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Vital Signs Official Publication of

Contents CMA NEWS.................................................................................................................................5

Fresno-Madera Medical Society Kings County Medical Society


Kern County Medical Society

Your Clearinghouse or Billing Service Can Help with Your EDI Issues!................................................7

Tulare County Medical Society

Never Events ...........................................................................................................................9

December 2008 Vol. 30 – Number 12 Editor, Abbas Mehdi, MD Managing Editor, Carol Rau Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Herbert W. Boro, MD David N. Hadden, MD Steven J. Hager, MD Abdirahman A. Nimeri, MD Prahalad Jajodia, MD Robb Smith, MD Roydon Steinke, MD Kings Representative, Sheldon R. Minkin, MD Kern Representative, John L. Digges, MD Tulare Representative, Gail Locke

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 93729-8337.

NEWS AMA News .............................................................................................................................10 PHYSICIAN WELL-BEING: On Choosing Happiness. What’s Your Choice ......................................11 CLASSIFIEDS ............................................................................................................................22 CME ACTIVITIES .......................................................................................................................22 FRESNO-MADERA MEDICAL SOCIETY .........................................................................................12 • President’s Message • Membership News • FMMS Announces Holiday Closure • FMMS Honors 50-year Members • FMMS Physicians Honored With Service Awards • Accolades and Achievements • Historical Library, Museum and Small Conference Center Now Open for Members’ Use KERN COUNTY MEDICAL SOCIETY .............................................................................................17 • President’s Message • Membership News TULARE COUNTY MEDICAL SOCIETY ..........................................................................................20 • Mind, Body and at This Present Moment

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Advertising Contact: Display: Annette Paxton, 559-454-9331 Classified: Carol Rau, 559-224-4224, ext. 118

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / D E C E M B E R 2 0 0 8

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Last month, some 20,000 California physicians received letters from the California Physician Performance Initiative (CPPI). These letters contain raw and relative performance scores for physicians on 15 quality measures based on claims data from Medicare and United Health, Blue Cross and Blue Shield PPOs. The letters do not contain the underlying data. CMA has serious concerns about the accuracy and integrity of the data used to establish these scores and at the potential use of these scores or these metrics by payors to do pay-for-performance or create tiered networks. In order to address CMA’s concerns and to improve the quality of the data, CPPI has created a reconsideration process that physicians should use to verify the data. CMA urges all physicians to request their data from CPPI and verify its accuracy. December 5, 2008 is the last day to request patient information. On January 30, 2009 findings will be reviewed with CPPI Physician Advisory Group. Visit: to download the CPPI “Request List of Commercial Patients” form. In checking the data, physicians should check whether CPPI correctly listed the patient name, physician name and speciality and whether or not the physician performed the procedure. While this is a time-consuming process, it is critical for physicians to take the time to verify their data. If physicians do not raise concerns now, payors will use this data in the future to adjust reimbursements and change the flow of patients to the practice. CMA also asks physicians to share with them any corrections or concerns and, if anything, what was wrong about your performance scores. This step is important to insure that CMA has the information needed to advocate on your behalf.



than a dozen physicians representing CMA and the California Psychiatric Association testified at a public hearing in opposition to a proposal that would expand the scope of practice of psychologists and potentially all other health care practitioners working in licensed health care facilities. The regulations – proposed in July by the California Department of Public Health and intended to clarify state law as it applies to medical staff membership and privileges for psychologists - would weaken medical staff self-governance rights and could be broadly interpreted to allow unqualified health care professionals to carry about the duties of a physician or surgeon.



has updated ON-CALL document #0813, “Language Interpreters,” to address various new health plan contract amendments related to the Language Assistance Program (LAP) regulations that will take effect next year. Because the law leaves it up to each insurer to establish its own LAP standards and procedures, physicians are understandably concerned about what these regulations mean to their practices. These new regulations require health insurance companies to

provide free interpretation and translation service in “threshold languages” to enrollees with limited English proficiency (LEP). They take effect January 1, 2009. The financial responsibility for compliance is on the insurers, except when delegated financial responsibility has been negotiated separated. Physicians’ obligations will vary by insurer, but in general physicians will be required to: inform patients of the availability of translation and interpretation assistance at the point of service; document when and if LEP patients refuse language assistance and complete provider language capability disclosure forms so that the health plans can assess the LAP needs of their enrolles. CMA is closely monitoring the situation and encourages physicians to report any burdensome requirements to CMA’s Reimbursement Helpline.


CMA members receive 30 percent off one-year subscriptions and 35 percent off two-year subscriptions to any Epocrates product. To receive your discount, log in to the CMA members-only website and follow the links to the Epocrates website.



the vigorous efforts of organized medicine, the Department of Managed Health Care (DMHC) regulation that seeks to prohibit ?balance billing? of Knox-Keene enrollees by providers for out-of-network emergency services was approved by the Office of Administrative Law on September 15, 2008. The regulation will become effective on October 15, 2008. The California Medical Association (CMA), California Orthopedic Association (COA), California Society of Anesthesiologists (CSA), California Radiologic Society (CRS), California Chapter, American College of Emergency Physicians (Cal/ACEP), and California Hospital Association (CHA) filed a lawsuit on September 26, 2008 and are working together to have this regulation enjoined and declared invalid by the court. We expect that the regulation will be in effect for a few weeks before the court is able to make its ruling. Accordingly, it is essential that physicians understand the scope of the regulation and not “balance bill” Knox-Keene enrollees for out-of-network emergency services. Physicians also can take a number of steps to position themselves and to help organized medicine demonstrate why the regulation is against sound public policy. Nonetheless, CMA cannot provide physicians with individual legal advice and urges physicians with specific questions to seek counsel from their personal attorney. NOTE: Physicians are urged to check the CMA website regularly to see if this document has been updated and to learn of new developments.

CMA HOTLINES AND MEMBERSHIP BENEFITS • Membership Help Line: 888-233-2937 • Legal Information Line: 415-882-5144 • Reimbursement Help Line: 888-401-5911 • Contract Analysis: 415-882-3361 • Legislative Hotline: 866-462-2819 V I TA L S I G N S / D E C E M B E R 2 0 0 8

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We hate lawsuits. We loathe litigation. We help doctors We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company. Donald J. Palmisano, MD, JD, FACS Board of Governors, The Doctors Company Past President, American Medical Association

The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. To learn more about our medical professional liability program, call us at (800) 862-0375 or visit us at


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Your Clearinghouse or Billing Service Can Help with Your EDI Issues! submitted by Palmetto GBA

HAVE YOU HEARD…? “I was submitting claims without issues to my outgoing contractor and then, as of our transition date, everything stopped!” Not to mention… “My electronic remits are no longer linked, but they were at the outgoing contractor.” “We are receiving Electronic Remit files for clients who used to be linked to our submitter.” “One client was linked in early September and we received payments from Palmetto, then the EMC became “delinked” at the end of September.” “My clearinghouse submitted new provider setups on the Early Boarding application in error, but I’ve learned that Early Boarding was only for providers they were already submitting claims to previous contractor. We can’t seem to get them to resubmit new applications.” These comments have been made to Palmetto GBA EDI repeatedly. Unfortunately, we cannot help to resolve these problems without the cooperation of your biller, who may be Billing Service or Clearinghouse. We need you to understand how and why the above quotes have become so popular, as well as apprise you of other issues that your biller can and should be assisting you with! First, it is important to understand that Palmetto GBA EDI received spreadsheets from each of the outgoing contractors with the following information: • All submitters set up to send electronic claims. • All providers linked to the submitters already set up to send electronic claims. • All remit recipients set up to receive electronic remits. • All providers linked to a submitter who is receiving the providers’ remits on behalf of the providers. • Palmetto GBA could not add brand new submitters during Early Boarding, because the OCGs still owned the system. Unless expressly requested by a provider, we made no changes whatsoever to this information. Therefore, if you would like to be linked or unlinked from a clearinghouse or billing service, we need the proper paperwork to make this happen. This information is found on our website. You and your biller need to coordinate the action you want to happen. If you or your biller still has questions after you have reviewed the information, one of the EDI team will be happy to answer any questions you may have via a call to our Technology Support Center, toll-free, at 866-749-4301.

Second, all submitters were required to submit a completed EDI Application. If your submitter did not do this, the submitter cannot submit claims on your behalf. Your biller is the first place you should go if you are not getting paid, and you need to ask the following questions: • Did you complete the required EDI Application during Early Boarding? • Have you submitted the claims I submitted to you to Palmetto GBA? • If you have submitted the claims I submitted to you to Palmetto GBA, where are the Response Reports that indicate acceptance, rejection and errors? • If you have submitted the claims I submitted to you to Palmetto GBA and received rejections, have you corrected those errors? Your relationship with your biller is an important one, and one you are paying for. You have entrusted your Medicare claims and (in some instances) remittances to your biller. In return, you should expect your biller to ensure the following: • Submit the claims you provide to them for Medicare reimbursement in the appropriate format. • Correct any submission errors they receive via the Medicare Response Report and resubmit those corrected claims. • Ensure that your provider entities are properly linked to your biller’s submitter ID for claim submission and/or receipt of electronic remittances. Your relationship with the Medicare Administrative Contractors to which you submit claims and receive remittances is also important and requires your attention to the following: An EDI Enrollment (aka EDI Agreement) is in place for any new provider entity within your provider group. You are responsible to coordinate with your new biller and to notify Palmetto GBA EDI in the event that you wish to change your billing entity. By addressing the aforementioned issues with your biller, you can help us keep our technical support call volume at a manageable level and assist you with problems for which you and/or your biller may truly need our assistance. In addition, we ask that you review our FAQs and articles on our website, which contains a wealth of information that will often answer your question without a phone call.

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Never Events submitted by NORCAL Mutual Insurance Company

The topic of Never Events is an important development within the healthcare industry, bringing changes to the hospital environment in which many physicians practice. Those changes are a result of many hospitals’ efforts to reduce these events. Physicians should find value in being able to identify Never Events, and in understanding the impact of recent state and federal regulations on Never Event reporting and reimbursement, and preparing for coming changes in inpatient care. The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF).1 There are currently 28 Never Events. They are grouped into six categories: 1. Surgical (e.g., wrong site, wrong procedure, wrong person surgery, retained objects, intraoperative or immediately post-operative death in a normal healthy patient) 2. Product or device (e.g., death or disability caused by contaminated drugs or devices, the use or function of a device or air embolism) 3. Patient protection (e.g., infants released to the wrong parents, patient elopement or patient suicide) 4. Care management (e.g., stage 3 or 4 pressure ulcers, death or serious disability caused by medication error, hemolytic reaction, hypoglycemia, kernicterus, spinal manipulative therapy or labor and delivery in a low risk pregnancy) 5. Environmental (e.g., an oxygen or gas line containing the wrong gas or contaminated with a toxic substance, patient death or serious disability caused by fires, electrical shock, falls or restraints) 6. Criminal (e.g., care ordered or provided by someone impersonating a licensed health care provider, sexual assault of a patient, abduction of a patient, death or significant injury caused by a physical assault).1 In general, Never Events are difficult to defend in medical liability litigation, mostly due to the alarm associated with their occurrence and the tendency for them to occur as a result of failed patient-safety systems or substandard medical care. That is not to say, however, that these events cannot occur when a patient’s care has been appropriate. Healthcare providers should also be aware of Never Event reporting laws. For example, in September of 2006, the California legislature adopted legislation that directs hospitals to report Never Events (referred to in the legislation as “adverse events”).2 Rhode Island and Alaska have not passed Never Event reporting legislation. The Joint Commission considers all of the NQF Never Events Endnotes 1 Patient Safety Primer: Never Events. Available on the AHRQ Patient Safety Network website. 2 California Health and Safety Code §§ 1279.1-1279.3 and 1280.4. 3 Sentinel Events. Available on the Joint Commission website. 4 CMS proposes additions to list of hospital-acquired conditions for fiscal year 2009. April 14, 2008. Available on the CMS website.

to be “Sentinel Events.” Accredited organizations are expected to identify and “respond appropriately” to all sentinel events, according to the Joint Commission. An appropriate response includes “conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements.” Although the Joint Commission does not mandate reporting, the organization encourages it.3 More information on sentinel event NEVER EVENTS: policies and requirements can be INDIVIDUAL accessed on the Joint Commission HEALTHCARE website, PROVIDERS WILL In addition to professional liaFEEL THEIR bility concerns, Joint Commission requirements and reporting manEFFECTS dates, hospitals will also experience increased difficulty obtaining reimbursement for treatment rendered as a result of a Never Event. For example, in August 2007, the Centers for Medicare and Medicaid Services (CMS) announced that beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for eleven conditions (some are on the Never Events list) when acquired during a hospital stay. These conditions are referred to as “Hospital-acquired Conditions” (HACs). As anticipated, private health insurers are following CMS’s lead in refusing to reimburse for care rendered as a result of a Never Event/HAC. For example, Aetna and WellPoint have started to include reimbursement refusal provisions in some of their contracts.4,5 Although Never Event rules, regulations and guidelines are currently directed towards hospitals, individual healthcare providers will feel their effects. Hospitals, if they haven’t already, will begin developing new policies and procedures to deal with these changes, and providers will be expected to comply with them. Furthermore, it is anticipated that Never Event legislation and reimbursement limitations will be used in malpractice claims against individual providers to support allegations of medical negligence. Finally, some commentators suggest that the Medicare and private health insurer reimbursement limitations will be extended to individual providers.6 Keeping a Never Event from occurring is an appropriate goal for any healthcare provider. Consistently adhering to policies and procedures designed to guard against the occurrence of Never Please see Never Events on page 19 Report of the board of trustees. Presented by: Edward L. Langston, MD, Chair. Available on the AMA website. Medicare’s no-pay conditions: not always preventable. July 14, 2008. Available on the American Medical News website. Printed by permission of NORCAL Mutual Insurance Company. NORCAL is the premier provider of professional liability insurance for physicians, medical groups, community clinics, hospitals and medical facilities. To access additional articles published by NORCAL, visit



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An online program recently released by the AMA, “Connecting patients to community resources,” provides physicians with an overview of available community resources “for smoking cessation, reducing risky drinking, eating healthier and increasing physical activity” to help patients improve their health behaviors. The video is the latest episode in the AMA’s Educating Physicians on Controversies and Challenges in Health series. Following the program, physicians should be able to identify the recommended guidelines for the four key health behaviors, including tobacco use, alcohol consumption, healthy eating and physical activity, and refer patients to appropriate community resources to improve these health-related behaviors. Visit to view this free video and others in the series.

JOINT COMMISSION RATES 2007’S MOST CHALLENGING STANDARDS The Joint Commission recently released data that identifies the standards and National Patient Safety Goals that were most frequently identified in 2007 as “not compliant” for hospitals and critical-access facilities. Each year the commission collects data on accredited organizations? compliance with its standards and goals to identify trends and focus education on challenging requirements. Visit 09_08.htm to view this data.

PHYSICIANS REMINDED TO UPDATE THEIR NPI INFORMATION The Centers for Medicare and Medicaid Services encourages physicians to keep their National Provider Identification (NPI) record up to date. To do this, physicians should know and maintain their password which is used to change information in the NPI system, reset their password once a year and review their NPI record to make sure the information is accurate. Physicians can visit to correct, add or delete information in their NPI record. A user ID and password is required to log on to the site. Physicians can call (800) 465-3203 if they have questions or problems accessing the system.

Doctors’ Opinions of Financial Bail Out Package The Allergists voted to scratch it, and the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve, and the Obstetricians felt they were all laboring under a misconception. The Ophthalmologists considered the idea shortsighted; the Pathologists yelled, 'Over my dead body!' while the Pediatricians said, 'Oh, Grow up!' The Psychiatrists thought the whole idea was madness, the Radiologists could see right through it, and the Surgeons decided to wash their hands of the whole thing. The Internists thought it was a bitter pill to swallow, and the Plastic Surgeons said, 'This puts a whole new face on the matter.' The Podiatrists thought it was a step forward, but the Urologists felt the scheme wouldn't hold water. The Anesthesiologists thought the whole idea was a gas, and the Cardiologists didn't have the heart to say no. In the end, the Proctologists left the decision up to some a–––––––s in Washington. – provided by an Anonymous email


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On Choosing Happiness. What’s Your Choice? by Jeffrey Gitomer


is a self-defeating word. It robs you of the present, and resigns you to wait without taking any action. You convince yourself that life will be better after something: After you get a new job, after you get a better job, after you get more money, after you get out of debt, after the economy rebounds, after your stocks go back up, after you get that big order. HAPPINESS IS You convince yourself that life NOW, NOT A will be better after an event: After GOAL OR A you get married, after you have a DESTINATION. baby, after you get a new house, after you take a vacation, after you come back from vacation, after summer is over, or some other action-procrastinating “after.” Are you frustrated that the kids aren’t old enough, and believe you’ll be more content after they’re in high school or out of high school? Are you frustrated that you have teenagers to deal with? You will certainly be happy after they’re out of that stage. Certainly you’ll be happier after they’re in college, or is it out of college? You tell yourself that your life will be more complete when your spouse gets his or her act together, when you get a nicer car, a new house, a raise in pay, a new boss, or worse, after you retire. The truth is, the fact is, the reality is, there’s no better time to be happy than right now. If not now, when? After the economy gets better? You may not be able to wait that long. Your life will always be filled with challenges, barriers, and disappointments. It’s best to admit this to yourself and decide to be happy anyway. Alfred Souza said, “For a long, long time it had seemed to me that I was about to begin real life. But there was always some obstacle in the way, something to be gotten through first, some unfinished business, time still to be served, a debt to be paid. Then life would begin. At last it dawned on me that these obstacles were my life.” There is no way to happiness. Happiness is the way. There is no after to happiness Happiness is now. Here’s the answer: It’s inside your head FIRST and everyplace else second. Happiness is a treasure. Your (missed) opportunity is to treasure every moment that you have.

Stop waiting until you finish school, until you go back to school, until you lose ten pounds, until you gain ten pounds, until you have kids, until after you quit smoking, until your kids leave the house, until you start work, until you retire, until you get married, until you get divorced, until Friday night, until Sunday morning, until you get your new car or home, until your car or home is paid off, until spring, until summer, until fall, until winter, until the first or the fifteenth, until your song comes on, until you’ve had a drink, until you’ve sobered up, until you win the lottery, or until the cows come home to decide that there is no better time than right now to be happy. And treasure the happiness of now more because you share it with someone special enough to invest your time in... Happiness is: Not a sale or a commission. Not an economy or a budget. Not a yes or a no. Not a game winning hit or a last second touchdown. Happiness is a way of life that is inside you at all times. It helps you get over the tough times, and helps you celebrate the special times. Seems pretty simple to define on paper, but real difficult to manifest when the chips are down. My experience has taught me the difference between resign and resolve. You can resign yourself to what is, and hope or wait for a better day. Or you can resolve that you are a positive person who finds the good, the positive, the happiness, the smile, and especially the opportunity in everything. Happiness is now, not a goal or a destination. It’s not an after, it’s a before. And it’s up to you. All you have to do is: decide. If you want a few more ideas about internal, personal happiness, go to, register if you a first time visitor, and enter the word HAPPY in the GitBit box. Jeffrey Gitomer is the author of The Sales Bible and The Little Red Book of Selling. President of Charlotte-based Buy Gitomer, he gives seminars, runs annual sales meetings, and conducts Internet training programs on selling and customer service at and He can be reached at 704-333-1112 or email to © 2008 All Rights Reserved – Don’t even think about reproducing this document without written permission from Jeffrey H. Gitomer and Buy Gitomer, Inc., 704-3331112.

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Fresno-Madera DAVID SLATER, MD

Post Office Box 28337 Fresno, CA 93729-8337 559-224-4224 Fax 559-224-0276 website:

President’s Message BACK TO THE FUTURE

I began my 2008 columns with a discussion of Medical Professionalism in the 21st Century. But FMMS Officers David Slater, MD, President Cynthia Bergmann, MD, President-elect Judy Davis, MD, Vice President Harcharn Chann, MD, Secretary/Treasurer Mohammed Arain, MD, Past President Board of Governors Herbert Boro, MD Lynda Gray, MD Sergio Ilic, MD David Hadden, MD Linda Hertzberg, MD Krista Kaups, MD Soo Y. Kim, MD Ranjit Rajpal, MD Oscar Sablan, MD Daniel Stobbe, MD Paul Yun, MD CMA Delegates: FMMS President John Bonner, MD Denise Greene, MD Clarke Harding, MD Abbas Mehdi, MD Salma Simjee, MD Robb Smith, MD Roydon Steinke, MD Toussaint Streat, MD Jeff Thomas, MD CMA Alternate Delegates: FMMS President-elect Adam Brandt, MD Pervaiz Chaudhry, MD Shahla Durrani, MD Steven Hager, DO Glenn Hananouchi, MD Robert Kezirian, MD Peter T. Nassar, MD Kanwal Jeet Singh, MD CMA YPS Delegate:

Kevin Luu, MD CMA Trustee District VI: Virgil Airola, MD Staff: Sandi Palumbo Executive Director


really, who are we kidding? It is wise to refresh and focus on present day exigencies, but key concepts of our professionalism have been known to physicians for a long time. Go back with me to 1847, to read from the AMA’s original Code of Ethics...

FROM THE INTRODUCTION: In framing a code… we have the inestimable advantage of deducing its rules from the conduct of the many eminent physicians who have adorned the profession by their learning and their piety. From the age of Hippocrates to the present time, the annals of every civilized people contain abundant evidences of the devotedness of medical men to the relief of their fellow-creatures from pain and disease, regardless of the privation and danger, and not seldom obloquy, encountered in return; a sense of ethical obligations rising superior, in their minds, to considerations of personal advancement. On physicians’ duty to society: As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community, and to bear their part in sustaining its institutions and burdens: they should also be ever ready to give counsel to the public in relation to matters especially appertaining to their profession… Physicians are peculiarly enjoined, by every consideration of honour and of conscientious regard for the health and lives of their fellow beings, not to advance any statement unsupported by positive facts, nor to hazard an opinion or hypothesis that is not the result of deliberate inquiry into all the data and bearings of which the subject is capable. On physicians’ conduct toward the patient and family: Every case committed to the charge of a physician should be treated with attention, steadiness and humanity. In their relations with the sick, physicians are bound, by every consideration of duty, to exercise the greatest kindness with the greatest circumspection; so that, whilst they make every allowance for impatience, irritation, and inconsistencies of manner and speech of the sufferers, and do their utmost to sooth and tranquilize, they shall, at the same time, elicit from them, and the persons in their confidence, a revelation of all the circumstances connected with the probable origin of the diseases which they are called upon to treat. On the concept that professionalism embodies both obligations and rights: Every duty or obligation implies, both in equity and for its successful discharge, a corresponding right. As it is the duty of a physician to advise, so has he a right to be attentively and respectfully listened to. Being required to expose his health and life for the benefit of the community, he has a just claim, in return, on all its members, collectively and individually, for aid to carry out his measures, and for all possible tenderness and regard to prevent needlessly harassing calls on his services and unnecessary exhaustion of his benevolent sympathies. Medical ethics cannot be so divided as that one part shall obtain the full and proper force of moral obligations on physicians universally, and, at the same time, the other be construed in such a way as to free society from all restrictions in its conduct to them… In vain will physicians appeal to the intelligence and elevated feelings of the members of other professions, and of the better part of society in general, unless they be true to themselves, by a close adherence to their duties, and by firmly yet mildly insisting on their rights; and this not with a glimmering perception and faint avowal, but, rather with a full understanding and firm conviction. The benefits accruing to the public directly and indirectly from the active and unwearied beneficence of the profession, are so numerous and important, that physicians are justly entitled to the utmost consideration and respect from the community. Please see President’s Message on page 19

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Fresno-Madera MEMBERSHIP NEWS New Members The following physicians are applicants for membership in the Fresno-Madera Medical Society. The Medical Society welcomes your comments, pro or con, if you have knowledge of these physicians.

Mimi Chao Mills, MD PS 9300 Valley Children’s Pl. Madera 93636 353-6277 Univ of Iowa ’02

Joseph M. Pascuzzo, DO *IM-*ON 1791 E. Fir Fresno, Ca 93720 326-1222 / FAX: 326-1230 Philadelphia Col of Osteo ’77

Jonathon D. Grossman, MD PM Sierra Pacific Orthopaedic Center 1630 E. Herndon Fresno 93720 256-5933 / FAX: 261-1906 St George Univ ’03

Nadeem U. Rahman, MD *U 6113 N. Fresno Fresno 93710 438-2777 / FAX: 438-4117 Duke Univ ’99

Jedidiah M. Monson, MD *RO 1791 E. Fir Ave. Fresno 93720 326-1222 / FAX: 326-1230 Stanford Univ ’91

Troy A. Scribner, MD *AI-*PD 6741 N. Willow #102 Fresno 93720 322-0787 / FAX: 227-7491 Wake Forest ’98

Committee Meetings

Membership Recap

All meetings are held at the FMMS offices unless otherwise noted.


DECEMBER 2 MRAC . . . . . . . . . . . . . . . . . . . 6pm 11 Membership . . . . . . . . . . . . . . . 6pm 15 Board of Governors . . . . . . . . . 6pm

Active ..................................................679 Leave of Absence.....................................2 Retired..................................................202 Residents ..............................................225 TOTAL ...........................................1,008 Applicants..............................................10

ARTHUR HOWARD, MD 62-year member

Arthur Howard, a retired general practitioner, passed away Oct. 27, at the age of 90. Dr. Howard was born in Fresno in 1919. He received his medical degree from St. Louis Univ. and completed his internship at Fresno County General Hospital. After serving for two years with the U.S. Army Medical Corps, Dr. Howard opened his private practice in Fresno in 1946 – retiring from active practice in 1976. From 1976 to 1996 he served as the Regional Medical Director for Equitable Life. Dr. Howard served as president of the Fresno-Madera Medical Society in 1963 and president of the Foundation for Medical Care from 1967-1974 as well as serving as a CMA Delegate, Chair of CMA’s Committee on Federal Medical Care Programs as well as being appointed by Gov. Reagan to the State’s Medi-Cal Advisory Health Review and Program Council. Dr. Howard is survived by his wife of 65 years.

FMMS Announces Holiday Closure In observance of the holiday season and New Years the Fresno-Madera Medical Society offices will be closed all day December 24-26, at noontime on December 31, 2008 and all day January 1-2, 2009. FMMS wishes its members and their families a happy and healthy holiday.

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Fresno-Madera FMMS Physicians Honored with Service Awards Doctor John Conrad Jr. was honored with the 2008 Lifetime Community Service award and Dr. Lee Snyder was honored posthumously for the 2008 Special Project Community Award at the Medical Society’s November general membership meeting. John Conrad, MD came to Fresno in 1951, as one of our early practicing pediatricians. During these early years, in addition to providing consultations and talks to outlying county hospitals, Dr. Conrad and a number of other pediatricians organized monthly clinical cardiology meetings at Valley Children’s Hospital. This group persuaded the Board at VCH to develop a program in heart catheterization and surgery – and as most of you know, the rest is history…. In 1962 Dr. Conrad was instrumental in organizing a county-wide project with over 3000 volunteers, to immunize residents against polio. Because there were three types of virus’ and each had its own vaccine, the project took place over three Sundays. Each person had to attend the correct clinic on three separate Sundays, where a sugar cube, coated with the vaccine was given. Approximately 70 percent of Fresno County’s population were immunized. The surplus funds that developed from the 25 cents donation for the vaccine were used to start the Medical Society’s Scholarship Foundation – which to this day – has provided medical school scholarships to over 180 students. Dr. Conrad has also served on that Board for several years. Since his retirement from active practice in 1995, Dr. Conrad continued with organizing monthly clinical meetings at Children’s Hospital, has served on the FMMS Well-Being and Historical committees and gives wellness presentations to senior citizens. Lee Snyder, MD has been honored posthumously for this award for his work with the Medical Society’s Air Quality program. It was through Dr. Snyder’s initial work and perseverance to seek out and convince a grantee – in this case the Hewlett Foundation – to fund and help further the development of this program to a higher level than what limited staff was able to do. To date, The Medical Society has received $300,000 in grants for this program. In addition, Dr. Snyder also appeared at hearings, meetings and other events when needed to lend a physician’s expertise in the health effects of poor air quality. He was active in these endeavors up until his death.

Accolades and Achievements

Prahalad Jajodia, MD

Joan Rubinstein, MD

Alex Sherriffs, MD

Prahalad Jajodia, MD: selected as the 2008 Champions of Justice Award by the Central California Legal Services. Joan Rubinstein, MD and Alex Sherriffs, MD: awardees of the 2008 Excellence in Teaching Award from the Haile T. Debas Academy of

Medical Educators at the UCSF School of Medicine. Congratulations Drs. Jajodia, Rubinstein and Sherriffs! If you know of any “accolades and achievements” by a Fresno-Madera Medical Society member, please call the Medical Society at 224-4224, ext. 18.


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“Afternoon Tea Reception” in conjunction with the traveling library exhibit:

Changing the Face of Medicine: Celebrating America’s Women Physicians Saturday, January 17, 2009 3-5pm UCSF Medical Education Center 155 N. Fresno St. You’re invited to celebrate the profession and women physicians who have overcome obstacles to succeed in every area of the profession while redefining women’s roles and society’s responsibilities. Browse through hundreds of photographs, search the physician database and watch a series of short films while socializing and partaking in an Afternoon Tea. This traveling exhibition, based upon a major exhibition displayed at the National Library of Medicine in 2003-2005, introduces some of these many extraordinary women. RSVP to: 559-224-4224, ext. 118 or to:

Fresno-Madera SAVE THE DATE:


An Evening With The Philharmonic

FMMS Honors Its 50-year Members THOMAS R. ELIASON, MD Internist/Cardiologist Dr. Eliason was born in Portland, Oregon in 1927. He received his medical degree from University of California Medical School in 1952 and completed his internship at San Francisco County Hospital, his Residency at Santa Clara County and Los Angeles County Harbor General hospitals and a Fellowship in Cardiology at Los Angeles County Harbor General Hospital. In 1957, Dr. Eliason – along with Dr. Roger Larson – developed the first cardiac catheterization lab at Valley Children’s Hosp. He was active in this program until his retirement from active practice on 1993. In 1999, Dr. Eliason received the Medical Society’s Physician Community Service Award for his volunteer service at the Holy Cross Clinic.


“Hollywood Movie Scores” Under the baton of Cleveland Pops Music Director and guest, Carl Topilow, The Fresno Philharmonic presents a concert of Hollywood film scores such as Star Wars, Chicago, Psycho, Spiderman, Pirates of the Caribbean, Harry Potter and Wizard of Oz. A delightful evening of sitting back and letting your mind replay memorable movies scenes.

Saturday, January 10, 2009 8pm Special pricing of tickets Front Orchestra/Loge, $46 Back Orchestra, $33 Tickets must be purchased by January 5, 2009 Exclusive Pre-concert Reception, 6pm FMMS members: no charge FMMS guests: $10 Reception sponsored by Premier Valley Bank Invitations to follow in December Further information: 559-224-4224, ext. 118

Radiology Dr. Harmston, born in Provo, Utah in 1921, received his medical degree from Univ. of Utah in 1945 and completed his internship at Milwaukee County Hosp in 1946. He followed up with Radiology service in the US Air Force, in San Antonio, Texas and postgraduate work in Radiology at Univ. of Utah. Dr. Harmston came to Fresno and opened his practice in 1957, retiring in 1978. He then began a new career in photography. Some of his photographs have graced the cover of the Medical Society’s directory for the last 10 years.

HOWARD KENNETT, MD General Practice Dr. Kennett was born in Pocatello, Idaho in 1920. He received his medical degree from College of Medical Evangelists in 1956 and completed his internship at Fresno General Hospital. (Residencies unknown) Dr. Kennett retired in 2000.

ALLAN MAU, MD Family Practice Dr. Mau was born in Honolulu, Hawaii on December 9, 1928. He received his medical degree from the University of Michigan in 1954 and completed his internship at Cook County Hospital in Chicago. Postgraduate education in OBGYN and family practice was through his military service in the Unites States Air Force Reserve. Dr. Mau retired from active practice in 1995.

THOMAS G. SAYEG, MD General Surgery Dr. Sayeg, born in Fresno in 1922, received his medical degree from UCSF in 1950 and completed his Internship and Residency at Fresno General Hospital. He served in the US Army from 1953-55. He opened his private practice in 1957 and retired in 1992.

JAMES L. SCHOOLEY, MD Pathology/OBGYN Dr. Schooley was born in Auburn, California in 1924. He received his medical degree at College of Medical Evangelists in 1948 and completed his internship, pathology residency and OB/GYN residency at White Memorial Hospital and the Fresno County Hospital. Dr. Schooley also served two years in the USAF. He retired in 2000.

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Fresno-Madera Historical Library, Museum and Small Conference Center Now Open for Members’ Use

Save the Date


a few finishing touches are still in progress, FMMS’ Historical Library, Museum and Conference Center – located in the FMMS’ offices at Cedar and Alluvial avenues – is now open for member use. The Historical Committee, with the support of its members and the FMMS Foundation, has been able to furnish the space and assemble both the book collection and electronic equipment. The electronics can be used for internet searches and projection of computer images for a small audience as well as word processing, printing, copying from texts, and scanning images.

THE LIBRARY The Library houses the collections donated by many FMMS members. All the volumes are dated before 1960. A keystone and star is the 98-volume Robert De Klotz Classics in Medicine Collection. This collection stretching from the Smith Papyrus, describing the 25 BCE work of Imhotmep, through Grey’s Anatomy and Sydenham’s text to modern times. Most if not all of the literature that documents the foundations of today’s medicine are represented. The extensive John Murray Historic Texts of Medicine Collection may be borrowed for 30 days by members only.

Don Knapp, MD, uses the new Conference Center for some Research and Study.

58th Annual Yosemite Postgraduate Institute April 3-5, 2009

THE CONFERENCE CENTER The Conference Center may be reserved for any members use. It will hold six comfortably for a brown bag style luncheon conference or up to eight for a presentation. The Electronic Center will project Power Point or other materials for easy reading. To reserve the room, call Judy at 559-224-4224 extension 110.

VOLUNTEERS AND FOUNDATION SUPPORT STILL NEEDED The Historical Committee is seeking a volunteer Librarian to keep the Historical Library updated. The time commitment would be not more than two, half days a month. The position includes cataloging and shelving donated books and comes with a lot of assistance and latitude. The Librarian needs to have knowledge and use of the computer to document and catalog incoming books. Financial support is also still needed to further this and other projects through the FMMS Foundation for the members’ benefit. Please consider a donation at anytime, but in particular now during dues time.


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Topics include: Cardiology Dermatology Geriatrics Endocrinology Stroke Migraines For brochure and reservations, call 224-4224, ext. 118


2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372

President’s Message During 2008 the Kern County Medical Society jointly sponsored, with Kern Medical Center, two presentations on Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorders. In January, we heard from Dr. Edward Riley, Distinguished Professor of Psychology at UCSD and a world renowned researcher on the detrimental effects that intrauterine alcohol exposure exerts on developing brains. Dr. Riley pointed out that the individuals manifesting the typical FAS phenotype represent only about five percent of the individuals whose brains have been adversely affected by exposure to alcohol. In addition, the FAS phenotype appears to result from significant exposure to maternally ingested alcohol during a specific time period (thought to be from day 21 until day 24 of fetal development), and does not necessarily correlate with the magnitude of the alcohol exposure. In other words, the brains of children with no stigmata of FAS may be as severely affected as the brains of children with the full FAS. Early exposure of the fetal brain to alcohol results in the death of developing brain cells and disrupts their normal pattern of proliferation and differentiation. It also results in forebrain abnormalities and alters the genetic expression of developing craniofacial tissue. Behavioral problems and difficulties with spatial learning may be linked to alterations in hippocampal GABA receptor expression and oxidation of hippocampal proteins induced by fetal exposure to alcohol. Dopamine levels in the locus ceruleus are altered by prenatal alcohol exposure, and this influences behavior through disruption of the reward cycle. Dr. Riley also talked about the opportunities which exist for both primary and secondary prevention. Fetal alcohol exposure has long been recognized as the single greatest cause of preventable intellectual disabilities. Additional detrimental impacts of intrauterine alcohol exposure include growth failure, adaptive functioning defects, behavioral problems, and difficulties with both impulse control and memory function. These impacts can be prevented by avoiding intrauterine alcohol exposure. Animal studies have suggested that the toxic effects on brain caused by fetal alcohol exposure can be eliminated or dramatically reduced by the administration of lecithin and certain other compounds shortly after the exposure occurs. Additional studies are underway to see if these findings apply to humans. In September, we heard from Theresa Kellerman, RN; who is Director of the FAS Community Resource Center in Tucson, Arizona. She was accompanied by her adopted son John, a 30-year-old Lakota Sioux who has FAS. Also joining them was John’s friend Richard, who is in his early 30s and has FASD. Theresa provided a comprehensive and highly referenced summary of the detrimental effects of prenatal exposure to alcohol. FAS and FASD individuals often have co-occurring disorders, such as ADHD, bipolar disorder, oppositional defiant disorder, reactive attachment disorder, autism spectrum disorder, Asperger’s, schizophrenia and anxiety disorder. As valuable as this information was, I found that the opportunity to observe John and Richard interact was an even greater help to developing pattern recognition abilities with respect to FAS and FASD. Both John and Richard displayed verbal abilities appropriate for an 18-year-old, but social skills and judgment were more appropriate for a six-year-old. John’s short stature and facial features provide a cue to others to lower their expectations concerning his behavior and social skills. Richard, on the other hand, provided no outward cue that his social development was at about the level of a six-year-old. The FASD individual without stigmata may therefore face even greater challenges than some children with FAS, because they are chronically frustrated by their inability to meet the unrealistic expectations of others.


KCMS Officers John L. Digges, MD President Brad Anderson, MD President-elect Mark Nystrom, MD Secretary Ronald L. Morton, MD Treasurer Wilbur Suesberry, MD Immediate Past President Board of Directors Portia Choi, MD Joel Cohen, MD Lawrence Cosner, Jr., MD Noel Del Mundo, MD Mathilda Klupsteen, MD Hemmal Kothary, MD Calvin Kubo, MD Anil Mehta, MD Philipp Melendez, MD Arun K. Softa, MD CMA Delegates: Jennifer Abraham, MD Lawrence Cosner, Jr., MD Ronald L. Morton, MD Arun K. Softa, MD CMA Alternate Delegates: Deepak Arora, MD Jeffrey Freesemann, MD Patrick Leung, MD Staff: Sandi Palumbo, Executive Director Mary Dee Cruse Adminstrative Assistant Kathy L. Hughes Membership Secretary

There is an organization called NINEZERO (nine months, zero alcohol), which has produced some effective outreach materials on the dangers of exposing developing infants to maternally ingested alcohol. They are planning educational activities for both physicians and the public next September, to coincide with the date 090909. I will endeavor to keep you posted concerning these activities in future issues of Vital Signs. V I TA L S I G N S / D E C E M B E R 2 0 0 8

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MEMBERSHIP NEWS New Members The following physicians’ names, etc. are being published in compliance with the KCMS Constitution & Bylaws. Board Certification will be listed only if the physician has been certified by a Specialty Board recognized by the American Board of Medical Specialists, as approved by the American Medical Association.

Afaq A. Kazi, MD (Physical Med. Rehab/Pain Management) Pain Institute of Central CA 6501 Truxtun Ave. #180, 93309-0633 661-665-7880 / FAX: 661-665-7881

Arturo E. Palencia, MD (Pain Management/Anesthesiology) Pain Institute of Central CA 6501 Truxtun Ave. #180, 93309-0633 661-665-7880 / FAX: 661-665-7881

Medical Degree: Liaquat Med. Clg., Pakistan 1992. Internship: Harbor UCLA 07/1999-06/2000 Residency: Barnes-Jewish Hosp., St. Louis, MO 07/2000-06/2003. Board Certified: Physical Med. Rehab 06/2007.

Medical Degree: UC San Diego 1992. Internship: San Bernardino County Hospital 07/1992-06/1993 Residency: LAC/USC Hospital 07/199306/1996

Membership Recap OCTOBER 2008 Active ...........................................................284 Resident Active Members................................0 Active/65+/1-20hr............................................6 Active/Hship/1/2 Hship ...................................0 Government Employed ..................................13 Multiple memberships ......................................2 Retired ............................................................59 Total..............................................................364 New members, pending dues............................4 New members, pending application.................0 Total Members .............................................368

SAVE THE DATE January 22, 2009 2-4pm CCS BILLING SEMINAR • Does your office need help filing claims for CCS Services? • Are claims being returned? • Are Service Code Groupings confusing about what services they cover?

RSVP: Janet Wheeler 635-2806

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KCMS Officers Sheldon R. Minkin, DO President John E. Weisenberger, MD President elect Theresa P. Poindexter, MD Secretary Treasurer Thomas S. Enloe, Jr. MD Past President

Board of Directors F.T. Buchanan, MD W.T. Chen, MD James E. Dean, MD Ying-Chien Lee, MD Daniel Urrutia, MD CMA Delegates: James E. Dean, MD Uriel Romel Limjoco, MD

California Children’s Services is conducting a training designed to help you.


PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581

CMA Alternate Delegates: Mario Deguchi, MD Sheldon R. Minkin, DO Staff: Marilyn Rush Executive Secretary

Never Events

President’s Message

Continued from page 9

Continued from page 12

Events can protect patients, reduce liability exposure, reduce reporting burdens and preserve reimbursement rates. NORCAL has provided risk management advice via the monthly Claims Rx and CME courses related to many of the 28 Never Events and CMS’s HACs. Providers are encouraged to review the following publications, available at Wrong patient, wrong site, wrong surgery, surgical site infections – The July 2008 Claims Rx entitled: “Risk Management and Patient Safety Strategies for Surgeons” Medication errors, contaminated devices – The June 2008 Claims Rx entitled: “Strategies for Making the Medication Delivery Process Safer” Hypoglycemia – The November 2006 NORCAL CME course entitled: “Diabetes: Managing Comorbidities” Hyperbilirubinemia / Kernicterus – The May 2008 Claims Rx entitled: “Focus on Newborn Patients: Strategies for Reducing the Incidence of Kernicterus as a Result of Hyperbilirubinemia and Vision Deficits as a Result of Retinopathy of Prematurity” Surgical Fires – The December 2007 Claims Rx entitled: “Reducing the Risk of Surgical Fires” Deep Vein Thrombosis/Pulmonary Embolism – The March 2008 Claims Rx entitled: “Deep Vein Thrombosis Prophylaxis” To learn more about new Medicare rules on reimbursement for hospital-acquired conditions (HACs), see “Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates,” in the Federal Register/Vol. 72, No. 162, August 22, 2007/Rules and Regulations. To learn more about proposed 2009 rule changes on HACs, see “CMS Proposes Additions to List of Hospital-Acquired Conditions for Fiscal Year 2009” at the CMS website at To learn more about California’s new rules on reporting adverse events, see the California Health and Safety Code, Sections 1279.1-1279.3 and 1280.4. As physicians interface with hospital staff and administrators, they will hear more about Never Events. As hospitals face the lack of reimbursement for patients who experience these events, physicians will be witnessing policy and procedure changes, discussions at medical quality and peer review committees, and other measures aimed at the prevention of these events. By understanding the history and the reimbursement factors associated with Never Events, physicians will be better prepared to be involved in these activities and offer support and input. Keeping a Never Event from happening from occurring is optimal. However, they continue to occur at a significant rate. Having appropriate policies and procedures in place to guard against the occurrence of Never Events can increase patient safety, reduce liability exposure, reduce reporting burdens and preserve reimbursement rates. When those policies and procedures do not work and a Never Event occurs, in addition to analyzing those policies and procedures to determine what has gone wrong, hospitals must follow adverse event reporting laws and be prepared for limitations in Medicare and private insurance reimbursement.

On imbalances between duties of physicians and what the profession believes are its rights: In deducing the rights of a physician from his duties, it is not meant to insist on such a correlative obligation, that the withholding of the right exonerates from the discharge of the duty. Short of the formal abandonment of the practice of his profession, no medical man can withold his services from the requisition either of an individual or of the community. On physicians’ conduct toward one another: In their intercourse with each other, physicians will best consult and secure their own self-respect and consideration from society in general, by a uniform courtesy and high-minded conduct towards their professional brethren. The confidence in his intellectual and moral worth, which each member of the profession is ambitious of obtaining for himself among his associates, ought to make him willing to place the same confidence in the worth of others. On matters of money: There is no profession, by the members of which, eleemosynary services (Ed. note: in case I am not the only unlearned one – “eleemosynary” means “charitable”) are more liberally dispensed, than the medical, but justice requires that some limits should be placed to the performance of such good offices. Poverty, professional brotherhood, and certain public duties… should always be recognized as presenting valid claims for gratuitous services; but neither institutions endowed by the public or by rich individuals…can be admitted to possess such privilege. If a state of probation be intended for moral discipline, there is, assuredly, much in the daily life of a physician to impart this salutary training, and to insure continuance in a course of selfdenial, and, at the same time, of zealous and methodical efforts for the relief of the suffering and unfortunate, irrespective of rank or fortune, or of fortuitous elevation of any kind. Physicians must be ever ready and prompt to administer professional aid to all applicants, without prior stipulation of personal advantages to themselves. On why FMMS has thrived for 125 years and remains relevant into the future: It is not enough… that the members of the medical profession be zealous, well informed and self-denying, unless the social principle be cultivated by their seeking frequent intercourse with each other, and cultivating, reciprocally, friendly habits of acting in common. By union alone can medical men hope to sustain the dignity and extend the usefulness of their profession. Among the chief means to bring about this desirable end, are frequent social meetings and regularly organized Societies… I thank the FMMS Board of Governors, our tremendously devoted and talented staff led by Executive Director Sandi Palumbo, our committees and their chairs, and all of you – who support our organization with your dues and time — for the honor of serving as President this year. Dr. Bergmann, Best to You and your Team in 2009! Best Regards, David V I TA L S I G N S / D E C E M B E R 2 0 0 8

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Tulare Mind, Body and at this Present Moment by Luis H. Velosa MD

Holidays have just arrived, they’re here with us, however because the economic crisis that fell upon 3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website:

TCMS Officers Timothy Spade, MD, President Mark Tetz, MD, Vice-President Ralph Kingsford, MD, Secretary/Treasurer Amber Chatwin, MD, Immediate Past President Board of Directors Steve Carstens, DO Debra Hanks, MD Karen Haught, MD Ahmad Shahroz, MD Leopoldo Valdivia, DO Amber Chatwin, MD, Ex-Officio CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Amber Chatwin, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Young Physician’s Section Delegate Amber Chatwin, MD Staff: Steve M. Beargeon, Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate

us, festivities will be different than before. We are already seeing signs of difficult times to come, shopping malls are not so crowded, front lawns are not so lavishly decorated and local merchants are voicing their pessimism because people are not buying Christmas presents as they did in the past. These trying times represents some changes in our day to day medical practice: our patients find their symptoms less tolerable, they are more pressured, more impatient, and more stressed. As a result emergency rooms are more congested than usual, our offices are scheduling more patients with acute and urgent symptoms, and we are answering more emergency calls from hospitals and patients. As physicians facing already the overwhelming task of practicing, we are facing one more factor that feeds our growing discontent. We are not happy with “how things are going in Medicine”. It is a well known fact that our professional lives are not easy; aside from the exercise in our own field in Medicine, which fulfills our innate desire of “making things better for our patients”, we are constantly struggling with difficult and unsolvable issues. Some of them are for instance the monumental task of “doing” paper work, the eventuality of a Medicare or Medi-Cal audit, the nightmare of malpractice litigation or the eroding image of our profession to the public. Christmas holidays are therefore not very well welcome by us, “it is just, more work.” Physician Burn Out is a very well documented phenomena described and studied quite well by our experts. I believe we are all facing a different situation. When we go to work, regardless of our specialties, there often are so many negative occurrences in our daily practice that we finish our very long and intense “working day” totally exhausted; having no emotional reserves at the end of the day to the point we do not have anything left to share and to enjoy with our loved ones. We are not “Burned Out” yet, even after such a terrible day, the following morning, regardless of the branch of Medicine we practice, we are willing to face our continuous challenges and struggles and we go back to work. I found two powerful and poignant definitions that describe precisely what can take place as we practice Medicine in today’s environment: “a gradual erosion of the soul” and the “silent anguish of the healers”. On one hand in our medical practice we feel our best when we act with compassion, with technical competence and with an overall presence of medical insight; on the other hand we are facing such an enormous workload we often lack control of our practice, to the extent the amount of work exceeds our capacity. This is a real dilemma. Health care organizations recognizes how difficult our situation is and they have adopted supportive policies such as making efforts to increase the recruitment and retention of medical staff, developing experiences to foster a sense of meaning of our work, establishment of mentor programs for new physicians, providing memberships at fitness clubs, involvement of the physician in the design and management of their practices, establishment of supportive Well Being Committees. It is commendable that external supportive systems are attempting to help us, but I like to propose that it is our individual responsibility to make any necessary efforts to protect ourselves and avoid a very well described emotional detachment in which we stop caring for our patients. But instead, to practice at our very best and finish the day feeling replenished and fulfilled so we can go home with enough physical and emotional energy to take care of ourselves and loved one. So, during the Holidays is a good opportunity to launch this column “Mind and Body in our Present Moment” Column I in which I will share mind and body “tools” with the hope that they can be used as your private armamentarium to protect yourself. I found these tools during these past forty years of practicing Medicine, tools that have been so personally useful and I became so enchanted with them that, after proper certifications, through these past ten years aside of been a physician I became a teacher in non-medical fields. Periodically I step out from my doctor role and “luis” (my teacher Continued on page 21


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Tulare Continued from page 20 name) shares mind and body tools or perhaps better described as “resourceful life lines”, to many students. I have had the wish to reach out to my fellow physician and offer another way to ease our stresses and pressures. This is the core and intention of writing this column. In every article I will describe a particular tool for your mind your body or both, it will contain a practical explanation and perhaps some words about the reasoning of each tool. My intention is to raise enough curiosity and interest that in the privacy of your home you will try them, twice a day, bid, morning and evening and invest a minimum of five to ten minutes each time. These particular tools are taking from the discipline of yoga, the art of meditation and the area of general fitness. As a disclaimer I must say that our society is forcing us to develop IT IS remedies or activities which will COMMENDABLE provide immediate results; this is THAT EXTERNAL not the case when we practice SUPPORTIVE these activities. I know however that if you use your determination, SYSTEMS ARE discipline and willpower and you ATTEMPTING TO give to yourself two or three HELP US, months with this plan, definitely BUT I LIKE TO positive changes will occur. PROPOSE THAT Let’s start with one of the IT IS OUR cardinal and essential tools I have encountered which actually INDIVIDUAL involves our mind and our body. In RESPONSIBILITY my opinion is the cornerstone for TO MAKE ANY the rest of the tools and once you NECESSARY mastered this simple yet powerful EFFORTS TO tool you will experience PROTECT formidable physiological and emotional gains. OURSELVES… Breathing which is an autonomic function remains basically unconscious, unless there is a particular somatic symptom. The purpose of this particular tool is to bring the breathing process to our full awareness for a short period of time. The benefits of this process consist in improving our pulmonary capacity and at the same time as we become more proficient it becomes excellent relaxing tool. As we begin, find a quiet, calm and private space free from any auditory or visual stimuli. You may sit comfortably, or you may stand having your feet slightly apart so the weight of your body will be equally balanced. Close your eyes. Breathe through your nose and count ten cycles of your breath making sure your breathing is smooth, not so rapid, perceiving the air coming in and going out. Take your time. Then take slowly a big breath, so big that you feel all your lungs are full with air and then hold your breath for three seconds. Through your nose release then all the air, very slowly, sensing all the air is out of your lungs; at the final stage of the exhalation use your abdominal muscles, contract them slowly to

release the rest of the air, and then hold your breath again for three seconds. Repeat the same process, and as you progress with your breathing cycles try to make your exhalation longer than your inhalation. As you are totally involved with your breathing begin to draw your attention and awareness to two separate elements. First begin to realize how different your breathing patterns are becoming and how each cycle of your breathing is providing you a different sensation and second draw your attention and awareness, very slowly, to your shoulders, rib cage, abdomen and noticed how these areas behave, as you continue bringing into consciousness your breathing process. An important question will be the length of time devoted to this particular exercise. I would like to advise the use of a timer and at first to start with two minutes. Make sure to practice the breathing process very slowly. Do not rush. As you begin to be more in touch with this process increase your time to five minutes. Practicing this tool in a regular basis and been able to incorporate it among your every day routine allow you to be truly in touch with the present moment. This powerful concept taken from Eastern philosophy manifests itself in practices such as this very first tool. As you diligently follow your breathing and your mind is totally devoted to the observations of the several sensations you are experiencing, almost naturally you are focusing on “this present moment”. Basically your mind is not preoccupied of issues that happened in the past and it’s not busy thinking of things that will happen in the future. This tool is the preamble to meditation exercises which I will be illustrating as this column evolves. Finally I hope this column has arrived at the right time and you are curious and willing to practice these tools on a regular basis. Like everything worthy and precious, it takes hard and persistent work. I wish you a Merry Christmas and a wonderfully well balanced 2009.

Luis H. Velosa M.D. is a Board Certified psychiatrist in Adult Psychiatry and Child Psychiatry. He was trained at Wayne State University in Detroit Michigan and University of Michigan in Ann Arbor Michigan. He has been in private practice in Visalia since 1980. He arrived to Visalia in 1976 with the Community Mental Health Center movement and was the Medical Director of the Children Services of Tulare County Mental Health Center. In 1995 he obtained an MBA degree and was a Medical Director of two private psychiatric hospitals. Dr Velosa has also practicing Forensic Psychiatry and has been an expert witness in four County Superior Courts (Tulare County, Kings County, Fresno County and Kern County.)Dr Velosa is a Chairman of the Well Being Committee of the Tulare Medical Society and in 1999 he served as a Chairman at the Reference Committee during the House of Delegates of the California Medical Association. Luis is a yoga teacher, a spinning teacher, a Zumba teacher and is an avid bicycle racer.

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CME Activities

MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words. NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Please contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.





Exceptional opportunity for qualified FP or ER dept. services. Stable group with excellent reputation seeks Board Certified or Eligible provider for FT position. Previous ER experience or training helpful but not required. Physicians are independent contractors with excellent compensation. Contact Terry Hilliand, 661-323-5918 or fax CV to Emergency Medical Services Group at 661-323-4703 email:

University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 320-0580. Fresno City College’s library is in need of medical journals: Journal of the AMA, New England Journal of Medicine, Consult, American Family Physician, The Cleveland Journal, The Mayo Clinic Journal, The Cortlundt Forum, Women’s Primary Health, Emergency Medicine, American Journal of Orthopedics, Nurse Weekly. For pick up, call Carolyn at 439-7123. Orthopedic Surgeons Ed Lembert, MD and Michael Oberto, MD announce their move to a new location mid-January 2009; 7235 N. First Street Suite 103, Fresno, 93720. Same telephone numbers.


Gar McIndoe: (661) 631-3808 David Williams: (661) 631-3816 Jason Alexander: (661) 631-3818

MEDICAL OFFICES FOR LEASE 820 34th St.– 2,398 rsf. 820 34th St. – 5,367 rsf. 2920 F Street – 2,052 rsf. 6000 Physicians Blvd. – 2,318 rsf. 3535 San Dimas St. – 1,290 rsf. 3535 San Dimas St. – 1,580 rsf. 4040 San Dimas St. – 2,035 rsf. 9900 Stockdale Hwy. – 2,457 rsf. 9900 Stockdale Hwy. – 1,500-3,000 rsf. SUB-LEASE 9500 Stockdale Hwy. – 3,000 rsf. 4100 Truxtun Ave. – 11,424 rsf. Medical Admin and Chart Storage FOR LEASE – ARVIN New 1,400 rsf. – 3 Exam Room Suite Adjacent to Bear Mtn. Pharmacy FOR SALE 9900 Stockdale Hwy. – 2,000-8,000 rsf. SOUTHWEST LOT TO BUILD Bahamas Dr. – 10,000 sf office


D E C E M B E R 2 0 0 8 / V I TA L S I G N S

Medical office space at 6234 N. First St. near SAMC. 3,900 sf. Call Laurie at 559-446-1000. 1,550 sf office space at 7565 N. Cedar. For more information, call 559-473-6789. Office space for sale or lease at Cedar & Alluvial, 2,280-4,506 sf. 6 parking spaces per 1000/sf. Ample allowances. Call 559-259-3077 or 559-355-8416. Medical space, Tower District; 1,500 sf. 4 exam rooms, 2 restrooms, lg. open area, break room, lab, reception area. $895/month. 559-288-6866. 3 bdrm/3 bath villa; Dec. 12-19 in St. John Westin USVI. New, fully furnished, ocean views, pool, jacuzzi in hotel. $700. Call Sue at 559-977-9000.

FOR SALE Medical office space at 6234 N. First St. near SAMC. 3,900 sf. Call Laurie at 559-446-1000. Office space (shell) for sale or lease at Cedar & Alluvial, 2,280-4,506 sf. 6 parking spaces per 1,000 sf. Ample allowances. Call 559-259-3077 or 559355-8416. Orthopedic Office Moving: Selling waiting room and office furniture, chart racks, tables, stools and assorted equipment. Call 559-432-2600 x 324. Medical space; 4,000 sf Fresno Bullard Park; Fresno/Escalon. 8 exam rms, 3 physician private offices. New paint & carpet. $1.45 sf. 559-288-6866.

PHYSICIAN WANTED Multi-specialty positions available for per diem, 2nd opinions & evaluations on industrially-related injuries. Flexible hrs & simple paperwork. Call 559222-9200 or email

UCSF Wednesday Lecture Series – Sept. 2008-May 2009 (every Wednesday of each month) Location: UCSF Education Center, Fresno; (Video-conferenced to Selma District Hosp & Veteran’s Hosp.) 12:00 pm; Credit: 1 hour. Fee: N/C. Call Suzanne at 559-499-6532. Advances in Orthopedics Clinical Practice – December 3, 2008 Location: Visalia: Kaweah Delta Health Care District, 6-8pm; Credit: 2 hours; Fee: N/C. Call 559-624-2595. Winter CME Symposium 2009 – Jan. 21-25, 2009 Location: Whistler, MC, Canada; Credit: 12 hours; Tuition: N/C. Call: 459-1777 or lsmith@communitymedical. org. Sixth End of Life Symposium – January 24, 2009 Location: Bakersfield, Doubletree Hotel, 8am-2:30 pm; Credit: 4.5 hours: Fee: $50. Call 661-632-5238.

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(559)437.4171 255 West Bullard Avenue, Fresno, CA 93704

V I TA L S I G N S / D E C E M B E R 2 0 0 8

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What’s the Big Deal with NORCAL’s CME? Last year NORCAL processed 15,264 Continuing Medical Education registrations — more than the number of our policyholders! Why? Because NORCAL policyholders use our unparalleled CME program over and over again. Visit today, or call 800.652.1051. NORCAL. Your commitment deserves nothing less. NORCAL is proud to be endorsed by the Fresno-Madera, Kern, Kings and Tulare County Medical Societies as the preferred professional liability insurer for their members.

You practice with passion. Our passion protects your practice. VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337 HAVE YOU MOVED? Please notify your medical society of your new address and phone number.

PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

2008 December  
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