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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

October 2009 • Vol. 31 No. 10

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 October 2009 Vol. 31 – Number 10 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 Robb Smith, MD Roydon Steinke, MD Kings Representative, Sheldon R. Minkin, MD Kern Representative, John L. Digges, MD Tulare Representative, Gail Locke

NEWS PRACTICE MANAGEMENT: Tips for Steering Clear of Problems with Pain-Med Prescribing ..............9 LETTER TO THE EDITOR ..........................................................................................................10 AIR QUALITY: Health Care Reform and Air Quality: Connecting the Dots .....................................11 CME ACTIVITIES .......................................................................................................................19 CLASSIFIEDS.............................................................................................................................19 FRESNO-MADERA MEDICAL SOCIETY .........................................................................................12 • President’s Message • General Membership Meeting • UCSF Launches Medication Consultation Service in Fresno • Medical Students Share $9,000 in Scholarships • Membership News KERN COUNTY MEDICAL SOCIETY .............................................................................................15 • President’s Message • Membership News TULARE COUNTY MEDICAL SOCIETY ..........................................................................................17 • Global Health Care: We Should be Thankful for What We Have: Access

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 apaxton@cvip.net Classified: Carol Rau, 559-224-4224, ext. 118 csrau@fmms.org

Cover photography: First Light Carmel by Newton Seiden, MD

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 / O C T O B E R 2 0 0 9

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Bakersfield

Porterville

Madera

661-663-8663

559-781-2500

559-664-9222

Tulare

Fresno

Stockton

559-688-2500

559-261-0222

209-478-4222

McFarland

Visalia

661-792-5531

559-636-2500


EDITORIAL A New Blood Center for the Valley’s Future by David Slater, MD, Editor, Vital Signs

My column this month has a personal theme, though its subject works tirelessly behind the scene on behalf of all of us. I was privileged to serve nine years on the Board of Directors of the Central California Blood Center (CCBC), and I am the Medical Director of the Transfusion Service at Community Regional Medical Center. Every day CRMC alone relies on around 75 donors to serve its patients’ blood needs. CCBC is the sole supplier of blood to 31 hospitals in Fresno, Tulare, Kings, Madera and Mariposa counties. At a time when many non-profits are struggling, when the expansion plans of many organizations have been iced, and when much of the health care universe is hunkering down in general, it is particularly pleasing to see this project completed. What makes this even more remarkable is that it was finished on time and it required no debt obligations for this non-profit, public benefit (501c3) organization. During my time on the CCBC board, the questions of first whether, and then where, to relocate the Blood Center’s headquarters followed many twists and turns. If you’ve built a building or served on a community board at a time when complex decisions needed to be made, you get the picture. This was a complicated equation with operational, financial, legal, governance, and political considerations all weighing in. Suffice it to say that many people – all of whom wanted the best for the Blood Center’s donors, customers and patients – had a range of reasoned ideas and expressed them to one other. In the end, a great end product emerged. One would be very pleased if current deliberations in Washington DC conclude half as rationally.

We should be proud of the leadership that area physicians have provided CCBC since its founding by forward-thinking Fresno Medical Society colleagues 55 years ago. No physician with us today has devoted more time and energy to the Blood Center than Dr. Donald Knapp. Dr. Knapp served as Board Chairman for many years and is now an emeritus member of the CCBC Board. I asked Dr. Knapp for some thoughts: “It has been a great privilege to have been associated with the Central California Blood Center over the past many years. The Blood Center has always served the five counties area with life-saving blood products when needed. However, as an observer, the Blood Center has evolved to be a major player in the community, not only for its blood products but recognized as a major focal point where individuals come together for a common purpose. Blood drives for specific needs foster lasting relationships. CCBC cherishes the support of the media and organizations that have given support on a regular and continuing basis. The dedication of the staff, employees, volunteers, physician members and public members of the Board, and Administrative Members has permitted the Blood Center to grow to what it is today. The past eight years, because of the total community support, CCBC has not had to import one unit of red blood cells to meet the needs of the community. This speaks to the dedication of donors supported by all of the above. Please see New Blood Center on page 6 V I TA L S I G N S / O C T O B E R 2 0 0 9

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Electronic Medical Records Freedom to practice medicine on your terms

Fresno Mayor Ashley Swearengin speaks at the dedication ceremony of the new CCBC facility.

New Blood Center Completes Construction by Patrick Sadler, MD Medical Director, CCBC

Central California Blood Center is proud to announce the successful completion of new construction and the Grand Opening of our new Fresno headquarters (administrative offices), donor center, and laboratory. The new 60,000 sq. ft. building is located on 8 acres at the S.E. corner of Herndon and Blythe in Fresno (4343 W. Herndon Ave.). plee@realtimeca.com www.realtimeca.com

Groundbreaking for the new building project was September 3, 2008, and construction on the building was completed in only 10 months, by mid-July 2009. Moving to the new facility from our old location at 3445 N First St. was accomplished in two phases: phase one over the July 24 weekend (administrative and support staff), and phase two over the August 8 weekend (selected donor services department staff and equipment, and all Laboratory staff and equipment). Apheresis (automated) donor collections were started at the new facility on August 10, 2009. The first blood donations at the new facility were made by Dean and Claudia Eller (along with son, Jeff, and daughter-in-law, Lisa). Dean is the President and CEO of the blood center. The donor center at the new facility is being dedicated in memory of Jenny Eller, Dean’s and Claudia’s daughter, who was an outspoken supporter of the blood center until her untimely death. Sadly, Jenny died in 1995 at age 21 from leukemia. The Jenny Eller Donor Center at the new facility is named in her honor. A formal dedication ceremony at the new facility was held August 28, 2009, attended by over 350 invited guests and dignitaries, including Fresno Mayor Ashley Swearengin. The public Grand Opening took place the entire week of August 31, 2009. Whole blood collections were started at the new facility this week and donors received a special commemorative T-shirt. The new Central California Blood Center was designed by Henderson Architectural Group. Michael R. Tolladay Construction was the general contractor on the project. The old blood center location at 3445 N. First St. in Fresno is still open, functioning now as a satellite collection site for whole blood and rbc donors only. As always, we thank you for your continued support of our lifesaving mission. Please drop by our new home to say ‘hello’ and, of course, to donate if you’re able!

New Blood Center Continued from page 5 The opening of the Jenny Eller Donor Center at the Central California Blood Center was a tremendous achievement and will serve the needs of many for a long time to come.” Editor’s Note: Want to see the new Jenny Eller Donor Center up close and personal? Roll up your sleeve sometime, doctor. Readers in Kern County, please do the same for your Houchin Blood Bank. 6

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CMA NEWS CMA’S SUPPORTS AND CONCERNS RELATED TO HEALTH CARE REFORM PROPOSALS

While CMA supports the coverage expansions, market reforms and physician payment fixes in HR 3200, they continue to have a number of misgivings. Although last minute amendments delinked the public plan payment rates from Medicare and allows negotiated physician payment rates with Medicare as the floor, CMA continues to have concerns about a number of provisions related to the public plan option, scope of practice expansions and other issues. To protect patient choice and ensure competition among public and private health plans within the exchange, CMA believes that it is imperative that the health plan market share be closely monitored. If market domination emerges, consideration must be given to countervailing market principles, such as antitrust relief for physicians to jointly negotiate with the health plans. HR 3200 includes nearly $400 billion in Medicare and Medicaid physician payment fixes, including rebasing the Medicare Sustainable Growth Rate formula to eliminate future cuts, a five percent bonus for Medicare E & M services and increasing Medicaid rates to Medicare levels for primary care doctors. CMA wants to make sure these important provisions are protected in the bill for the best possible end-game outcome. The biggest fight facing California physicians is a proposal from providers and representatives in the Midwest states to implement a “value index,” which is currently being discussed in the Senate Finance Committee. The value index, which is being proposed in the name of controlling costs and improving efficiency, would effectively shift billions in funding from highercost places like California to lower-cost places like Minnesota, Wisconsin and Iowa. California physician cuts could be 10 to 15 percent. CMA believes it is unacceptable to consider such fundamental changes to the Medicare geographic payment formula without further study to understand what accounts for the difference in medical practice costs by regions, such as practice costs, ethnic diversity of the population and socioeconomic status of patients. The biggest source of health care spending is lack of access to care, not regional overspending. When patients don’t see a primary care physician, health problems can develop and fester into more-expensive-to-treat maladies. CMA believes health reform should focus on practice, costsaving, preventive care. Congress should promote primary care, prevention and care coordination to reduce unnecessary ER visits and hospitalizations. In contrast, the value index and proposals like it would reward doctors and patients with the least challenges and short-change the regions with the biggest health care needs. This short-sighted approach would do nothing to improve efficiency and reduce costs. CMA is aggressively fighting the value index and other similar proposals. CMA and others in organized medicine were successful in removing a similar cost-cutting proposal from HR 3200, the House health reform legislation. The bill, as currently written, would instead give the Institute of Medicine (IOM) one year to complete a study on regional variation in costs and quality

of care, including an analysis of practice costs and patient socioeconomic and health status factors and make recommendation to the Department of Health and Human Services.

SUPREME COURT UPHOLDS CALIFORNIA’S MALPRACTICE REFORM LAW

The California Supreme Court has declined to review an appeals court ruling that upheld the constitutionality of California’s landmark Medical Injury Compensation Reform Act. (MICRA). The CMA-sponsored law 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 providers. 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 noneconomincal damages deprived Mr. Van Buren of his constitutional rights to a jury trial. They also argued that the cap violates constitutional provisions that prohibit the legislature from exercising judicial powers, as well as the equal protection clauses of the state and federal constitutions.

CMA OFFERS ASSISTANCE WITH SIGNING CONTRACTS

Physicians

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: www.cmanet.org/member (click on “Reimbursement Advocacy” under “Physician Advocacy” in the main menu.

CMA HOTLINES AND MEMBERSHIP BENEFITS • Membership Help Line: 800-786-4262 • Legal Information Line: 415-882-5144 • Reimbursement Help Line: 888-401-5911 • Contract Analysis: 415-882-3361 • Legislative Hotline: 866-462-2819 • Medical-Legal Documents: On-Call at www.cmanet.org/member

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Now, more than ever.

Reducing health insurance expenses must be a priority for every physician. In the current economic climate, spending more than you have to for health insurance doesn’t make sense. As premiums continue to increase, don’t accept the status quo. There are ways to provide health insurance while effectively managing your expenses. These are just a few of the strategies that Marsh has used to assist many group practices to help reduce health insurance premiums:

High Deductible Health Plans – Our physician clients, particularly those over age 50, are taking advantage of this cost reduction strategy. Significantly reduces premiums and enables you to open a health savings account. Most physicians should review this strategy. Rate Adjustment Factors (RAF) – For groups of 6–50 employees, insurers reduce the RAF for new business placing health insurance “on sale”.

Why not use one of your member benefits and let us help you select a strategy that works best for you. Call a Marsh Client Service Representative today at 800-842-3761 for more information. Sponsored by:

Fresno-Madera Medical Society Kern County Medical Society Tulare County Medical Society

Administered by:

Compare – Rate competitiveness and plan design varies by insurer, type of plan (PPO, HMO or HDHP) and location. We work with many insurers to find the right plan designs to meet your group health insurance needs. There is a special discount available only to CMA members through Blue Shield. Health Savings Accounts (2009 limits) – Contributions of up to $3,000 for individuals and $5,950 for families; plus another $1,000 if you are between ages 55 and 64. Unused funds roll over each year to be used for future medical, dental and vision expenses. HR KnowHow – Provides the latest information on group benefit plans and compliance issues for employers. Available at no cost to Society members who purchase their group health insurance through Marsh. 8

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42581 (10/09) ©Seabury & Smith Insurance Program Management 2009 d/b/a in CA Seabury & Smith Insurance Program Management • CA License #0633005 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • CMACounty.Insurance@marsh.com www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).


PRACTICE MANAGEMENT

Tips for Steering Clear of Problems with Pain-Med Prescribing by Mary-Lynn Ryan, Risk Management, NORCAL Mutual Insurance Company and the NORCAL Group

The

following tips will help you prescribe narcotics/opioids appropriately to patients in chronic pain: Obtain a thorough history and determine the specific cause of pain. In an article on treating patients’ pain, Eliot Cole, MD, a physician associated with the American Academy of Pain Management, advises, “Do not call [a patient’s] pain a headache or backache but try to find a specific pathological process to explain why your patients hurt.”1 Stephen Richeimer, MD, Chief of Pain Medicine at the University of Southern California, says, “Assessment is a key issue. The history and physical examination provides the information that allows the physician to judge if the patient is legitimately in pain or if the patient is improperly seeking drugs.”2 Document well. Cole advises, “Chart everything you see, think, feel, and hear about your patients. Leave nothing to the imagination of the future reader… Explain what you are doing, why you believe opioid analgesics will be helpful or continue to be helpful, what alternatives have been considered, that your patient agrees to the treatment, and how you intend to follow your patient over time.”1 Richeimer agrees: “Good record keeping is part of good medicine, and it is also your best protection from frivolous lawsuits,” he says.2 Ask chronic-pain patients to agree to use a single pharmacy. Discussing pain treatment with the patient and getting the patient to agree to certain parameters associated with long-term pain management are mutually beneficial strategies: they help you avoid inadvertently supplying medication that might be diverted for street sale, and they reassure the patient in pain that he or she can count on obtaining needed medication. An especially useful rule is that the patient will use a single pharmacy for all pain medications. Make use of a written pain medication agreement with chronic-pain patients. A signed agreement by the patient that he or she will follow rules for obtaining pain medication will

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improve the likelihood of appropriate behavior by the patient. It discourages patients from seeking an unlimited supply of medication and helps staff members verify the legitimacy of refill requests. Monitor patients over time on their needs for and use of pain medication. Richeimer observes that patient trustworthiness “can only be assessed by monitoring the patient over time.”2 Cole suggests talking with patients periodically to reduce dosage appropriately, as well as periodically ordering “urine drug screens for… patients of concern to document that you are able to recover their prescribed medications.”1 If you keep controlled substances in your office, establish a reliable process for safeguarding and reconciling such medications and for tracking their distribution. The federal Drug Enforcement Administration (DEA) requires physicians who administer or dispense controlled substances from their offices to have effective controls to guard against theft and diversion. Controlled substances must be stored in a securely locked, substantially constructed cabinet. Using a controlled substances inventory log can help you account for each and every dose of medication that goes through your office. These strategies are aimed at fostering appropriate pain management within the limits of professional practice. Furthermore, they can help physicians and staff consistently meet regulatory requirements on the management of pain medications. References 1. Cole E. Prescribing opioids, relieving patient suffering, and staying out of personal trouble with regulators. The Pain Practitioner. 2002;12(3):5-8. Available at: http://www.aapainmanage.org/literature/PainPrac/V12N3_Cole_PrescribingOpioids.p df. Accessed June 3, 2009. 2. Richeimer S. Opioids for pain: risk management. California Society of Anesthesiologists Online CME Program. Available at: http://www.csahq.org/cme2/ course.module.php?course=3&module=12. Accessed June 3, 2009. Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL insureds. To learn more, visit www.norcalmutual.com/cme.

DATE!

29TH ANNUAL CENTRAL VALLEY CARDIOLOGY SYMPOSIUM • SATURDAY, NOVEMBER 7, 2009 featuring – David B. Badesch, MD, FACP, FCCP University of Colorado Barry H. Greenberg, MD University of California, San Diego Jason T. Lee, MD Stanford University 6 hours, CME credit: $75 Call 559-224-4224, ext. 118 or csrau@fmms.org

Topics: • Improving Outcomes of Acute Heart Failure including Cardiorenal Syndrome • Variable Presentation and Pathophysiology of Acute Heart Failure Syndrome • Early Detection and New Classification of Pulmonary Hypertension • Management & Treatment Options for Pulmonary Hypertension • Endovascular Therapy for Acute Limb Ischemia • Treatment Strategies for Abdominal & Thoracic Aortic Aneurysms

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LETTER TO THE EDITOR

Dear Editor:

FOR LEASE FOUR-STORY CLASS-A MEDICAL OFFICE BUILDING • On Community Regional Medical Center downtown campus • Adjacent parking structure • Steps to all key hospital facilities • State-of-the Art electrical and HVAC systems • Attractive exterior design; efficient floorplanning

Contact Michael Schuh / Scott Buchanan

(559) 221-1271 www.colliers.com/fresno

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I am writing to take issue with comments by Dr. Weinberg and Dr. Bergmann in your September issue. First Dr. Weinberg’s history is frankly distorted. Health insurance did not begin in the 70s, but in the 40s during and after WWII. Although there was federal legislation defining a class of HMOs, the push for managed care came from corporate America, to fight their inflating insurance premiums. Physicians, frightened of losing their patients, signed up in droves, as they had for Medicare a decade before, not because any one was forced to. Charity care by individual physicians stopped being an effective way of serving the uninsured when good medical practice required modern lab services, a radiology suite, and more pharmaceuticals than would fit in our black bags. The reality is that we have rationing in this country now. We ration by way of the family budget. We have long waits in the ER and at home for those who put off the doctor visit because they cannot afford the tests and the treatment. Our rationing is not just costing time but costing lives. I am also curious that Dr. Bergmann describes the Canadian, British, and German systems as failed. These are three different systems, yet each produces better health statistics at a much lower cost than the American “system.” Additionally, repeated polling over the past two decades has shown that both citizens of these countries and physicians working in these countries’ health care systems, are much more satisfied with their countries’ health care than are either American citizens or American physicians. So where is the failure? Good legislation and policy like good diagnosis and treatment require accurate data, not personal bias. He or she who does not know the past is doomed to repeat it. Sincerely, Michael V. DeLollis, MD


AIR QUALITY

Health Care Reform and Air Quality: Connecting the Dots by Michelle Garcia, Air Quality Director

Some say that reform is the secret to improving our health care system, while others say it will not improve the health care system. This has been debated all summer long. What you may have not heard is how smart growth and healthy lifestyle choices can improve our health care system. A recent article “Reform may not improve health care” by Dr. John Telles in The Fresno Bee laid out the connection very clearly. The article cites simple and cost free things that can help reduce the burden to the health care system and on your wallet. Choosing active transportation options such as walking and biking not only improve respiratory health by reducing air pollution but also promotes general health and well-being through increased physical activity. Healthy lifestyle choices are important for so many reasons and can best be supported by smart growth policies that make these choices inviting and convenient. Senate Bill 375 (Steinberg 2008) is landmark legislation that aligns regional land use, transportation, housing and greenhouse gas reduction planning efforts. It requires the Air Resource Board to set greenhouse gas emission reduction targets for passenger vehicles and light trucks for 2020 and 2035. The targets are for the 18 Metropolitan Planning Organizations (MPOs) in California. These MPOs are responsible for preparing Sustainable Community Strategies and, if needed, Alternative Planning Strategies that will include the regions strategy for meeting the established targets. Ambitious targets are believed to be the key to California’s fight against air pollution and chronic disease.

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SB 375 will help champion smart growth with the planning of sustainable, mixed use communities around mass transit. Walking and cycling which will reduce greenhouse gases will also provide other harmful air pollutants and provide opportunities for improved health outcomes such as: Reduced exposure to air pollutants such as ozone, particulate matter and toxic air contaminants Increased walking and bicycling to everyday destinations and therefore increased physical activity which can reduce obesity, diabetes, depression, and a range of other negative health outcomes More equitable access to nutritious foods and health care services can help to reduce the prevalence of chronic illnesses Reduced injury and death from traffic accidents and encouraged physical activities For more information on the public health benefits of smart growth and how you can become involved to promote healthier, more livable communities, contact Michelle Garcia, air quality director at 559-224-4224 ext. 119 or airquality@fmms.org.

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ASTHMA UPDATE: ENVIRONMENTAL TRIGGERS & MANAGEMENT • OCTOBER 29, 2009 • 6-8 PM Doctors John Balmes and Kathy Hammond of the University of California, Berkeley will present new data collected by the local FACEs study, which focuses on the enviromental triggers that effect asthma and its management. Information will also be presented on current treatment strategies for asthma and local resources that are available for physicians and patients for treating and manageing asthma. FMMS offices: 1382 E. Alluvial Ave. • RSVP: 559-224-4224, ext. 118 CME: 1.5 hours credit • FMMS member; No charge • Nonmember: $15

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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

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 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 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

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“Health Care Reform” is still in a state of flux. After the August recess a large portion of the Congress is aware that the majority of Americans are not in favor of the current bills and proposals. As of September there are still efforts to come out with a bipartisan bill. I believe that some bill will eventually be presented and passed that will be considered “Health Care Reform.’ The goal should be universal ACCESS not universal COVERAGE. I have a few items that I think are essential for any changes in how we distribute and pay for health care in this country. I would like you to not only consider them but also feel free to add your own. Eliminate “Budget Neutral” from the process. As long as we allow the government to pit one doctor against another, we will all lose. It should not be a case of the Midwest gets paid more and California gets less, that primary care gets more and specialists get less, or that radiologists get paid for x-rays, bone density tests, and ultrasounds, but orthopedists, endocrinologists and obstetricians do not. Fixing the Geographic Cost-Price Index (GPCI) and rebasing the Sustainable Growth Rate (SGR) to eliminate the January 2010, 20.5 percent cut to Medicare rates need to be done post haste. Separate social services from the health care system budget. Other countries have extensive social service systems that provide care for the ill and disabled. In our country both Medicare and Medi-Cal will pay for nursing home and in–home care. I have not been able to determine the total amount that the federal government spends on what is essentially a social service (board and care) but is charged to the health care system. I doubt that it is inconsequential. Change health insurance rules so that the ability to have and keep insurance is no longer linked to employment. Have pooled risk sharing, be able to carry insurance from one community to another, and eliminate pre-existing conditions, enrollment periods, and exclusions. These reforms would provide coverage for at least one-third of the currently uninsured. Make everyone have proof of health care coverage for catastrophic illness. In Fresno County a healthy family of four can obtain coverage with a $7,000 deductible and $5,000,000 per person maximum lifetime coverage for $173 a month. You’ll note I did not say that everyone had to have insurance. For those who are wealthy enough or who have their health care paid for in other noninsurance fashions such as a trust fund, posting a bond to prove ability to pay for illness should be sufficient. Extend the malpractice reforms like we have in California’s MICRA to the rest of the nation. A system of compensation for medical injuries based on Workman’s Comp might also be a possibility, though one that really would take considerably more time to work out than the four months President Obama has given the Congress. Ensure that there is a direct way for physician-to-physician appeal for any denied patient service. The physicians should be of like specialty and qualification in order to help assure that patients receive appropriate treatments, testing, and medications. As you read my list and prepare your own, be aware that you need to take action. Both the CMA and AMA have talking points available on line for additional information. A letter to your senators and congressman signed personally by you and sent via USPS is much more powerful than an email or even a phone call. Schedule a meeting with your representative or his staff. Write a letter to the editor, call your local radio or TV station for an interview. Ask your friends and relatives to contact their representatives as well. If we do not do this for ourselves, we will surely have it done to us.

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Fresno-Madera UCSF Launches Medication Consultation Service in Fresno The

UCSF School of Pharmacy has launched a Medication Management Service in Fresno to address the urgent need among California Central Valley residents and their health care providers for assistance in managing their prescriptions. Through the program, patients meet one-on-one with an experienced faculty clinical pharmacist to evaluate the prescriptions they currently use, ensure the medications are safe and effective for them, and help them manage their daily drug regimens. The faculty work collaboratively with the patients’ health care providers and communicate directly with providers via email, telephone, face-to-face visits and forwarded progress notes (for inclusion in provider’s patient chart). The service includes a complete medication review to identify any duplicate or unnecessary medication therapies, assess which medications are best for the individual patient, resolve medication-related problems and help patients adhere to their drug schedules. These consultations include advice on which over-the-counter drugs or herbal supplements might interfere with or enhance patients’ prescription therapies. Faculty pharmacists also advise health care providers on medication options, as well as possible medication interactions for patients on multiple prescriptions. In addition, faculty pharmacists help patients identify lowercost solutions to their medication needs, where necessary, and help low-income patients find and apply for medication assistance

programs for which they are eligible. These programs help eligible patients get free access to medications. “As patient advocates and UCSF faculty, we have heard many Fresno residents voice an unmet need for medication consultation services in the Central Valley,” said Nancy Nkansah, PharmD, MBA, director, UCSF Medication Management Service, Fresno. “We decided to take the services we offer in other California cities to Fresno and to tailor these services to meet Fresno’s needs.” Fresno currently has only four primary care clinical pharmacists with advanced training for every 100,000 residents, in an area with high levels of chronic diseases, such as diabetes and heart disease. The program is the first of its kind in the Central Valley and serves patients throughout the area. Medication management services have been widely recognized in the biomedical literature as a successful approach to helping patients manage, adhere to, and afford their medications, Nkansah said, but added that such services are often only found near academic medical centers or in isolated practices and are rarely accessible to the entire community. Appointments with the UCSF Medication Management Service can be made online at http://mms.ucsf.edu, by sending an appointment request to mms@fresno.ucsf.edu or by calling 559499-6511. Health care providers can download a referral form at http://mms.ucsf.edu.

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

James Anthony Reid, MD *PD CCP 6235 N. Fresno St. #103 Fresno 93710 559-449-4350 Univ of Oklahoma ’03

Retired Physicians The Fresno-Madera Medical Society wishes the following physicians a happy and fulfilling retirement from active practice and a special thank you for their years of membership and service.

Bernard Freeburg, MD GYN Leonard Thompson, MD PD

Medical Students Share $9,000 in Scholarships Seven medical students from Fresno and Madera counties have been named as scholarship recipients by the FMMS Scholarship Foundation. The following students will share grants totaling $9,000 for the 2009-2010 academic year. Bonnie Her: 4th year, Drexel Univ. College of Medicine Peter A. Michas-Martin: 4th year, New York Medical College Peter Anaradian: 2nd year, St. Louis Univ. Harshith Avula: 2nd year, Univ. of Calif. San Diego Ethan Neufeld: 2nd year, Loma Linda Univ. Nathan Singh: 2nd year, Univ. of Calif. San Francisco Angela Hernandez: 1st year, Univ. of Southern Calif. Charles Achki, MD Scholar: Bonnie Her: 4th year, Drexel Univ. College of Medicine The Scholarship Foundation was created in the 1960s for the purpose of aiding the medical education of local area medical students. The Foundation was initially funded through the Sabin Oral Polio Sunday clinics in 1962-63. The organization continues to utilize interest from the invested money, as well as memorial contributions.

SCHOLARSHIP FOUNDATION ANNOUNCES BOARD NOMINATIONS The Fresno-Madera Medical Society Scholarship Foundation announces its nominations for Board members and officers for 2010: Charles Touton, MD – President David Slater, MD – Vice President Christine Lopopolo, MD – Secretary/Treasurer NEW BOARD MEMBERS (three-year term): William Ebbeling, MD; Brian Ginsburg, MD; Stewart Mason, MD; Andre Minuth, MD; Michael O’Shaughnessy, MD; Steven Stoltz, MD; and David R. Taylor, Jr., MD.

SAVE

THE

DATE!

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

OCTOBER 7 13 15 20 21 26

FMMS GENERAL MEMBERSHIP MEETING Wednesday, November 4, 2009 TorNinos Banquet Hall • 6:00 pm

Medical Managers . . . . . . . . 12pm CME . . . . . . . . . . . . . . . 12:30 pm Membership. . . . . . . . . . . . . . 6pm MRAC. . . . . . . . . . . . . . . . . . 6pm Editorial . . . . . . . . . . . . . . . . . 6pm Board of Governors . . . . . . . . 6pm

ROLAND STUCKY, MD

Membership Recap

57-year member

AUGUST 2009

Roland Stucky, MD, a retired general practitioner and surgeon, passed away on

Active ..................................................655 Leave of Absence.....................................1 Retired..................................................201 Residents ..............................................239 TOTAL ...........................................1,096 Applicants................................................0

August 9, 2009 at the age of 85. Dr. Stucky was born in Kansas in 1924. He received his medical degree from the University of Kansas in 1958 and completed his internship and residency at Kaiser Hospital in Oakland. In 1951 he opened his medical office in Kingsburg and practiced there for 35 years. He retired in 1986. Dr. Stucky is survived by his wife, three children, six grandchildren and one great-grandchild.

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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 FEAR TRUMPS REASON, REASON TRUMPS FAITH, FAITH TRUMPS FEAR

In this health care debate, we reason that to provide

health care is a moral issue that runs as deep as “Am I my brother’s keeper?” It is framed around eight principles: • Affordability of health care for all Americans and Legal residents

website: www.kms.org

KCMS Officers Bradford A. Anderson, MD President Mark L. Nystrom, MD President-elect

• Transportability of insurance

Portia S. Choi, MD Secretary

• Eliminating pre-existing conditions

Ronald L. Morton, MD Treasurer

• Reducing long-term growth of health care costs • Investing in wellness and prevention

John L. Digges, MD Immediate Past President

• Improving safety and wellness • Guaranteeing choice of doctors and health plans • Protecting families from bankruptcy of debt because of health care costs I recently attended two circuses disguised as health care town hall meetings. Every vile fear was expressed in its glorious ignorance, which reminded me of the disquietude that occurred during the civil rights movement. It presented as anger against our fellow citizens and the government that would have the audacity to support that change. The health care circus has left town. The tent stakes have been pulled up and the clowns removed their make up exposing their true selves. So the question arises: where do we go from here? I suggest a game that may lead us out. Growing up, we would play a game called rock, paper and scissors, (Roshambo) Roshambo may have taken its origin from Asia, Africa or Europe. The game may actually help us reason our way through this health care reform maze. On the count of three, two players would present a hand sign corresponding to one of the three objects. The character of the object would determine if it would overcome the challenge. Rock would crush scissors, paper would wrap up rock, and scissors would cut up paper. As in the book “Assault on Reason”, we can take these same principles to see if they govern how we process the acceptance of change. For example, one would substitute fear for rock, reason for scissors, and faith for paper. Fear trumps reason, reason trumps faith, and faith trumps fear. We are currently in the fear stage of the process. The fight or flight portion of our nervous system is in play. The very thought of the possibility of change becomes synonymous with enuresis. Every boogie man has yelled Boo! And we flinched.

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

If we want to trump this phase, we must re-establish our faith in each other. Knowing that we, American physicians, when faced with a crisis, band together and find a solution that is fair and equitable. Yes, just like after being scared from the movie creature jumping in front of the screen, we must take a breath, collect ourselves, and laugh at our foolishness of being afraid. The eight basic principles are a foundation to build upon. To do nothing is not an option. We must now be engaged in the process. Our task is to find solutions that will make the principles work. Change the way we look at the delivery and reimbursement in the system, preserve our autonomy, and educate and accommodate the health needs of America. This is a task we can accomplish. To paraphrase Michelangelo “Our folly is not that we aim too high and miss, but that we aim too low and reach it.” The Straight Dope, July 10, 2001 The Assault on Reason, 2007

V I TA L S I G N S / O C T O B E R 2 0 0 9

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Kern

Kings

MEMBERSHIP NEWS

KCMS Alliance Says “GoodBye” to a Long Time Member

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

ELLA LOUISE DAVIS March 10, 1936 - August 31, 2009

Ella was born in Radisson, WI. She attended Minnesota Bible College, graduating with her Bachelor of Christian Education Degree. She married Philip Davis August 22, 1959 and just celebrated their 50th wedding anniversary. The Davis family moved to Bakersfield in 1969. Ella was a “multitasking” woman – she was KCMS Alliance President from 1988-89 and continued to serve on numerous committees; for over ten (10) years she was a driver for the American Cancer Society transporting patients to their appointments; Board member of the Sierra Christian Service Camp; a faithful member of Christ’s Church of the Valley – serving as a Sunday School teacher, choir member, head of the kitchen and recently as a Deaconess. Ella could best be described as a servant’s heart. She loved people and was happy to serve in any possible way. She faithfully fulfilled any promised task – even the unpleasant ones. She loved her family and was a rock of support for them. She touched the lives of innumerable people throughout the years. Her persistent statement was “I’ve lived over 72 years in good health. Why should I complain now?” Ella will be greatly missed by all that knew her, especially the KCMS staff. When Mrs. Davis called and asked for anything, we never hesitated to help her and she always “rewarded us with home baked goodies”! She truly was a very special lady!

Membership Recap AUGUST 2009 Active ...........................................................264 Resident Active Members................................0 Active/65+/1-20hr ...........................................3 Active/Hship/1/2 Hship ...................................0 Government Employed ..................................11 Multiple memberships......................................2

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O C T O B E R 2 0 0 9 / V I TA L S I G N S

Retired ............................................................60 Total .............................................................340 New members, pending dues............................3 New members, pending application ................0 Total Members.............................................343

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 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

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

Women waiting in line to be screened.

Global Health Care: We Should be Thankful for What We Have: Access

Board of Directors Thomas Daglish, MD Karen Haught, MD Mark Reader, DO Ahmad Shahroz, MD Gaurang Pandya, MD

by Gaurang Pandya, MD Director, Secretary, Pandya Family Foundation Inc.

In 2004 two years after diagnosis, my mother-in-law passed away in India due to advanced breast cancer. She never had a screening examination. Looking more into it we realized that in Ahmedabad/Gujarat, there is no system for deployment of resources for people’s education, early detection and management of breast cancer. The reasons for this are many. Thereafter we established a charitable Pandya Family Foundation with a mission to increase awareness of value of early detection of breast cancer. We decided that in an unscreened population with lack of access to physicians, mammography and education regarding early detection of breast cancer, the best initial screening should be awareness and breast self examination. We then set up a simple plan to go to women who are the biggest stakeholders and beneficiaries of early detection. Looking for a potential opportunity to pass on our message, in 2008 and 2009 some of us visited India three times. We looked for opportunities to collaborate with Government Department of Health and local NGOs. In June and November 2008, armed with multiple silicone breast models with hidden small to medium size lumps and method of Dr. Pandya with patient. teaching women, we set up camps in city of Patan. The women from ages 14 to 60 attended the camps. After going through the training we gave them pink ribbons to put on and to talk about it and teach and encourage other women who were not present. We felt good when the women leaders of this group asked about how to buy the silicone breast models to carry this on. We gave them our models that we had. In the summer of 2009, we took this effort a notch higher. We partnered with two different nonprofit organizations doing clinical work in Gujarat, India. This time our team also included four female medical students from Philadelphia. Our first partner was Trust for Reaching the Unreached (TRU). We helped them survey and screen the tribal population around the remote town of Shivrajpur. With this NGO we traveled to a different village for five consecutive days. We interviewed patients, we took their blood pressure

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

Please see Pandya on page 18 V I TA L S I G N S / O C T O B E R 2 0 0 9

page 17


Tulare Pandya Continued from page 17 and checked finger stick blood sugar, asked them to stop smoking, counseled them on other complaints, and taught women selfbreast exam on the silicone models and gave them a screening clinical breast exam. We found several biopsiable lesions. This time I had taken a laptop-based ultrasound system with me, and I was able to do ultrasound guided FNAs at the base camp for those who followed up. We taught the NGO employed outreach female workers how to teach the technique of self-examination with the use of breast models that we gave them. Hopefully they will carry this effort forwards. Our second partner was Shamalaji Community Hospital, a 30bed rural government hospital being managed by two retired physicians from Philadelphia, Dr. Haren Joshi and Dr. Pratima Tolat. This facility does not have Ultra sound equipment. Here our focus was more on ultrasound-based screening, breast selfexamination teaching and clinical breast exam. I performed breast ultrasounds on women who were referred after screening clinical breast exam, identified thyroid masses, and did screening abdominal and pelvic ultrasounds on people complaining of abdominal pain. I found a variety of pathologies, including hydronephrosis, renal calculi, liver abscess, liver tumor, uterine tumors, thyroid goiter, breast tumors and ovarian cysts. Some of these resulted in same or next day surgery on site at the hospital. About 272 patients were screened by ultrasound in five days. The breast cancer education and screening was continued, and 370 women were taught over five days. We were successful in training the staff nurses at Shamalaji on the relevance of early detection of breast cancer, and taught them how to teach patients self-breast exam. Now the hospital will maintain a breast cancer education program. Two mornings during the week in Shamalaji all these activities were carried out at sites in interior villages. At Shamalaji Hospital we were able to collect and donate sutures for the benefit of low-income patients. These sutures had been donated to the students of the International Health Organization at Temple University School of Medicine, for a charitable purpose. Although we took prophylactic medications, food and water precautions some of us picked up malaria and gastrointestinal disorders that required treatment. We had to drink boiled water from bottles that we carried on us. We could not trust any food or drinks. The local women got their water from open wells as you see in the photo. Some people live in huts and work on small farms with their bullocks and sow seeds by hand and hope for a crop depending on monsoon rains. In some places the women deliver their babies at home where a local midwife is paid about 50 rupees, about $1 to deliver. The cord is at times tied with whatever cloth thread is available in the hut and is cut with any available sharp instrument. There is no Medicare or Medicaid or social security. Most health care is paid by cash, if you have cash then you have access to health care. If not then you could go to distant government staffed and run clinics to see if they can help you with their limited abilities, if not then you go home and wait for nature to take its course. If you get better then thank God and if you die then family would say, “so was God’s wish.” 18

O C T O B E R 2 0 0 9 / V I TA L S I G N S

Women getting water from an open well.

Here in a small town like Porterville we can get safe drinking tap water. The high quality and safety of food in grocery stores and restaurants is expected. We have effective EMS system and trauma networks. Mammography programs are monitored by FDA, physicians have to keep up with CME and get relicensed every two years. These are only some of the high lights of what we have that the most of the world does not. This is so, due to the deployment of systems of licensing and expectation of quality of products and services. The credit goes to the physicians and clinicians of our and past generations who did identify preventable and manageable health related issues, conditions and their causes, helped design systems of prevention, early detection and effective management and took leadership in helping people to implement various systems for people’s benefit. We plan to go back to India and may be other places as it also reminds us how good we have it in Porterville. Comparing the systems around the globe I found that the improvement in the health status of people depends on timely and regular access to qualified experienced physicians and a support system that supports them, such as hospitals, EMS, trauma network etc. We know the difference and we are thankful for what we have, but we need to protect our system and people’s access to services. We have this rare opportunity to get involved in shaping the design of the new system that recognizes and protects the core value in our Health delivery system: Access. Pandya Family Foundation Inc. is USA Public Charity organized under chapter 501(c)3, Federal Tax ID #20-5484071. We are thankful to our friends and colleagues who have believed and supported us in our efforts. If you have a question please contact me at gpandyamd@gmail.com. Dr. Pandya practices General Surgery in Porterville.


CLASSIFIEDS

CME Activities FRESNO/MADERA AREA Lung Cancer Conference – October 3 Location: UCSF Ed. Center, Fresno. Credit: 5 hrs. Fee: N/C. Oncology Symposium – October 17 Location: SAMC, Fresno. Credit: 4 hrs. Fee: TBA. Call 559-450-7566. Best Practices Summit – October 21 Location: Fresno Convention Ct. Credit: TBA. Fee: N/C. Call 559-4596240 or cstrom@communitymedical .org. Neuroscience Symposium 2009 – October 23 Location: Radisson Hotel, Fresno. Credit: TBA. Fee: TBA. Call 559-459-7212 or jlarmondin@communitymedical.org. Environmental Triggers for Asthma – October 29 Location: Fresno-Madera Medical Society; Credit: 1.5 hours; Fee: N/C. Call: 559-2244224 or airquality@fmms.org. 29th Annual Central Valley Cardiology Symposium – November 7 Location: Madera Municipal Golf Course; Credit: 6 hours; Fee: $75 Call: 559-224-4224. 4th Annual Medical Imaging Update – November 7 Location: Calif. Imaging Institute, Fresno. Credit: 6 hrs. Fee: $25. Call 559-325-5872 or mschulz@cmirad.com. Diabetes Symposium – November 21 Location: SAMC, Fresno. Credit: TBA. Fee: TBA. Call 559-450-7566.

VISALIA AREA: Updates in Diabetes and Fluid and Electrolytes – October 8 Location: KDHCD Blue Room. Credit: 2 hour. Contact: nasaesee@kdhcd.org.

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.

University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 559320-0580.

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

MEDICAL OFFICES FOR LEASE 1902 B Street – 1,720 sf. 1902 B Street – 3,750 rsf. 2920 F Street – 2,052 rsf. 2701 16th St. – Mid Town Medical: 1,500-5,000 rsf. 2201 19th St. – 1,772 sf. 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. 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 RENT / LEASE Deluxe medical office available for immediate occupancy, 2,813 sf, near St. Agnes. Ample Parking. $1.40 sf with 3-yr lease. Call 559-4326468. Office space available, 2,000 sf. Peachwood Medical Group, Clovis. Call 960-4474. Fresno Bullard Park medical office, 4,000sf. Near Fresno Surgery Hosp. & Fwy 41. $1.25 sf. New paint & carpet. Appt: 559-288-6866 1,550 sf office space at 7565 N. Cedar. For more information, call 559-473-6789. 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.

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.

PHYSICIAN WANTED Opportunities for Primary Care Physicians at Peachwood Medical Group - Clovis. Call 559-9604474. Lg healthcare system in Fresno searching for a physician informatics officer to help implement its new hospital information system, to include: physician educational/collaboration, design sessions, charting & decision support tools, workflows, naming conventions, flow-sheets, identifying improvement areas and applications for EHR. Parttime position with potential for fulltime, offers competitive salary. Contact Tom Utecht, MD at 559-459-7413.

FRESNO / TULARE ALLIED PROVIDER WANTED FNP/PA full or part time wanted for internal medicine, private practice. Full benefits & competitive wages. Call 559-804-1624. Busy OBGYN practice in Fresno looking for NP to do GYN only. Contact Lisa Cochran at 559-9085906.

28th Annual Norman Sharrer Symposium: Life’s Final Journey – October 15 Location: Enchanted Playhouse. Credit: 2 hours. Fee. N/C. contact: nasaesee@kdhcd.org. Mycobacterial Infections – November 19 Location: KDHCD Blue Room. Credit: 2 hours; Fee. N/C. Contact: nasaesee@ kdhcd.org. V I TA L S I G N S / O C T O B E R 2 0 0 9

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2009 October