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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

November 2009 • Vol. 31 No. 11

Vital Signs

Happy Thanksgiving


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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 November 2009 Vol. 31 – Number 11 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

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

NEWS CMA FOUNDATION: 2010 AWARE Provider Toolkit for the Cold and Flu Season .............................9 LETTER TO THE EDITOR ..........................................................................................................10 CME ACTIVITIES .......................................................................................................................19 CLASSIFIEDS.............................................................................................................................19 TULARE COUNTY MEDICAL SOCIETY ..........................................................................................11 • An Overview of Cardiovascular Tests • TCMS Holiday Dinner Event, December 3 • Membership News KERN COUNTY MEDICAL SOCIETY .............................................................................................14 • President’s Message • Annual Meeting, November 17 FRESNO-MADERA MEDICAL SOCIETY .........................................................................................15 • President’s Message • Medical Manager’s Forum • A Fun Evening with the Philharmonic Pops, December 4 • 29th Annual Central Valley Cardiology Symposium, November 7 • Request for FMMS Representation • Town Hall Lecture Series Begins • Membership News

Cover photography: Dusk at Shinzen Japanese Garden, Fresno by Ning Lin, OD, 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 / N OV E M B E R 2 0 0 9

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The Pursuit ursuit o of Excellence Excelle ce

Community’s Winter CME Symposium 2010 Speakers include: NASA Shuttle Astronaut Robert “Hoot” Gibson International Physician Wellness Expert Richard Gunderman, MD, Phd Transformational Trends in the Medical Industry Joseph Bujack MD, FACP Political Analyst Cokie Roberts

wednesday-Sunday, February 3-7, 2010 The Phoenician Resort & Spa, Scottsdale, Arizona The target audience for this NO tuition fee event is all regional physicians of all specialties. The 12 CME will cover topics of interest to all regional physicians. For detailed information visit:

www.cvent.com

Click on “RSVP for an Event”; enter event code “65N2DRN58M2”; Click on “Go to Event” and complete the registration.

Community MEDICAL CENTERS

We fight frivolous claims. We smash shady litigants. We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship. We don’t give up. We are not just your insurer. We are your legal defense army. We are The Doctors Company. The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. To learn more about our medical professional liability program, call (800) 352-0320 or visit us at www.thedoctors.com.

Robert D. Francis Chief Operating Officer, The Doctors Company

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EDITORIAL The Joy of Giving and Examples of Why by David Slater, MD, Editor, Vital Signs

Vital

Signs readers learned last month that the 2009 FMMS scholarships had been awarded to seven medical students who have roots in our area. Last year I told readers a bit about our 2008 recipients and got positive feedback for doing so. I said then, and was again reminded this year, that acquainting one’s self with the qualifications and dedication of those entering medicine is a great way to feel good about the future of our profession.

sponsored by Johns Hopkins Center for Talented Youth. This Latina student comes from modest means and faces a $32,000 gap between financial aid and anticipated first year costs.

You know that already if you have children in medicine or in training for it. For those of us who don’t, it’s time for our annual positive reinforcement session. And right now, the theme of continuity among generations of physicians and the satisfaction accruing to physicians by mentoring and supporting aspiring physicians is brought into sharp focus by the recent passing of my friend, Dr. Jack Schiff. (Read more on that below.) First, here’s a glimpse of just three of our 2009 FMMS Medical Student Scholarships recipients.

Which brings me to my thoughts about Dr. Jack Schiff: Jack came from modest beginnings (although just being a Minnesotan gives one a certain leg-up in life). He arrived in Fresno in 1955 after training in the Midwest, spent several years as chief of urology at the VA Hospital, and then entered private practice in 1957. Through many long years in practice and beyond, Jack was a tireless, generous, hands-on supporter of younger physicians, of physicians in training, and of high school and college students exploring a medical career. He did this because he remembered and was grateful for his breaks and those who made them possible and because he knew just about anything is possible for those who work hard and don’t become too self-important. Jack wished for others the professional joy and immense fulfillment he found in his patients and his work. Over many decades he paved the way for young people to experience that world.

Recipient #1 was presented to you last year as a stand-out undergraduate at Stanford. He is now entering his second year at UCSD Medical School In the past year this student has worked in San Diego’s “Doc for a Day” program teaching children about basic anatomy and the “Doctors Ought to Care (DOC)” working with children on health and nutrition issues. In his second year he will be student manager of the Cardiology Specialty Clinic within UCSD’s student-run Free Clinic for adults and at Catholic Charity’s refugee health screening center. He might have a few course obligations, too – remember your second year of medical school? Recipient #2 is entering her final year at Drexel University College of Medicine in Philadelphia. This immigrant mom of two pre-teens has overcome many life challenges, not least of them financial at a school with annual total costs above $70,000. Recipient #2’s OB clerkship director says she “relates extremely well with patients... Her clinical skills were exceptional and she is able to similarly data and come to comprehensive management plans for patients. She has a natural gift for the healing parts, and I believe she will be an outstanding physician.” Clearly, FMMS has made a great investment in this individual, who is likely to return to Central California. Recipient #3 is a new applicant headed for USC School of Medicine after an outstanding undergraduate record at UC Davis. At Davis she excelled in all things writing and as a tutor of pointy-headed students taking an intensive summer course

Just like last year, column space gets tight far before an adequate recounting of our awardees’ talents and financial needs can be given. You get the idea — — these are outstanding individuals who need and deserve our encouragement and support.

Many of us remember Jack as a bigger than life lover of life and of his family, who never allowed the material or emotional trappings of affluence to get hold of his soul. He did not seek privilege but instead considered himself to have been privileged. And yes, he told a few jokes along the way. I think for the last 20 years of his life he was too old to buy a green banana, and we always knew not to worry because things are really much worse than they seem. And those “Schiffisms” that involved gestures with a somewhat arthritic urologist’s examining finger? I’m not going there. I hope that Jack Schiff’s wonderful legacy and these small glimpses into our 2009 Scholarship recipients will motivate record giving to the FMMS Scholarship Foundation. (One of the memorials to Jack’s life suggested by his family is to make a gift to the FMMS Scholarship Foundation, and that is a wonderful way to honor any physician who has passed away). Note the line for donations at the top of your 2010 membership renewal letter, go on-line to www.fmms.org to donate, or call FMMS to arrange a gift. Giving made Jack Schiff happy for decades – try catching some of that yourself.

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Open Wide...

With Confidence!

O

It’s Open Enrollment time for the Fresno-Madera, Kern and Tulare County Medical Societies’ sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees. • Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on December 31, 2009. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.

Sponsored by:

Underwritten by:

Administered by:

Fresno-Madera Medical Society Kern County Medical Society Tulare County Medical Society by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health U Underwritten Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

42582 (11/09) © Seabury & Smith Insurance Program Management 2009 • CA Ins. Lic. #0633005

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d/b/a in CA Seabury & Smith Insurance Program Management • 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).

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CMA NEWS CMA’S CONCERNS ABOUT SENATE HEALTH REFORM BILL

While the Senate Finance Committee’s health reform bill has some positives, such as a 10 percent Medicare bonus payment to expand access to primary care and the authorization of non-profit community co-ops in lieu of a public insurance option, CMA strongly opposes many other provisions that will undermine the profession of medicine and threaten patient access to doctors. Initial analysis by CMA projects that the net effect of various provisions relating to Medicare payment could result in a large percentage cut in Medicare payments for California physicians depending on specialities, region and mode of practice. Other notable shortcomings in the bill include: • Expands the unreliable “Physician Feedback” program • Imposes five percent penalties on physician outliers • Fails to eliminate the Medicare Sustainable Growth Rate (SGR) • Creates independent and unaccountable Medicare Commission to set Medical policies • Includes an enrollment fee for Medicare and Medicaid providers • Fails to protect physicians from expanded liability from new clinical guidelines • Fails to update Medicaid physician payments. Repealing the SGR is one policy objective that is a common goal of all physicians. The AMA will be activiating its physician and patient grassroots networks and begin running television advertisements in key states.

CMA SUES SCHWARZENEGGER OVER MEDICAL BOARD FURLOUGHS The CMA is sueing Gov. Schwarzenegger and other state officials who are responsible for ordering and/or implementing (1) a provision of the 2008 Budget Act that transfers $6 million from the Medical Board's Fund (Contingent Fund) to the state’s General Fund for general use and (2) The Governor’s executive orders imposing three furlough days per month on the Medical Board. CMA argues that the State cannot raid the Contingent Fund and use its money for general purposes because it is a special fund (funded entirely with physician fees) that by law can only be used by the Medical Board to carry out its public charge under the Medical Practice Act. They also argue that the Governor does not have authority to furlough employees of the Medical Board, because they are paid directly from the Contingent Fund. The Medical Board is seeing unprecedented backlogs in its licensing and enforcement division – impacting new physicians who are not able to practice medicine and ease patient demands. CMA has collected numerous examples of physicians who cannot start seeing patients and may not be able to sit for board exams due to the delays.

CMA PROPOSES HEALTH REFORM AMENDMENTS

CMA

and Californians Allied for Patient Protection have developed amendments to the House and Senate health reform bills that would protect physicians from increased liability.

CMA’s proposed amendments would ensure that physicians are protected if they deviate from any clinical guidelines produced through “clinical effectiveness” research and other provisions in the health reform legislation. CMA’s amendments would also prevent government performance-based value purchasing decision – such as nonpayment for hospital acquired conditions – from being used to create a presumption of medical negligence.

AMA CREATES CPT CODES FOR H1N1 VACCINE; MANY BILLING QUESTIONS REMAIN

AMA has published a new CPT code specific to H1N1 vaccine administration (90470) and revised existing code 90663 to include H1N1 vaccine. The CMS has also created unique HCPCS codes for administration of the H1N1 vaccine (G9141) and for the vaccine itself (G9241). Because the vaccine is provided free of charge by the federal government, physicians will not be reimbursed for the vaccine itself. Practices have been instructed to submit claims for the vaccine, but for zero dollars. This will allow for proper vaccine tracking. Physicians will be reimbursed for administration of the vaccine. Some payors, clearinghouses and physician billing systems may not be able to accommodate a zero dollar charge, and the practice will have to bill vaccine claims with a 1¢ charge.

NEW FEDERAL REGS REQUIRE PHYSICIANS TO NOTIFY PATIENTS OF SECURITY BREACHES

The U.S. Department of Health and Human Services (HSS) recently implemented regulations that require health care providers, health plans and other entities covered by HIPAA to notify patients when their health information is breached. These regulations require HIPAA-covered entities to promptly notify affected individuals of a breach and, in cases where a breach affects more than 500 individuals, the HHS and the media must also be notified. Breaches affecting fewer than 500 individuals must be reported to HHS on an annual basis. California law already requires any person or business that conducts business in California, including physicians and physician groups, to disclose any security breach to any California resident whose unencrypted computerized personal information was or is reasonably believed to have been acquired by an unauthorized person. To help physicians understand their obligations, under this new federal regulation, as well as existing state law, CMA has published On-Call document #1144, “Security Breach of Health Information.” CMA On-Call documents are free to members. 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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C M A F O U N D AT I O N

2010 AWARE Provider Toolkit for the Cold and Flu Season by Carol A. Lee, Esq. President and CEO, CMA Foundation

Every

year, approximately five to 20 percent of the U.S. population gets seasonal flu; more than 200,000 people are hospitalized from flu complications, and about 36,000 people die from flu-related causes. We know that the best way to prevent seasonal flu is by getting a flu vaccination annually. Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious complications from seasonal flu. This year, another type of influenza has grabbed our attention: novel influenza A (H1N1). Worldwide transmission of the novel influenza A (H1N1) virus has continued since June 2009 in both the Northern and Southern Hemispheres. In contrast to the seasonal influenza, current evidence indicates that relatively few severe cases of novel influenza A (H1N1) virus infection have occurred among older persons, and the highest hospitalization rates for illness caused by this virus have been among persons less than 65 years. Healthcare providers must continue educating our patients and community members about the importance of decreasing the spread of influenza. Enhanced respiratory hygiene, frequent hand washing and getting vaccinated are all reasonable strategies that have been demonstrated to reduce respiratory infections. Because we still cannot eliminate either the seasonal flu virus or the novel influenza A (H1N1) virus, recognizing appropriate treatment and managing these illnesses are equally important. To aid in prevention efforts, the California Medical Association (CMA) Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) project has developed the 2010 AWARE Provider Toolkit for the cold and flu season. AWARE supports physicians’ efforts to promote appropriate antibiotic use and decrease the incidence of antibiotic resistance. The 2010 AWARE Provider toolkit contains resources that support the work of physicians to educate patients. The toolkit contains:

• 2010 Acute Respiratory Tract Infection Guideline Summary (Adult and Pediatric versions) • Prescription Pad – Available in English and Spanish, this handout offers over-the-counter treatments that may help alleviate symptoms of colds. • Medical Office Posters (offered in English and Spanish): Feel Better Soon…Without Antibiotics! – These posters inform patients that viral infections cannot be treated with antibiotics. • Patient Education Materials: Feel Better Soon…Without Antibiotics! – These brochures identify common symptoms and home remedies that can provide symptomatic relief (in English and Spanish). • I Choose…To Prevent Influenza! – These handouts contain information on influenza, how to prevent influenza, and what to do should one get sick (in English and Spanish). • Take 3 – The Centers for Disease Control and Prevention (CDC) recommends three steps people can take to prevent and treat influenza (in English; includes H1N1 information). • H1N1 Flu Health Alert – The Centers for Disease Control and Prevention (CDC) prevention, recognition and management information on Novel H1N1 Flu, 5/09 (in English and Spanish). • Health Tips – This handout provides tips to stay healthy, promotes proper antibiotic use and encourages frequent hand washing (in English and Spanish). For more information about AWARE and additional materials regarding influenza prevention, please contact Sandra Navarro, AWARE Project Director, at 916-779-6620 or by e-mail at aware@thecmafoundation.org. Visit www.aware.md for additional clinical resources and patient education materials.

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LETTER TO THE EDITOR

MARIJUANA LEGALIZATION

Currently there has been talk of legalizing marijuana. (A bill has been introduced by Assemblyman Tom Ammiano of San Francisco). As coroner, I have been asked recently for my opinion on this issue. Since you may be receiving similar inquires, I thought it might be useful to share some drug information from the perspective of my forensic practice. Over the years the role of drugs in human deaths has become ever more prominent, until now it is a major part of any forensic practice. Of all the vast array of drugs we deal with, marijuana is of the least concern. Deaths associated with marijuana are usually not due to the drug itself but rather some activity taking place while under the influence of pot. Even though drug screens are often positive for THC, the active ingredient of marijuana, it is not part of the official cause of death. That being said, it should be recognized that as noted forensic pathologist Werner Spitz points out in the latest edition of his text Medicolegal Investigation of Death, “Alcohol potentiates the effect of marijuana and visa versa. The combined use of alcohol and marijuana causes impairment of driving skills, exceeding the effect of either of these drugs alone; psychomotor skills and information processing are particularly affected.” A retired judge is urging legalization of marijuana on the basis, among other things, that it is “no worse than alcohol.” That supposes that alcohol is fairly benign and therefore, by extension, so is marijuana. That is an argument that folks are likely to believe. The pot proponents would like their product to be thought of as “no worse” than alcohol for in their world it follows that since alcohol is socially acceptable then marijuana should be also. However, as a society we hide most of the negative aspects of alcohol. It is well known that many automobile accidents are the result of drunk driving, and the yearly total is staggering. Over 60 people died from drunk driving in Fresno County alone last year. Less well known is the fact that just under half of the victims of homicides, drownings, suicides and fires are drunk. Either half of our population is drunk or being drunk puts you in harms way. Then there are the victims of alcohol who die alone on the streets or in tawdry motel rooms. All of these are the relentless day in and day out cases of the coroner’s office. From the coroner’s perspective “no worse than alcohol” is a specious argument. And anything that makes the effects of alcohol worse should be discouraged. Perhaps the strongest argument for not legalizing marijuana is that there will be serious problems for law enforcement. While the correlation between blood alcohol levels and certain behavior is well established and is reproducible, no such relationship exists between TCH and aberrant behavior. This is attributed to the biological variability that pot produces in humans. Thus, courtroom testimony concerning the role played by marijuana in the violation of a law will not bear the same weight as similar testimony would for alcohol. “Under the influence” would be a vague but not necessarily irrelevant condition. Getting high is the single purpose of the pot user. So valued is this experience that rational anti-legalization arguments are not given serious consideration by the proponents of legalization. Conversely, those who view the issue as a moral one are not interested in any “pro” arguments. Much of this discussion is beyond the purview of the medical examiner or coroner ie. disrupted families, dropping out, gateway drugs and so forth. We will defer those discussions to others. What can be said is that everything I have seen as coroner makes me feel that legalization of marijuana is not a good idea. – David M. Hadden, MD

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Tulare An Overview of Cardiovascular Tests by Kusai S. Aziz, MD, FACC Interventional Cardiologist Visalia Cardiovascular and Medical Center, Inc

Among all medical specialties, cardiovascular medicine is the one field with the widest variety of tests. This is because there are many aspects of cardiovascular pathologies like coronary artery disease, valvular heart disease, cardiac muscle disease (cardiomyopathies), arrhythmia (electricity problems), vascular diseases (peripheral and carotids) and adult congenital heart disease. I will try to summarize most of the widely used cardiovascular tests, the rationale of obtaining them and some of their advantages and disadvantages: COMMON CARDIAC TESTS Electrocardiogram (EKG): one of the oldest available cardiac tests that can point to different aspects of cardiovascular pathologies like arrhythmia, ischemia or acute infarction (heart attacks) and some structural heart abnormalities like left ventricular hypertrophy. The disadvantage of EKGs is that it only reflects the cardiac status during the few seconds during which it was obtained and it lacks sensitivity. Although it is the logical first step in cardiac testing, its limitations should be always kept in mind in light of clinical suspicion. For example the sensitivity of EKG in the diagnosis of acute myocardial infarction is about 50 percent. Echocardiogram (transthoracic and transesophageal): many cardiologist including myself consider the transthoracic echocardiogram as an extension to physical exam. It gives excellent information about the systolic function (ejection fraction), diastolic function, valvular heart disease and some adult congenital heart disease. It is a quick test and safe since it involves the use of ultrasound waves. The main disadvantage is that it cannot evaluate for the presence of coronary artery disease. Transesophageal echocardiogram has the added advantage of evaluating left atrial thrombi and intracardiac shunts (abnormal holes between heart chambers) more accurately due to the vicinity of the esophagus to the heart. Echocardiogram can be combined with exercise stress test (stress echo) to evaluate for exercise induced wall motion abnormalities as a sign of coronary artery disease. Stress test with Myocardial Perfusion Scan (Nuclear Stress Test): Represents the most commonly used test to rule in or out significant coronary artery disease non invasively. Myocardial perfusion scans performed using nuclear tracer at rest and during stress. Stress can be achieved by exercise or by using pharmacological agents (like Adenosisne or Dobuatmine) for patients who cannot exercise. The test also evaluates the systolic function (ejection fraction). The test however does not give an idea about valvular heart disease. Please see Cardiovascular Test on page 14

SAVE

THE

DATE!

PLAN TO JOIN US:

Tulare County Medical Society Holiday Dinner Event

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

TCMS Officers Mark Tetz, MD President Ralph Kingsford, MD President-Elect Steve Carstens, DO Secretary/Treasurer Timothy Spade, MD Immediate Past President Board of Directors Thomas Daglish, MD Karen Haught, MD Mark Reader, DO Ahmad Shahroz, MD Gaurang Pandya, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Amber Chatwin, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Staff: Steve M. Beargeon, Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate Maui Thatcher Executive Assistant

Thursday, December 3, 2009 Visalia Convention Center

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Tulare

Electronic Medical Records Freedom to practice medicine on your terms

plee@realtimeca.com www.realtimeca.com

MEMBERSHIP NEWS Did You Know? Gail Locke, Physician Advocate at TCMS is available by phone or email to assist you or members of your staff with ANY questions or issues pertaining to your practice. Here are just a few examples of areas I can assist you with: • HIPAA resources • Assistance with FTC Red Flag Rules requirements • Labor Law, HR questions such as overtime, vacation time, FMLA, etc. • Employee handbook resources • Palmetto GBA • California Physician’s Legal Handbook, access to on-line library of medical, legal, and reimbursement information • Medical records management and retention laws • Practice Management resources • Salary Survey, assistance with job descriptions Tulare County Medical Society Members please feel free to utilize our resources, research abilities and sincere desire to assist and support your practice. Please feel free to call 559-734-0393 or email, gail@tkfmc.org.

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.

Abiy Meshesha, MD General Surgery Jimma Health Sci. Inst., Ethiopia ’96 220 S. Akers St., Suite C Visalia 93291 Jonathan Chin Hau Liu, MD General Surgery St. Georges University, West Indies 5533 W Hillsdale, Suite C Visalia, CA 93291 Songlin Liang, MD Pathology Shanghai Jiao Tong University, China 263 N. Pearson Dr., Suite 108 Porterville, CA 93257 12

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Tulare

Kings

Cardiovascular Tests Continued from page 11 Cardiac monitors: Those are small devices connected to the patient and provide continuous monitoring of cardiac rhythm for a specific amount of time. The commonest is Holter monitor usually for 24 hours. Event monitors can be used for longer durations (typically 21 or 30 days) to capture rare events. Cardiac monitors are mainly used for the evaluation of conditions that can be caused by rhythm problems like palpitations, dizziness or syncope (fainting). Vascular tests: the commonest tests are ultrasound based and used mainly to detect Carotid artery disease and peripheral vascular disease. The severity of the disease is evaluated by visualizing the plaque, measuring the velocity and analyzing the wave forms at different levels of the artery.

LESS COMMON CARDIAC TESTS Positron Emission Tomography (cardiac PET): another form of nuclear myocardial perfusion scans that has more accuracy than standard nuclear studies. It has an important role in evaluating cardiac muscle viability before coronary artery bypass surgery or interventions (angioplasty or stent). Cardiac CT (computed tomography): can be used to measure the degree of calcification in the coronary artery (Calcium score) as a risk factor rather than definite diagnosis of significant coronary artery disease. Combined with the use of intravenous contrast (CT angiography) it can be used to visualize coronary arteries and evaluate the degree of blockages. Despite early enthusiasm, multiple studies shows that the accuracy of the test still not high enough to make it its use routine. Also it involves the use of higher amounts of radiation and contrast relative to other diagnostic cardiac tests. Cardiac MRI: has special role in the diagnosis of some congenital heart diseases , rare cardiac muscle diseases and certain cardiac tumors.

INVASIVE CARDIAC TESTS Namely cardiac catheterization and coronary angiography, which is an invasive procedure; vascular access is obtained through the femoral artery most of the times though it can be performed through radial or brachial arteries. Then small plastic tubes (catheters) can be passed to the coronary arteries, contrast is injected to take pictures of the coronary arteries (angiography). It is the gold standard for the diagnosis of coronary artery disease. If severe stenosis (blockage) is found then percutaneous intervention (angioplasty or stenting) can be performed through catheters to fix the blockage. Since it is an invasive tests it carries some risk of complication and very rarely death. Therefore it is preserved for the use in emergencies like myocardial infarctions (heart attacks) or when there is high suspicion of significant coronary artery disease based on non invasive tests.

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

In summary, cardiovascular diseases are the commonest cause morbidity and mortality among men and women in the United States. Early detection and treatment can lead significant risk reduction. There is a wide spectrum of tests that can be performed to evaluate different aspects of the cardiovascular diseases, in certain situations more than one test is needed, the choice will depend on the clinical picture, risk factors and should be guided by history and physical exam.

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Kern BRADFORD A. ANDERSON, MD

President’s Message In September, the Kern County Medical Society had a physician round table conference to discuss and address solutions to the physician issues regarding health care reform. I highly recommend this to any medical society. It was refreshing to hear the diversity of ideas and the ability to come to consensus. Congressional staff members were invited to listen but not to participate directly in the conversations. Suggestions included: • Insurance companys are not to lower reimbursements below a certain threshold. • Coverage must be mandated to all just as car insurance. • Tort reform is a crucial key • The concept of basic coverage must include at least basic coverage that is provided to prisoners in the correction system. • Resolution needs to be made in regards to regional reimbursement • Expand the reimbursement possibilities with the use of technology to compensate for -inadequate physician workforce Some believe that we cannot support a public option because people need to be responsible for their care, and this would encourage irresponsibility. I disagree. I recently saw a patient who was very responsible. He worked as a manager of a sizable corporation. He purchased excellent insurance for himself and his family. Two years ago, he was laid off and lost his health insurance. He did the responsible thing and purchased a truck and worked for a trucking company. The company did not provide insurance. He was unable to find reasonable affordable insurance due to pre-existing conditions. But he did the responsible thing and purchased very high deductible insurance. He slipped off of his truck and badly fractured his knee. After paying off his bills, he will loose everything; his home, truck, and child’s education money over a broken leg. Pressure needs to be kept on insurance companies to force premium control. Some form of public option that provides real competition needs to be formed. Fair reimbursement needs to be part of that reform. You’ve seen our current public option as coin containers in the local 7 Eleven and street corner car washes. We can do better than that. We need to continue to push forward in reforming health care. Physicians need to continue to be engaged in the process, be mindful of our practice and families. Joe Welden tells the story of the winding river. To paraphrase; Life is like a snake river with many twists and high walls on both sides. The walls are too high so you can’t see around the bend. Look forward not back. The river of your life flows forward not backwards. Pay attention to your boat (your family and business), and make it to the next bend in the river.

TUESDAY, NOVEMBER 17, 2009

ANNUAL MEMBERSHIP MEETING “E-Prescribing and The Top Ten Billing Errors” presented by Sandra Siddall, RN, MSN, Provider Outreach Educator, Palmetto, GBA and Presentation of 2010 Slate of KCMS Officers $45/person Entrée Choices: Filet Mignon with Cognac sauce, Salmon with port wine sauce or Roasted Garlic Alfredo with sun-dried tomatoes and mushrooms Dessert: Malva Pudding or Chocolate Oblivion Truffle with Carmel Sauce T.L. Maxwell’s 1421 17th Place, Bakersfield, CA 6:30 pm No-Host Cocktails • 7:00 pm Dinner • 7:45 pm Meeting

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2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website: www.kms.org

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


Fresno-Madera CYNTHIA BERGMANN, MD

Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1382 E. Alluvial Avenue #106 Fresno, CA 93720

DON’T GET WET

559-224-4224 Fax 559-224-0276

My older son played soccer in grade school. To say that his team was not the best team is a gross

website: www.fmms.org

understatement. It was frankly the worst team in his or any other league. Bunch ball for them was not just a problem – it was a way of life. They had goalies who thought that picking dandelions was far more important than a soccer ball could ever be. The forwards had no sense of direction, and the half backs were as likely to pass to an opponent as a teammate. It wasn’t just that they never won a game – they never even scored a goal.

Cynthia Bergmann, MD President

One particularly ugly November day my son’s team caught a break. It had been raining all night. The field was sloppy with mud. By some miracle my son’s team had stolen the ball. Ten little bodies were charging down the field with nothing between them and the goalie but a 20 foot puddle. We parents were jumping up and down – we were surely about to get the first goal of the season! The goalie ran out from the box, waving his hands and shouting “DON’T GET WET!” Ten little bodies slid to a halt. The ball sat in the middle of the puddle. The goalie trotted right out to the center of the puddle, grabbed the ball and kicked it down to the opposite end of the field. The other team scored. What had happened? Ten obedient little boys had been taught by their parents that getting wet was wrong. It was so wrong that when reminded that they shouldn’t get wet, the desire to be good, to be correct, overwhelmed the desire to score a goal. The goalie understood the power of distraction, taking my son’s team and presenting them a false goal of staying dry when their true goal was to score. As I watch the current upheaval in our government, I am struck by how often a reasonable question or argument is turned aside by various distracting techniques. Person A makes a point. Person B launches into an ad hominem attack calling their opponent a racist or sexist or socialist or conservative. Person A immediately responds to the attack entirely losing the real goal of the argument in the struggle to not be thought of as a “bad” person. Just like those 10 little soccer players, we all wish to be good people. It is easy to get distracted by personal attack. Yet as physicians and people of science, it behooves us to recognize that it is the debate not the debater that takes precedence. We know that you cannot achieve a true conclusion from a false assumption, that statistics must be viewed in the context of the group studied, that extrapolations may only be taken so far before they become absurd. As Congress lurches toward some kind of action on health care, keep your focus clearly on the goal of supplying heath care to those who currently do not have access to the system except through the emergency room. The Federal government trying to reduce THEIR costs by one-third in the single stroke of a pen will not assure access for all patients. Do not be distracted and above all remember “DON’T GET WET!”

FMMS Officers

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

V I TA L S I G N S / N OV E M B E R 2 0 0 9

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Fresno-Madera Session I TOP 10 BILLING ERRORS 9:00 to 11:00 am Continental Breakfast During this session the top 10 claim submission errors will be explored. Tips on proper coding, billing and documentation to assist in avoiding denial and delays will be covered.

presents

Sandra Siddall, RN, MSN PROVIDER OUTREACH EDUCATOR

from

PALMETTO, GBA

A series of seminars addressing current Medicare issues exclusively for FMMS-member physicians, their Office Managers and Office Medical Staff

WEDNESDAY, NOVEMBER 18, 2009 9:00 am to 4:00 pm – Medical Managers 6:00 to 8:00 pm – Physicians FRESNO-MADERA MEDICAL SOCIETY BOARD ROOM 1382 E. Alluvial Avenue #106 (w/Cedar Ave.) • Fresno, CA 93720 559-224-4224 x112 • statarian@fmms.org

Attend all 3 sessions or choose one and/or two sessions of your choice. SESSIONS I – III

$75 includes Continental Breakfast and Lunch

SESSION I

$25 includes Continental Breakfast

SESSION II

$35 includes Lunch

SESSION III

$25 includes Refreshments

SESSION IV

$35 includes Dinner – Physicians Only

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N OV E M B E R 2 0 0 9 / V I TA L S I G N S

RESERVATIONS MUST BE PREPAID BY VISA, M/C, CHECK OR CASH Contact Sheryl Tatarian at 559-224-4224 x112 or statarian@fmms.org

Limited to first 50 people per session who RSVP with payment. All attendees must be FMMSmember physicians and office medical ataff. SESSION IV for PHYSICIANS ONLY

Session II MEDICAL DOCUMENTATION 11:30 am to 1:30 pm – Lunch This session will focus on key words and exact, but short, entries that address all aspects of the medical need and necessity for the patient visit and other services. EVALUATION & MANAGEMENT SERVICES What are the check-off points that a physician and his staff need to remember when documenting an E&M visit plus clues in selecting the appropriate level of code. Session III RAC and CERT AUDITS & MEDICAL REVIEW 2:00 to 4:00 pm – Refreshments What is the RAC, CERT and Medical review audits? Who is the agency that collects this data and how do you respond to each type of audit? Session IV MEDICAL DOCUMENTATION Physicians Only 6:00 to 8:00 pm – Dinner This physician session will focus on key words and exact, but short, entries that address all aspects of the medical need and necessity for the patient visit and other services. RAC and CERT AUDITS & MEDICAL REVIEW This presentation will cover information that physicians need to know about the RAC, CERT and Medical review audits, who the agency is that collects this data, and what your proper response should be to each type of audit. E-PRESCRIBING The basic principles of E-Prescribing will be detailed and Medicare Learning Network booklets will be given out. This is one of CMS’ incentive programs for providers to net more income.


Fresno-Madera A Fun Evening with the Philharmonic Pops CIRQUE de la SYMPHONIE Friday, December 4, 2009 The William Saroyan Theatre 6 pm Reception 8 pm Performance This concert will feature aerialists flying overhead and acrobatic feats on stage while being performed to classical masterpieces and favorite holiday music. Begin your evening enjoying hors d’oeuvers and beverages while socializing at an exclusive pre-performance reception for Fresno-Madera Medical Society members and guests.

Reception: No charge FMMS member • $10, non-FMMS member Concert: $45 Information: 559-224-4224, ext. 118 With appreciation to our reception sponsor: Premier Valley Bank

SATURDAY, NOVEMBER 7, 2009

29TH ANNUAL CENTRAL VALLEY CARDIOLOGY SYMPOSIUM 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 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

Request for FMMS Representation It has been requested to have a representative of The Fresno-Madera Medical Society appointed to serve on the Executive Committee of the Children’s Health Initiative for Fresno County (CHIFC). The CHI-FC was created to help ensure all children living in Fresno County have health coverage, access to preventative health care and a medical and dental home. The CHI-FC supports ensuring effective outreach, enrollment, retention and utilization efforts for Healthy Kids, Medi-Cal, Healthy Families, AIM, Kaiser and other safety net health insurance programs. It also serves as a catalyst for relationship building and partnering with community organizations and populations with disproportionate unmet health needs. The Executive Committee is the decision making body of the CHI-FC and consists of the Chairs of the standing committees, operational partners, a representative of the administrative organization and at least two community CHI-FC members. Responsibilities of CHI-FC Executive Committee include: • Participation in Executive Committee meetings: 2nd Wed. of each month: 10-11:30 am; Fresno Metro Ministry, 1055 N. Van Ness Ave. Fresno • Promote the public face and vision of CHI-FC • Represent CHI-FC at community presentations, public relations and media contacts • Support fund development If you are interested in submitting your name for consideration to this position, please contact the Fresno-Madera Medical Society at 559-224-4224, ext. 118.

6 hours, CME credit: $75 • Call 559-224-4224, ext. 118 or csrau@fmms.org

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Fresno-Madera MEMBERSHIP NEWS Committee Meetings All meetings are held at the FMMS offices unless otherwise noted.

NOVEMBER 4 9 10 17 18

General Membership ............ 6 pm TorNino’s Banquet Hall Electronic Health Records.....6 pm CME ................................12:30 pm Professional Relations.....12:30 pm Medical Managers ..................9 am

Membership Recap SEPTEMBER Active ..................................................653 Leave of Absence.....................................1 Retired..................................................200 Residents ..............................................236 TOTAL ...........................................1,090 Applicants..............................................12

Town Hall Lecture Series Begins The San Joaquin Valley Town Hall 20092010 lecture series includes nationallyknown experts in their fields. All of the lectures are held on Wednesday mornings at 10:30 am at the Saroyan Theater. Season – or single – tickets are available by contacting 559444-2180 or at www.valleytownhall.com. Programs for the season include: November 18: Dr. Edward Diener, professor of psychology at the University of Illinois speaking on “Happiness and Complete Wealth.” January 20: David Brancaccio, host of PBS’ NOW program, speaking on “Dissecting Economic Disaster.” February 10: Robert Fitzpatrick, past CEO, Chicago’s Museum of Contemporary Art and Euro Disney president, speaking on “Passionate About the Arts.” March 17: Juan Williams, NPR senior correspondent and Fox News analyst, speaking on “A Powerful Mix: Money Race and Age.” April 21: Steve Coll, Pulitzer Prize author, speaking on “The Changing World of Terrorism.” 18

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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.

Mark S. Bernard, MD *NM 1867 E. Fir #104 Fresno 93720 325-5809 Med Col of Wisconsin ’97

Gabriela Tarav, MD *R 1867 E. Fir #104 Fresno 93720 325-5809 luliu Hatieganu, Romania ’93

Bruce Ginier, MD *NRN 1867 E. Fir #104 Fresno 93720 325-5809 West Virginia Univ ’86

Mandeep Singh, MD NEP 568 E. Herndon #201 Fresno 93720 228-6600 Dryanand Med India ’01

Edward Math, MD *DR 1867 E. Fir #104 Fresno 93720 325-5809 NYU ’93

Paul Speece, MD *DR VIR 1867 E. Fir #104 Fresno 93720 325-5809 Univ San Diego ’02

Ivan Ramirez, MD *DR 1867 E. Fir #104 Fresno 93720 325-5809 Univ of Puerto Rico ’02

Benjamin Teitelbaum, MD *OTO 1351 E. Spruce Ave. Fresno 93720 432-3303 Univ Illinois ’89

JACK J. SCHIFF, MD 51-year member

J.J. Schiff, MD, a retired urologist, passed away on September 18, 2009 at the age of 89. Dr. Schiff was born in Minneapolis in 1919. After serving in World War II as a medic surviving Omaha Beach, he received his medical degree from Chicago Medical School in 1951 and completed his internship and residency at Hines Veterans Hospital. Dr. Schiff moved to Fresno in 1955, where he opened his private practice. He retired in 1998. While a member of FMMS, Dr. Schiff served on several committees including Well Being and the FMMS Scholarship Foundation, serving as its president for several years. Dr. Schiff will be remembered for his involvement in many philanthropic activities for area hospitals and for mentoring young medical students. Dr. Schiff is survived by his son, William M Schiff, MD, a daughter and 4 grandchildren.


CLASSIFIEDS

CME Activities FRESNO/MADERA AREA 29th Annual Central Valley Cardiology Symposium – Nov. 7, 2009 Location: Madera Municipal Golf Course; Credit: 6 hours; Fee: $75 Call: 559-224-4224. 4th Annual Medical Imaging Update – Nov. 7, 2009 Location: Calif. Imaging Institute, Fresno. Credit: 6 hrs. Fee: $25. Call 559-325-5872 or mschulz@cmirad.com. Diabetes Symposium – November 21, 2009 Location: SAMC, Fresno. Credit: 3.5 hrs. Fee: TBA. Call 559-450-7566. Winter Symposium – Pursuit of Excellence – Feb. 3-7, 2010 Location: Scottsdale, Arizona. Credit: 12 hours. Fee: N/C. Call 559-459-1777.

VISALIA AREA: Mycobacterial Infections – November 19, 2009 Location: KDHCD Blue Room. Credit: 2 hours; Fee. N/C. Contact: nasaesee@ kdhcd.org.

Salvation Army Seeking "Bell Ringers" The Salvation Army is looking for volunteers to participate in this holiday season’s Bell Ringing Program – Nov. 27-Dec. 24. Two-hour shifts are available at several Fresno locations including: Fig Garden Village, Fashion Fair Mall and River Park Shopping Center Contact Judi Wright at 559-2330139.

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.

FRESNO / MADERA

BAKERSFIELD 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.

Dr. Ning Lin is pleased to announce the association of Dr. Wai-Ling Wong to the practice of Eye and Vision Care at 6700 N. First St. #104, Fresno. Call 559-432-2332. Announcing Regenerative Medicine at Pacific Medical Center of Hope, Inc., practicing holistic and integrative medicine. Referrals welcomed. 1660 E. Herndon Ave. #101, Fresno, CA 93720. 559-475-4300. 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.

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

FOR RENT / LEASE

MEDICAL OFFICES FOR LEASE 1902 B Street – 1,720 sf. 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 2633 16th Street – 4,800 rsf. 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

Office space, 2,027 sf shell at 2325 E. Cleveland Ave. Madera. Call 559-930-1918 Deluxe medical office available for immediate occupancy, 2813 sf, near St. Agnes. Ample Parking. $1.40 sf with 3-yr lease. Call 559-4326468. 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 Olympus (OSF-2) 60 cm flexible sigmoidoscope with stand and suction machine – works well. $490 Call 559-261-0266. 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.

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 OB-GYN practice in Fresno looking for NP to do GYN only. Contact Lisa Cochran at 559-9085906.

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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 November  
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