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July 2010 • Vol. 32 No. 7

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: • Christmas in July! • West Nile Virus Season Begins • Particulate Pollution in the San Joaquin Valley


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 July 2010 Vol. 32 – Number 7 Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau

NEWS Christmas in July?....................................................................................................................6 PRACTICE MANAGEMENT: Communication Important in Hospitalist Model....................................9 BLOOD BANK: As Summer Begins, So Does West Nile Season. Fight the Bite!...........................10 AIR QUALITY: Particulate Pollution in the San Joaquin Valley: Translating Science Into Policy .......11

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 ..........................................................................................12 • Medical Students in Tulare County!?!? • “Correct Coding for Physician Services” by Practice Management Institute • CA Medical Board Consumer Notification KERN COUNTY MEDICAL SOCIETY .............................................................................................14 • Physician Wellness Committee • Membership News FRESNO-MADERA MEDICAL SOCIETY .........................................................................................15

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

• FMMS President’s Message • Membership News • Fresno County Department of Public health Community Health Division – Selected Communiable Diseases Report, April 2010

Cover photography: Driftwood on the Beach, Moss Landing by Newton Seiden, MD Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / J U LY 2 0 1 0

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How Successful Is Your Practice? Let physician members know your practice is available for referrals Use Vital Signs to advertise your practice at special rates offered to member physicians. contact: Annette Paxton Vital Signs Advertising Representative (559) 454-9331

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EDITORIAL

We All Need to Take Responsibility by Ralph Kingsford, MD President, Tulare County Medical Society

“You cannot escape the responsibility of tomorrow by evading it today.” – Abraham Lincoln

On Memorial Day weekend, I was contemplating my article for this upcoming “Vital Signs” issue and could not help but think that I needed to write about “responsibility.” I believe President “BEING Lincoln’s words hold true. We are facing yet another crisis, with the RESPONSIBLE Gulf oil well catastrophe, a disaster SOMETIMES of monumental proportions, which threatens to dwarf that of the MEANS PISSING Exxon Valdez spill, in part because PEOPLE OFF.” of evaded responsibilities. There have been several attempts to establish who is responsible for this disaster, which – GENERAL has already directly touched the COLIN POWELL families of the 11 who died and will continue to affect lives of millions along the Gulf Coast and possibly all along the Eastern seaboard, not to mention the environmental impact on all the other forms of life in the Gulf, wetlands and beyond. Obviously, the direct responsibility for this disaster lies with the oil giant British Petroleum and their immediate business associates Transocean and Halliburton. Of course, in the early stages following the disaster, they each felt their responsibility was limited, since the others had some hand in it. The fact of the matter though is they have all been responsible. In their greed for profits, there has been much cost cutting, limited attempts to ensure proper procedures were followed and blatant disregard for the environment and people affected by their callous behavior. This point is brought home by the insensitive (dare I say bonehead) remark made by BP’s CEO when in a recent interview he said, “I just want my life back.” No kidding – what about the unfortunate 11 who died and their families? What about all the working folk in Louisiana, Alabama and possibly even Florida,

whose livelihoods are in jeopardy? Do they just want their lives back? You better believe they do. Indirectly, the responsibilities go beyond the corporations involved. It is our legislators who have to share some blame. They receive huge campaign contributions from all the big oil companies and often bend over backwards to accommodate their demands. Here too, we see the familiar finger pointing at “past administrations” when there is a problem. Regulatory agencies appointed also play their role. They are either corrupt or inefficient at best, in ensuring the rules are followed and taking to task those that flaunt them. Time and again we learn, after the fact, of these failures where they have not properly monitored those they have been assigned to and have failed to ensure current laws were not violated (the recent mining accident and banking/financial meltdown immediately comes to mind). Lastly, we too, as a society share some responsibility. We have become so dependent on petro-chemicals in our day to day lives that we are indirectly complicit in the way it is obtained, irrespective of the effect on the environment and how it will impact the future of our kids and subsequent generations. We often look the other way when we see a breach, as long as it does not affect us personally. We are all too content to go along and not make waves. Worse, we are sometimes critical of those that do care, labeling them as “green freaks” or “tree huggers.” During the early days following this current disaster when there was a great deal being made to “limit off shore drilling,” a pompous talk show radio host spouted, “What’s all the fuss about? The ocean will take care of it.” Yes, really! I think we need to shake ourselves up from this stupor and take on our share of the responsibility for caring for our environment, so that our kids and theirs in turn, do not have to suffer the ill-effects of damage to the earth caused by our selfish behavior. I choose to close with a quote from General Colin Powell, “Being responsible sometimes means pissing people off.” Let us not evade our responsibilities today, doing whatever we can in small ways or big, holding those in charge accountable and if in the bargain, we piss someone off – so be it.

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Christmas in July? by Sandi Palumbo, Executive Director Fresno-Madera Medical Society and Kern County Medical Society

No‌ but with the way this year is flying by, the Holiday Season will be upon us before we know it, and anytime is a good time to think of ways to help the less fortunate. I have a simple, low-cost Holiday project that I wish to coordinate on behalf of Fresno-Madera and Kern medical societies and ask your support and participation for. Participation is easy! During your travels away from home over the next six months, please make a conscious effort to collect the complimentary toiletries provided by hotels during your stays. Past experience shows that if you remove the toiletries from the vanity each day, housekeeping will refresh the toiletries on a daily basis throughout your stay. Drop your toiletries off at the FMMS and KCMS offices between now and December 10, 2010. Staff will bag the toiletries for individual use, apply a label with an appropriate Holiday message noting toiletries provided compliments of FMMS and KCMS, and deliver them to local homeless shelters for distribution throughout the holidays to those in need. A simple project designed to share a little joy during the coming Holiday Season. Your participation and support is greatly appreciated. If you have a similar project to help the less fortunate that you wish to announce and seek assistance with, please submit details of your project in 200 words or less for publication in Vital Signs.

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CMA NEWS ACCOUNTABLE CARE ORGANIZATIONS: HOW WILL THEY IMPACT YOUR PRACTICE?

The recently passed federal health reform legislation authorized the creation of “accountable care organizations” (ACOs) to encourage greater coordination of care. ACOs may give physicians the opportunity to get back in the driver’s seat when determining the most efficient and appropriate ways to provide care to patients. The idea behind ACOs is that coordination of care will improve quality, avoid unnecessary hospitalizations and emergency room visits, and ultimately produce a more costeffective health care system. Under the new federal law, providers who join an ACO will share in the cost savings they achieve for the Medicare program. To learn more about ACOs and how they will impact the delivery of health care in California, sign up for CMA’s webinar, “Medical Foundations, Accountable Care Organizations, and the Bundling of Services.” In this webinar, professor and attorney Anthony Schiff will discuss federal health reform and the new drive to “capture” physicians, consolidate practices, and further integrate physicians and hospitals. The webinar will be presented twice, once on Wednesday, June 9, 6:00-7:00 pm and again on Tuesday, June 15, 12:15-1:15 pm. The webinar is free to members. Nonmembers can register for $100. For more information, or to register, visit CMA’s calendar. Contact: CMA’s member service center, 800-786-4CMA or memberservice@cmanet.org.

Five hundred California Medi-Cal claims will be selected for audit over the course of one year, approximately 130 claims per quarter. Audited claims will have dates of service of October 1, 2009, to September 30, 2010. Providers whose medical records have been selected for review will begin receiving written requests for medical records beginning this August. DHCS is urging all providers to comply with requests for medical records from the federal contractors or DHCS. If you fail to submit the requested records, an error will be counted against California and you will be required to refund the claim payment amount to DHCS. Your cooperation will help ensure that the audit results are accurate and that California retains its muchneeded federal matching monies for the Medi-Cal program. For more details on the federal audits, see DHCS’s March 2010 Medi-Cal Update newsletter. The DHCS Audits and Investigations Unit has also been stepping up anti-fraud efforts, including investigations of physicians and other providers. This year’s budget proposal includes a request for 38 additional DHCS positions to implement an anti-fraud initiative, with an estimated net savings of $26.4 million resulting from the increased audit efforts. For more information on Medi-Cal audits, see CMA On-Call document #0626, “Medi-Cal Audits.” CMA also recently hosted a webinar on Medi-Cal fraud and abuse. The previously recorded webinar is available for on-demand viewing to members only. Contact: CMA’s reimbursement help line, 888-401-8911 or economicservices@cmanet.org.

BLUE SHIELD PHYSICIANS: DID YOU GET A BLUE RIBBON?

AMA SUES FTC TO STOP RED FLAG RULE; FTC AGAIN DELAYS IMPLEMENTATION

Blue

AMA has filed a lawsuit to stop the Federal Trade Commission

Shield of California’s “Blue Ribbon” physician rating program goes live today, June 1. Blue Shield decided to publish this faulty data despite serious concerns about the validity and accuracy of the underlying California Physician Performance Initiative (CPPI) data and with blatant disregard for the confusion will cause patients and the irreparable harm it will do to physicians’ reputations. CMA vehemently objects to this program and is evaluating all avenues to protect physicians from Blue Shield’s misleading physician rating program. If you are contracted with Blue Shield, please take a few minutes and complete a very brief survey. Your responses are confidential and will be used to help us advocate on your behalf on this issue. If you have additional questions or concerns, we encourage you to contact CMA at 800-786-4262 or legalinfo@cmanet.org. Contact: CMA’s member service center, 800-786-4CMA or legalinfo@cmanet.org.

FEDERAL MEDI-CAL AUDITS TO BEGIN IN AUGUST

The

Centers for Medicare & Medicaid Services will be conducting audits of Medicaid claims in California. The audit is part of the federal Payment Error Rate Measurement (PERM) Program, mandated by the Improper Payments Information Act of 2002. The purpose of PERM is to estimate the number of payment errors made in the Medicaid programs of all 50 states and report back to Congress with an “improper payment estimate.”

(FTC) from extending its “Red Flag Rule” to physicians. The rule, after yet another delay, is now scheduled to take effect on December 31, 2010. As you know, the Red Flag Rules require financial institutions and “creditors” to implement identity theft detection and prevention programs. Despite objections from CMA, AMA, and others in organized medicine, the FTC insists that physicians who regularly bill their patients for services (including copayments and coinsurance) are considered “creditors” and must develop and implement written identity theft prevention programs for their practices by the June 1 deadline. CMA and AMA for two years attempted to get the FTC to reconsider its interpretation of physicians as “creditors.” CMA believes the Red Flag Rule imposes an unnecessary burden on physician practices, which often already operate under severely strained conditions. CMA also believes the new rules are unnecessary for most physicians because the Health Insurance Portability and Accountability Act (HIPAA) imposes strict requirements to safeguard the confidentiality and security of electronic patient information. AMA’s lawsuit asks for a declaratory judgment finding the rule is unlawful and void as applied to physician members of medical associations and state medical societies. The lawsuit does not, however, suspend the December 31 deadline. For more information on the Red Flag Rule, see CMA’s Red Please see CMA News on page 8 V I TA L S I G N S / J U LY 2 0 1 0

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CMA News Continued from page 7 Flag Rule toolkit and webinar, available free to members. Contact: Samantha Pellon, 916-551-2872 or spellon@cmanet.org.

PECOS ENROLLMENT DEADLINE: JULY 6, 2010

The Centers for Medicare & Medicaid Services (CMS) recently announced that the PECOS enrollment deadline will be moved up by six months. Pending any changes resulting from the public comment period, physicians now have less than 60 days to update their enrollment in Medicare if necessary. As previously reported, Medicare physicians who have not updated their enrollment information in the past five years may need to fill out another application or risk facing payment problems for ordered or referred services. Although the new rules were previously scheduled to take effect January 1, 2011, with the signing of the federal health reform law that deadline was moved up to July 6, 2010. CMS announced the change on May 5 in the Federal Register. Under the new rules, Medicare is authorized to reject claims if an ordering or referring physician is not identified in Medicare’s Internet-based PECOS enrollment system. Thousands of otherwise acceptable Medicare claims could go unpaid merely

CPLH 2010 offers 7 volumes with more than 4,500 pages of comprehensive legal information including current laws, regulations, and court decisions related to the practice of medicine. CPLH 2010 also includes new sections and forms to help physicians comply with the most recent changes in health care law.

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because they were submitted by providers who enrolled in Medicare before the PECOS database was developed. Physicians should also be aware that federal law requires providers who are enrolling or revalidating their PECOS enrollment to also sign up for electronic funds transfer (EFT). Although the online PECOS revalidation process appears to allow you to opt out of EFT, opting out is not an option. If you do not also complete the CMS-588 EFT enrollment form, you will be notified by CMS of the requirement and must do so before your claims are paid. CMA has developed a step-by-step guide to walk physicians through the process, from determining if they are already in PECOS to accessing the Internet-based PECOS enrollment system. This guide is available to members only at the membersonly website. CMA also hosted a PECOS enrollment webinar with Palmetto, California’s Medicare contractor. The previously recorded webinar is available for on-demand viewing to members only at the members-only website. Contact: CMA’s member service center, 800-786-4CMA or memberservice@cmanet.org.


PRACTICE MANAGEMENT

Communication Important in Hospitalist Model By Karen Davis PMSLIC Insurance Company

Hospitalists are becoming well established in the U.S., and the concept of hospital medicine has expanded to pediatrics, obstetrics, and some other fields. Recognized benefits of the hospitalist model have fostered its quick and enthusiastic acceptance across the country. However, one concern about the hospitalist model is that it intentionally disrupts the continuity of care. Risk management experts often advise physicians to BECAUSE THE concentrate on the continuity of patient care because gaps in TRANSFER physician-patient communica(OF PATIENTS) IS tion can lead to bad outcomes. PREMEDITATED, The hospitalist model has the potential to disrupt continuity of PHYSICIANS CAN care by setting up a deliberate DEVELOP break in communication between the patient and his or PROTOCOLS TO her usual physician in the form BOLSTER AND of the transfer to another provider – the hospitalist. PROTECT Robert M. Wachter, MD, who COMMUNICATION. coined the term “hospitalist” and who has been a leader in the development of the hospitalist concept, notes that from the early days, organizations using hospitalists have had to “[focus] on ensuring a smooth ‘hand off’ to prevent any ‘voltage drops’ at the inpatient-outpatient interface.”1 Because the transfer is premeditated, physicians can develop protocols to bolster and protect communication. Hospitalists and outpatient physicians should discuss the potential for

communication failures and make specific plans for transferring patients and for communicating about the care they each render. Communication protocols can include: • a method for the outpatient physician to discuss with patients how the hospitalist will be involved in care; • a plan for the outpatient physician to communicate with the hospitalist at or near the time of the patient’s admission; • a plan for sharing treatment and discharge information; • a plan for the hospitalist to be available to the patient if needed between discharge and the first visit back to the outpatient physician; • a plan for the hospitalist to phone the patient after discharge; and • any other procedures that facilitate clear and timely interaction between the patient and the physicians involved in care. Communication is especially crucial when new information about a patient becomes available after the patient has been discharged from the hospital. How does follow-up occur when, for example, a tissue sample evaluated as benign is subsequently interpreted as showing malignancy? Because follow-up is a known risk area, it is a good strategy to have a protocol for notification when new information comes to light after a patient is discharged. A good protocol has provisions for notification of both the outpatient physician and the patient. Hospitalists and the physicians who refer patients to them should think about areas where their communication with each other and with patients might be vulnerable to collapse. Any actions they can take to identify and diminish risks will improve patient care and decrease the likelihood of lawsuits.

Reference: 1 Wachter RM. The state of hospital medicine in 2008. Medical Clinics of North America. 2008;92(2):265-273. Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. PMSLIC is a wholly owned subsidiary of NORCAL Mutual. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL insureds. To learn more, visit www.norcalmutual.com/cme. V I TA L S I G N S / J U LY 2 0 1 0

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BLOOD BANK

As Summer Begins, So Does West Nile Season. Fight the Bite! by Patrick Sadler, MD Medical Director, CCBC

REPORT ESTIMATES WEST NILE VIRUS INFECTIONS IN THE PAST DECADE

According to a surveillance summary for West Nile virus (WNV) published in April, infection rates seem to have been stable from 2004 to 2007, and a drop in incidence rates in 2008 may be a good sign. However, WNV transmission through blood transfusion and organ transplantation has continued, despite the nationwide screening of blood donations that was instituted in 2003. The study, which was published in the April 2 issue of Morbidity and Mortality Weekly Report (MMWR), analyzes the number of cases reported to the Centers for Disease Control and Prevention from 1999, when WNV was detected in the US, until 2008. Its authors were led by Nicole P. Lindsey, MS, of the CDC’s Division of Vector-Borne Infectious Diseases, in Fort Collins, Colo. WNV is carried by mosquitoes from infected birds to humans. It is the leading cause of arboviral disease in the US. While 80 percent of people with WNV experience no symptoms, the virus can cause head-aches, rashes, gastrointestinal problems and other symptoms. In the most severe cases, WNV can cause neuroinvasive disease, most often in the form of encephalitis, meningitis, or acute flaccid paralysis. In the US, WNV was first detected in the New York City area in 1999; it spread substantially in 2000 and 2001, and by 2006, cases had been reported in all of the contiguous states except Maine. It has now been reported in 47 states and the District of Columbia, but not in Maine, Alaska, Hawaii, or US territories. Findings. Since 2000, state and metropolitan health departments have reported cases of WNV to the CDC through ArboNET, an electronic passive surveillance system. This summary of the surveillance data indicates 28,961 confirmed and probable cases of WNV from 1999 to 2008. Neuroinvasive cases of WNV peaked in 2002, with 1.02 cases per 100,000 people. The number was relatively stable from 2004 to 2007; it dropped slightly from 0.50 in 2006 to 0.41 in 2007 to 0.23 in 2008. The authors posit that this stability may represent an endemic level of transmission; however, they also point out that it is not yet clear whether the slight downward trend will continue. The neuroinvasive form of the disease was most likely to develop in older people, particularly men, and in the West North Central and Mountain states. The illness can begin at any time during the year, but for most patients (93 percent), the onset of symptoms began during July, August, or September, with the peak coming in August. Transmission of WNV through blood transfusion was first reported in 2002, when platelets, red blood cells, and fresh frozen plasma from 16 viremic blood donors were found to have caused infection in 23 transfusion recipients. 10

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Figure 1. Average annual incidence (calculated using US Census Bureau population estimates for July 1, 2004) per 100,000 population of West Nile virus neuroinvasive disease (n=11,822), by state of residence – United States, 1999-2008.

Figure 2: West Nile virus disease cases (N = 28,961), by week of illness onset –US, 1999-2008.

WNV can be transmitted from blood donations with virus levels lower than those detected by the screening tests instituted in 2003. Through 2008, 10 breakthrough cases occurred. Transmission through donated organs was first reported in 2002, when WNV infection developed in four patients who received organs from one infected donor. Another three recipients were infected in 2005. Citation. Lindsey NP, et al. Surveillance for human West Nile Virus diease – US, 1999 – 2008. MMWR 2010 Apr 2;59(2): 1-17. Source: ABC Newsletter April 16, 2010


AIR QUALITY

Particulate Pollution in the San Joaquin Valley: Translating Science Into Policy by John Balmes, MD and Don Gaede, MD Edited by Michelle Garcia, Air Quality Director The Fresno Asthmatic Children’s Environmental Study (FACES) Exposure Assessment: Katharine Hammond, PhD, Jennifer Mann, PhD, MPH

The Fresno Asthmatic Children’s Environment Study is a large epidemiological study of the effects of air pollution on children with asthma. The overall goal of this study is to determine the effects of different components of particulate matter (PM), in combination with other ambient air pollutants, on the natural history of asthma in young children. The study is being conducted by investigators at the University of California, Berkeley. The Pollutants studied include: • Particulate Matter, • Criteria air pollutants (NOx, SO2, CO, Ozone) • Polycyclic Aromatic Hydrocarbons (PAHs) • Volatile Organic Compounds (VOCs) • Environmental tobacco smoke • Allergens. Key findings: The FACES team found that exposure to two pollutants, NO2 and coarse particles, increased the risk of wheezing in asthmatic children living in Fresno. Also, two sub-groups of children had the greatest risk of wheezing with pollutant exposures, boys with mild, intermittent asthma (whose asthma may not be adequately controlled) and children allergic to molds and cat. A Tale of Three Cities –Tim Tyner, MS Tim is a co-investigator and project leader in Fresno for a CDC funded childhood asthma surveillance program (Fresno Kicks Asthma) and is working with investigators at UC Berkley and Stanford on an NIH study in Fresno examining the impacts of air pollution on the regulation of genes associated with the onset of asthma in children. He is also the co-investigator of a study assessing the relative impacts of air pollution on asthma hospitalizations and ER visits in three San Joaquin Valley cities – Modesto, Fresno and Bakersfield. He recently presented results from this study at a regional PM conference in Fresno. Key findings: • PM2.5 was associated with emergency department visits for asthma in Fresno and, to a lesser extent, in Bakersfield and Modesto. However, while an estimated 8% of all asthma hospitalizations in Fresno were shown to be a consequence of elevated PM2.5, similar associations were not found in

Bakersfield or Modesto. These results may have been reflective of differences in population socioeconomics, as Fresno represents a lower income and consequently poorer quality of care population. Conversely, it was demonstrated by previous speakers at the conference that the chemical composition of PM2.5 in Fresno differs from that in Bakersfield (data for Modesto was not presented) and suggested the composition of PM2.5 may contribute to relative differences in toxicity and health impacts. • Proximity to traffic has been the most consistent variable associated with respiratory (asthma) health effects in epidemiological studies to date, both in terms of acute exacerbation, as well as onset of disease (prevalence). Ozone analysis has not been completed yet but is in progress. Translating Science into Policy – A Message from the Governor’s appointed physician to CARB – John Balmes, MD Dr. Balmes leads a research program involving the respiratory effects of ambient air pollutants. He conducts controlled human exposure studies of the acute effects of ozone and other Pollutants. Dr. Balmes’ expertise in the health effects of ambient air pollution has been recognized by multiple awards. Key findings: The Clean Air Act requires review of the National Ambient Air Quality Standards on an every 5-year basis. The US EPA is assisted in this task by the legislativelymandated Clean Air Scientific Advisory Committee (CASAC), which is charged with reviewing the scientific knowledge about the health effects of the pollutant under review. During the last federal administration, the advice of CASAC was ignored (on both the PM and ozone standards) because of “scientific uncertainty.” Dr. Balmes made the case that CASAC’s job was to evaluate the level of scientific uncertainty and EPA administrators should respect that advice. Two new air quality standards have recently been announced that provide greater protection for persons with asthma – 1-hour standards for both NO2 and SO2. For more information on these projects as well as several others such as: • Fine Particulate Matter in the San Joaquin Valley by Dr. Michael Kleeman • Toxicology of Secondary Inorganics by Dr. Henry Jay Forman • Pulmonary Health Effects: Inside the Lungs by Dr. Ning Li • Bioaerosols and Pulmonary Health by Dr. Fred Lurman • What are We Breathing on Shaw Avenue: Understanding the Chemical Makeup and Health Implications of Individual Particles by Dr. Anthony Wexler Visit www.valleyair.org

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Tulare

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

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

A.T. Still University School of Osteopathic Medicine medical students working at a teen health fair at the Family Healthcare Network, Cutler-Orosi Health Fair, 2009.

Medical Students in Tulare County!?!? by Janelle Pieros, OMS III; Jennifer Krauland, OMS III; and Vanessa DeSousa, OMS III

As some of you may know, in July of 2008, 10 aspiring doctors descended upon the Central Valley, eager to take on years 2-4 of their medical education. With the cooperation of Family Healthcare Network, Porterville and Visalia serve as community campuses of A.T. Still University School of Osteopathic Medicine in Arizona. You might wonder, “What school? I’ve never heard of it!” or, “Why are students shadowing doctors in their second year of medical school instead of being stuck in lectures for hours?” or, “Why are medical students doing rotations in such small towns with no medical university nearby?” We hope to answer some of these important questions! So let’s begin.

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

“What school? I’ve never heard of it!” In 1892, Dr. Andrew Taylor Still founded the first school of osteopathic medicine now located in Kirksville, Missouri. In 2007, a sister school of the same name (A.T. Still University) welcomed its first class of student osteopathic doctors to Mesa, Arizona. Touted as innovative and progressive, our curriculum is based on the clinical presentation model. There are 125 known ways patients present to a doctor’s office. During our first two years, each week had a different clinical presentation as the topic, and we learned all the basic sciences as it pertained to that particular presentation using schemes to help frame the information. The presentations were divided by body system. In addition, we learned osteopathic manipulative techniques, history taking, and techniques for physical exams. We spent an entire 12 months on campus in Mesa, AZ, and then continued our learning while applying our clinical knowledge at 11 community campuses across the nation, from New York to Hawaii. The Central Valley is one of these sites. One of the main goals of our school is to address the nationwide shortage of physicians in primary care and under-served communities. In our class, there are students pursuing careers in both primary care as well as other specialties. Starting in July of 2010, there will be 30 students, OMSII-OMSIV, from our school rotating between the community clinics, Kaweah Delta Healthcare District, Sierra View District Hospital, and many private offices. “Why are students shadowing doctors in their second year of medical school instead of being stuck in lectures for hours?” We spend 8-12 hours per week during year two of medical school shadowing physicians in various fields, with a main focus of primary care. This is called Integrated Clinical Experience. The goal is Please see Students on page 13

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Tulare Students Tulare County Medical Society Members Continued from page 12 to start applying basic science knowledge to clinical practice early on in our training. In a nutshell, we are learning medicine hands-on in the manner in which it will be practiced. By doing this in our second year, it enables us to have a seamless transition to what is thought of as the traditional clinical rotations in years three and four with more experience under our belts. “Why are medical students doing rotations in such small towns with no medical university nearby?” Given our partnerships with community health centers in medically underserved areas, we have an opportunity to fully immerse ourselves within these areas with the hope of returning once we are practicing physicians. Our school employs two learning facilitators at each community campus to guide our learning and help establish connections with physicians from the community to serve as preceptors. While our main campus may be miles away, we are well connected via our facilitators and of course, the internet. We have really enjoyed our time here in the Central Valley and truly appreciate all of the physicians who have opened their practices to us. The patients we have met and skills we have learned will certainly help us be the best physicians possible. We look forward to working with some of you during our final year of medical school!

SAVE THE DATE Wednesday, August 25 • 9am-4pm Sequoia Regional Cancer Center “Correct Coding for Physician Services” by Practice Management Institute $149 per participant (Continental breakfast and deli style lunch will be provided)

• Comprehensive look at ICD-9, CPT and HCPCS Level III coding systems. • Use the language of coding to tell the story of the patient encounter. • Maximize productivity when you learn to use your coding books more effectively. • Systematic method for translation of documentation into coding to the CMS 1500 Contact Gail Locke, TCMS 559-734-0393 for more information or to reserve your seat for this FULL day Coding Course

Tulare County Medical Society Members Are you in compliance with the upcoming CA Medical Board Consumer Notification regulation that goes into effect on June 27, 2010? Would you prefer not to hang a sign on a wall in your office and instead easily affix the sign to glass? TCMS printed the CA Medical Board signage on static cling material that can adhere and be removed easily from glass. Please call Gail Locke, TCMS at 559-734-0393 if you would like a static cling sign sent to you or if you need any other information about the CA Medical Board Consumer Notification regulation.

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Kern

Kings Physician Wellness Committee by Portia Choi, MD, President-Elect Kern County Medical Society

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

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 Kathy L. Hughes Membership Secretary

We doctors have been used to stress right from the beginning of training and into practice. We are used to multi-tasking, decision making that impacts a person’s life, working with lack of sleep, not having time to relax for ourselves and always doing for others. These are especially challenging and stressful times for doctors. Stress is a result of any change. There is the positive stress – when you buy the home of your dreams, meet your wonderful spouse, a newborn baby in your family. And there is negative stress – when you have major repairs in your home, divorce, the child or teenagers worries you. It’s all stress. When you live, you are bound to get stressed. The importance is how you cope with stress. You can cope by exercising more, eating healthier foods, findings ways to relax, counting one’s blessings more, finding a source of help for your life. Then there are ways of coping that makes one’s life more complicated. These are using drugs or drinking more alcohol, becoming more angry and behaving in violent or inappropriate ways. With concern for our doctors, the Kern County Medical Society has formed a committee to help ourselves. On May 24, 2010 the following Medical Society members met: Doctors Robert Marshall, Dan Grabski and Portia Choi. We have formed the Physician Wellness Committee to help our doctors. We will be in contact with the Medical Board of California and hope to work closely with them in dealing with physician wellness issues. What we realized is that to help our doctors, we need more doctors to provide input and help this committee. If you are interested in this committee or wish to serve, please call Portia Choi, MD at 661-868-0461.

MEMBERSHIP NEWS Membership Recap MAY 2010 Active . . . . . . . . . . . . . . . 258 Resident Active Members . 0 Active/65+/1-20hr . . . . . . . 3 Active/Hship/1/2 Hship . . . 0 Government Employed. . . 10 Multiple memberships . . . . 2 Retired. . . . . . . . . . . . . . . . 62 Total . . . . . . . . . . . . . . . . 335

New members, pending dues. . . . . . . . . . 0 New members, pending application . . . . 1 Total Members . . . . . . . . 336

UPCOMING MEETING OF INTEREST

h

KCMS Membership Meeting Thursday, September 23 – NORCAL CME Presentation CMA Annual Session October 1-4, Sacramento, CA

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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


Fresno-Madera HARCHARN CHANN, MD

Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1382 E. Alluvial Avenue #106 Fresno, CA 93720

THOUGHTS ON HEALTHCARE

Healthcare is very different from other goods and services and cannot be easily compared. Healthcare is very individual, and each person needs individual care. Some medical decisions make a difference between a person having a normal life versus a person having pain or disability for the rest of their life. Given the very specific need for each disease process in each person, one cannot compare expenditures in one geographical location to another in any intelligent way. It is a very well known fact that free medical insurance tends to be overutilized. Services are used much more often than when the services are less easily obtainable, and one has to go through a greater effort to receive the same service. One could consider that the person who has developed symptoms of “flu and cold” may take rest, plenty of fluids and get better in seven days. But if this person has good health coverage and help is readily available, one would tend to utilize services, and many times may actually get more harm and side effects from the medications than if he/she had just taken rest, plenty of fluids – and stayed away from other contacts. Some individuals do not need or obtain any healthcare all their life other than routine immunizations, while some individuals need a lot of medical care, especially if they have any chronic illness. There is a lot of uncertainty about an individual’s need for medical care, and healthy individuals for most of their lives may not need any medical care except when they meet an unexpected accident or an illness like a cancer. The utilization of medical care then suddenly becomes another extreme. Expenditures for most services are not of much concern for “public policy,” and market forces between supply and demand decide the competitive pricing. This cannot be applied in the case of medical care because of several reasons. First, in a model of demand and supply, we have to assume the consumer is very intelligent and well informed. When it comes to obtaining medical care, even the well-educated and intelligent person does not have information to make a very informed decision. Our measures of quality are very crude to say the least. A hospital system may get five stars in one area of their care, while they may be on probation in another area. Hospitals give extra attention to quality measures, and all emphasis is placed on fulfilling these measures rather than on providing quality of care to the patients. Providing specialty care in a community is a very different and complicated decision for even the best informed consumer. There is a very intricate interplay between the facilities where the care is provided and the physician who is in charge of the care. More and more new physicians want to be in a model where they are employed and work for fixed hours, needing and wanting a quality life of their own. In this model, the continuity of care of the patient is the first to suffer. America has the best medical care, and it is obvious that Americans have decided that the care has been “too expensive,” and a change was needed. The different geographical areas have different challenges to meet the new challenge with the passage of the patient protection and affordable care act of 2010, also known as “Obama Care.” Time will decide how this act is going to affect the care of our patients. As physicians, we have to be cognizant of our role as an advocate for the patient and for the best possible care. The medical delivery model may change, but the role of the physician is not going to change. The corporate practice of medicine bar is being attacked in many different ways, and physicians need to recommit themselves to protect this act for the benefit of our patients. Whenever patients are benefited, physicians are also indirectly benefited, as they will too be patients one day. Hospitals are cheering up to the model of physician employment and to somehow circumvent the true intentions of the act. We should really look to each other for a solution to the problem rather than looking at each other as a competitor, and in the process, totally “lose the game.”

559-224-4224 Fax 559-224-0276 website: www.fmms.org

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 Ujagger Singh Dhillon, MD David Hadden, MD Sergio Ilic, MD Prahalad Jajodia, MD Yuk-Yuen Leung, MD Stewart Mason, MD Ranjit Rajpal, MD Krishnakumar Rajani, MD Bonna Rogers-Neufeld, 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 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

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Fresno-Madera Fresno County Department of Public health Community Health Division Selected Communiable Diseases Report, May 2010 4 Week Period Ending: 05/29/2010

DISEASE

REPORTED CASES FOR WEEKS 18 - 21

2010 AIDS Botulism (Infant, Foodborne, Wound)* Campylobacteriosis Chlamydia Coccidioidomycosis Encephalitis-total* E. coli O157:H7 Giardiasis Gonococcal Infections HIV** Hepatitis A Hepatitis B, acute Hepatitis C* MRSA*** Meningitis - Bacterial Meningitis - Viral Meningoccocal Infections Mumps Pertussis (Whooping Cough) Rubella (German Measles) Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Total Tuberculosis West Nile Virus TOTAL DEATHS REPORTED THIS PERIOD Deaths from pneumonia and influenza TOTAL BIRTHS REPORTED THIS PERIOD

2009

2008

TOTAL CASES REPORTED TO DATE

5 YEAR ANNUAL AVERAGE

2010

2005-09

2009

2008

11 0 20 366 19 0 0 1 34 33 0 0 64 0 2 13 0 0 41 0 6 1 1 1 2 2

12 0 33 330 48 0 4 3 66 5 1 2 137 2 3 11 3 0 2 0 20 10 0 2 3 2

6 0 18 447 17 0 1 2 44 14 1 3 192 0 3 8 2 0 1 0 11 17 0 1 1 8

34 0 86 2262 103 0 1 9 255 113 1 1 417 3 12 43 2 0 76 0 52 6 2 3 5 20

44 0 94 2294 232 0 5 9 292 37 1 2 529 5 13 46 3 0 11 0 55 25 0 3 4 12

34 0 73 2074 76 2 1 7 265 52 1 7 807 0 15 19 4 2 7 0 36 36 1 1 2 18

79 1 193 4520 467 7 15 26 946 80 8 12 1045 N/A 29 149 4 1 145 0 137 60 1 4 9 58

0

0

0

0

0

0

22

507

553

540

2733

2726

2827

65

50

55

314

319

286

1,376

1,302

1582

7481

7179

7105

**Name reporting began on 04/2006. *** Disease added to monthly report on January 1 st 2009. Note: Reported 2009 data is Provisional. Official data will be reflected in the 2009 Annual Report

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

Haifaa Abdulhaq, MD *IM-*ON-*HEM 2828 Fresno St #203 Fresno 93721 Damascus Univ ’96 Eyad Almasri, MD *IM-*SM-*CCM 6311 N Fresno St. #106 Fresno 93710 Damascus Univ ’96 Cyrus F. Buhari, MD *IM 110 N. Valeria St. #508 Fresno 93701 Western Univ of Health Sciences ’03 Praneetha Narahari, MD *GS 7415 N. Cedar #102 Fresno, 93720 Osmania Med Col ’87

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

JULY 7 13 14 19

Medical Managers ..............12:00 pm Scholarship...........................6:00 pm Editorial................................6:00 pm Board of Governors..............6:00 pm

45-year member

William A. DeFires, MD, a retired preventive medicine specialist, passed away on April 5, 2010 at the age of 93. Dr. DeFries was born in Manila, Philippine Islands in 1916. He received his medical degree from St Louis Univ. School of Medicine in 1940. After completing his internship at St. Luke’s Hospital in San Fransicso, Dr. DeFries served for 20 years in the USAF. He moved to Fresno in 1964 and served for nine years as Fresno County Health Officer and practiced at the County free clinic in Firebaugh. Dr. DeFries retired to Santa Barbara, CA in 1983 and had been living in Florida since 1994. Dr. DeFries is survived by his wife, 5 children, 15 grandchildren and 12 greatgrandchildren.

WOODWARD SHAKESPEARE FESTIVAL SUMMER 2010 Plan to join FMMS members and their families for two fun-filled evenings this summer under the stars at the Woodward Shakespeare Festival at Woodward Park.

JULY 15: MERCHANT OF VENICE AUGUST 20: KING LEAR All performances are in the Stage on the Meadow, northeast side of Woodward Park by the Friant/Fort Washington entrance. Pre-show at 7:30 pm Performance at 8:00 pm FMMS will provide water and light refreshments – attendees are also encouraged to bring own snacks. No charge to attend, but for $10 reserved seating go to www.woodwardshakespeare.org. To RSVP or further information, call 559-224-4224, ext. 118.

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CME Activities Updates in Wilderness Medicine – July 18-23, 2010 Multi-Day Pack Trip into the John Muir Wilderness; Credit: 10 CME. Contact: Allen Clyde, MD at clyde559@ yahoo.com. What Every Practitioner Should Know About Bariatric/Metabolic Minimally Invasive Surgery – August 7 Location: Riverpark Conference Center at Fresno Heart & Surgical Hospital; CME: 4 CME; 8am-12pm; Fee: N/C; Contact: 559-433-8122 or rryder@ fresnoheart&surgical.org.

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. 2501 H Street – 1,234 rsf. 2701 16th St. – 2,400 - 4,800 - 10,000 rsf. 608 34th St. – 1,935 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. 3115 Latte Lane – 5,637 rsf. 9508 Stockdale Hwy. – 1,459 rsf. 2731 H Street – 1,400 sf. 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. 2701 16th Street – 10,000 sf. Crown Pointe Phase II – 2,000-9,277 rsf. 3311 Latte Lane – 5,637 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

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

FRESNO / MADERA 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 LEASE / RENT Fresno Bullard Park medical office, 4,000 sf, 95 cents psf. Very clean, available immediately. Call 559-288-6866. Medical space in Tower District; 1,580 sf, $895/month. Call 559-288-6866. Office complex, well-maintained, central location; 3 units, up to 4 spaces each, ranging 600 – 1175 sf, $700 - $1250 month. Parking. 6276 N. First, Fresno. 559-908-5893. Medical office space, up to 2880 sf, located in Kerman, retail center near HWY 180/HWY 145. Email: kermanlease@yahoo.com or call 408-6125804. Medical office space, 2,000-3,000 sf in Madera. Close access to Hwy 99. Call Dr. Ted Nassar at 559-674-0917. Medical office space, 1,500-6,500 sf, $1.20 psf plus. Near Fresno Surgery Center at 6137 N. Thesta. Call Bill Brar at 559-681-6390. Professional office building at 7045 N. Maple Ave. (Maple & Herndon) near SAMC. 2,5004,500 sf, $1.40 psf. TI negotiable. Call Scott Buchanon at 256-2430.

FOR SALE Owner/user opportunity in a proposed medical office, multi-story building, up to 61,000 sf, directly across from Clovis Community Hospital. Call Chad McCardell at 559-256-1717.

PHYSICIAN WANTED Full or part time for Occupational medicine facility, Care for injured workers, new-hire physicals & on-site visits for work place safety. Contact: Su Rosenthal: su@palmmedical or 559-2229200x228 or 559-287-0172. Co-sponsor need for foreign med. Graduate for his elderly Slovak mother to come to Lincoln. Neb. Contact Dr. Milulas Bendik at 402-4384309.

SERVICES OFFERED Disability Income Protection with Guardian, Standard & Principle. Contact Scott Karl at 559307-6103.

KERN FOR RENT / LEASE Medical building up to 7000sf, 2 blocks from San Joaquin Hospital. Priced below market. Private employee parking & off-street patient parking. Total remodel just completed. Available immediately. Call 661-323-7933 or email wwlaw@pacbell.net. 18

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PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

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.

Mutualinterest Your reputation matters. Period.

Some insurers cap their defense costs or take them from your coverage limits. NORCAL Mutual does not. We are committed to protecting you regardless of the cost. There is no cap on the value of the reputation you’ve earned.

Call NORCAL Mutual today at 800.652.1051. Or, visit www.norcalmutual.com. NORCAL Mutual is proud to be endorsed by the Fresno-Madera Medical Society and the Kern, Kings and Tulare County Medical Societies as the preferred medical professional liability insurer for their members.


2010 July