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Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

o 31 No. 4 April 2009 • Vol.

Vital Signs


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Vital Signs Official Publication of

Contents EDITORIAL ..................................................................................................................................5

Fresno-Madera Medical Society Kings County Medical Society

CMA NEWS.................................................................................................................................7

Kern County Medical Society Tulare County Medical Society April 2009 Vol. 31 – Number 4 Editor, David Slater, MD Managing Editor, Carol Rau Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD David N. Hadden, MD Steven J. Hager, DO Prahalad Jajodia, MD Abbas Mehdi, MD Abdirahman A. Nimeri, 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 BALLOT INITIATIVES: 2009 Ballot Propositions Related to Health Care ........................................9 PRACTICE MANAGEMENT: The Federal Economic Stimulus Plan Health IT Provisions ..................11 AIR QUALITY: ........................................................................................................................12 CLASSIFIEDS ............................................................................................................................22 CME ACTIVITIES .......................................................................................................................22 FRESNO-MADERA MEDICAL SOCIETY .........................................................................................13 • President’s Message • Red Flag ID Theft Regulations • Volunteer Services • Membership News KERN COUNTY MEDICAL SOCIETY .............................................................................................17 • President’s Message • Membership News TULARE COUNTY MEDICAL SOCIETY ..........................................................................................19 • When a disaster strikes, you can make the difference • Cochlear Implants: What are they and whom do they help? • Mind, Body and at This Present Moment • Membership News

Cover photo: Bearded Iris by Michael DeLollis, MD Advertising Contact: Display: Annette Paxton, 559-454-9331 apaxton@cvip.net Classified: Carol Rau, 559-224-4224, ext. 118 csrau@fmms.org

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

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 / A P R I L 2 0 0 9

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EDITORIAL

In These Tumultuous Times by David Slater, MD, Editor, Vital Signs

No matter whether as a busy physician, as a family’s provider, as one hoping for a secure retirement, as one who supports a non-profit organization; as someone with family and friends in far-off places; or just as a citizen of a town or city, of California, of the United States, or as a tiny part of the international fabric – these are tumultuous and anxiety-laden times for all of us. In such times, one appreciates the value of being part of a community, including your community of organized medicine. Even in the best of times, communities built on shared values (our professionalism) and pooled resources (our dues, our time and energy, our intellect) have much to recommend them: “We don’t accomplish anything in this world alone… and whatever happens is the result of the whole tapestry of one’s life and all the weavings of individual threads from one to another that creates something.” – Sandra Day O’Connor. In times like these, participation in the community of organized medicine is especially important. I do not say this from a narrow minded, self-protective perspective. The missions of CMA and its component societies such as those represented in Vital Signs, are focused upon the public’s health and advancement of our profession and the care we give: The mission of the Fresno-Madera Medical Society is to promote the art and science of medicine, the care and well-being of patients, the enhancement of the public’s health, and the general welfare of the medical profession; to cooperate with organizations of like purpose; and to unite with similar societies in California as component societies of the California Medical Association We cannot allow ourselves to gravitate toward self-centeredness – that’s the path to impaired professionalism and loss of the joy and sense of privilege that ought to be with us always. At the same time, any physician familiar with public discourse knows that some are too quick to level that accusation against us and our organizations. We should not hesitate to say so. In the coming months there will be critical – and contentious – debate at all levels in our state and country. The public’s passion and the political resolve to put into play some fundamental aspects of America’s health care structure are high. Anyone who has seen Medicare’s future cost projections and takes ED call knows that more tinkering at the margins isn’t where real leadership lies. Beyond the mega-topic of US health care policy are the proliferating public policies and laws – and those corporate medicine things – that impact us and our patients every day. It has been observed that the need for reform of US health care is well exemplified by the chaotic, intrusive and cross-purposed smaller things we must deal with. In today’s environment, some of these will assume more importance than they otherwise would have, and some will be subject to influences they otherwise would not have been. Find a sample of these in the CMA News Legislative Agenda section that follows (and find much more at www.cmanet.org). You are represented at these many tables by organized medicine. Your support makes such representation both possible and powerful. But this is not a spectator sport. Each of us in the community of physicians has experiencebased wisdom and perspectives – most of us have decades of both. We underestimate the potential influence of our wisdom and counsel. Our patients and society at all levels need (and yes, want) physicians’ best ideas and guidance. Some of this will come from those who represent us at tables with limited chairs and podium time, but grassroots involvement is crucial. You local medical society intends to invite your participation, but please don’t wait to be invited. If your self confidence needs some bolstering, remember what Einstein said (keeping in mind that if you have to invoke this too often, it may not apply to that particular idea…):

“Great ideas often receive violent opposition from mediocre minds.”

V I TA L S I G N S / A P R I L 2 0 0 9

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CMA NEWS CMA OPPOSES EXPANSION OF CHIROPRACTIC SCOPE OF PRACTICE

CMA

has submitted objections to proposed regulations that would allow chiropractors to perform manipulation under anesthesia (MUA). MUA involves chiropractic manipulation of the spine of an individual that has first been sedated. CMA believes that MUA raises important patient safety concerns, and the regulations, as proposed by the Board of Chiropractic Examiners, would allow chiropractors to perform a procedure that is not authorized under current law. Beyond the legal concerns abut scope of practice, spinal MUA is considered experimental by all major health plans, and the safety, efficacy and long-term effector of the treatment has not been adequately studied.

RULE AGAINST DRUG MAKER IN LIABILITY CASE BENEFITS PHYSICIANS

The

US Supreme Court upheld a $6.7 million ruling against Wyeth for failure to provide adequate warning about the dangers of its anti-nausea drug, Phenergan. This was an important case for doctors. Had the Court ruled for Wyeth, pharmaceutical companies would have been protected from many state-based failure-to-warn claims, potentially increasing the risk that doctors would get sued for harm caused by pharmaceutical products. CMA had filed a brief in this case, telling the justices that preemption of pharmaceutical failure-to-warn claims would obstruct physicians’ access to complete and truthful information about prescription drug safety and efficacy and would compromise patient safety. Wyeth is appealing the Vermont Supreme Court’s decision. The issue on appeal focused on whether FDA approval of a drug should preempt state legal actions against the pharmaceutical company for failure to warn of known risks.

PRESIDENT PROMISES SGR FIX

Part of President Obama’s 2010 budget proposal directs $634 billion to a “health care reserve fund” over the next decade to finance expanded health insurance coverage and other health care investments. Of particular importance to physicians, the budget proposal includes $330 billion to “…effectively eliminate the enormous deficit and scheduled Medicare physician payment cuts of 40 percent over the next seven years.” The proposed budget also signals the Administration’s willingness to consider further modifications to the Medicare sustainable growth rate (SGR) formula. Approximately half of the health care reserve fund would be generated by increasing taxes on couples earning more than $250,000 a year and individuals earning more than $200,000. Other funding would come from Medicaid and Medicare cuts, including cutting the Medicare Advantage funding by an expected $177 billion over 10 years by establishing a “competitive bidding” process for health plans that want to participate in the Medicare Advantage program. Hospitals, home health care and pharmaceutical companies are also slated for multi-billion dollar cuts. Unfortunately, the proposal would ban future physician-owned hospitals. CMA continues to ensure the voices of physicians and patients are heard and considered as new health care policies are

developed. CMA physician leaders have made trips to Washington DC to meet with key Congressional representatives who will be writing the Medicare and Health Reform legislation.

NEW AT CMA ON-CALL: NEW LAW FOR RADIOLOGIC SERVICES

CMA On-Call has been updated to discuss a new California law that restricts physicians from billing patients or insurers for the technical component of diagnostic imaging services (CT, PET, or MRI) that were not rendered by the physician or someone under his or her supervision. This means that radiologic facilities or imaging centers must now directly bill the patient or the responsible third-party payor. CMA also reminds physicians that it is a violation of law to allow physician assistants or other staff to perform x-rays without proper certification. On-Call is CMA’s library of medical-legal information. OnCall documents are free to CMA members at www.cmanet.org/ member.

E N B P I H S R E B M d n a S E N I L T O H A M C 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

2009 LEGISLATIVE AGENDA: CMA SPONSORED BILLS

The California Medical Association has announced the state legislative bills it will sponsor in 2009 on behalf of its member physicians and their patients. These bills promote the interests of doctors and their patients on a wide range of issues: access to health care, patient safety, health insurance, public health, health care resources and more. There are numerous other bills on health care issues that will impact physicians and their patients, some of which CMA expects to support, and some of which CMA expects to oppose. These issues include changes to the peer review process, expanded scope of practice for allied health professionals, eroding the bar against corporations practicing medicine, clinic licensing, and improving the MediCal Treatment Authorization Request (TAR) process. CMA' federal agenda will be distributed soon. Where's the value in your CMA membership? You will find it in this legislative agendas and the federal one to follow! • AB 2 (De La Torre) – Unlawful Rescission: Independent Review AB 2 provides protection to patients by requiring a health care service plan or health insurer to obtain final approval from an independent review organization prior to rescinding a health plan contract or insurance policy. This review would use a clear legal framework to determine whether the rescission is appropriate while protecting the enrollee’s rights during the review process. The bill would also improve the process at the front-end by requiring plans and insurers to complete medical underwriting prior to issuing a policy and to make applications easier to fill out accurately and completely. This is a reintroduction of AB 1945, which was vetoed in 2008. Please see CMA Legislative Agenda on page 8 V I TA L S I G N S / A P R I L 2 0 0 9

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d Vital Signs is now accepting advertising from its physician members Use Vital Signs to advertise your practice at special rates offered to member physicians. contact: Annette Paxton Vital Signs Advertising Representative (559) 454-9331

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• AB 497 (Block) – High Occupancy Vehicle (HOV) Lanes Access for Physicians This bill would allow physicians to use the high occupancy vehicle (carpool) lanes on the freeway when responding to an emergency. This bill would expand current law which allows physicians, with the appropriate decal on their car, to exceed speed limits in rural areas when responding to an emergency. • AB 526 (Fuentes) – Public Protection and Physician Health Program Act of 2009 This bill will create the Public Protection and Physician Health Program. This is a reintroduction of AB 214 (Fuentes), which was vetoed last year with a request from the Governor that we work more closely with his Administration on a plan to replace the Medical Board’s diversion program. As discussions continue with the Administration, AB 526 is currently in “spot” form to allow for negotiated language to be inserted at a later date. • AB 583 (Hayashi) – Health Care Practitioners: Disclosure of Education CMA is co-sponsoring this bill with the California Society of Plastic Surgeons. It is becoming increasingly difficult for the public to identify the license, education, and training of health care professionals who practice in the state and many are unable to distinguish between physicians and non-physicians. To protect the public’s health and safety, this “truth in advertising” legislation will require a health care professional to disclose information in various health care settings to help patients understand who will be helping them with their health care, such as information about their license, education, and recognized board certification • AB 1201 (M. Perez) – Adequate Reimbursement for Vaccines CMA is co-sponsoring this bill with the American Academy of Pediatrics and the California Academy of Family Physicians. The bill requires plans/insurers to adequately reimburse for both the acquisition and administrative costs of giving shots, such as purchasing the vaccine, storage, inventory, staff time, supplies, etc. This bill also prohibits plans from applying co-pays, deductibles and other cost-sharing mechanisms to immunizations. CMA has heard repeatedly from pediatricians and family physicians that reimbursement is barely enough to cover the cost of the vaccine and does not adequately compensate them for administrative overhead. In the past, they have absorbed the loss – but the introduction of new and expensive vaccines has pushed them to the brink on this issue. • SB 606 (Ducheny) – Steven M. Thompson Loan Repayment Program: Osteopathic Physicians CMA will co-sponsor this bill with the Osteopathic Physicians and Surgeons of California to allow Osteopathic Physicians (DOs) to access the Steve Thompson Loan Repayment Program (STLRTP). The STLRP is currently available to MDs, but not to DOs, who tend to focus on primary care and would be good candidates for the program. This legislation would make DOs eligible for the STLRP and require them to pay an additional $25 fee toward the program, as MDs are now required to do. • Improve Peer Review (to be amended into an existing bill at a later date) This legislation is intended to be CMA’s response to the Lumetra report, to improve peer review and lead to appropriate transparency in sharing information among medical staffs and the Medical Board. Based on policy approved by the CMA HOD and BOT, this bill would add fairness and clarity to the peer review process.


B A L L O T I N I T I AT I V E S

2009 Ballot Propositions Related to Health Care BACKGROUND

As part of the budget deal passed last month, the Legislature and the Governor agreed to place six measures before the voters in a special election to be held on May 19th. These measures relate to a wide array of issues regarding the State Budget. Only three, however, have direct implications for health care. A brief summary of those three is below.

PROPOSITION 1A – STATE SPENDING CAP Current Law: In 2004, the voters passed Proposition 58, which created the Budget Stabilization Account (BSA). Each year, 3 percent of State General Fund revenues are transferred into the BSA, until the account reaches the higher of $8 billion or 5 percent of revenues (currently about $5 billion). The State also has another “rainy day fund,” known as the State Fund for Economic Uncertainties (SFEU). This fund includes any unexpected monies the State receives, such as unanticipated tax windfalls. Proposal: Under Proposition 1A the State would, every year, determine the amount of tax revenue expected by looking back at the previous ten years and adjusting for inflation and population growth. Any money that came in over that expected amount would be spent on the following (in descending order): • Funding for K-14 Education under Proposition 98. • Transfers to the Budget Stabilization Account (renamed the Budget Stabilization Fund). • Paying off borrowing and debt. Only after all of the above are done could additional monies be spent on one-time tax relief or infrastructure spending. The target amount for the Budget Stabilization Fund would be increased to 12.5 percent of revenue, or about $12 billion. The Governor would also be given new power to unilaterally reduce state spending on general government operations (such as equipment purchases) and to suspend COLA’s in some programs. Health Impacts: Health Care spending, including Medi-Cal and Healthy Families, is the largest “unprotected” section of the State Budget. That is, unlike education (Prop. 98), Transportation (Prop. 42) and Local Government (Prop. 1A of 2004), the voters have never specifically voted to protect health care funding. Therefore, when there are Budget deficits, it is usually the first place the Legislature looks to cut. This proposal could have the effect of even further squeezing Medi-Cal and Healthy Families, as in lean times the Legislature has been forced to make cuts to get under the spending cap.

PROPOSITION 1D – REDIRECTION OF PROP. 10 FUNDS Current Law: In 1998, the voters approved Proposition 10, which imposed a $.50 per pack excise tax on cigarettes to pay for health and wellness programs for children up to age 5. The funds can also be spent for advertising on health and wellness issues, including tobacco awareness. The money is split between the State First 5 Commission and First 5 Commissions in each of the counties. As of June 30, 2008, the State First 5 Commission had almost $400 million in unspent reserves, and the county commissions had total reserves of over $2 billion.

Proposal: Under Proposition 1D, $340 million held in reserve by the State First 5 Commission would be redirected to the State General Fund before July 1, 2009. For the next five years, the proposition would annually divert up to $54 million from the State Commission and up to $214 million from the county commissions to the General Fund. All of the funds diverted from First 5 would be used to support health and human services for children from birth up to age 5. The services the State could pay for with these funds would include: early prevention and screening for children with disabilities, foster care, adoption services, and direct health care services. The last term is undefined but could be read to include Healthy Families and Medi-Cal. The Proposition would also delete the ability of First 5 to pay for media awareness campaigns. Health Impacts: To the extent that physicians and county medical associations work with and support their local First 5 Commissions, this could have deleterious effects on those programs. The First 5 Commissions have argued that their surpluses, while large, are being held in reserve for future expansions of their programs. That being said, the provisions of the measure that allow for Prop. 10 funds to be spent on other state health programs could have beneficial effects on those programs. Late last year, the Healthy Families Program faced a shortfall, and was set to begin disenrolling kids from the program. Only a last-minute allotment of $17 million from the First 5 Commissions stopped that from happening. This Proposition is a larger version of that one-time event.

PROPOSITION 1E – REDIRECTION OF PROPOSITION 63 FUNDS Current Law: In 2004, the voters approved Proposition 63, which levied a personal income tax surcharge of 1 percent on the portion of a taxpayer’s income over $1 million. The funds, which have ranged from $900 million to almost $1.5 billion, are used to pay for mental health programs. The funds can be used to support community services, mental health workforce training programs, and prevention and early intervention. Proposal: Under Proposition 1E, roughly $230 million would be redirected from the Prop. 63 account into the General Fund for the next two years. The funds would be used the support the mental health portion of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, part of the state Medi-Cal program. Health Impacts: This measure is similar to the previous one, in that it has good and bad effects for health care in California. The EPSDT program is a Federal mandate that costs the State almost $500 million (General Fund) annually. Shifting Prop. 63 funds will ease some cost pressure on the Medi-Cal program, which could relieve pressure to cut in other places. On the other hand, Prop. 63 funds are used to pay for a range of services for an otherwise difficult to treat population, the mentally ill. The loss of funding in the program could make it more difficult for the mentally ill to find treatment, leading to increased costs for incarceration, medical care, homelessness, and other programs. V I TA L S I G N S / A P R I L 2 0 0 9

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PRACTICE MANAGEMENT

The Federal Economic Stimulus Plan Health IT Provisions BACKGROUND

On February 17, President Obama signed HR 1, the American Recovery and Reinvestment Act of 2009, publicly known as the “Economic Stimulus Bill.” Included in the bill is $20 billion for the promotion of electronic health records (EHRs), the bulk of which will be in the form of provider incentives. Under the provisions of the bill, Medicare providers will be eligible for bonus payments of up to $44,000 (plus additional amounts for physicians operating in designated health profession shortage areas), paid out from 2011-2015 for meaningful use of an EHR system. Medicaid providers who are not Medicare providers will be eligible to receive up to $65,000 paid through the State Medicaid (Medi-Cal) program.

FREQUENTLY ASKED QUESTIONS: Who is eligible for direct bonus payments? Medicare providers who are not hospital-based will receive bonus payments directly from the Federal Government. Hospitals and ASC’s also qualify for bonus payments, which will be paid separately. It is important to note that, in order to qualify, a physician will be required to demonstrate “meaningful usage” (to be defined by a standards committee) of an EHR system and that he or she is participating in a Health Information Exchange (such as a Regional Health Information Organization). Who is eligible for payments through Medi-Cal? • Medi-Cal providers (who are not Medicare providers) will qualify if they fall into one of these categories: • Non-hospital-based physicians for whom at least 30% of their practice (by patient volume) is Medicaid. • Non-hospital-based pediatricians for whom at least 20% of their practice is Medicaid. • Physicians practicing in Federally-qualified Health Centers (FQHC’s) or Rural Health Centers (RHC’s), for whom at least 30% of their practice is “needy individuals” (Medicaid, SCHIP, sliding-scale, or uncompensated care patients). The methodology for how these payments will be made is left to the States to determine. CMA will distribute more information on that program as it becomes available. How much are the bonus payments? For Medicare providers, the bonus payments will be paid starting in 2011, or the first year that the physician demonstrates EHR usage. Generally, the bonus payments will be $44,000, paid out as follows: • $18,000 for the first payment year; • $12,000 for the second payment year; • $8,000 for the third payment year; • $4,000 for the fourth payment year; and • $2,000 for the fifth payment year.

Physicians who adopt EHR systems after December 31, 2012, will receive lower payments. On the other hand, physicians who operate in a Federally-designated Health Professional Shortage Area (HPSA) will receive an additional 10% payment each year. Regardless of what year a physician first receives payments, the last year to receive payment is 2015. For Medicaid providers who are not also Medicare providers, the bonus payments can be up to $65,000, paid as $25,000 the first year and up to $10,000 for each of the next four years. Medicaid-only providers can receive bonus payments starting with the first year that they purchase and implement the system. Again, these payments will be directed through the state, and will come from the state’s Medi-Cal program. Do I still qualify if I have already purchased and/or am already using an EHR system? Yes. The bonus payments are based on usage, not on purchasing the system. What is a “qualified” EHR system? As defined in the bill, a qualified EHR system is one that: “includes patient demographic and clinical health information, such as medical history and problem lists; and has the capacity to (i) to provide clinical decision support; (ii) support physician order entry; (iii) capture and query information relevant to health care quality; and (iv) exchange electronic health information with, and integrate such information from other sources.” In addition, the Office of the National Coordinator for Health IT (ONCHIT) will be convening a standards committee to develop more comprehensive standards for functionality and interoperability. How will I report that I am using an EHR system? A physician may report meaningful EHR use by an attestation, submitting claims with proper coding, a survey response, or other means to be specified by the Secretary of Health and Human Services. Reporting standards will also be fleshed out by ONCHIT. Will this affect the Medicare e-prescribing bonus program? Yes. Physicians who use an EHR system that is capable of eprescribing will no longer be eligible for the e-prescribing bonus program once he or she begins receiving the EHR bonus to prevent “double-dipping.” Is there a penalty for physicians who don’t adopt EHR? Yes. Starting in 2015, physicians who are not using an EHR system will face a 1% cut in Medicare payments. That cut will grow to 2% in 2016 and 3% in each year thereafter.

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AIR QUALITY

Valley’s Own Dr. John Telles Received Re-confirmation for Two Air-Pollution Boards by Michelle Garcia, Fresno-Madera Medical Society Air Quality Director

On Wednesday, February 25, 2009 Fresno cardiologist John Telles received overwhelming support during his state confirmation hearing resulting in an unanimous reappointment to two air-pollution boards (California Air Resource Board and the San Joaquin Valley Air Pollution Control District). It is expected that he will also be confirmed by the full Senate later this year. Dr. Telles brings broad practical knowledge of both the health impacts of air pollution and the importance of the agricultural economy to air pollution control decisions at the state and local levels. Dr. Telles has proven to be a fair, reliable and a favorite. It was evident during his confirmation hearing when a room full of organizations testified including: the FresnoMadera Medical Society, the Environmental Defense Foundation, the American Lung Association, Central Valley Air Quality Coalition, Coalition for Clean Air and many more. The room overflowed with supporters, all of which came to show their support without being asked by Dr. Telles.

John Telles, MD

“We are very supportive of Dr. Telles’ appointment to CARB and the San Joaquin Valley Air District. What he brings to the air quality dialogue is a willingness to listen to both sides on a rule and ask important questions. He also brings industry and environment stakeholders together to understand each other better and hammer out possible solutions. We thank him for his diligent work to clean our air,” testified Laura Fultz Stout of the Coalition for Clean Air. The Valley air board oversees local air-pollution rules, and the state board oversees air-pollution regulations and greenhouse-gas emissions. By serving on both boards, Dr. Telles is in a strong position to make strides toward improving air quality, and protecting public health. Dr. Telles fills one of four Valley board positions created by legislation in 2007 to increase the board’s size to 15 members from 11. The expansion adds two city appointees and two health experts to the board. The other health slot was appointed to Henry Forman, a professor of chemistry and biochemistry at the University of California at Merced. As a mother, clean air advocate, and community member, I am delighted to have Dr. Telles as my representative. For more information contact Michelle Garcia at 559-224-4224 ext 119 or airquality@fmms.org.

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Fresno-Madera CYNTHIA BERGMANN, MD

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

President’s Message

website: www.fmms.org

THE ANT AND THE GRASSHOPPER

I took a fair amount of Latin during my schooling – eight years to be exact. It was an enormous help during those first two years of medical school. I already knew the roots of most of the 40,000 new words learned during that time. At this point I must admit that I don’t remember a lot of my Latin training. However there were some phrases that have just stuck with me – the beginning to Caesar’s Commentary on the Gallic Wars, the odd bit of poetry, Ciceroean construction, and the Aesop’s fable of the ant and the grasshopper. Haec est fabula de cicada et formica. We know this story as a cautionary tale. The ant works hard all summer to store away grain. The grasshopper plays his fiddle and sings. In some versions he even teases the ant about how hard she works. When the winter storms rage, the grasshopper visits the ant and begs for food outside her door. In the original version the ant refuses to even open the door, saying the grasshopper sang while she worked. The moral? It is best to prepare for the days of necessity. It is easy to find human grasshoppers everywhere. These are people who seem to have no plans for the future. They seem unaware that what they do or don’t do today will have a profound impact on their lives tomorrow. They do not have health insurance because they took a new job that although paid $200 a month more, does not provide the health benefits that their old job did. They make $72,000 a year but cannot find money to buy even catastrophic coverage. They think they should be compensated for their work but that health care should be free. EMTALA makes sure that hospitals and physicians treat these patients much more kindly than the original ant treated the grasshopper. However, their irresponsibility puts a strain on the entire health care system. The collapse of the mortgage industry shows us even more grasshoppers. Where a house was once the largest investment and the greatest source of wealth for most Americans, it became a commodity to be gambled with. People took equity out of their homes in order to buy cars or boats or pay off their credit cards. With housing prices rising, why not use some of that money now? The “why not” has become quite apparent. What good is a fancy car, a boat, or those other consumer goods when you owe more on your home than your home is worth? The lure of a rising real estate market should never offset the security of being able to afford a place to live. We even find grasshoppers among the doctors. There are too many physicians who don’t join any medical organizations, who don’t attend meetings, or who would rather play than use the same amount of money to pay dues. Fortunately for them, the physician advocacy and lobbying that CMA does applies to all physicians in California. Unfortunately their talents and abilities to help us change the future are lost. With looming Medicare cuts, health care reform, and increasing poverty in the Valley, we need each other more than ever. If you are not yet a member, please contact us about how you can join or contribute to our activities. If you are a member, we thank you for your dues and will be calling on you to help improve the health of our community. The month of May will kick off our Physician Service Announcement campaign. Everyone is needed and everyone can help.

FMMS Officers Cynthia Bergmann, MD President Harcharn Chann, MD President-elect Krista Kaups, MD Vice President Oscar Sablan, MD Secretary/Treasurer David Slater, MD Past President Board of Governors Sergio Ilic, MD Margaret Hadcock, MD David Hadden, MD Linda Hertzberg, MD Soo Y. Kim, MD Abbas Mehdi, MD Ranjit Rajpal, MD Krishnakumar Rajani, MD Daniel Stobbe, MD Philip Tran, MD Tanya Warwick, MD Paul Yun, MD CMA Delegates: FMMS President John Bonner, MD Denise Greene, MD Clarke Harding, MD Kevin Luu, MD Abbas Mehdi, MD Salma Simjee, MD Robb Smith, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates: FMMS President-elect Adam Brant, MD Pervaiz Chaudhry, MD Shahla Durrani, MD Glenn Hananouchi, MD Sergio Ilic, MD Peter T. Nassar, MD Kanwal Jeet Singh, MD Rajiv Verma, MD CMA YPS Delegate: Kevin Luu, MD CMA Trustee District VI: Virgil Airola, MD Staff: Sandi Palumbo Executive Director

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Fresno-Madera

Medical Professionals: Tzu Chi Medical Outreach Needs You! by Yangming Cao, MD

Doctors and translator worked as a team seeing a patient under the tent.

On the windy morning of Feb 15, 2009, a team of physicians, nurse practitioners, nurses and other supportive volunteers gathered in the yard of a farm worker camp in Caruthers, a town of about 2500 people and 30 minutes south of Fresno. We are the medical team of Tzu Chi Foundation who provide free medical care to the indigent and uninsured people. This was the first outdoors clinic I had ever seen since I moved to this country from China 15 years ago. I was surprised there was even an outdoors clinic in California! Senior providers were stationed in the Medical Mobile, while we, junior providers, were working under a huge tent without wall. With advanced warning from Tzu Chi organizers, we already wore more clothing to keep ourselves warm. Luckily it was not raining. But still the strong wind would sweep away papers from the tables any minutes. It was the first time Dr. Mike Huang, a UCSF-Fresno Medicine resident, came to help in the Tzu Chi clinic. I personally felt it was a great experience. As the largest Asian charity organization in the world, Tzu Chi has provided disaster and humanitarian relief programs in 67 countries. Tzu Chi has also built 195 Schools of HOPE in 16 countries and 14,754 houses (Great Love Village) in 11 countries. In the past year, for example, it has provided monetary and personnel service to victims of Burma’s cyclone, China’s Earthquake, Haiti’s hurricane, US Midwest flood and Hurricane Ike. There are over five million members and volunteers in over 45 countries who carry out Tzu Chi’s missions 24-hours-a-day. Tzu Chi’s missions focus on giving material aids to the needy and inspiring love and humanity to both givers and receivers. In addition to charity, the foundation dedicates itself to the fields of medicine, education, environmental protection, international

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relief work and the establishment of the world’s third largest bone marrow donor registry. It also promotes humanistic values and community volunteerism. Tzu Chi Fresno Free Health Clinic started its service in 2001. Thus far, 10,000 uninsured and underserved people have been served in the valley. In 2008, the Fresno County Council presented a proclamation to Fresno Tzu Chi for its excellent services. Currently, Tzu Chi holds monthly clinic at various locations on a rotation basis in Fresno and surrounding areas such as Reedley to the south and Livingston to the north. Soon Tzu Chi will operate weekly clinic with their Medical Mobile. Many of the patients come for a common cold, stomach ache, vision screening, blood pressure and glucose check, or teeth cleaning. As Steven Voon, the Tzu Chi Fresno medical team leader, pointed out, “if they come to see us, they don’t have to line up in the ER. That helps everyone to reduce their costs.” Over the past three years, I have been participating in the clinic. I certainly agree with Steven. In the hardship of this economic crisis, we have seen more and more people lose medical insurance. They need your help. I understand that many of you have already been providing free medical service through different clinics and organizations. Tzu Chi also needs more volunteers to help. Dentists and hygienists are needed, too. The monthly clinic is on the weekends, which will nicely fit into your busy schedule. Tzu Chi will cover your mal-practice insurance when you volunteer in their events. If you would like to volunteer or know someone who wants to help, please contact Steven Voon at tima_fresno@sbcglobal.net. You can visit Tzu Chi website www.tzuchi.org for more information or contact Fresno office at 559-298-4894 and fax 559-570-0172.


Fresno-Madera MEMBERSHIP NEWS New Members THOMAS R. RICHARDSON, MD 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.

John S. Boswell, MD IM 2828 Fresno Street Fresno 93721 Tulane Univ ’05 Diane C. Tsai, MD *RO 7257 N. Fresno Street Fresno 93720 NJ Med Sch ’91

Membership Recap FEBRUARY 2009

33-year member

Thomas Richardson, MD, a retired radiologist, passed away on Feb. 9, 2009 at the age of 69. Dr. Richardson was born in Berkeley in 1940. He received his medical degree from USC in 1965 and completed his internship at Sacramento County Hospital, his residency at Wayne State University and a fellowship at Sacramento Medical Center. Dr. Richardson practiced in Fresno for 30 years and retired in 2003. He served on the FMMS Scholarship Foundation Board for several years. Dr. Richardson is survived by his wife, a daughter, a son and three grandchildren.

KENNETH ROOT, MD 51-year member

Kenneth Root, MD a retired anesthesiologist, passed away Feb. 9, 2009 at the age of 82. Dr. Root was born in Bakersfield in 1926. He received his medical degree from the Univ. of Calif. Medical School in 1953, completed his internship at Fresno County Hospital in 1954 and his residency at the University of California in 1956. He began his practice with the Fresno Anesthesia Group in 1956 and retired in 1998.

Active ..................................................705 Leave of Absence.....................................1 Retired..................................................202 Residents ..............................................219 TOTAL ...........................................1,127 Applicants................................................2 presents

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

APRIL 5 Finance..................................12:30pm Membership ............................6:00pm 20 Board of Governors.................6:00pm 21 MRAC ....................................6:00pm 22 Editorial..................................6:00 pm 28 Historical..............................12:30 pm

GENERAL MEMBERSHIP MEETING Wednesday, May 6, 2009 • 6:00 pm TorNinos Banquet Hall

“Environmental Sustainability” Each year, California’s population increases by 462,000. This creates more demand for energy, water and materials, puts more strain on the state’s infrastucture and land resources, as well as increases pollution, air emissions and waste. Being environmentally sustainable is to meet current human needs without undermining the capacity of the environment to provide those needs over the long term. It’s a question of being smarter about how to use resources, rather than doing without. What are you doing to be “green?” What exactly is “green?” Can one person’s efforts really make a difference? How do we protect human health and environmental well-being? How can going “green” add to your bottom line? Don’t miss this opportunity to learn California’s strategies, programs and resources for building a greener California and the contributions each individual can make to a sustainable future. RSVP: 224-4224, ext. 118

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Fresno-Madera FMMS IS AT WORK TO SERVE ITS MEMBERS' BUSINESS NEEDS:

presents

Medical Managers Forum

RED FLAG ID THEFT REGULATIONS AND THEIR IMPACT ON MEDICAL OFFICES Guest Speaker Howard Sagaser, Esq. Sagaser, Jones & Helsley

Don’t miss this incredible opportunity to hear a local attorney share vital information relating to the prevention of such topics for: • Hacking of IT Information • Employee-theft of your Data • False Insurance ID Presentation There will be a Q&A time following the seminar to present specific concerns.

THURSDAY, APRIL 16, 2009 12:00-2:00 p.m. LUNCH: $12.50/person prepaid by credit, check or cash with reservation Limited to 50 people – 2 per FMMS doctor’s office FMMS member staff only RESERVATIONS must be made by April 10, 2009 Contact: Sheryl Tatarian, statarian@fmms.org 559-224-4224x112

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Kern BRADFORD A. ANDERSON, MD

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

President’s Message We

find ourselves at the vortex of the winds of change. Organized medicine is entering the transition from the paper world to the electronic world and resistance is futile. During these times of economic uncertainty, opportunities abound. We must take advantage and take control of these opportunities. Computer Platform: We have an opportunity as collective consumers to demand a basic platform for our electronic medical records and not just accept whatever Silicon Valley wants to provide in their best interest. The current chaos prevents one platform from sharing information extremely difficult. Once the basic platform is formulated, each individual practice can adapt it to its special needs. This can be tailored depending on the size of each practice, the need for multiple users, clinical correlations with instant access to the internet for differential diagnosis, etc. If we do not determine a platform for ourselves, one will be decided for us. It may not be the best interest of the practice of medicine. E-scripts: The Federal Government is offering incentives for establishing approved electronic prescribing in your practice. All is not bleak if we take advantage of the opportunities before us and use our collective untapped power in shaping the future of medicine. Beginning this year and until 2013, an incentive payment will be given based on the allowed charges from the physicians’ payment fee schedule. The e-prescribing incentive percent amount for reporting years 2009-2010 is 2.0%; for reporting years 2011-2012 is 1.0% and for reporting year 2013 it is 0.5%. For more information – http://www.cms.hhs.gov/EPrescribing Medical Home Model: The AMA and CMA are in the process of laying the groundwork is see if this will be the paradigm shift from our current office-hospital base model. We have the ability to shape the future of this system. Try to become familiar with this model. There are seven basic components partially described below as listed by the American Academy of Family Physicians’ website: Personal Physician – Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. Physician Directed Medical Practice – The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patents. Whole Person Orientation – The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services and end of life care. Care is Coordinated and/or Integrated – Across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’ s community (e.g., family, public and private community-based services). Quality and Safety – Hallmarks of the medical home. Enhanced Access to Care – Available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff. Payment – Appropriately recognizes the added value provided to patients who have a patientcentered medical home. Additional information available at: American Academy of Family Physicians – http://www.futurefamilymed.org American Academy of Pediatrics – http://aappolicy.aappublications.org/policy_statement/index.dtl#M American College of Physicians – http://www.acponline.org/advocacy/?hp American Osteopathic Association – http://www.osteopathic.org

website: www.kms.org

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

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Kern

Kings

MEMBERSHIP NEWS Mark Your Calendars for These Upcoming Events CMA LEGISLATIVE CONFERENCE Tuesday, April 14, 2009 – Sacramento, CA (All Day)

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

CMA LEADERSHIP ACADEMY April 24-26, 2009 – Disneyland Hotel, Anaheim, CA

KCMS PICNIC Saturday, May 9, 2009 – Silver Creek Park; Watch your mail for more information

KCMS/NORCAL TOWN HALL MEETING Tuesday, May 19, 2009 – Bistro at the Sheraton, Bakersfield, CA

KCMS Member Recognition KCMS is pleased to announce a new addition to our website, www.kms.org, “Recognizing Our Members.” In this section, we will pay tribute to KCMS member physicians by recognizing their contributions to the community, to their patients, etc., the day-to-day activities that some of us take for granite. But, we need your help. Attention all office managers, staff, etc. – if your doctor has done something you think deserves recognition and/or if your doctor is reluctant to be noticed for a “Good Deed” or he/she just feels as if the things they do are “no big deal – just part of their daily routine” – we want to hear about it. Contact the society office via fax 661-328-9372 or email: khughes@kms.org. We value your input!

Membership Recap FEBRUARY 2009 Active............................................................285 Resident Active Members ................................0 Active/65+/1-20hr ............................................6 Active/Hship/1/2 Hship....................................1 Government Employed ...................................13 Multiple memberships.......................................2 Retired .............................................................61 Total ..............................................................368 New members, pending dues ............................2 New members, pending application .................0 Total Members..............................................370

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KCMS Officers John E. Weisenberger, MD President

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.

Charles D. Wong, DO (General Surgery) Kern Faculty Medical Group 2201 Mt. Vernon Ave. #211, 93306-3312 661-872-7000 FAX: 872-0499 Medical Degree: U of Hlth. Sciences, Osteopathic Clg., MO 2002 Internship/Residency: Kern Medical Center – 07/2002-06/2008

Jeffrey W. Csiszar, MD President elect Theresa P. Poindexter, MD Secretary Treasurer Sheldon R. Minkin, DO Past President

Board of Directors F.T. Buchanan, MD James E. Dean, MD Ying-Chien Lee, MD Uriel Limjoco, MD Daniel Urrutia, MD CMA Delegates: James E. Dean, MD Uriel Romel Limjoco, MD CMA Alternate Delegates: Mario Deguchi, MD Sheldon R. Minkin, DO Staff: Marilyn Rush Executive Secretary


Tulare When a Disaster Strikes, You Can Make the Difference by Cyndie Coverston RN, PHN, BSN Public Health Emergency Preparedness Health and Human Services Agency of Tulare County

Take this scenario: Tulare County experiences a major pandemic flu outbreak, all the hospitals are overflowing and alternate care sites are required to be opened to vaccinate the whole population of Tulare County, along with care for the surge of ill residents. You are a health professional of Tulare County who wants to help, so you go to the volunteer staging center for the disaster. We have to turn you away, because we have no record of your credentials, or who you are, until a lengthy credentialing process is completed. This is what happened with the 911 and Katrina disasters. The Disaster Healthcare Volunteer registry was developed to identify and register health professionals that are able and willing to help in the case of a disaster. The statewide registry can be found at www.healthcarevolunteers.ca.gov. Registering now allows verification of your license and credentials, promotes training opportunities, and helps disaster managers understand how many volunteers might be available. This will help us match your skills with the needs required in each emergency situation. When you register on the secure web-based registry, you will indicate your volunteer preferences and enter information about your skills. Your professional license will be verified electronically with your licensing board by the Emergency Medical Services Authority and this information will become a part of the secure Disaster Healthcare Volunteer Statewide Registry. During a disaster, state or local (county) officials will determine what kind of professionals are needed, search the database for available volunteers, and send an alert to selected members via email, telephone and pager. If you receive an alert in the event of a disaster, you will have the chance to accept or decline the volunteer request. If you accept, you will receive special instructions on where and when to report, and what is needed for the incident. There is NO obligation to participate during activation. This website is for any licensed, healthcare professional as well as a section for non-medical volunteers. There may be others in your office or realm of influence that can also pre-register, including but not limited to: RNs, LVNs, nurse practioners, physician assistant’s, MA’s, secretaries, lab assistants, pharmacists, technicians within all fields, dentists and assistants/hygienists, therapists and specialists in all fields. Your participation and support is vital to the success of any public health emergency response in Tulare County. If you have any additional questions, or would like more information on how you can become further involved with the Emergency Preparedness program in Tulare County, please call Cyndie Coverston RN, Hospital Preparedness Program Coordinator at 559-737-4660 x2127.

3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org

TCMS Officers Mark Tetz, MD President Ralph Kingsford, MD President-Elect Steve Carstens, DO Secretary/Treasurer Timothy Spade, MD Immediate Past President Board of Directors Thomas Daglish, MD Karen Haught, MD Mark Reader, DO Ahmad Shahroz, MD Gaurang Pandya, MD 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 Staff: Steve M. Beargeon, Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate Maui Thatcher Executive Assistant

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

Anwer Baloch, MD Internal Medicine Ain-Shams Univ. Medical School, 1981 245 W. Cherry Ave. Porterville 93257

Pawan Kumar, MD Endocrinology King George’s Medical College, 1995 324 N. Vermont Ave. Dinuba 93618

Nallathamby Thayapran, MD Cardiology Univ of Colombo Faculty of Medicine, 1990 999 W. Morton Ave., Ste. B Porterville 93257

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Tulare Cochlear Implants: What Are They and Whom Do They Help? by Mark Reader, DO, FAOCO

There are an estimated 28 million Americans with some degree of hearing loss and 500,000 of these individuals would benefit from cochlear implants but only 50,000 of these individuals have received an implant. Every year, in the US alone, there are 12,000 babies born with hearing loss. The cochlea is like a piano keyboard with the high pitches located on the proximal portion and the low pitches located on the distal portion. The implant is a hearing assistive device that directly stimulates the nerve that transmits signals to the brain resulting in the sense of hearing. The location on the nerve stimulated then determines the pitch that is heard by the recipient. There are two components to the implant, the internal and external components. The internal device is actually inserted into the patient’s cochlea surgically and is the portion that directly stimulates the acoustic portion of the eighth cranial nerve. Mark Reader, This portion of the device is designed to be permanent. There is also an external device that DO, FAOCO looks much like a hearing aid that rests behind the ear and can be removed by the patient whenever desired. This portion of the device takes sound and converts it into digital signals that are transmitted into the internal receiver through a magnetic coil. It will need to be replaced periodically like a traditional hearing aid. Cochlear implants are intended for people whose hearing is severe enough that a hearing aid provides very little or no benefit in improving they’re hearing. Unlike a traditional hearing aid though, the implant not only increases the volume of sound heard but also usually improves the ability to understand or discriminate what is being heard. Initially the implants were designed for adults who had hearing at one time but later lost it. Now the indications have expanded to include children and even infants born deaf. If provided at an early enough age, it allows them to develop speech and hearing pathways in the brain. Several criteria need to be met before someone is selected to receive an implant. There needs to be an intact cochlea and nerve path to the brain. Some conditions can interfere with this. There also has to be a desire to undergo a surgical procedure as well as a rehabilitative program following the surgery. The brain needs time to adjust to the new signals being sent to it by the device so repeated programming sessions are essential and speech therapy can enhance the outcome as well. Cochlear implants certainly aren’t for everyone with impaired hearing but they provide an option for many people who formerly had no hope of hearing or hearing again. I have successfully completed 20 implants in the last 3-1/2 years with one of the recipients receiving a bilateral implant. Please contact me should you have questions about this procedure. Mark E Reader, DO, FAOCO 390 N Pearson Dr., Porterville, CA 202 W Willow Suite 103 Visalia, CA Ph: 559-791-1779 DrREADER.COM Dr Reader is board certified in ENT and completed neurotology fellowship in Minneapolis, MN.

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

For us physicians, time is a valuable commodity but also is the factor that does not seem to be enough around; we need to accomplish our work, to take care of our patients, to take care of paper work and administrative responsibilities and to take care of our family. There is very little time left to enjoy simple pleasures in life, no time to be with ourselves and definitely no time for meditation, yoga or any other discipline that Luis H. train us to take a real look to our physical Velosa MD body, to recognize our true feelings, and to stop the incessant chatter of our brain maintaining our mind quiet for a while. Let’s try to get some time by finding a quiet and peaceful place, sit comfortably with your legs crossed. Take a deep breath, make sure your entire lungs are filled and hold your breath for a few seconds. Then release your breath, exhale, make sure all the air is out of your lungs and hold your breath for a few seconds. Let’s name this process Primary Breathing and repeat this cycle a minimum of ten times and when you feel is time to move on, just breath normally soften your breathing, inhale and exhale slowly and gently until you feel you are ready for the next tool. We will try a sitting forward bend. Continue to breath softly and gently Imaging your head being a helium balloon, so every time you inhale your head goes up, carrying your spine with it, softening the curves in your spine, maintaining a straight and vertical line on your back. Gently move your entire spine forward, preserving the vertical line. Then place your hands on the floor, in front of you, and keep breathing softly for two or three cycles. Moving with your breath when you exhale your fingers advance few inches and when you inhale your entire body remains still. Keep this process going: exhale and hands go forward, inhale stay still, always preserving the spine straight “vertical line straight.” Continue to move your torso forward until the moment you feel your spine has reached to the maximum. At this moment keep your breathing going, sense the different sensations that are taking place in your lower back and stay in this particular pose for a minimum of five cycles of your breath. Gently recover bringing your hands to your knees and in a sitting position, practice Primary Breathing for a good nine times,

very slowly, take your time and do not rush. Now we will try the “child pose” Let’s place our body on the four limbs or “all fours” making sure your hands are at the same level than your shoulders and your knees are slightly apart. Slowly lower your hips between your legs then lower your spine, your rib cage, and your shoulders to the floor and place your hands back holding your feet. Activate your breathing. Breathe smoothly and as you exhale let your entire body become relaxed. Give yourself a minimum of ten cycles of this particular breathing and then slowly recover by placing yourself in “all fours.” Now it is time to slow down, to relax your body and your mind at this present moment with one of the simplest yet powerful meditation techniques. Prepare your meditation process by determining the time, so you can set your timer with a minimum of five minutes. Begin your primary breathing suggesting to your mind that as you enter into your meditation practice, you will not place any expectations in this process. You will encounter your thoughts, sensations and feeling just like they are. Sit on a comfortable position and you may use a cushion or even a chair. Visualize your body, your head is just in the center, place your tongue on the roof of the mouth, shoulders are aligned and relaxed, your arms are loosely placed on your knees and you may hold your thumb in contact with your second finger. Initiate your primary breathing until you sense that you are relaxed enough to initiate the meditation. Then change the style of your breath, inhale and exhale very softly and transition slowly from your inhalation to your exhalation. No hold. This time when you finish your exhalation count aloud “one” then “two” and so forth till you reach to “ten.” Then start another cycle until “ten”; always counting aloud. As you keep this process, notice all the subtle physical and mental “happenings”, just observe and keep the process until the timer will notify you that it is time to come back. I wish a very good day, find time for your mind, for your body and stay at the present moment. In May I will be recapping all the tools I have been describing during these past five articles. Dr Velosa is a Board Certified Psychiatrist, a yoga teacher, a spinning and Zumba teachers and loves to race bicycles. Readers may write to him at lhvelosa@yahoo.com.

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CLASSIFIEDS

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.

BAKERSFIELD

FRESNO / MADERA

PHYSICIAN WANTED

ANNOUNCEMENT

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 661323-4703 email: HLTGUY@aol.com.

Fresno Women’s Medical Group announces the opening of its Downtown Fresno’s office in a beautiful historic Victorian at 1125 “T” St. Accepting new OB-GYN patients. 559-322-2900. Fresno Women’s Medical Group welcomes Dr. Sharon Kopacz back home to Fresno. Now accepting patients. 559-322-2900. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 3200580. 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.

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. 820 34th St. – 5,634 rsf. 2920 F Street – 2,052 rsf. 3911 Coffee Rd. – 5,210 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 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. 9500 Stockdale Hwy. – 1,459 rsf. 9900 Stockdale Hwy. – 2,457 rsf. 9900 Stockdale Hwy. – 1,500-3,000 rsf. SUB-LEASE 3850 River Lakes Dr. – 2,859 rsf. 9330 Stockdale Hwy. – 7,376 rsf. 9500 Stockdale Hwy. – 3,000 rsf. 4100 Truxtun Ave. – 11,424 rsf. Medical Admin and Chart Storage DENTAL OFFICE FOR LEASE OR SALE 500 Old River Road – 4,479 rsf. FOR SALE Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 2000 Physicians Plaza – 17,939 sf. gross 9900 Stockdale Hwy. – 2,000-10,000 rsf. 1800 Westwind Dr – 25,036 sf. gross SOUTHWEST LOT TO BUILD Bahamas Dr. – 15,600 sf office

FOR RENT / LEASE 2,813 sf. medical office at 1648 E. Herndon near St. Agnes. Price negotiable. Call 559-4326468. 1550 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 1,000/sf. Ample allowances. Call 559-259-3077 or 559355-8416. Premium medical office, 5,500 sf shell at Maple/Herndon, easy access to Herndon/Hwys 41 & 168, next to MRI specialists & St. Agnes. Build to suit. TI’s $35-$45 sf, $1.60 sf. Fax 559433-9496 or call 559-681-6390. Turn-key lease of 3,900 sf medical office, in a free-standing building at 6234 N. First St near SAMC. Includes X-Ray, computers, phones, fax, printers, copier, autocave, centrifuge, scales, washer/dryer, refrigerator, desks, chairs and mobile filing system. Call 559-446-1000. Walking distance to St. Agnes. Plenty of parking. 2,813 sf deluxe medical office for immediate occupancy. Call 559-432-6468.

FOR SALE Turn-key lease of 3,900 sf medical office, in a free-standing building at 6234 N. First St near SAMC. Includes X-Ray, computers, phones, fax, printers, copier, autocave, centrifuge, scales, washer/dryer, refrigerator, desks, chairs and mobile filing system. Call 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 559-355-8416.

PHYSICIAN WANTED Full or P/T board certified in FP, GP or IM for Urgent Care & Family Practice in Fresno serving patients in a multidisciplinary practice. M-F hours, no weekends. Competitive salary & full benefits. Fax CV to 559-435-3462.

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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. Cyberknife Weekly Conference Live Web Cast – Wednesdays Time: 12pm, Credit: 1 hour; Fee: N/C. Call 559-459-2500 Practical Developmental Screening – April 18, 2009 Location: UCSF Ed. Ct. Time: 8am4pm; Credit: 7.75 hours. Fee: $40. Call 559-499-6532. Perinatal Mood & Anciety Disorders – April 23, 2009 Location: UCSF Ed Ct. Time: 8am-4pm Credit: 8 hours. Fee: $65. Call 559-4996532. Interdisciplinary Communication – April 23, 2009 Location: Kaweah Delta Health Care District. Time: 6-8pm. Credit: 2 hours. Fee: N/C. Call: 559-624-2595. Pediatric Palliative Care – April 24, 2009 Location: Children’s Hosp. Madera. Time: 8am-4:30pm. Credit: 6.5 hours. Fee: $80-$100. Call 559-353-7230. 16th Annual Living with Grief Teleconfefence “Diversity and End-of-Life Care” – April 29, 2009 Location: SAMC, Fresno; 10am-1:30 pm, Credit: TBA, Fee: N/C to SAMC staff. Call 559-450-3997. Updates in Sleep Medicine – April 30, 2009 Location: Kaweah Delta HCD. Time: 68pm. Credit: 2 hours. Fee: N/C. Call 559-624-2595. Pediatric Cardiology Conferene – May 1-3, 2009 Location: Tenaya Lodge, Fish Camp; Credit: 12.5 hours. Fee: $150-$300. Call 559-353-7230. Pediatric Clinical Symposium – May 30, 2009 Location: Children’s Hosp. Madera. Time: 8am-1:30 pm. Credit: 4 hours. Fee: N/C. Call 559-353-6621.


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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


2009 April