy Floridians. Dr. George Smith, ECMS 2012 President has been named to the 2013-2014 Council on Medical Education.

Dr. Christopher Burton, ECMS Vice-President and Dr. James Natalie have been named to the Council on Medical Services and Health Care Delivery Innovation.


Announcements

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

William Reed Bell, Sr., M.D.

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By Jimmy Jones, M.D.

(December 24, 1936 – July 28, 2013)

E.C.M.S. President 1969

When does leadership begin? For Reed Bell it began in high school sports. At Pensacola High he captained the football and basketball teams. His football jersey was honorably retired in 2011. He obtained a football scholarship at the University of Florida but played for one year before joining the Navy. After military duty he attended the University of The South (Sewanee) where he was Captain of both the football and basketball teams, achieving Little All American status, while graduating Phi Beta Kappa. Sewanee inducted him into the Athletic Hall of Fame and retired his football jersey. After graduating from Duke University Medical School and pediatric and endocrinology training at Baylor College of Medicine he enter private practice in Pensacola. And then the visions began! All eight pediatricians in town agreed that there was a need for a Children’s Hospital and worked diligently toward that end.. They approached the three hospitals – Baptist, Sacred Heart and Escambia General –for support. As a sincere good faith gesture all eight pediatricians contributed $1000 toward the planning and early expenses. Sacred Heart agreed and the region’s first Children’s Hospital opened on April 1, 1969. Dr. Bell became the Medical Director

Reed’s vision was for a pediatric sub-specialty group. and he worked tirelessly toward that end – and succeeded. He was very persuasive. He would take you by the arm and say, “Jimmy, we ought to do thus and so. Translated means I think You should do thus and so! Never resting, he organized a pediatric residency program and was the Director for 17 years. He served as President of the Escambia County Medical Society, Medical Staff of Sacred Heart Hospital, Florida Pediatric Society and the Florida Chapter of the American Academy of Pediatrics. He also served as Director of the Escambia County Health Department and District I of Children’s Medical service. President Regan appointed him as Special Assistant and Consultant to the Administrator of the Alcohol, Drug Abuse and Mental Health Administration. Always planning, always enthusiastic. If you saw him coming your way you had best duck because he would have some project that needed your help. But above all it was For the Children, For the Children, For the Children

Always Remembered

Rick Sims, FSU COM M4 is selected for the 2013-2014 ECMS Michael Redmon, M.D. Scholarship “I value the opportunity to work so closely with the ECMS board, as a nonvoting member, and network with other peers and physicians, as well as learn the problems that face the future of medicine. I look forward to playing a significant part in shaping the future of medicine.” Recipients of this scholarship must be 4th year FSU College of Medicine Students who play an active role in organized medicine.

Howard Egbert Herring, Jr., M.D. (1925-2013) Dr. Herring was an active ECMS member from 1953-1987. Mariano S. Pacheco, Sr., M.D. (1935-2013)


Medical/Legal 6 Diagnosis and Treatment By David B. Troxel, MD, Medical Director, of Acute Pulmonary Board of Governors, The Doctors Company Embolism ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

In a review of 363 consecutive closed claims from January 2004 through January 2006 at The Doctors Company, 3 percent involved deep venous thrombosis (DVT) and pulmonary embolism (PE). Most malpractice claims of this type result from the failure to recognize patients at high risk for venous thromboembolism (VTE) and implement appropriate prophylaxis, failure to diagnose DVT in patients who subsequently have a PE, and failure to rule out PE in patients with nondiagnostic pulmonary symptoms. When VTE is seriously considered in the differential diagnosis, it should be confirmed or excluded by appropriate testing. In the fourth quarter 2008 issue of The Doctor’s Advocate, I reviewed the risk factors for VTE, the prevention of VTE, and the diagnosis of DVT. The discussion in this issue will focus on the diagnosis and treatment of acute pulmonary embolism. Diagnosis of Acute PE Without treatment, pulmonary embolism has a mortality rate of 30 percent, resulting largely from recurrent embolism. Most emboli are multiple, primarily involve the lower lobes, and cause pulmonary hemorrhage. Only 10 percent of emboli cause pulmonary infarction. The symptoms and signs of PE are relatively nonspecific and include dyspnea, pleuritic pain, cough, hemoptysis, tachypnea, and tachycardia. Fewer than one-third of patients have symptoms or signs of DVT. Lab tests often show leukocytosis and elevation of lactate dehydrogenese (LDH) and aspartate aminotransferase (AST) with normal bilirubin. Troponin 1 and troponin T are elevated in 30 to 50 percent of patients with moderate to large PE, due to right ventricular strain. Arterial blood gases (ABGs) may show hypoxemia, hypocapnia, and respiratory alkalosis; however, these changes are often absent, so ABGs have limited diagnostic value. ECG and chest x-ray abnormalities are usually nonspecific and are seldom helpful diagnostically. Echocardiograms show abnormalities suggestive of PE in 30 to 40 percent of patients (increased right ventricular size, decreased RV function, and tricuspid regurgitation). Clinical assessment and these studies alone are usually not sufficient to reliably confirm or exclude the diagnosis of PE—and further testing is required. • Ventilation/perfusion lung scan (V/Q scan) is the best validated noninvasive approach to evaluating patients with suspected PE. However, a high percentage of scans are nondiagnostic, and scans are most useful when they are either negative or indicate a high probability of PE. o Patients with both a high clinical and high V/Q scan probability have a 95 percent likelihood of PE. o Patients with both a low clinical and low V/Q scan probability have a 5 percent likelihood of PE. o A normal V/Q scan virtually excludes PE. • Pulmonary angiography is the definitive diagnostic test. When negative, the diagnosis of clinically significant PE is excluded. • Spiral (helical) CT scanning with intravenous contrast (CT pulmonary angiography, CT-PA) is an increasingly available noninvasive approach, although results vary depending on the experience of the person interpreting the images: o 83 percent of patients with PE have a positive CT-PA (sensitivity). o 96 percent of patients without PE have a negative CT-PA (specificity). • CT-PA in conjunction with the modified Wells score. o If the CT-PA is positive, the likelihood of PE in patients with high, intermediate, or low clinical probability is 96, 92, and 58 percent, respectively. o If the CT-PA is negative, the likelihood that PE is absent in patients with low, intermediate, or high clinical probability is 96, 89, and 60 percent, respectively. A Practical Approach to the Diagnosis of Acute PE 1. CT experienced institutions: o If PE is suspected, apply the modified Wells criteria (clinical criteria used to estimate the probability of PE). o If a patient is classified as PE unlikely, proceed to the D-dimer test. A negative test (<500 ng/ml) excludes PE. o Patients classified as PE likely or who are PE unlikely with elevated D-dimer levels (>500 ng/ml) should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE; if negative, PE is excluded. 2. CT inexperienced institutions: o If PE is suspected, apply the modified Wells criteria and obtain a V/Q scan. o A normal V/Q scan regardless of clinical probability excludes PE. o A low probability V/Q scan plus a low clinical probability excludes PE. o A high probability V/Q scan plus a high clinical probability confirms PE. o For all other combinations, obtain either pulmonary angiogram or serial lower extremity venous ultrasound examinations. Treatment of VTE Most deaths from PE occur within the first few hours due to recurrent PE. Therefore, if there is high clinical suspicion or a diagnosis of PE, anticoagulant therapy is promptly initiated—usually with subcutaneous low molecular weight (LMW) heparin or intravenous unfractionated heparin with the goal of achieving a therapeutic level within the first 24 hours. Heparin should be continued for at least five days. For most patients, oral anticoagulation can be started simultaneously with the heparin and overlapped with heparin for at least four to five days. Heparin can be discontinued on day five or six if the internationalized normalized ratio (INR) has been therapeutic for two consecutive days. Persistent


Medical/Legal

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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hypotension due to PE is an accepted indication for thrombolytic therapy. However, due to the risk of major hemorrhage, anticoagulation must be temporarily discontinued during infusion. Hospital medical staff protocols for the treatment of VTE should be followed. Additional Resources Each of the following references is from UpToDate, Rose BD (Ed), UpToDate, Waltham, MA 2008. Copyright 2008 UpToDate, Inc. Accessed on November 28, 2007. For more information, visit www.uptodate.com. Thompson BT, Hales CA. Overview of acute pulmonary embolism. Thompson BT, Hales CA. Diagnosis of acute pulmonary embolism. Tapson VF. Treatment of acute pulmonary embolism. The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues. The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor. Reprinted with permission. ©2013 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, first quarter 2009.


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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Medical/Legal

Tracking & Follow-Up of Test Results What You Don’t Know Can Hurt You Medical malpractice cases involving tracking and follow-up errors are difficult to defend. Why? Because there is less room for reasonable minds to differ when a case boils down to simple tracking and follow-up failures. To avoid such errors, ProAssurance’s risk management experts encourage medical practices to implement reliable systems that help ensure the following six steps occur: 1. tests are performed; 2. results are reported to the practice; 3. results are made available to the physician for review and sign-off; 4. results are communicated to the patient; 5. results are properly filed in the patient’s chart; and 6. results are acted upon, if indicated. Test results may be reported to your practice in a number of ways—by hand delivery, mail, telephone, fax, or email—just to name a few. They come from multiple places in multiple forms and at varying times of the day. As a result, you have to rely on staff members to ensure you receive the information. Staff should understand the importance of bringing test results to your attention when they are received. Unfortunately, test results are all too often misplaced, misfiled, lost, or simply not communicated to the physician until it is too late.

Submitted by ProAssurance

If you are insured with ProAssurance and would like more information about tracking and follow-up systems, please contact your local ProAssurance risk management department. This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct. Copyright © 2013 ProAssurance Corporation ProAssurance is a national provider of medical professional liability insurance and risk management services. For more information about the company, visit ProAssurance.com.


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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COU


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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

In the Community

Hospital News - Baptist Health Care Baptist and Mayo In July, Baptist Health Care (BHC) announced its new membership in the Mayo Clinic Care Network. This network membership gives patients: • Increased resources at the point of care here in our community • Physician access to Mayo Clinic knowledge and expertise • The resources to receive care closer to home Membership in the Mayo Clinic Care Network fosters greater physician collaboration to better provide quality health care close to home, often for some of the most challenging and complex medical conditions. Learn more about this exciting clinical collaboration by visiting eBaptistHealthCare.org/Mayo. Private Rooms As part of a system-wide initiative to enhance the patient experience, Baptist Health Care (BHC) now offers private rooms to all patients at all four of hospitals: Baptist, Gulf Breeze, Atmore Community and Jay. BHC recognizes that comfort is vital to the healing process. Private rooms promote better rest, limit noise and provide privacy for patients and their visitors. No one looks

forward to a hospital stay, but when you need this level of care, you can depend on patient-centered service at Baptist. Read more about private rooms on page 10, and visit eBaptistHealthCare. org to find out more about your community’s only locally owned, nationally recognized health care system. Introducing the Baptist Vein Center Baptist Health Care is proud to announce the opening of the new Baptist Vein Center, led by board-certified cardiothoracic surgeon James Lonquist, M.D., F.A.C.S., of Cardiology Consultants. The center is located on the campus of Gulf Breeze Hospital and offers a broad range of services including treatment of venous insufficiency and its complications, varicose veins, spider veins and venous ulcers. Patients complaining of lower extremity pain, heaviness, itching or edema may benefit from a comprehensive vein evaluation. Referring physicians and practitioners will receive a copy of the treatment plan and immediate feedback following procedures. Learn more at BaptistVeinCare.org. Referrals can be made by calling 850.969.VEIN.


In the Community

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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Sacred Heart

Sacred Heart’s Joint Replacement Program Earns TJC Accreditation Sacred Heart Hospital has earned The Joint Commission’s Gold Seal of Approval® for its Joint-Replacement Program, specifically for replacement of the knee and hip. The certification award recognizes Sacred Heart’s dedication to continuous compliance with TJC’s state-of-the-art standards. Sacred Heart is the only hospital in the Pensacola area to achieve this level of certification by TJC. EBUS Technology Helps Diagnose Lung Tumors Sacred Heart Hospital recently acquired an endobronchial ultrasound system, known as EBUS, which makes lung-biopsy procedures safer and more accurate. The new technology allows physicians to view the patient’s lungs, lymph nodes and surrounding areas, and to conduct a biopsy if needed, through a catheter inserted into the large airways leading to the lungs. In some cases, the procedure gives physicians the information needed to stage a cancer without requiring patients to undergo more invasive, more costly procedures. Sacred Heart ED Improves Patient Satisfaction For the past 18 months, Sacred Heart Hospital’s Emergency Department physicians and leadership have been working toward vastly needed improvements in ED patient satisfaction. Their study of patient throughput – from the ED to the admission to discharge – has led to new triage processes and surge plans that keep patient-flow moving through high-volume situations. These new processes continue to yield significant improvements in decreased door-to-doctor times and decreased length-ofstays.


www.escambiacms.org

8800 University Pkwy., Suite B Pensacola, FL 32514 Ph: 850-478-0706 Fx: 850-474-9783 Email: info@escambiacms.org Executive Director: Erica Huffman

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MECOP Reminder 13th Annual Best Clinical Practice Symposium Saturday, January 18, 2014 Sacred Heart Hospital Dudley Greenhut Auditorium 7:30 a.m. to 4:30 p.m. 8 AMA PRA Category 1 Credits TM The best evidence-based practices for practitioners treating adult and aging patients.

Member Benefit: The Health Care Attorney On Call Hotline (561) 306-5699 View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission.

Sept.Oct Bulletin 2013  
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