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March 2010 • Vol. 32 No. 3

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

Vital Signs

See Inside: Physician Outreach: The Joy of Being A Doctor CAL-REC Awards $34 million EHR Grant The Healthcare Time Bomb


M A R C H 2 0 1 0 / V I TA L S I G N S

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 March 2010 Vol. 32 – Number 3 Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau

NEWS CAL-REC: Alliance of Clinics, Doctors and Public Health Systems Receive $34 million EHR Grant ..8 PHYSICIAN OUTREACH: The Joy of Being A Doctor ......................................................................9 CORONER’S CORNER: What We Wish For.................................................................................11 AIR QUALITY: How Do We Approach Cleaning Up Our Air? .........................................................12

Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Prahalad Jajodia, MD Roydon Steinke, MD Kings Representative Sheldon R. Minkin, MD Kern Representative John L. Digges, MD Tulare Representative Gail Locke

CLASSIFIEDS.............................................................................................................................18 CME ACTIVITIES .......................................................................................................................18 TULARE COUNTY MEDICAL SOCIETY ..........................................................................................13 • Behaviors That Undermine A Culture of Safety • The Healthcare Time Bomb: HIPAA 5010 • Annual Wine Social KERN COUNTY MEDICAL SOCIETY .............................................................................................15 • Membership News FRESNO-MADERA MEDICAL SOCIETY .........................................................................................16

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 Classified: Carol Rau, 559-224-4224, ext. 118

• President’s Message • Membership News

Cover photography: Rhododendren by S. Vathayanon, 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 / M A R C H 2 0 1 0

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Sharing in Difficult Times by Prahalad Jajodia, MD Editor, Vital Signs


boom turns to bust and a vital economy sags into a recession, it is the poor who suffer the most. For those of us who have the luxury of steady employment, the current recession is more a topic of conversation than a day-to-day struggle. And though our incomes may be slightly impacted, the decisions we face will most likely be whether to put off buying a new car or trimming back on vacation plans. But the picture is quite different for those at the bottom of the socio-economic spectrum. Their decisions revolve around finding their next meal. When businesses close and workers are laid off with no money to make house payments, homes are repossessed, cars are repossessed, and people who are not substantially different than you or I, end up living on the streets or in shelters. I’m talking about men and women – many times with children – who are both willing and able to work but who simply cannot find a job in this, the worst recession of our lifetime. These people need our help, and they need it now. There are numerous organizations dedicated to helping the poor; Poverello House at 412 “F” Street in Fresno is one. They feed the hungry, offer focused rehabilitation programs, temporary shelter, and other basic services to the poor, the homeless, and the disadvantaged. In addition, an all-volunteer staff of doctors

and nurses provide desperately needed medical and dental care for those who would otherwise go without. Their administrative expenses are low; 89 percent of every dollar donated to them goes to providing services for the poor. Poverello House serves between 1,200 and 1,400 hot meals every day, 365-days-a-year. At an average cost of forty-one cents per meal, a donation of $100 to Poverello House (the cost of a night on the town) will provide over two-hundred meals for men, women and children who are hungry and have nothing to eat. Please remember, it is not hard work alone that has given us in the medical field the opportunities we have in life. Mixed in with our labor has been a measure of good fortune. So let us open our hearts and give some of that good fortune back to the world – to those who need it the most. I ask you to please consider making a donation, or volunteering your services to any organization or facility that needs your expertise and/or assistance. To learn more about the Poverello House, please visit their website,, or call them at 559-498-6988. On a personal note, I would like to give my most sincere thanks to the Fresno-Madera Society editorial board members for giving me the opportunity to serve as editor of Vital Signs for 2010.

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St ad 201 op Bo er 0 C by se s a C no fo hip lifo AP is r a Ac rn ’s b e c a ia o ca h de H o nc an m e th el ce y i alt at lin t n h t g o w Sa Ca he he in n re Di ad eg ph o on es ! Le

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and so much more. Mutual Protection Trust (MPT) is the nation’s only physician-owned medical professional liability provider Rated A+ (Superior) by A.M. Best!

Superior Physicians. Superior Protection.



SACRAMENTO The Mutual Protection Trust (MPT) is authorized under Section 1280.7 of the California Insurance Code as an unincorporated interindemnity arrangement among physician members of the Cooperative of American Physicians, Inc. (CAP). Members do not pay insurance premiums. Instead, they pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs. No assurance can be given as to the amount or frequency of assessments. Members also make a tax-deductible Initial Trust Deposit, which is refundable according to the terms of the MPT Agreement. ©2009



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CMA has filed an amicus brief in a Medicare whistleblower case before the Ninth Circuit Court of Appeal, arguing that a violation of state corporate bar laws should be grounds for filing a whistleblower claim for fraudulent Medicare billing. Medicare requires providers to certify that they are in compliance with all state laws. The CMA amicus brief does not comment on the facts in the underlying case, but rather defends the integrity of a state’s corporate bar as it relates to Medicare billing. Proponents of SB 726, the legislation to weaken the corporate bar, have begun a grassroots effort to support their efforts, including asking local city and county councils to pass resolutions supporting the legislation. In February, The Selma City Council had an action item on their agenda to send a letter of support for SB 726. The action item was buried in the consent calender. Dr. Stanley Louie, a family practice physican in Selma, attended the meeting, caught the item and had it removed from the consent calendar. At the following week’s council meeting, Dr. John Bonner testified against the legislation. As a result of Dr. Bonner's testimony, the City of Selma voted not to send a letter of support for SB 726. CMA expects labor unions and hospitals to continue their efforts to weaken the corporate bar and continue efforts to obtain local support for SB 726.



Department of Managed HealthCare (DMHC) recently proposed regulations that would regulate “discount health plans” in California. Over the years, DMHC has floated informal proposals to regulate discount health plans. However, this is the first time they’ve initiated the formal rulemaking process. CMA has serious reservations about the legitimacy of discount health plans in California. CMA has opposed a number of legislative attempts to legitimize these illegal referral services. Not only does CMA believe that they are illegal, but they also remain unconvinced that DMHC has jurisdiction to regulate them. From a public policy perspective, they bring little value to consumers, as the benefit they purport to provide is illusory at best. CMA has requested a public hearing on this issue.



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: member (click on “Reimbursement Advocacy” under “Physician Advocacy” in the main menu


Dustin Corcoran, who has worked for CMA for nearly 12 years, has been promoted to chief executive officer. Mr. Corcoran led CMA’s lobbying efforts for five years before becoming Deputy CEO last fall.


CMA met with Blue Shield in January to discuss the insurer’s plans to publish the results of the 2009 California Physician Performance Initiative (CPPI). Despite serious concerns with the validity and accuracy of the data that has been collected, Blue Shield continues to move forward with plans to give digital “blue ribbons” to physicians who scored in the top 50th percentile. The report also infers that some physician are not quality doctors because they did not receive a “blue ribbon.” Although Blue Shield has not backed down from its plans to publish the data, the insurer has agreed to continue the dialogue with CMA to see if there is a middle ground. CPPI is a quality reporting pilot project operated by the California Cooperative Healthcare Reporting Initiative (CCHRI). Over the past two years, CPPI has used claims data from private PPO patients from Anthem Blue Cross, Blue Shield and United Healthcare to measure physicians on a set of quality measure. Blue Cross and United have not yet indicated whether they will publish the CPPI results. CMA FILES SUIT AGAINST GOVERNOR FOR CONDONING VIOLATIONS OF STATE SCOPE LAWS

CMA and the California Society of Anesthesiologists (CSA) filed a lawsuit asking a court to overturn a decision by Gov. Schwarzenegger to opt out of the federal requirement for physician supervision of anesthesia care for Medicare patients. This would enable hospitals to allow nurses to administer anesthesia on Medicare patients without physician supervision. In June 2009, the governor requested and received an exemption from the federal Medicare requirement that physicians supervise nurse anesthetists. The exemption was requested without input from any professional medical organization and with blatant disregard for state law that requires physician supervision of nurse anesthetists. Despite the exemption, hospitals in California still have the authority to requrie physician supervision of nurse anesthetists and must affirmatively opt-out of the supervision requirement. For more information on the scope of practice of nurses, see CMA On-CAll document #1615, “Nurses.” CMS DELAYS PECOS ENROLLMENT POLICY The Center for Medicare and Medicaid Services (CMS) has delayed the PECOS enrollment policy until January 1, 2011. Medicare physicians who have not updated their enrollment information in the past five years may need to fill out another application or face payment problems for ordered or referred services. The new rules authorize Medicare to reject claims if an ordering or referring physician is not identified in Medicare's PECOS enrollment system. CMA and others in organized medicine have been pushing for the delay in this policy. The actual PECOS enrollment porcess can be confusing for physicians. CMA is developing a step-bystep guide to walk physicians through the process, from determining if they are already in PECOS, to accessing the internet-based PECOS enrollment system. For questions, contact Michele Kelly at 213-226-0338 or V I TA L S I G N S / M A R C H 2 0 1 0

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Electronic Medical Records Freedom to practice medicine on your terms

Alliance of Clinics, Doctors, and Public Hospital Systems Receive $34 Million EHR Grant The California Primary Care Association


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(CPCA), the California Medical Association (CMA), and the California Association of Public Hospitals & Health Systems (CAPH) announced February 12, 2010 that their united effort called CalREC was awarded $34 million to help primary care providers implement electronic health records (EHRs). This grant will help make support services available throughout most of California, with Los Angeles and Orange Counties served by other organizations. The Health Information Technology for Economic and Clinical Health (HITECH) Act of February 2009 provides for the establishment of Regional Extension Centers (RECs). The purpose of the RECs is to furnish assistance defined as education, outreach and technical assistance to help primary care providers in their geographic service areas to select, successfully implement and meaningfully use certified EHR technology to improve the quality and value of healthcare. “This is an exciting opportunity for California physicians and the patients they serve. There are many challenges physicians face in implementing EHRs. The Cal-REC services will be invaluable in helping physicians address these challenges and implement and use EHR systems,� said Brennan Cassidy, MD, President of CMA. Physicians are encouraged to watch for release of additional information and details related to program participation.


The Joy of Being a Doctor Saving the Life of a Little Boy by Linda Halderman, MD

LBJ Tropical Medical Center, American Samoa

LBJ General Surgery Team, American Samoa, October 2009

It’s Saturday night in Pago Pago. As I write this from a little tropical hospital in the middle of the Pacific Ocean on a tiny island called American Samoa, I’m trying hard to make sense of the last 72 hours. I remember sleeping at one point, eating some Ramen noodles yesterday, and wondering often – but without much interest – if it was light or dark outside. I can’t wrap my brain around what has happened, so I’ll just report it and let you make your own assessment. For almost 10 days, I watched my five-year-old patient as he healed from dengue fever and a set of superimposed infections (heart, both lungs, entire abdomen, blood, and urine), any one of which could have taken his life. But he had so many medical victories. Three days ago, I sat with him on the regular pediatric ward and watched him play with his brothers and eat Bongos (a Samoan version of Cheetos … yuck) and smile at me. He breathed the same air I did, needing no extra oxygen or any of the dozens of treatments he had required when I first arrived on the island. I had drained infected fluid from around his heart three hours into my assignment at the LBJ Tropical Medical Center. And he was getting better! No tubes, no ICU, no beeping machines. Just a little boy recovering nicely, surrounded by parents and siblings who spoiled him. For the past three days, I have watched my five-year-old patient try to die. Three days ago, I walked by his bed on the pediatric ward and was stunned. He was short of breath and miserable. The muscles between his ribs were visibly moving in and out, trying to keep his lungs full of air. By four o’clock in the morning, he was on a ventilator in the intensive care unit. The rest of that day and most of the next, his team of pediatricians and I struggled to stabilize him. There were X-rays and ultrasounds and blood tests and microbiology cultures. I put in chest tubes and placed intravenous lines that went directly to the blood vessels near his heart. There were four powerful antibiotics and a pharmacy’s worth of drugs.

LBJ Medical Center Emergency Trailer

The ancient ventilator we have for children gave us few options, but we tried all of them. I put my head together with my colleague, Dr. John DePasquale, a pediatrician from New York who came to us from the CDC in Atlanta. John spent so many hours in the ICU with this patient that nurses brought him sandwiches when he forgot to eat. We were losing the war and could not even identify the enemy. Tuberculosis? Bacteria? Fungus? A novel virus or a vicious strain of a known one? We had no answers. Every time I met with his helpless parents, they thanked me. I thought to myself, “For what?” I could not help this child. When it became clear that this remote facility had no more resources to make a difference in the outcome of a five-year-old who had been happily munching on artificially colored orange snacks 24 hours earlier, my colleagues and I struggled to get the closest hospitals, those on Hawaii, to consider accepting the boy in transfer. We were unsuccessful. I don’t really know which of the two dozen phone calls was the one I placed to Dr. Bill Dominic, a burn surgeon/mentor of mine from Fresno. But after I described to him what was in front of me, he offered to make some calls himself. A few minutes later, Dr. Kathleen Murphy, a pediatric intensivist with the Children’s Hospital of Central California called me. “We’d be happy to take care of him.” She was unfazed when I explained that although the child was a U.S. national, the care would be charity. There were no family or island resources for the kind of care he needed. “It’s what we’re here for.” Then the logistical nightmare began. There was no transportation to California for this child. He was far too sick for commercial travel even if he could survive the four days until the next flight left American Samoa. An air ambulance was essential. But such a trip would carry an astronomical cost and require at least an overnight stay with a medical team on the way to the mainland. That presupposed he could survive 11 or 15 hours in transit. Please see Pago Pago on page 10 V I TA L S I G N S / M A R C H 2 0 1 0

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Pago Pago Continued from page 9 I left a desperate message for U.S. Congressman Jim Costa of California’s Central Valley. He called me back. I explained the situation in what must have sounded like an incoherent medical rant against bugs and bureaucracy and one doctor’s frustration at having the child’s only hope of survival destroyed by 7,000 miles of ocean. Congressman Costa told me to keep doing what I did as a doctor and let him deal with the rest. The next call I received was from David with the office of Congressman Eni Faleomavenga of American Samoa. And then there was a really friendly call from Congressman Costa’s chief of staff in Washington, DC, Lisa Williams. (She and I have the same streak of relentlessness. We recognize that it’s occasionally useful but mostly just irritating to those around us.) Then there was somebody from the State Department and then Homeland Security and of course the “Theater Patient Movement Requirement Center” (!) because they are the United States military medical transport people in the Pacific region. There were at least five of those guys and a cool, high-ranking lady named Captain Ellenberg. I don’t want to forget the U.S. Coast Guard’s Chief Petty Officer Smedley or Lt. Max Sada. Both intervened to help the sick boy, investing hours trying to cut red tape for a child they’d never meet at the request of a surgeon who they’d never heard of. And then there was a call from the military doctor with the pediatric ICU at Tripler Army Medical Center in Hawaii. She said that the facility would be happy to care for the child if logistics were overcome. She also gave us some good suggestions for his care, which we instituted. Between all of these calls and a series of late night and 5:00 a.m. conferences with Dr. Jim Marone, head of pediatrics at LBJ Tropical Medical Center, we spent our time in the ICU with our critically ill patient. Dr. DePasquale had a full load of pediatric patients to care for in addition. 10

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Tafuna residents Dean Hudson with daughter and LBJ Surgeon Linda Halderman with U.S. Congresswoman Laura Richardson (CA).

I depended heavily on LBJ surgery chief Dr. Kamlesh Kumar and the seriously overworked doctors of LBJ’s emergency department to cover cases and shifts while I worked in the ICU and fought cell phone battles. They are buried under the workload but never complain. I hope reinforcements come soon to relieve them. My favorite call was from Major Matthew Nims, MD, United States Air Force anesthesiologist, Medical Transport team leader and all-around superhero. It was his commitment to care for a dying five-year-old child en route to Tripler that made the impossible possible. At 2:30 p.m., a United States Air Force C-17 (a sort of flying intensive care unit) landed at the Tafuna International Airport in American Samoa. In addition to the pilots, there were two physicians, two pediatric ICU nurses, and a respiratory therapist. Did I mention that these people had volunteered for this mission? For four hours the Army/Air Force team and the LBJ Hospital team worked together to stabilize the boy. At some point – don’t ask me how, medically – the child began to show noticeable improvement. The LBJ intensive care unit nurses worked as hard as the visitors, and they had been doing it for three days straight. The little boy’s parents expressed their gratitude to everyone who entered the ICU doors. They gave the same grateful recognition to the X-ray technician as they did to Congressman Faleomavenga. Transporting a critically ill five-yearold with every available monitor, tube, and life support device is no simple task. I rode in the ambulance with the boy and three other team members to the airport and was awed by how easy these men and women made the effort seem.

The sight of the C-17 waiting for us on the runway had me repeating, “Holy Cow!” I couldn’t find any other words to describe the impossibly massive jet, nicknamed “The Globemaster.” It is the only aircraft in the world to have a selfcontained onboard oxygen system. After the little boy was safely delivered to the warehouse-sized interior of the jet, I hugged Major Nims and his colleagues and walked down the ramp to find Ele (“ELL-eh”), the LBJ social worker who had conquered limitless paperwork hurdles in the past three days. I looked back from a distance at the giant plane. When I saw the words “United States Air Force” on the nose, I choked up. “She’s ours,” was the thought I had. During the ride back to LBJ, all of the exhaustion and hopes and fears and frustrations and victories and grief of the past 72 hours hit me. I didn’t have the luxury of indulging my emotions while caring for a child for whom death was a much greater likelihood than survival. I don’t know if my patient will survive. I don’t know if the beautiful long dark eyelashes I looked at in the ambulance ride to the airport will open again. But I do know that if he has a chance, it is inside the C-17 that left American Samoa tonight, in the pediatric ICU of a Hawaiian military hospital, and in the greatness of a nation that can aim its military might at saving the life of a little boy on a tiny tropical island in the middle of the Pacific Ocean. P.S. There were at least 40 other people I know of – and many more I don’t – who participated in this effort, and I don’t diminish their kindness or commitment to this work by not naming them individually. I did make one critical omission though: U.S. Representative Laura Richardson intervened with Homeland Security as a member of the Energy and Transportation Committee to cut a huge spool of red tape. She deserves credit, though neither she nor her staff asked for any. Note: Since returing from American Samoa, Dr. Linda Halderman has declared her candidacy for the State Assembly, 29th District.


What We Wish For by David Hadden, MD Fresno County Coroner


was one of those hot Valley evenings that inspire fervent wishes for a convertible in the soul of every car lover. It was nearly 11 pm and still 80 degrees, and there was no glaring sunshine to spoil a convertible experience. On this Saturday evening, two blond young ladies were enjoying the breeze in their hair and the soft warm wind caressing their faces when something went terribly wrong. Their bright red convertible veered sharply to the right. The little car hit the curb David Hadden, MD and flipped. The now inverted machine continued down the road for another 145feet before coming to rest. The results for the driver and her passenger were instant and catastrophic. The young driver, with fatal injuries to her face and head, was dead at the scene. The equally young passenger was unconscious with facial injuries so major that she was all but unrecognizable. She was identified at the hospital using the contents of her purse. When her parents arrived her face was covered with gauze bandages. She was still unconscious, and they could not communicate with their daughter. At the accident scene, the deputy coroner found the driver’s purse. Inside was the driver’s license. He was unable to match the face with the DMV photo due to the driver’s injuries, but the height, weight, hair color and age were consonant with the body. Meanwhile, the police ran the plates from the wrecked car. The registration, license plate and ID were a match, so as soon as the body was removed, the deputy went to the address taken from the driver’s license to make the death notification. Death notification is the most stressful part of the coroner’s duties and never more so than when it is to the parents of a youngster dead as the result of a motor vehicle accident. Unexpectedly, the most precious part of their lives is ripped from them without warning and without mercy. It was early Sunday morning when the deputy arrived at the house where the descendent had lived with her parents. It is never possible to know how the loss of a loved one will be received. Reactions vary from stunned silence to cries of anguish. This early morning notification was decidedly different. The parents were devastated.

After composing himself, the father asked the usual questions seeking the details surrounding the fatality. Then, with tears in his eyes, from the depths of his agony he implored the startled deputy to explain, “Why did it have to be my daughter? Ashley was everything to me. Why couldn’t it have been my son? My daughter was wonderful. My son is worthless. Why couldn’t it have been my son?” He went on to explain that his son, who lived in Oregon, did drugs, was not interested in employment and sadly had little use or affection for his parents. They had not spoken to their son in months. A few minutes after 10 a.m. on Sunday, a car pulled up in front of the parent’s house and their daughter, Ashley, climbed out. A neighbor doing yard work out front was stunned. He rushed over and told the girl that her parents were at the mortuary arranging her funeral. The following story emerged. All three girls had been at a sorority party that Saturday evening. As the evening wore on, there developed a shortage of booze. Ashley, the owner of the red convertible, was having too good a time to leave the party. She offered her car to a younger girl if she would make the liquor run. The younger girl was delighted to have the opportunity to enjoy a spin in the coveted car, but she was under age and could not purchase alcohol. Ashley decided that the two of them looked enough alike that the younger blond could get away with using her ID. So Ashley gave the eager volunteer her purse containing Ashley’s ID and car keys. The excited soon-to-be driver invited a friend to go along. When the girls who borrowed the car were not seen again, it was assumed they had gone home and had left the car in the back parking lot. Ashley slept that night at the sorority house and was unaware of the Saturday night tragedy. The surviving passenger was unable to straighten things out because of her injuries. While the confusion in this case is understandable, it is one of the worst mistakes that can befall a coroner. Incredible emotional damage was visited on the wrong parents, and a delayed notification had to be given to another set of parents. Fortunately, the loved ones involved, despite their grief, were understanding. All of that occurred on Sunday. Monday morning, Ashley’s father called the Coroner’s Office. He said, “I thought you should know that late Saturday night or early Sunday morning my son in Oregon committed suicide.”

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New Chair Named to Community Health & Relations Committee

How Do We Approach Cleaning Up Our Air? by William Ebbeling, MD

It is a privilege to represent you this year on the Community Health & Relations Committee as its chair. If I were to describe my approach to problems, it would be this: “How do I fix a problem without causing new and worse ones.” I guess I’m a practicalist. I’m in favor of cleaning up the valley air but in a way that doesn’t bankrupt the valley economy. Diesel emissions and particulate matter are issues that need attention – as does methane William production. Ebbling, MD Cow smog is such an intolerable odor that it can’t be healthy. But what is the best way to fix the problem? Increasing the number of cows in the valley increases the methane production. If they can capture the methane to use for energy production, fine. But producing more methane in our San Joaquin Valley bowl doesn’t make sense. Since their food is trucked in, why not have them on a wind swept plain near Edwards Air Force base rather than the San Joachim Valley pollution bowl. I don’t want to hurt the dairymen, but increasing the cow supply doesn’t make a lot of sense.


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Past legislatures have produced so much anti-business legislation that we now don’t have the tax revenues to work out the problems. From these examples, I’m trying to show a “practical philosophy” of identifying problems and finding effective methods of fixing them without creating more problems like unemployment. I’m also a “localist” who thinks problems are best settled by the local owners of the problem rather than by big government. I’m looking for your ideas on how to fix our problems. After 27 years in the US Navy and two years at Children’s Hospital San Diego, I moved to Fresno in 2003 and opened a private allergy practice. I really enjoy my associations with my fellow physicians, and I think this city has many wonderful qualities. But having kids with rescue inhalers for their asthma and no controllers for those with persistent asthma is unacceptable. For that reason, my office tries on-going research protocols so we can treat patients at no cost. Physicians tend to think out of the box, so I’m looking to you for practical new ideas. Feel free to contact me about your ideas.

Tulare The Healthcare Time Bomb: HIPAA 5010 submitted by Dr. Bill Bysinger PhD Principal, WGB Advisory Group

There is a “Time Bomb” ticking in the healthcare industry that is more important that the crazy healthcare debates that are taking place in Congress. This revolves around the ability to get medical billing to the insurer for reimbursement and receiving successful payment. This is the process that if not done properly in January 2011, will result in “Zero” payment for some healthcare organizations. So what is this ticking “Time Bomb”? It is the format for the HIPAA billing transactions that define what data and in what form is authorized to be sent from a medical facility to a healthcare insurer. In short it is the electronic transaction that is mandated by HIPAA. This format is present in every practice management system, hospital system, claims processing system, financial system, and in some EMR systems in Healthcare. The format is controlled by the vendor of the healthcare information system whether at a practice, a hospital, a payer, or a clearinghouse. How can the “Time Bomb” be defused? Simple, ask your vendor of the practice management systems, hospital information system, claims processing system when they will be able to confirm that they are “HIPAA 5010 Compliant). The HIPAA transaction formats currently exist in a 4010 format. These must change to the 5010 format to accommodate the new implementation of the mandated ICD10 codes by 2013. In order to streamline the process, accommodate ICD10 and to create a new HIPAA compliant transaction process the “5010 Format” must be implemented and testing during 2010. If done properly your practice management, hospital information system, claims processing, clearinghouse software or billing company will be updated in late 2010. This will accommodate the tested HIPAA 5010 Billing Transactions and your practice will be able to submit bills and receive reimbursement after January 1, 2011. If not done you will be wondering why you are having rejected bills and not being reimbursed for services rendered. So ask all of all your vendors (including your 3rd party billing company) today where they stand on making their systems HIPAA 5010 compliant and protecting your organization from revenue short falls in 2011. Demand a timeline of their compliance, testing and certification, as well as their schedule of when they will have your systems ready to submit with 5010 billing transactions.

TCMS Annual Wine Social Friday, April 16 6:30-8:30pm

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

TCMS Officers Ralph Kingsford, MD President Steve Carstens, DO President-Elect Mark Reader, DO Secretary/Treasurer Mark Tetz, MD Immediate Past President Board of Directors Thomas Daglish, MD Karen Haught, MD Gaurang Pandya, MD H. Charles Wolf, MD Parul Gupta, MD Thomas Gray, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, 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

Chinese Cultural Center Visalia

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Behaviors that Undermine a Culture of Safety by Judy Cotta Kaweah Delta Health Care District District Compliance and Privacy Officer


American Medical Association (AMA) has defined disruptive behavior as a style of interaction with physicians, hospital personnel, patients, family members or others that interferes with patient care. The Joint Commission defines it further as intimidating and disruptive behaviors that can foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and others to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communications and a collaborative environment. The majority of physicians and health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. Most of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is readily recognized by patients and their families. The AMA policy (H-140.918 Disruptive Physician) indicates “Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes disruptive behavior.” Disruptive behavior can have a significant impact on the delivery of care, which can adversely affect patient safety and quality outcomes of care. Physicians and other health care professionals must promote teamwork, the free exchange of ideas and a collaborative approach to problem solving if medical errors are to be reduced. Both physicians and other health care professionals must fulfill their obligation to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of patient care. Disruptive behavior causes stress, anxiety, frustration, and anger, which can impede communication and collaboration. Physicians agree that the number one cause of this behavior among their ranks is stress. The typical physician has too much too do with too little time and overly high expectations to meet. Plus, many are dealing with life-or death-situations. Meanwhile, tensions are exacerbated by nursing shortages, lower compensation, managed care restrictions, increasing liability risks and regulatory requirements that affect productivity. Disruptive behavior is a two-way street with health care professionals exhibiting disruptive behaviors towards physicians. Collaboration will fully evolve when shared goals pertaining to patient care and professional values are discussed openly. Attitudes, tolerance, equality, receptiveness and staff and physician interactions help mold the culture.


M A R C H 2 0 1 0 / V I TA L S I G N S

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 KCMS Officers Jeffrey W. Csiszar, MD President Mario Deguchi, MD President elect Theresa P. Poindexter, MD Secretary Treasurer John E. Weisenberger, MD Past President

Board of Directors Bradley Beard, MD Frank T. Buchanan, MD James E. Dean, MD H. James Jones, MD Ying-Chien Lee, MD Kenny Mai, MD Sheldon R. Minkin, DO Daniel Urrutia, MD

CMA Delegates: James E. Dean, MD Thomas S. Enloe, Jr., MD CMA Alternate Delegates: Sheldon R. Minkin, DO Staff: Marilyn Rush Executive Secretary


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

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

JOHN WILLIAM LANG, MD October 9, 1945 - January 18, 2010

Dr. Lang was born on October 9, 1945 in Jersey City, New Jersey. He received his B.A. in 1967 from Iona College, New Rochelle, New York and went on to receive his Medical Degree in 1971 from Georgetown University, DC. He completed his Internship at the National Naval Medical Center, Bethesda, MD and Residency at the Boston Naval Hospital, Chelsea, MA and the Naval Hospital, Oakland, CA becoming a Board Certified Surgeon in 1977. He then went on to complete a Fellowship at the University of Pittsburgh. Dr. Lang also served his country in the U.S. Navy from July 1, 1971 - July 31, 1978 with rankings of LCDR, MC and USN. Dr. Lang and his family settled in Bakersfield in 1981, the same year he began his practice. Besides his wife and daughter, Dr. Lang had MANY loves. He had a great love of music, Latin, our great country and its military, the Catholic Church and his faith, football and his many beloved dogs. He enjoyed good conversation and debate, movies with sophomoric humor, history, and trivia on any subject. The last week of Dr. Lang’s life was spent in Hawaii for his niece’s wedding. They enjoyed whale watching, a helicopter ride, and scenic drives around the island. He was the consummate story teller, a lover of a long story longer. He is survived by his wife of 33 years Dione Lang; a daughter; Kristyn; a brother, Paul and his wife Barbara; and many nieces and nephews. Dr. Lang will be missed by all that knew him, the medical community and his many medical colleagues.

MEMBERSHIP NEWS Membership Recap JANUARY 2010 Active ...........................................................270 Resident Active Members................................0 Active/65+/1-20hr ...........................................3 Active/Hship/1/2 Hship ...................................0 Government Employed ..................................11 Multiple memberships......................................2 Retired ............................................................62 Total .............................................................348 New members, pending dues............................0 New members, pending application ................0 Total Members.............................................348

IMPORTANT DATES TO REMEMBER • Friday-Sunday, April 9-11 – CMA Annual Leadership Academy, San Diego, CA • Tuesday, April 27 – CMA Annual Legislative Day in Sacramento • Friday-Monday, Oct 1-4 – CMA Annual Session, Sacramento, CA



2010 KCMS Membership Directory has arrived. If there are changes and/or corrections to be made to your listing or you need to order additional copies, please fill out the form on page 7 and send to the KCMS Office. Any other questions, please feel free to contact the KCMS Office. Member Correction • Edward Taylor, MD, add to General Surgery listing on page 46.

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Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1382 E. Alluvial Avenue #106 Fresno, CA 93720 559-224-4224 Fax 559-224-0276 website:

FMMS Officers Harcharn Chann, MD President Oscar Sablan, MD President-elect Robb Smith, MD Vice President Krista Kaups, MD Secretary/Treasurer Cynthia Bergmann, MD Past President Board of Governors David Hadden, MD Sergio Ilic, MD Stewart Mason, MD Ranjit Rajpal, MD Krishnakumar Rajani, MD Rohit Sundrani, MD Muhammad Sheikh, MD Philip Tran, MD CMA Delegates FMMS President John Bonner, MD Adam Brant, MD Denise Greene, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Robb Smith, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Sergio Ilic, MD Prahalad Jajodia, MD Toby Johnson, MD Peter T. Nassar, MD Trilok Puniani, MD Rajeev Verma, MD

All critics and admirers of President Obama would agree that the healthcare bill is one of the most consequential votes the Senate would have cast since the creation of Medicare in 1965. President Obama promised to deliver healthcare that is both affordable and available to every American, including the citizens and non-citizens. Past President Bill Clinton was not able to muster enough support for his “Universal Healthcare Bill.” America’s healthcare is excellent for those who have good insurance, but it is more expensive than the rest of the world’s, and the results are mediocre at the most. Our present system encourages over-prescription and over utilization by the consumer. No one is watching the cost. In the present bill, the same flaws exist which have made the present system overused by the ones who have insurance and millions of people uninsured. Unless we start thinking differently, the advancing technologies will definitely bankrupt the system. The demand for healthcare is definitely rising, and it is a global challenge. By 2025, the global population of age 65 and over will definitely double. The cost of chronic diseases like heart disease, diabetes and obesity continues to increase and will continue to add to our healthcare demands and costs. The solution has to be based upon the simple facts that the best healthcare is administered at home, and the responsibility of the care has to return back to the individual. The new technologies that are available for people with chronic diseases can be monitored at home and could be an extension of hospital care. Unless – in some form or shape – a person or individual shares the cost of this care, the system will continue to need increasing financial support, and the cost will continue to rise. President Obama’s bill did not even address the issue of medical malpractice, which continues to increase our cost of care. This needs to be addressed. With attorneys being supported by both Democrats and Republicans, only time can tell whether they are willing or able to tackle the monster of medical malpractice. We as physicians need to prepare ourselves on how to work with new reimbursement issues and prepare ourselves for the care of patients with chronic diseases at home and – in some shape or form – the “ration” of medical care (“Ration” is a bad word when it comes to medical care.).

CMA YPS Delegate Paul J. Grewall, MD CMA YPS Alternate Yuk-Yuen Leung, MD CMA Trustee District VI Virgil Airola, MD Staff: Sandi Palumbo Executive Director


M A R C H 2 0 1 0 / V I TA L S I G N S

CMA’s Annual Legislative Day Tuesday, April 27, 2010 Sacramento Information: 559-224-4224, ext. 118 or

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.

Maryam Ardaian, MD OBG 445 S. Cedar Fresno 93702 459-5755 West Azerbaijan Uni of Medical Sciences ’92

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.

Artin Jibilian, MD Urology Robert Morris, MD Dermatology Robin Smit, MD Ophthalmology Emila Ting, MD Pediatrics Karin Wammack, MD Family Practice

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

MARCH 11 15 16 23

Membership ..........................6:00 pm Board of Governors...............6:00 pm MRAC ..................................6:00 pm Well Being ............................6:00 pm

JOHN CONRAD, JR., MD 58-year member

John “Jack” Conrad, Jr., MD a retired pediatrician, passed away January 20, 2010 at the age of 87. Dr. Conrad was born in Sacramento, CA in 1922. He received his medical degree from the Univ. of Calif. in 1946. After completing his internship at the U.S. Naval Hospital in Oakland, Dr. Conrad served two years in the U.S Navy. He completed his residency training at San Francisco Hospital and opened his private practice in Fresno in 1951. Among his many medical contributions, Dr. Conrad was instrumental in organizing a county-wide project with over 3,000 volunteers to immunize residents against polio in 1962, where a sugar cube coated with the vaccine was given on three separate Sundays. The surplus funds from the project’s 25-cent donations were used to start the Medical Society’s Scholarship Foundation. Dr. Conrad was also one of the organizers of monthly clinical cardiology meetings at Valley Children’s Hospital, which in turn, lead to the development of heart catheterization and surgery. Since his retirement in 1995, Dr. Conrad continued his organized meetings at Children’s Hospital and serving on FMMS’ Well Being and Historical committees and the FMMS Scholarship Foundation Board. Dr. Conrad is survived by two children, four grandchildren and one great grandchild.

Directory Changes

Membership Recap

Please update your 2010 Pictorial Directory with the following:


Board Certifications: J. Scott Boswell, MD – *Dermatalogy Leslie Storey, MD – *Dermatalogy

Active ..................................................668 Leave of Absence.....................................0 Retired..................................................203 Residents ..............................................234 TOTAL ...........................................1,105 Applicants................................................4

New Address and phone numbers: Pathology Associates 305 Park Creek Dr. Clovis 93611 326-2815 / Fax: 326-2816 Doctors: Paul Atmajian Stephen Avalos Baorong Chen Rueben Doggett Robert Futoran Clarke Harding William Pitts John S. Pollard David Slater Michael Weilert

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CME Activities

CLASSIFIEDS MEMBERS: 3 months/3 lines* free;

back by popular demand...

Sandra Siddall, RN, MSN from

PALMETTO, GBA MEDICAL REVIEW • CONSULTATION CODES ...viewing them in a different way • THE 3 ENFORCED AUDITS ...Medicare Review, CERT, RAC • DOCUMENTATION REQUIREMENTS ...avoid getting downcoded or denied WED., MARCH 10, 2010 Fresno-Madera Medical Society Boardroom 1382 East Alluvial #106 Fresno, CA 93720 12noon to 3pm $25 lunch Contact Sheryl Tatarian at 559/224-4224 x112 or RESERVATIONS MUST BE PREPAID BY VISA, M/C, CHECK or CASH All attendees must be FMMSmember physicians and office medical staff. Limited to first 50 people who RSVP with payment.


M A R C H 2 0 1 0 / V I TA L S I G N S

Yosemite Postgraduate Institute – March 26-28, 2010 Location: Yosemite National Park. Credit: 12-16 hrs. Fee: $325. Call 559224-4224.

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. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.

Suicide Rates Amoung the Lesbian, Gay, Bisexual, Transgender Community – May 13, 2010 Location: Visalia: Kaweah Delta Health Care District. Credit: 2 hours. Time: 6-8pm. Fee: N/C. Call 559-6242595 or


STD & Teen Pregnancy in our Community – May 19, 2010 Location: Visalia: Kaweah Delta Health Care District: Credit: 2 hours. Time: 6-8pm. Fee. N/C. Call 559-6242595 or

ANNOUNCEMENT 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.

FOR RENT / LEASE Professional office building at 7045 N. Maple Ave. (Maple & Herndon) near SAMC. 2,500-4,500 sf, $1.40 psf. TI negotiable. Call 559-940-3740. 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.

ALLIED PROVIDER WANTED Large OB-GYN group seeking NP/PA for busy practice. Contact Mandi at 559-495-3120. Busy OB-GYN practice in Fresno looking for NP to do GYN only. Contact Lisa Cochran at 559-908-5906.

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

MEDICAL OFFICES FOR LEASE 1902 B Street – 1,695 sf. 2920 F Street – 2,052 rsf. 2701 16th St. – Mid Town Medical: 1,500-5,000 rsf. 2201 19th St. – 1,772 sf. 608 34th St. – 1,935 rsf. 3911 Coffee Rd. – 5,210 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 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. 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 3819 Mt. Vernon – 1,000 rsf. 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. * 100% Leased: 1800 Westwind Dr – 25,036 sf. gross * SOUTHWEST LOT BUILD TO SUIT Bahamas Dr. – 15,600 sf office

Save the Date

59th Annual Yosemite Postgraduate Institute March 26-28, 2010 Topics include: • Wilderness Medicine • Travel Medicine • Immunizations • Coronary Artery Disease • Preventive Cardiology • Adolescent Healthcare • Drug Reactions • Chronic Cough • Diabetes For brochure and reservations, call 559-224-4224, ext. 118 or visit

V I TA L S I G N S / M A R C H 2 0 1 0

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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

2010 March  
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