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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

July 2009 • Vol. 31 No. 7

Vital Signs

Fresno Grizzlies Fireworks Presentation by Don Davis Photography/


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Vital Signs Official Publication of

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

Fresno-Madera Medical Society Kings County Medical Society

CMA NEWS.................................................................................................................................6

Kern County Medical Society Tulare County Medical Society July 2009 Vol. 31 – Number 7 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 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. Advertising Contact: Display: Annette Paxton, 559-454-9331

NEWS PRACTICE MANAGEMENT: Highlights of California’s New Medical Privacy Laws .............................8 AIR QUALITY: Where We Have Been and Where We Are Going .....................................................9 BLOOD CENTER: Collections and Transfusions .........................................................................10 CLASSIFIEDS ............................................................................................................................19 TULARE COUNTY MEDICAL SOCIETY ..........................................................................................11 • President’s Message • Membership News KERN COUNTY MEDICAL SOCIETY .............................................................................................13 • President’s Message • Membership News FRESNO-MADERA MEDICAL SOCIETY .........................................................................................15 • President’s Message • Medical Managers Forum • Well Being Committee • Historical Corner • FMMS’ new website • Membership News

Cover photography by Don Davis Photogrpahy/

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

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 / J U LY 2 0 0 9

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Electronic Medical Records Freedom to practice medicine on your terms

MRI CT Ultrasound

Imaging Center

X-Ray Bone Densitometry

Multiple modalities for your convenience! Advanced patient-centric Open MR produces outstanding images Unparalleled service to patients, referring physicians and offices • Fast, flexible scheduling with no-wait policy for patients • Rapid turn-around of reports and images – film/CD/online • Compassionate, professional, bilingual staff takes great care of you and your patients Todd D. Spencer, M.D., Medical Director

Tel: 559.226.2888 . Fax: 559.226.2887 108 W. Shaw Ave . Fresno, CA 93704 .

The Imaging Center That Cares


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EDITORIAL ANFSCD: [ :-) ] by David Slater, MD, Editor, Vital Signs

I hope you noticed in last month’s Vital Signs a short news piece that FMMS’s completely redone web site has launched. It is waiting for your visit and it will soon be fully ready for the public’s visits. It’s hard to know where to start in describing the marked improvement in functionality and content. I will mention just a few attributes of the all-new A District VI page and links to easily connect all the District VI medical societies. This will really build relationships, make us more effective, and permit vital efficiencies for all these organizations. A new Members-Only area. Medical societies have long provided a sense of community and fostered collegial interaction. Today there’s,, and other on-line communities. We are aiming for a middle ground between yesteryear’s cigars with port in horsehair chairs – and tweeting madly like Roland Hedley of Doonesbury (who would know all about “ANFSCD”). The Members-Only area will host physician and office manager discussion forums, leadership blogs, a members’ calendar, and society reports and documents. NOTE: FMMS needs your e-mail so that a password can be assigned. (This process is admittedly not an elegant one right now). Please send an e-mail requesting a password to Carol Rau at Current News and Current Event headlines with links to in-depth coverage and resources. This will be from reputable sources including content from CMA, AMA, and California Healthline. There is so much information out there – let FMMS extract some items we believe you’ll want to know about. You will find current and archived issues of Vital Signs there, too. Direct link for readers to e-mail articles, letters and opinion to the Vital Signs Editor through the Publication/Newsletter section. You also have the option to e-mail the President directly, through the Leadership page, under the President’s name. Much emphasis on providing content for the public and other health organizations in the Central Valley. We want to be

a top-of-mind resource for others working for health advocacy and delivering care, for regional public decision makers, and for our patients. It will take time to develop all that content, and we will welcome your suggestions. But even at this early point you can see those footprints embedded in the web site. No professional organization will thrive without a strong web presence. The Internet is how the physicians who comprise the future of this society will obtain and transmit information – and how they will commune with one another. (Many more senior physicians are well down that road, too). FMMS leadership is to be commended for securing the Hewlett Foundation grant that largely funded the development of our new web site. Now that it is a reality, we (and by this, I mean we physicians, not just our staff) own it and must build it out to full potential. Please give feedback and suggestions, especially at this early juncture. And if all this really gets your juices flowing, please join FMMS’s Editorial Committee! I close with a request to Vital Signs readers in all five counties. Vital Signs is now a larger, higher quality, regional publication. Its production costs have significantly increased. Each issue costs about $6,500 to publish and mail. (Yes, we post Vital Signs on the web site but we do not envision mailed copies going away soon.) The newly expanded readership and content offer a unique vehicle for advertisers to reach 2,200 Central Valley physicians, our office managers, and many regional opinion leaders on its mailing list. We ask readers to consider whether an ad in Vital Signs might enhance your practice’s marketing program. We also know you are well connected in your communities and with people offering professional products services who’d like to reach an audience like ours, but likely are not familiar with Vital Signs. In these challenging financial times, we need all Vital Signs readers to help us secure advertising relationships to cover direct costs and help toward our indirect costs. Carol Rau at FMMS has full information about advertising opportunities in both Vital Signs and in our widely distributed annual Pictorial Directory.

FRAUD ALERT: FRAUDULENT REQUESTS FOR PROVIDER ENROLLMENT INFORMATION Palmetto GBA has been notified of a recent scam that asks providers to complete an enrollment application within 48 hours or risk payment interruption. This fax or mailing may include official-looking logos, but it’s not from the Centers for Medicare & Medicaid Services (CMS) or Palmetto GBA. These requests are from identity theives who use the information to route payments to their accounts. If you receive a request like this, call CMS or Palmetto GBA at 866-895-1520 to verify the request for information.

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Representative Sam Farr (D-Calif.) and Senator Dianne Feinstein (D-Calif.) introduced CMA-sponsored legislation to correct the longstanding Medicare geographic payment inequity for a number of California counties. Low rates in affected counties have forced many doctors to opt out of Medicare or limit the number of Medicare patients they treat. The net result is that Medicare recipients in these counties have a difficult time finding a doctor. The Medicare payment formula includes a geographic adjustment factor (GAF) that adjusts the payment rate for local geographic market conditions. The goal is to base physician reimbursement on what it costs to provide care in a particular geographic region. The formula calculates a geographic adjustment factor for every California county, and assigns each county to one of nine of California’s Medicare regions, called payment localities. However, because of rapid growth and development in recent years, physicians in some California counties (El Dorado, Monterey, Placer, Riverside, Sacramento, San Benito, San Bernardino, San Diego, San Joaquin, San Luis Obispo, Santa Barbara, Santa Cruz, Sonoma and Yolo counties) have practice costs that are up to 10 percent greater than the average costs of other counties in their Medicare localities. The legislation would place California localities into up-to-date Metropolitan Statistical Areas, which more accurately reflect regional costs, and hold harmless all counties that might experience a payment reduction by such a change. By doing this, many areas qualify for higher rates. Contact: Elizabeth McNeil, 415-882-3376 or emcneil@


Three House committees with Health Reform jurisdiction jointly released a general outline of their health reform proposal. Most significantly for physicians, the House proposal would eliminate the sustainable growth rate (SGR) payment formula, which has been an enormous hurdle in our fight to raise Medicare physician payment rates. The proposal would also, among other things: • Increase reimbursement for primary care E&M services by up to 15 percent (3 to 5 percent per year for three years); • Allow physicians to organize into virtual or real groups to coordinate care and receive bonus payments for reducing unnecessary hospitalizations; • Expand the Medicaid program to cover more low-income families; • Increase Medicaid rates to Medicare levels for primary care services; • Require everyone to have health coverage. It also provides tax credits and subsidies to families up to 400 percent of the federal poverty level to help them purchase insurance; 6

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• Require medium and large employers to offer health insurance to their employees or pay into a fund on behalf of their uncovered workers; and • Create a national health insurance exchange. Although CMA strongly supports health coverage expansion and insurance market reforms (such as limits on medical loss ratios) called for in this proposal, the association is concerned that these reforms will be illusory if they don’t also guarantee meaningful access to doctors. CMA is urging physicians to contact their representatives in Congress and tell them that they must increase all Medicare and Medicaid reimbursement rates. Without these important rate increases, the promise of access to care for California’s uninsured will be a false one. The uninsured may be given health insurance coverage but they may not be able to find a doctor to care for them. The House proposal also establishes a national health insurance exchange, through which the uninsured (and only the uninsured) can purchase insurance. The exchange would include both private insurance plans and a new public government-run plan. While specific details were not provided, it appears that the House proposal may require all participating Medicare physicians to also participate in the new public plan. While CMA understands that House leaders are concerned about building an adequate physician network to compete with the private health plans, CMA vigorously opposes mandatory participation in any health insurance plan. CMA also believes that any government plan must be adequately financed to ensure appropriate access to care. More details, including talking points and representatives’ contact information, are available at Contact: Elizabeth McNeil, 415/882-3376 or emcneil@


The Joint Legislative Audit Committee voted unanimously to approve CMA’s request for an audit of the Medi-Cal Treatment Authorization Request (TAR) process. Over the last five years, the TAR process has been a target for review; however, changes have yet to materialize. The need to change the TAR system was recognized by a 2003 Medi-Cal Policy Institute report and in the 2005 California Performance review. The TAR program costs the state an estimated $1.5 billion to administer and creates considerable added paperwork for physicians serving Medi-Cal patients. CMA is advocating that those funds be spent on providing actual health care, like maintaining the state’s Health Families program, rather than wasteful administration. The overly burdensome TAR process, on top of Medi-Cal’s persistently abysmal reimbursement rates, has forced many physicians to stop seeing new Medi-Cal patients. CMA FENDS OFF TRIAL LAWYERS’ ATTACK ON MICRA; APPEALS COURT UPHOLDS CONSTITUTIONALITY OF LANDMARK LAW

The 5th District Court of Appeal has unanimously upheld the constitutionality of California’s landmark Medical Injury Compensation Reform Act (MICRA). It was enacted in 1975 by overwhelming bipartisan support in response to a crisis of runaway medical liability costs and the resulting shortage of health care

CMA NEWS providers, most predominately in high-risk specialties. In this case, James Van Buren v. Sian Evans, MD and Yosemite Surgery Associates, the trial attorneys argued that MICRA’s $250,000 cap on recoverable non-economic damages deprived Mr. Van Buren of his constitutional rights to a jury trial. CMA along with its coalition partners filed an amicus brief opposing this attack on MICRA and presented oral arguments before the appellate court. CMA told the court that MICRA’s limit on non-economic damages is a key component of a complex and balanced legislative plan that has ensured the availability of medical care in California. Under our forward-thinking law, injured patients are entitled to unlimited medical and economic compensation, which often amount to millions of dollars to cover true damages, such as lost wages, medical expenses, and long-term care costs. Physicians support such full compensation of injured patients. Also under MICRA, patients can also recover an additional quarter of a million dollars in non-economic or ““pain and suffering”” awards. The law also limits contingency legal fees so that those seriously injured patients get more (and their attorneys get less) of the award. In its ruling, the appellate court agreed with CMA and rejected each of the trial attorneys’ constitutional arguments. As the court noted, the legitimate state interest is to limit medical malpractice insurance costs because without MICRA insurance rates pose ““serious problems for the health care system in California, threatening to curtail the availability of medical care in some parts of the state and creating the very real possibility that many doctors would practice without insurance, leaving patients who might be injured by such doctors with the prospect of uncollectible judgments

PHYSICIANS HAVE OPPORTUNITY TO VERIFY ACCURACY OF CALIFORNIA PHYSICIAN PERFORMANCE INITIATIVE DEMOGRAPHIC DATA ONLINE Physicians who treat PPO or HMO patients insured by Anthem Blue Cross , Blue Shield of California, HealthNet, and United Healthcare may receive quality performance results from the California Physician Performance Initiative (CPPI) this summer. The quality measures are based on insurance claims data from patient care provided in 2007-2008. Physicians will be provided with a percentile rank compared to their physician peers, as well as performance results by measure and by patient group. CPPI is a project of the California Cooperative Healthcare Reporting Initiative (CCHRI), which received federal funding in 2006 to develop a system for measuring and reporting the quality of health care provided by physicians. CPPI collected data on approximately 25,000 physicians for a limited set of nationallyendorsed quality measures. These quality measures generally involve adult care provided by primary care physicians, cardiologists, endocrinologists, obstetricians/gynecologists, allergy/immunologists, pulmonologists, gastroenteronologists, and rheumatologists. In the fall of 2008, CCHRI completed the third cycle of CPPI reports, which exposed numerous problems in the accuracy of the data on which physician performance results were based. For example, some doctors were given credit for treatment they did not provide, and conversely, other doctors were not given credit for

treatment they did provide. Also, some patients were attributed to the wrong physicians and some doctors had incorrect specialty designations. Physicians interested in helping CCHRI improve the data will have two opportunities to do so for the 2009 round of reports. Right now, physicians can verify their demographic information – including name, specialty, and mailing address – at the CPPI website. Your California State License Number is needed to login. Please provide corrections no later than June 12 so that they can be incorporated in this cycle of performance reporting. Later this summer, Physicians will have an opportunity to correct their quality data, on which the actual performance ratings are based. CMA continues to have a number of concerns about the validity and accuracy of the data that has been collected and has communicated those concerns to CCHRI.


A practice cannot provide quality medical care unless it can keep its doors open. Physicians who work in well-run practices can spend less time dealing with administrative hassles or worrying about making ends meet, which, in turn, affords them more time for patient care. CMA, with generous support from the Physicians’ Foundation, has published a 140-page toolkit to help physicians improve the efficiency, and in turn the quality, of their practices. In this tool kit, you will learn: • What every physician needs to know about running a practice; • How to find and keep qualified staff; • Why your receptionist can make or break your business; • How to make sense of your revenue stream; • When it makes sense to cancel a payor contract; • And much more. The Best Practices toolkit, available free to all physicians, is organized into nine chapters that can be read sequentially or on an as-needed basis. Download the toolkit today at http://www. CMA will also be presenting live lunchtime “Best Practices” seminars at county medical societies around the state. These seminars will highlight some of the important features of the document to help you optimize your practice. If you would like to see the “Best Practices” seminar in your area, contact your local county medical society. Contact: Frank Navarro, 888/401-s5911 or fnavarro@cma



are reminded that before they sign a health plan contract, it is important to know what value that relationship will bring to their practice. Physicians do not have to accept contracts that are not mutually beneficial. To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting tool kit, “Taking Charge: Steps to Contracting.” The tool kit is available free to members at the members only website: (click on “Reimbursement Advocacy” under “Physician Advocacy” in the main menu. V I TA L S I G N S / J U LY 2 0 0 9

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Highlights of California’s New Medical Privacy Laws – Are You in Compliance? Prompted by the disclosures of “snooping” into celebrity medical records at UCLA and the use of patient data for fundraising at UCSF, new medical privacy laws became effective January 1, 2009 – SB 541 and AB 211. SB 541 authorizes the California Department of Public Health (CDPH) to investigate health information privacy breaches and assess penalties of up to $25,000 per patient (up to a maximum of $250,000 per reportable event). Health facilities must notify both CDPH and the patient of a privacy breach within five days of detection. The law also mandates the confidentiality of medical information and requires the implementation of appropriate administrative, technical, and physical safeguards to protect the privacy of a patient’s medical information and safeguard it from unauthorized access and viewing, use, or disclosure of medical information. The new law is layered on top of current HIPAA and existing state law.

REPORTING OBLIGATIONS Facilities covered by the new law must report any unlawful or unauthorized access, viewing, or use or disclosure of a patient’s medical information to CDPH and to the patient no later than five days after the unlawful or unauthorized access, use, or disclosure has been detected by the facility.



How Successful Is Your Practice?

If a hospital fails to report a detected breach to CDPH or to the patient, CDPH may assess a penalty of $100 per day after the initial five-day period. It is not clear how this late fee will be calculated for late reporting of a breach of multiple patients’ records.

LIMITS ON PENALTIES The total combined penalty assessed by CDPH for breaches and for late reporting is $250,000 per reported event. “Reported event” covers all breaches included in any single report made by a facility to CDPH, regardless of the number of breach events contained in the report. When CDPH has completed its investigation of a privacy breach, it may refer violations to the Office of Health Information Integrity (OHII).


Let physician pembers know your practice is available for referrals 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 211, a companion measure to SB 541, requires health care providers to prevent unlawful access, use or disclosure of patients’ medical information, authorizes OHII to enforce state medical privacy laws and to assess penalties against individuals for breaches of the Confidentiality of Medical Information Act. OHII will investigate individuals (which includes physicians, nurses, medical records clerks, dentists, therapists, pharmacists and chiropractors) upon receipt of a referral from CDPH. OHII may assess fines against such persons and may also recommend that the person’s licensing board (Medical Board of California or the Board of Registered Nursing), if any, investigate or discipline an individual. The licensing board must review any evidence it receives from OHII, but it has discretion regarding whether or not to discipline its licensee. Health care providers are required to: • implement appropriate administrative technical and physical safeguards to protect the privacy of a patient’s medical information; • Safeguard patient medical information from unauthorized or unlawful access, use or disclosure

PENALTIES Administrative and civil penalties may be assessed against any person or entity, whether licensed or unlicensed which includes $2500 for negligent disclosure and up to Please see Privacy Laws on page 16


Where We Have Been and Where We Are Going: An Update on Air Quality Bills and Legislation by Michelle Garcia, Fresno-Madera Medical Society Air Quality Director Americans and How to Close the Gap” report, email


AB 1404: ensures that policies used to reach California’s global warming pollution reduction goals maximize environmental and public health benefits for the state – particularly through limiting and prioritizing the use of compliance offsets. On June 3, 2009 AB 1404 passed by 44-29. AB 1404, introduced by Assembly member Kevin De Leon (D-Los Angeles) and Manuel Perez (DCoachella) is developed to lower offsets to 10 percent as well as to charge fees to fund validations of their reliability. The bill will help maintain green jobs in the state rather than allow offsets to occur outside California. The bill is also addressing the public health concerns that face the underserved and people of colorwho will be hurt the most. For more information on this bill or to request a copy of “The Climate Gap, Inequalities in how Climate Change hurts

AB 1405: COMMUNITY BENEFITS FUND BILL AB 1405: creates a Community Benefits Fund to direct a portion of the revenues generated through the implementation of AB 32 to help Californians who are least able to confront the expected impacts of the climate crisis at a local level. The Problem: In adopting the California Global Warming Solutions Act of 2006 (AB 32), the State made a promise to ensure that low-income and minority communities are protected from and strengthened by efforts to tackle California’s climate crisis. However, the California Air Resources Board has yet to fulfill this promise. For more information on this bill email

The effect of offsets on criteria air pollution levels in California 8000 CO

Metric Tons per Year in 2020

6000 NOx






PM10 SOx






Offset policies could have a significant impact on criteria air pollutants in California, including total organic gases (TOG) like methane; reactive organic gases (ROG) like benzene; carbon monoxide (CO); and smog-forming pollutants such as nitrogen oxides (NOx) and fine particles (PM, PM10, and PM2.5). The black bars show how these pollutant levels would change if roughly half of the emissions reductions expected under a cap-and-trade system were achieved through offsets generated in California (mostly from the agriculture, landfill, and forestry sectors), compared with implementing AB 32 without offsets. The results are mixed, with decreases in methane but increases in NOx.1 The gray bars show what would happen if all of the cap-and-trade reductions were achieved through the use of out-of-state offsets, compared with implementing AB 32 without offsets. As the chart shows, all air pollutant levels would be higher.


Data source: Roland-Holst, D. 2009. Carbon emission offsets and criteria pollutants: A California assessment. Research Paper No. 081017. March. 1

In the in-state offset scenario, the economic model that was used assumes that every available global warming emissions reduction in the forestry, agriculture, and landfill sectors will be available as an offset. In reality, not every reduction may be easily and cost-effectively quantified, packaged, and sold in the offset market. Therefore, in-state co-pollutant reductions may not be as large as shown in the chart. V I TA L S I G N S / J U LY 2 0 0 9

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The National Blood Collection and Utilization Survey (NBCUS) is a CDC/ CMC/FDA/NIH/AABB sponsored biennial survey of blood centers and hospitals to assess the amount of blood collected and transfused in the United States. According to the recent 2007 NBCUS report, the supply of available allogeneic whole blood (WB) and red blood cell (RBC) units after accounting for test discards was 15,688,000. This number exceeded transfusions of allogeneic WB/RBCs (14,461,000) by a margin of 1,227,000 units – 7.8% of available supply (see figure). And the report indicates that this excess of supply is cause for optimism since these data, combined with the lowest rate of units outdated in recent years, suggests that hospitals and blood centers continue to improve efficiencies in delivering the appropriate product when needed. This WB/RBC supply was provided by 9,553,000 allogeneic donors who successfully gave blood [2,726,000 (28.5%) of whom were first-time donors and 6,828,000 (71.5%) of whom were repeat donors]. These repeat donors provided 11,697,000 donations, the equivalent of 1.7 donations per donor. The total supply of WB/RBCs in 2006 was 16,174,000 units before testing. Compared to total collections from 2004, 2006 collections increased 5.8%. The increase is primarily attributed to a 96.4 % increase in rbc apheresis collections that accounted for 10% of total blood collections in 2006. RBC units collected by apheresis typically yield a double volume of rbcs. Whole Blood and Red Blood Cell Collection and Transfusion, 1989-2006. 16.5 16.0 15.5 15.0

Millions of Units

14.5 14.0 13.5 13.0 12.5 12.0 11.5 Collections Transfusions Available Collection

11.0 10.5 10.0 1989







Survey Year

(Source: The 2007 National Blood Collection and Utilization Survey Report) 10

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Tulare From Mrs. Young’s Winnipeg Garage to the Visalia Fox Theatre by Lyle B. Stillwater, MD, FACS. Otolaryngology, Visalia Past President Tulare County Medical Society 3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431

Some of the most enjoyable and memorable evenings we have spent in Visalia have been attending world-class Rock concerts at the Visalia Fox Theatre such as Peter Frampton (November 2007) and Boz Scaggs on April 27, 2009. My earliest recollection of watching world-class Rock musicians up-close and personal was watching Neil Young and the Squiers in 1963 practice in Neil’s mother’s garage which was one street over from where I lived. Even then, not withstanding the surfer music they played, you knew he was destined for Greatness (my band tried to audition for the local band, the Guess Who, as an Lyle B. opening act, but were never chosen). Stillwater, MD Many years later, while living in the Bay area, I was lucky enough to see the Bee Gees and then Fleetwood Mac live at the Cow Palace and much more recently Bob Seger in Oakland. At that level, it can be like watching Tiger Woods play golf or Michael Jordan play basketball. I started to wonder if I gave a wish-list, to my son, Ryan, and his co-workers at the Fox Theatre in Visalia, of the artists I would most want to see perform at the Fox Theatre, would they pay any attention to anyone’s wish list? Never being one to give up without a fight or at least an old-school try, I would like to present a list of world class Rock performers I would like to see play at the soon-to-be improved/refurbished Visalia Fox Theatre… so here goes… Tina Turner, Stevie Wonder, Fleetwood Mac, Simon & Garfunkel, The Eagles, Led Zeppelin, Pink Floyd, Sting, Crosby, Stills, Nash & Young, James Taylor, AC/DC, Santana, Cream, Blind Faith, Derek and the Dominoes, Pete Gabriel, Genesis, Phil Collins, Eric Clapton, Steve Winwood, Neil Young, Dire Straits, Rod Stewart, Steely Dan, Tom Petty and Heart Breakers, and/or Tessa Claire and the Regurgitators, (my granddaughter’s new band). Anyone of those shows would be a fine kick-off to the Visalia Fox Theatre’s new persona. Some of the ticket prices would be in the stratosphere, but would be well worth the price of admission. Remember to bring ear protection as Neil Young has always played at very high volumes, ask me, I know, and that has not changed in forty-six years.


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

MEMBERSHIP NEWS Did You Know? Physicians that are interested in submitting articles for future editions of Vital Signs should contact Gail Locke, Physician Advocate 559-734-0393. Please don’t miss the rewarding opportunity to articulate your thoughts on any topic, issue, or personal interest you have. Please consider submitting an article to Vital Signs. The publications continued success depends on your contributions. Thank you in advance for your support!

Maui Thatcher Executive Assistant

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.

Shirley A. NealParker, MD OB/GYN Hahnemann Med Col, Philadelphia ’79 575 W. Putnam Ave. Porterville 93257

Oscar A. Hernandez, MD Family Practice UCLA ’90 590 W. Putnam Ave. Porterville 93257

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Mrs. Dana Ramos, TCMS Provider Relations; Dr. and Mrs. Alex Torres

Dr. Michael Levine, Dr. and Mrs. Thomas Gray

CMA Delegate Dr. John Hipskind and Dr. and Mrs. Charles Boniske

Dr. and Mrs. Mark Garfield

Dr. and Mrs. Daniel Jones

TCMS President Dr. Mark Tetz, District VI CMA Trustee Dr. James Foxe and Dr. Sukhvinder Bhajal


The Tulare County Medical Society proudly hosted its annual Wine Social on April 30, 2009 at the Chinese Cultural Center, Visalia. This is one of the social events of the year and highly recommended not to be missed. Napa wineries, including selections from Caymus and Merryvale Wineries were premiered at this year’s event and Brenda Isaac of Ma Cuisine Creative Catering worked her cookery magic and prepared an array of exceptionally scrumptious hors d’oeuvres. Thank you to everyone who attended this event and made it so memorable!


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TCMS Family Day 2009 A Walk in the Park Saturday, September 26 12-4PM Bennett Ranch, Visalia


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

President’s Message Change is coming, and change is coming quickly; like a freight train on a rail. We will not be able to stop this train. We can only hope to help guide its path so that we are not run over by it. In this era, it is very important for physicians to participate in both local societies as well as national medical organizations. Keep this in mind: Congress’ approach to healthcare is like Woody Allen’s quote “I have no idea what I’m doing, but incompetence has never prevented me from plunging in with enthusiasm.” If we do not have adequate active participation by membership and financial support by members, we will not be able to adjust the direction of this oncoming train. For some reason it appears that some physicians believe in the urban legend that if you put a penny on a train track, you can derail a train. It takes more than pennies to protect the practice of medicine and guide the direction of health care reform. We need to be visibly present both in large numbers of members and in our financial support. I hear a lot of physicians say that they are in support of local medical society and national organizations; however, they feel that their dues are too expensive. Let your nonmember colleagues know if they believe in their vocation and lifestyle, they should be willing to stand behind it and support it financially. By freeloading off of your good will and support, they make our efforts harder. Specialists run the risk of losing their income, and those in primary care medicine run the risk of losing autonomy. We have been revisited by ghosts of the past: MICRA and Corporate practice of medicine. We recently averted another challenge to MICRA, which could have resulted in at least a doubling of current premiums for malpractice. Thanks to the efforts of the American Medical Association with support from the California Medical Association the case was defeated. Without a doubt, the savings far exceed five years’ worth of dues annually. The corporate practice of medicine, if allowed to succeed in California, could result in a serious compromise in the physician-patient relationship. Your ability to admit or have surgical privileges may be determined by if you are an employee or not. Decisions could be made with preference to the employee-physician for surgical time or room availability for admission. As a physicianemployee, the threat always exists of being laid off or having cuts in salary due to the downturn in the economy and not in your competence or quality of care. The American Hospital Association survey found that 53% of hospitals were considering staff cuts due to financial stress. Think about it; your decision to do the right thing for your patient could result in your loss of employment if your decision does not agree with the administrator’s point of view. And you thought you didn’t like insurance companies telling you what to do. Remember “Say yes to KCMS.”


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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MEMBERSHIP NEWS KCMS Member Recognition KCMS is pleased to announce a new addition to our website – – “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 ( We value your input!

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.

Guruman S. Kalra, MD Premier Hospitalists of Bakersfield 6401 Truxtun Ave., 93309-0613 661/323-5300 FAX: 323-5455 Email: Medical Degree: U of Hlth. Sciences, India 2001 Internship/Residency: U of Illinois 07/2002 – 06/2005 Board Certified: Internal Medicine 2005 Hobbies: Oil painting, badminton, swimming, traveling, pets and World History

Membership Recap MAY 2009


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KCMS Officers John E. Weisenberger, MD President 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

New Members

Active ...........................................................268 Resident Active Members................................0 Active/65+/1-20hr ...........................................5 Active/Hship/1/2 Hship ...................................0 Government Employed ..................................11 Multiple memberships......................................2

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

Retired ............................................................60 Total .............................................................346 New members, pending dues............................3 New members, pending application ................1 Total Members.............................................350

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


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



Every year when dues are paid it is natural to wonder “What’s happening with this money? Is it really worth it? Why do I keep paying these dues?” We all know the savings we get from MICRA and the excellence of CMA advocacy on legislative issues. Sometimes we get to experience our dues dollars on a very personal basis. I am doing so right now. In September of 2006 we decided to change office locations. We needed a bit more space and a lot more parking. We also had an opportunity to move to a complex with a lab and radiology nearby, something we had not had for over 20 years. At the beginning of October I instructed our office manager to start collecting addresses so we could mail out change of address notification to all of our vendors and payers. In January I told her to mail out the change of address effective April 1. She said that she had everything ready to go. In mid April I saw that we were getting only forwarded mail and no mail with the new address. On questioning my manager she stated that she had decided it would be more efficient to use the forwarding labels from the post office rather than send out our own . All I could do was sigh and put down a mental black mark for her next evaluation. At the end of July the manager came to me and said that we had to send in a special change of address form for Medicare. I helped her fill out the appropriate changes on the 855. She then wanted our articles of incorporation, business license, etc. I went over the change of address forms with her again, pointing out that Medicare only wanted us to note what had changed – our address and phone number. Everything else was to be the same. Two days later she quit without notice. It was then that we found out that Medicare had not paid us for three months and that because she had delayed for over 90 days, we would have to submit new applications for our corporation. The new application was in to NHIC by the end of the week. It only took three months of back and forth before it was accepted and approved. The last month I personally called our contact at least three times a week to help things through. We were fortunate that we are not on assignment so it did not have a large impact on our bottom line. However it did take over a year to get the accounts straightened up and all the payments in the right places. We weathered the NPI changes and Palmetto changes with only minor difficulty. I was actually feeling pretty smug. So it took over six months to change the bank for our electronic deposits. At least we were getting deposits sent to our old account, and we could access the money. Then in May of 2007, Palmetto discovered that some of its billing “switches” had not been set properly. Boom – all our claims were denied because we weren’t enrolled with Medicare. Additionally Palmetto had unilaterally ruled that it would no longer pay claims submitted more than 30 days after the date of service, and you can’t submit claims if you are not enrolled. What the heck happened? Apparently when NHIC had said they had all the information they needed in August of 2007 they forgot that each doctor needed to reapply as well as the corporation re-applying. (They also assigned the corporate and physician NPI numbers to our old address even though we had moved more than a year before.) We had been paid as a corporation but Palmetto would no longer pay unless the doctors were also enrolled. I knew that CMA had a person designated to help with Palmetto problems so I called Michelle Kelly and told her our tale of woe. When I mentioned that I wasn’t convinced it was worth re-enrolling and that I was seriously considering opting out of the program, she was able Please see President’s Message on page 19

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 Ranjit Rajpal, MD Krishnakumar Rajani, MD Daniel Stobbe, MD Philip Tran, MD CMA Delegates: FMMS President John Bonner, MD Denise Greene, MD Clarke Harding, MD Kevin Luu, 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 Glenn Hananouchi, MD Sergio Ilic, MD Peter T. Nassar, MD Shahla Rahmatullah, 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

BYLAWS UPDATE This is to report that due to not achieving the required percentage of returned ballots, the proposed amendment changes to the FMMS bylaws will not take effect.

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Fresno-Madera HISTORICAL CORNER We invite you to become a user of the FMMS Historical Library, Electronics Learning Center and Members Small Conference Room, which is now open to all members of the Medical Societies of Fresno-Madera, Kings, Tulare and Kern Counties. But for now test your memory and historic information!

Well-Being Committee Working to Replace Diversion Program by Toussaint Streat, MD Well-Being Committee, Chair



better hospital building with better Surgical Facilities was needed shortly after the Burnett Sanitarium (that was to become Community Hospital in 1945) was established in Cynthia Burnett’s Fulton and Calaveras Streets Boarding house in 1897. In 1904, the Board built the smaller building in the distance at Fresno and S Streets which became the Burnett Sanitarium until the 1916 construction of the much larger five-story structure next door to the West. The 1916 structure still serves, integrated into the Community Regional Medical Center. For a number of years there was blue neon sign over the door in the middle of the building to identify its entrance at night. Ref: Recollections p. 251.


Using the Library and Learning Center Facilities: open from 8 to 4:30 M-F located in the Society’s office, 1382 East Alluvial #106. The Conference Center may be reserved by calling 559-224-4224 Extension 110. The Library contains historic references in almost all specialties. The Electronics Center provides Internet Access to all Medical Historic Sites. The Conference room is equipped with computer based projection equipment and will seat up to eight for conference and discussion and 14 for a presentation. Come by and see us and browse for a few minutes in your area of choice.

Privacy Laws Continued from page 8 $25,000 for knowingly and willfully obtaining, disclosing and using medical information.

RECOMMENDATIONS • Conduct confidentiality training for all staff, thereafter conduct annually • Have staff sign confidentiality agreements, to include impact on medical records, faxes, email, conversations, release of information on the phone and disciplinary action for violations and fines • Ensure employees know that they can be held individually liable for unauthorized access or use of medical information • Discuss with hospitals how to share inforamtion appropriately


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of June 30, 2008, California’s Physician Diversion Program closed, causing a gap in services. Since then, a coalition of physician organizations, including the Toussaint CMA, has been workStreat, MD ing on a legislatively mandated, independent comprehensive statewide program to replace the Diversion Program. Until a new program is in place, the FMMS Physician Well-Being Committee intends to continue to develop policies and procedures and have a strong program in place as it moves forward to assist physicians in Fresno and Madera counties. It is my intention to have this column be the beginning of an ongoing discussion between our committee and you, the members of the Fresno-Madera Medical Society, to address your health and wellbeing. Over the course of our conversations, I hope to discuss them with you and provide references for your review. In addition, I hope the committee can provide you with concrete ways to enhance your overall self-care in all spheres of your life and share new ways for you to think about well-being. In May 2009, the committee’s leadership and staff attended the “21st Annual Western States Regional Conference on Physicians’ Well-Being” in Riverside, California. It was very fruitful and contained a wealth of information pertinent to this committee’s mandate. Thank you in advance for your time and input. Any questions and/or inquiries may be directed to any committee member or Sheryl Tatarian, committee coordinator at or at 559-224-4224, ext. 12. The 2009 committee members include Drs. John Conrad, Jr., Alex Habibe, James Osborne, Jr., Trilok Puniani, Helen Rockas, Alan Sortor and Charles Touton.

Fresno-Madera MEMBERSHIP NEWS Accolades & Achievements Bonna

Rogers-Neufeld, MD: Inducted as a Fellow in the American College of Radiology. Dr. RogersNeufeld is one of 315 female Fellows out of 3502 fellows nationally to achieve this distinction.

Bonna RogersNeufeld, MD

Congratulations Dr. Rogers-Neufeld. If you know of any “accolades and achievements” by a Fresno-Madera Medical Society member, please call the Medical Society at 224-4224, ext. 118.

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

Visit FMMS’ New Website FMMS’ new website is up and running. Thanks to a grant awarded by the Hewlett Foundation, FMMS was able to hire a website designer for a new site that improves communications with its members and the public with timely news alerts and response mechanisms. This new site will also have members’-only items, such as practice management materials, calendar of events and meetings and FMMS reports.

CALL FOR ALL FMMS MEMBERS’ E-MAILS The members’-only sites can only be accessed with a password and email address. To begin the process, a temporary password will be e-mailed to each member. Members will then have the capability to determine their own permanent password. Please send your email address to FMMS at or to

JULY 8 9 16 21 22

Medical Managers ..................12pm Finance .............................12:30 pm Scholarship...............................6pm MRAC......................................6pm Editorial ....................................6pm

Membership Recap MAY 2009 Active ..................................................701 Leave of Absence.....................................1 Retired..................................................200 Residents ..............................................218 TOTAL ...........................................1,120 Applicants................................................2

FMMS PHYSICIANS… Make sure your Medical Manager and/or Medical Office Staff is part of the Medical Society’s

MEDICAL MANAGERS’ FORUM WE MEET MONTHLY DURING LUNCH TIME in a brown-bag round table setting and host

QUARTERLY SEMINARS addressing current issues that affect your office. All it takes to sign up is a current and active email address!

CALL OR EMAIL TODAY! Sheryl Tatarian Medical Managers Forum Coordinator 559/224-4224x112 • V I TA L S I G N S / J U LY 2 0 0 9

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Fresno-Madera The Vitamin D Explosion by John P. Conrad, Jr., MD Retired Pediatrician

Over the last two years our quiet sunshine cod-liver oil rickets preventing vitamin D has exploded into a hormone like substance that is in every cell of our body. We must change our views and routine to make sure that our patients have adequate vitamin D blood levels to protect against many preventable illnesses. All of the recent studies started in seniors with getting blood vitamin D levels and then dividing the results into normal or low. Ten John P. Conrad, year articles showed that with low levels of Jr., MD the vitamin, the mortality was increased by 50%; then cardiac deaths increased by a factor of 2.42 and then breast, prostate, colon and ovarian cancer were 50% higher. At the cellular level, normal vitamin D values were associated with longer and more healthy telomere length. The first studies were in elders, and from 50 to 90% of them showed low vitamin D levels. Then a wider study of population of all ages revealed that 30% of everyone in the USA were deficient in vitamin D. The most recent studies give the importance of vitamin D for all ages. Vitamin D is important in regulating over 200 genes and 37 major organs. 1. 2. 3. 4. 5.

6. 7. 8. 9.

Vitamin D prevents falls and/or fractures Vitamin D reduces respiratory infections and colds. Vitamin D reduces depression, Alzheimer’s and Parkinson. Vitamin D reduces toxemia in pregnancy. Adequate D in pregnancy and infancy helps prevent Type I diabetes in 30 to 50% of cases according to at least four studies, one each from Finland and Sweden. The others are from Europe. Adequate D in pregnancy and/or infancy seems to prevent asthma. Recent interest has suggested that Autism could be caused by low vitamin D in pregnancy and/or infancy. Low vitamin D in teens has been a problem with obesity, type I and II diabetes. Hypertension is less with normal vitamin D

All doctors should develop their own vitamin D expertise by getting their own vitamin D blood level. Remember that low levels do not present with any symptoms. All patients, at all ages, should be put on 1,000 IU of D-3 supplement until you can get a blood level.; Supplemental D-3 available in 1,000, 2.000 or 5,000IU caps or tabs and 5.000 IU/ml. liquid.


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Risk factors for low vitamin D include: 1. Elderly 2. Darkly pigmented skin 3. Institutionalized or homebound 4. Increased distance from the Equator 5. Winter time 6. Cover-up clothing and/or sunscreen 7. Air pollution 8. Smoking 9. Obesity 10. Mal-absorption 11. Liver disease 12. Kidney diseases 13. Diabetes 14. Pregnancy and the first year of life.

VITAMIN D STATS Vitamin D blood levels – there are minor variations in various studies but these are the average: Vitamin D blood level Condition < 20 ng/ml Deficient 21 to 30 ng/ml Insufficient >30-ng/ml Normal 30 to 120 ng/ml Considered normal range Over 150 ng/ml Toxic levels

SUPPLEMENTAL D-3 GUIDELINES FOR TREATMENT The following daily doses of D-3 will raise the blood level by___ ng/ml after eight weeks of treatment Daily oral dose of D-3 Increases blood levels by 1,000 IU 12 ng-ml 23 ng-ml 2,000 IU 5,000 IU 59 ng-ml 50,000 IU 258 ng-ml Information to the public on vitamin D deficiency is widespread so that we as doctors will need to educate ourselves. Develop your own vitamin D protocol for each patient with adequate oral vitamin D supplement maintaining a normal vitamin D blood level. Remember that vitamin D deficiency is a preventable disease! Editor’s Note: More information is available from the NIH’s Office of Dietary Supplement at vitamind.asp.

CLASSIFIEDS MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words.

President’s Message

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 Continued from page 15 to inform me that you cannot charge a Medicare patient until you have officially opted out of the Medicare Program. Oh, and you can’t opt out until you have been enrolled. Being dropped by Medicare is insufficient. She made a contact for us at Palmetto who is personally shepherding our application through the system. Michelle also said that the CMA is vigorously opposing the new “30 Day” rule as it is taking 30-90 days to process the applications from the time they are received. Sandi Palumbo, the FMMS executive director, also contacted Frank Navarro of the CMA and Stacy Higginbotham of Congressman Radanovich’s office on our behalf... They are also helping us through this mess. With the help of the CMA staff and the ties that FMMS forged with Rep Radanovich under Dr Slater’s presidency I am hopeful that we will be re-instated with a minimum of fuss and dislocation. Stay tuned for the outcome! PS: 6/15/09 Today we got an email that our applications had been rejected because they had not been counter-signed by our “Designated Official.” Both Marshall and I had signed our own applications both as the applicant and as an official of the corporation. We double checked our corporate application. Cynthia Bergmann and Marshall Noel were the names typed in the appropriate spots. However Palmetto has our designated officials as “Cynthia Borgman” and “Neal Marshall.” Palmetto also notified us that they are sticking to their “30 Day Rule.” Palmetto, CMA and Rep Radanovich have all been apprised of this latest mishap. Stay tuned!




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:

Drs. Naeem M Akhtar and Shahla (Durrani) Rahmatullah and Mikhail Alper, PA-C are pleased to announce the association of Dr. Ambreen Khurshid to the practice of gastroenterology at California Gastroenterology Associates at 1382 E. Herndon #104, Fresno. Dr. Khurshid is Board Certified and is accepting new patients. Call 559-438-0017 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 559-439-7123.

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

Professional office building at 7045 N. Maple (Maple & Herndon) near SAMC. 2,500-4,500 sf, $1.60 psf. TI negotiable, will build to suit. Call 559-681-6390 or fax to 559-323-0938. Madera office space; 1,650 sf on West Yosemite Ave. Call Dr. Nassar at 559-674-0917. 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.


MEDICAL OFFICES FOR LEASE 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. – 1,580 rsf. 4040 San Dimas St. – 2,035 rsf. 9508 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. – 2,000-6,000 rsf. 1800 Westwind Dr – 25,036 sf. gross SOUTHWEST LOT TO BUILD Bahamas Dr. – 15,600 sf office

FOR SALE Custom home located in upscale area. 3419 sf; prof. landscaped w/putting green & sports court. Appraised 10/2007 at 805K. Reasonable offers considered. 559-645-0888. Olympus 60cm flexible sigmoidoscope (OSF-2) with cart, suction machine and biopsy forceps. Works well. 559-261-0266. Office space (shell) for sale or lease at Cedar & Alluvial, 2280-4506 sf. 6 parking spaces per 1000 sf. Ample allowances. Call 559-259-3077 or 559-355-8416.

PHYSICIAN AVAILABLE FRESNO / MADERA ANNOUNCEMENT Pacific Medical Center of Hope, Inc. at 1660 E. Herndon #101, Fresno, provides counseling & preventive measures for pts with dementia & their families. Genetic testing available. Referrals accepted with no waiting time for appts. Call 559-435-3725. Gastroenterologist Shahla Durrani, MD has recently changed her name to Shahla Rahmatullah, MD. Accepting patients (559) 438-0017. 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.

Available at this time for a locum tenens position in Fresno. Family medicine and general medicine specialty. Call 559-999-7678.

STAFF WANTED Multi-Specialty Group seeks office manager with 3+yrs exp in a physician office or similar healthcare setting. Email or fax: 559-453-5233.

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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 July  
2009 July