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Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

August 2013 • Vol. Vo ol. 35 No. 8

Vital Signs

See Inside: Covered California Unveils Qualified Health Plans Pediatric Crisis Checklists Rare Conditions Manifesting as Sinus Disease

We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.



For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like internal medicine specialist James Strebig, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.


CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the nearly 12,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.


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Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society

Contents CMA NEWS ................................................................................................................................5 NEWS Webinars At-A-Glance ..............................................................................................................8 HEALTHCARE REFORM: Covered California unveils Qualified Health Plans, Expected Premiums ....9 SAVE THE DATE: 33rd Annual Central Valley Cardiology Symposium..........................................10

August 2013 Vol. 35 – Number 8

PEDIATRICS: Crisis Checklists ...............................................................................................11 BLOOD CENTER: Golf Tournament: September 9 .....................................................................17

Editor, Bonna Rogers-Neufeld, MD, FACR Managing Editor Carol Rau Yrulegui Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD

CLASSIFIEDS ...........................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................12 • President’s Message • Walk With A Doc Recap and Upcoming Dates • FMMS Community Service Award Nomination Forms KERN COUNTY MEDICAL SOCIETY ............................................................................................15 • President’s Message TULARE COUNTY MEDICAL SOCIETY.........................................................................................16

Kings Representative TBD Kern Representative John L. Digges, MD

• Two Rare Conditions Manifesting as Sinus Disease • 2014 Coding Book News • Upcoming Dates to Remember

Tulare Representative Thelma Yeary

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 937298337. Advertising Contact: Display: Annette Paxton, 559-454-9331 Classified: Carol Rau Yrulegui 559-224-4224, ext. 118

Cover photography: Kīlauea Lighthouse on Kīlauea Point, Kilauea Point National Wildlife Refuge, Kauai, Hawaii by Bonna Rogers-Neufeld, MD, FACR Equipment used: Nikon on auto settings. 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 / A U G U S T 2 0 1 3


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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You said what to the Medical Board’s investigator? Physicians often come to us after they have been interviewed by a Medical Board investigator or after they have already provided a written description of their care. Did you know that a Medical Board investigator is a sworn peace officer, with a gun, and a badge, and the power to arrest you? When the Medical Board demands an explanation, seek help immediately. The attorneys at Baker, Manock & Jensen have helped many physicians through the maze that is a Medical Board investigation. We would be honored to help you.

George L. Strasser 5260 North Palm Avenue Fresno, CA 93704 559 432-5400


Trial lawyers and their front group “Consumer Watchdog” recently sent registered voters a cadaver toe tag with the message that “toe tags are needed (in California) because of preventable medical errors.” With the start of this direct mail campaign, it is clear the trial lawyers are looking to score a victory this year and encourage legislators to modify or overturn California’s Medical Injury Compensation Reform Act (MICRA) with their over the top tactics. The California Medical Association (CMA) and its MICRA coalition members at Californians Allied for Patient Protection (CAPP) are fully engaged. With increased legislative visits and the preparation of our own direct mail campaign and updated materials, we are telling the full story of MICRA and its important role in maintaining access for all. CMA has completed polling to update our public messaging and to help guide our strong, coordinated defense of MICRA. The voters of California support MICRA and its provisions. You as the

physician voice are their most trusted advisor on medical issues, but we need to make sure your voice is heard! Physicians will be victorious in this fight, but in order to do so, we need your help. JOIN: If you are not already a member of CMA, please consider joining today. By joining CMA, you will help to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond. Together, our unified voice can move mountains. JOIN TODAY on the CMA website, or call the member help line at 800-786-4262. DONATE: A fight of this magnitude will be extremely costly. CMA is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections. DONATE TODAY SPEAK OUT: Sign up to be a CMA Key Contact. As a Key Contact, we will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters. CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue such as MICRA. SIGN UP TODAY. For more information on MICRA, and what you can do to help in the fight, visit Please see CMA News on page 7

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Let us help find the right Long-T Long-Term erm Car Care e insur insurance an me on things that tha plan for you, so you can spend time matter the most most.. People People are living living longer these days, days, but as life expectanc expectancies ies increase, so does re long-term care. In fact, the risk of serious health problems that ccould ould require will will at retirement age, g 70% of Americans w ill need long-term g g-term care and 40% w home. enter a nursing g home ome.1 And with with the average average cost cost for or nursing home care in a ould literally semiprivate room equating to more than $67,500 per year, that could cost most or all of your life’s life’s sa vings.2 cost savings. LLong-Term ong-T Term Care insuranc insurancee ma mayy not b bee for ever everyone. yone. But w with ith soaring healthcare ccosts, osts, insuranc insurancee restrictions and the need ed to stretch retirement savings savings through more years . . . it’s it’s a good idea to seriously cconsider onsider this ount. valuable coverage discount. coverage while receiving receiving a member member premium disc

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CMA NEWS Continued from page 5


The California Supreme Court recently issued a long awaited ruling in a case involving peer review and medical staff self-governance, El-Attar v. Hollywood Presbyterian Medical Center (no. S196830). In this case, the hospital board at Hollywood Presbyterian Medical Center ignored and overrode the medical staff executive committee's (MEC) recommendation to reappoint a physician on staff. The physician then invoked his right to a joint review committee hearing to challenge the hospital’s termination of his privileges. Frustrated that the hospital overrode its decision that the physician should remain on staff, the MEC decided that since it was the hospital that wanted to terminate him, then it should be the hospital to prosecute the peer review action. Subsequently the hospital's lay governing board appointed the hearing officer and members of the review committee, which ultimately terminated the physician's privileges. Under the medical staff bylaws, however, only the MEC has authority to determine the joint review process, including the appointment of the hearing officer and joint review committee members. At issue in this case was whether state law allows the MEC to delegate this responsibility, or if by doing so the physician's rights were violated. On June 6, the California Supreme Court ruled that the mere fact that the hospital appointed the joint review committee and hearing officer did not violate fair procedure. CMA had filed a joint amicus brief with the American Medical Association (AMA) to explain the carefully balanced statutory relationship between a hospital governing body and its medical staff. A broad coalition of two dozen current or former chiefs of staff throughout California also had filed a separate amicus brief focusing on the practical aspects of maintaining self-governance and working with hospital administration. Together, the amicus briefs argue that the hospital in El-Attar failed to respect the medical staff self-governance rights when it unilaterally appointed the review panel and hearing officer in a peer review action. Notwithstanding the fact that the court ruled against the individual physician in this case, CMA believes the court’s El-Attar decision can be cited to affirm some important principles concerning peer review. To be sure, the specific result in this case is limited to a unique set of facts that makes it less likely to apply broadly, namely, that the MEC delegated its powers to the hospital and thereby facilitated, if not was complicit in, the violation of the medical staff bylaws. The court acknowledged: “The situation would be different if the Governing Board had exercised this power [to appoint the JRC panel and hearing officer] in the face of active resistance by the MEC. If the Board had appointed the hearing participants despite the medical staff's own efforts to do so, the Board would have violated the provisions of the peer review statute providing that it is the peer review body or its designees that determine the manner in which a judicial review hearing is held. Although we need not decide the issue, such a usurpation of the medical staff's power of appointment may provide grounds to presume that the hearing participants were biased, for in such a case there would be greater reason to think that the Board sought to stack the review panel

with participants who would rule in its favor.” Furthermore, despite finding that the physician was not deprived of fair procedure under the specific circumstances, the El-Attar opinion makes some keen observations about the peer review system and potential for abuse by hospitals: “There is certainly the potential for a hospital's governing body to abuse the power of appointment in a way that would deprive a physician of a fair hearing. A hospital's governing body could undoubtedly seek to select hearing officers and panel members biased against the physician. It might even do so because it wishes to remove a physician from a hospital staff for reasons having no bearing on quality of care. But where, as here, the medical staff has left to the hospital 's governing body the task of selecting the participants in the judicial review hearing, we are not persuaded that we must presume any hearing officer or panel member appointed by the governing body is likely to be biased.” Finally, the court added a “cautionary note” about misreading its decision. It explained: “Although we hold that the assumed violation of Hospital's bylaws in this case was not material, we do not suggest that such bylaws are meaningless or that a violation of a bylaws provision that implements procedural protections above and beyond those specifically mandated by the Legislature could never be found material. Moreover, we emphasize that even when a violation of the bylaws is immaterial, that does not mean it is irrelevant. The violating entity's decision to depart from procedures delineated in the bylaws may constitute evidence of that entity's bad intent, and it may bolster a claim that the entity has taken other action that deprived a physician of his or her right to a fair proceeding. (Opn. at 22.)” These statements reflect the court’s understanding that in reality hospitals can abuse the peer review process. Although CMA is disappointed that the court ruled against the physician, in the long term we believe that this opinion can be used in a positive way to further bolster the importance of fair hearing rights. More Information: For more information, see CMA On-Call documents #5206, “Peer Review – Fair Hearing Requirements," and #7007, "Retaliation by Managed Care Plans


Beginning January 1, 2015, Medicare physicians who have not successfully attested to meaningful use of an electronic health record (EHR) system may incur payment penalties, as mandated by the HITECH Act. These payment adjustments are one-to-two percent of total Medicare charges in 2015, to two percent in 2016 and three-to-five percent in 2017 and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use. Physicians who began participation in the Medicare EHR Incentive Program in 2011 or 2012 must demonstrate meaningful use for a full year in 2013 to avoid payment adjustments in 2015. Physicians who begin in 2013 must demonstrate meaningful use for a 90-day reporting period in 2013 to avoid payment adjustments in 2015. Those who begin in 2014 must demonstrate for a 90-day period in the first nine months of calendar year 2014 (by October 1, 2014) in order to avoid the payment adjustments in 2015. Please see CMA News on page 8 V I TA L S I G N S / A U G U S T 2 0 1 3


CMA NEWS Education Series CMA Center for Economic Services

Webinars At-A-Glance Most webinars are FREE for CMA members, $99 for non-members. CMA members are eligible for special discounts on ICD-10-CM Training from AAPC

Aug. 21: HIPAA Compliance: The Final HITECH Rule – David Ginsberg • 12:15-1:15pm The HITECH Act created the extensive funding incentives and standards for adopting electronic health records; it also created new HIPAA rules or modified existing ones. This webinar will provide an overview of the changes to HIPAA and key steps medical practices can take to comply with these changes.

Aug. 28: Medicare: Proposed Changes for 2014 – Michele Kelly • 12:15-1:15pm This webinar will focus on proposed policy changes to the physician fee schedule for the year 2014 (excluding any discussion on the SGR, or revised payment methodology). This discussion will provide an opportunity for physicians to hear how new or revised policies may impact their practice, and allow them to provide input to CMA during the Notice and Comment period.

Sept. 4: Appropriate Prescribing and Dispensing: New Measures • 12:15-1:15pm This webinars has been postponed indefinitely. We will inform you if and when it is rescheduled. We apologize for any inconvenience.

Sept. 11: California’s Health Benefit Exchange: The Positives and Perils of Contracting – Brett Johnson • 12:15-1:15pm Beginning in 2014, California’s private health insurance market will never look the same – individuals and small employers will be able to purchase health insurance coverage through the state’s health insurance exchange, named Covered California. It is estimated that by the end of 2016, over one in five Californians will get their health insurance through the Exchange. In October of 2013, Californians will be able to access the Covered California website and begin enrolling in plans for the 2014 benefit year. Depending on health plans’ distribution of enrollees, a surge of physician contracting efforts may occur as these plans attempt to ensure adequate networks are in place prior to January 1, 2014. In this presentation, you will learn more about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of being contracted to provide services to exchange enrollees.

Sept. 12: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15-1:15pm Continued on Sept. 19 and 26.

Sept. 18: Recipe for Financial Success: Key Steps to Increasing Your Net Income – Debra Phairas • 12:15-1:15pm Physicians and office managers need business management skills, particularly in the financial area. This workshop will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms. At least one source of comparison data specific to your medical specialty will be given to each participant.

Sept. 19: ICD-10 Documentation for Physicians: Part 2 AAPC • 12:15-1:15pm Continued from Sept. 12 and ends Sept. 26. This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD-10, but for all the regulations surrounding your practice today.

Sept. 26: ICD-10 Documentation for Physicians: Part 3 AAPC • 12:15-1:15pm Continued from Sept. 12 and 19. This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD-10, but for all the regulations surrounding your practice today.

Questions? CMA Member Help Center: 800-786-4262 Please note: this calendar is subject to change. Visit for updates. 8

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Continued from page 7 Once physicians demonstrate meaningful use, they must continue to do so every year to avoid the payment penalties. Only physicians that are eligible for the Medicare EHR Incentive Program are subject to payment adjustments. For more information, view CMS’s Payment Adjustments and Hardship Exceptions Tipsheet and How Payment Adjustments Affect Providers Tipsheet. Contact: Michele Kelly, 213-226-0338 or


Rental Cars: CMA members receive up to 15 percent off daily, weekend, weekly, and monthly rates from Avis. With Hertz, members can save up to 15 percent off daily rates and 10 percent off standard daily, weekly, and weekend rates on all car classes for business and leisure rentals. Special international discounts are also available. Upgrades and other special coupon offers are available. Members-only codes are needed to take advantage of these discounts. Click here or call the member service center at 800-7864262 (4CMA) to get your codes. CMA HEALTH LAW LIBRARY UPDATED FOR 2013

CMA On-Call, the California Medical Association’s (CMA) online health law library, is fully updated for 2013. One of CMA’s most valuable member benefits, On-Call contains over 4,500 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. The searchable online library contains all the information available in the California Physician’s Legal Handbook, an annual publication from CMA’s Center for Legal Affairs. New documents for 2013 include: E-prescribing (#3207), Compounding Drugs (#3208), Physician Alignment Models (#0312),Value Based Purchasing (#7103), the California Health Benefit Exchange (#7450), Electronic Health Records: Meaningful Use Stage 2 (#4305) and Physician Use of Mobile Devices and Cloud Computing (#3301). In addition, physicians can find answers to common physician practice questions in the most frequently referenced On-Call documents: Prescribing (#3201), Retention of Medical Records (#4005), Medical Records: Allowable Copying Charges (#4002), Termination of the Physician-Patient Relationship (#3503), and Allied Health Professional Relationships: Liability Issues (#3001). CMA members can access On-Call documents in CMA’s online resource center for free at Nonmembers can purchase On-Call documents for $2 per page. The complete health law library (CPLH) is also available for purchase in an 8-volume print set or annual online subscription service. To order your copy, visit the CMA resource library or call 800-882-1262. CMA members can also contact the CMA legal information line at 800-786-4262 or

HEALTHCARE REFORM Covered California Unveils Qualified Health Plans, Expected Premiums CMA VOICES CONCERNS

Covered California, the state agency implementing California’s exchange pursuant to the Affordable Care Act (ACA), has announced participating health insurers and proposed premiums for the state’s health benefits exchange, which is expected to offer health insurance coverage to roughly five million Californians following its launch in January 2014. In all, 13 commercial health plans were selected to offer products on the exchange, including California’s three largest insurance providers, Kaiser Permanente, Anthem Blue Cross and Blue Shield of California (see chart below). Throughout the process of drafting a model contract and selecting qualified health plans, the California Medical Association (CMA) has voiced several concerns, many of which have yet to be adequately addressed. One major concern for contracting physicians is a loophole in the ACA that could see physicians left to foot the bill for services provided to patients who haven’t paid their insurance premiums. The law allows for a three month “grace period” for non-payment of premiums, but only requires insurers to pay the claims through the first month of non-payment. The final version of the exchange model contract included a provision that requires 15 days advance notice to physicians when a patient has entered the second month of the grace period, but still leaves the burden of 60 days worth of unpaid claims on the physician and the patient. A second issue that has yet to be adequately addressed is that of network adequacy in the selected qualified health plans. While Covered California staff has stated that exchange enrollees will have access to an adequate network of health care providers, CMA has repeatedly asked that the exchange take extra steps to ensure that provider directories submitted by plans contain up-to-date and accurate networks. Despite these requests, Covered California continues to favor the status quo method of monitoring network adequacy, relying on the Department of

Health Care Services and Department of Insurance, which have been lax at best when it comes to ensuring adequate networks. A history of poorly monitored network adequacy in California, along with the fact that many physicians are likely to be hesitant to contract with exchange plans, casts doubt over Covered California’s claim that it will provide enrollees access to “80 percent of practicing physicians” in the state. The exchange’s expected premiums could also pose a challenge for success of the new marketplace. Under the premium rates announced earlier this month, the total monthly premium for a “silver” level (basic) plan in the Sacramento region for a 40-year-old single individual would range from $332 to $476. A 21-year-old enrollee could expect to pay more than $130 per month for the most affordable catastrophic plan Statewide Average Unsubsidized Premium Rates Lowest Silver Plan $304

2nd Lowest 3rd Lowest Silver Plan Silver Plan $325 $335

Average of 3 Lowest $321

Statewide Average Bronze/Silver Plans for a 21 Year-Old After Subsidies (Bronze / Silver) Most Affordable 2nd Most 3rd Most

150 % FPL $0 / $44 $5 / $58 $14 / $63

200% FPL $64 / $108 $69 / $122 $78 / $127

250% FPL $137 / $181 $142 / $195 $151 / $200

300% FPL+ $172 / $216 $177 / $230 $185 / $234

Federal subsidies will be offered on a sliding scale for individuals with incomes up to $45,960. Individuals eligible for the highest subsidy, $276 per month, would still face out-ofpocket expenses of $56 for monthly premiums. These subsidized premiums generally far exceed earlier focus groups’ notions of affordable (i.e., no more than $25-50 per month for individuals, $100-150 for families). Given that the annual penalty for not having health Please see Healthcare Reform on pag 10

Health Plans Selected to Offer Products on the Exchange Issuer (Product Type) Kaiser Permanente (HMO) Anthem Blue Cross (PPO, EPO, HMO) Blue Shield of California (PPO, EPO) Health Net (PPO, HMO)

Regions Served All of California except Monterey, San Benito and Santa Cruz All of California All of California Alameda, Contra Costa, Kern, Los Angeles, Marin, Mariposa, Merced, Monterey, Napa, Orange, Riverside, San Benito, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus and Tulare Western Health Advantage (HMO) El Dorado, Marin, Napa, Sacramento, Solano, Sonoma, Placer and Yolo Molina Healthcare (PPO) El Dorado, Los Angeles, Placer, Riverside, Sacramento, San Bernardino, San Diego and Yolo L.A. Care Health Plan (HMO) Los Angeles Sharp Health Plan (HMO) San Diego Alameda Alliance for Health (HMO) Alameda Valley Health Plan (HMO) Santa Clara Ventura County Health Care Plan (HMO) San Luis Obispo, Santa Barbara and Ventura Contra Costa Health Services (HMO) Contra Costa Chinese Community Health Plan (HMO) San Francisco and San Mateo

Network 14k physicians | 30k physicians | 114k physicians 44k physicians |

35 hospitals 300 hospitals | 838 hospitals 204 hospitals

3k physicians | 15 hospitals 4,568 physicians | 29 hospitals 1,005 physicians | 35 hospitals 2,600 physicians | 7 hospitals 3,100 physicians | 12 hospitals 993 physicians | 4 hospitals 176 physicians | 6 hospitals 5k physicians | 10 hospitals 315 physicians | 9 hospitals

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Healthcare Reform Continued from page 9 insurance during the exchange’s first year will be $95 or one percent of income, it remains to be seen whether healthy people will be willing to pay the high cost of participating in the exchange. Higher premiums could also have patient delinquency implications, which may result in more physicians being on the hook for two months of claims submitted during the “grace period” for premium non-payment. CMA encourages physicians to carefully review any contract solicitation, including those for exchange products, and to call CMA’s reimbursement helpline at 888-401-5911 with any questions. Additional contracting resources are available on the CMA website at For further resources ab o u t C o v e r e d C a l i f o r n i a , v i s i t


33rd ANNUAL CENTRAL VALLEY CARDIOLOGY SYMPOSIUM November 9, 2013 Madera Municipal Golf Center 8:00am - 3:30 pm Featured Speakers: Hossein Almassi, MD Professor, Cardiothoracic Surgery, Med. Col of Wisconsin Norman M. Kaplan, MD Professor, Dept. of Internal Medicine Univ. of Texas Jordan M. Prutkin, MD Assistant Professor, Cardiology Univ. of Washington Six (6) hours, Category 1 CME Credit No charge for Fresno-Madera Medical Society members Information: 559-224-4224 x 118: or visit


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Pediatric Crisis Checklists Virgil M. Airola, MD At the Surgery Department meeting a couple of months ago, Children’s Hospital orthopedist Joe Gerardi, proposed that our ORs have a set of “howto” checklists similar to those described by Arriaga et al in “Simulation-Based Trial of Surgical-Crisis Checklists” from January’s New England Journal of Medicine. The idea was quickly adopted both because the Arriaga article proved more key lifesaving steps were performed with checklist use and because Dr. Joe Gerardi astutely pointed out Virgil M. they could probably get the anesthesiologists to do Airola, MD the work since these checklists involved anesthesia “stuff!” Dr. Gerardi and I ended up as project co-chairs. Reading taught me “checklists are tools that can improve standardization, teamwork, and overall performance in crisis situations. Checklists for routine perioperative use have been shown in multiple studies to substantially reduce death and complications and are rapidly becoming established as the standard of care. Checklists are standard in management of emergencies in aviation and other high reliability fields, but they have not achieved widespread consideration for use in operating room crises.”1 The NEJM article revealed several key points.2 Simulations showed a significant reduction in missed critical steps when checklists were used in a crisis (six percent compared to 23 percent). In a more complex crisis, more keys steps are omitted in both groups. Performance delays were also found without checklist use – chest compressions were initiated after only 17 seconds in simulated asystole with a checklist compared a delay longer than 1.5 minutes without a checklist during simulated V Fib. Study participants ranked using checklists at 4.7 (out of 5) when imagining that they might be the patient. Clearly, Joe’s idea had merit! Studies have shown, however, that “crisis checklists will not be used if the potential users are unaware of them and untrained… Awareness alone is also not enough – practice is critical.”3 Clearly, development of these checklists is important, but engaging in simulated crises while using the checklists is key to meaningful use during a real crisis. Practice makes perfect! The Ziewacz et al and the Arriaga et al articles had 12 checklists. Dr. Nadine Van Wyk found 24 checklists for kids developed by the Society for Pediatric Anesthesia. Using these as templates, we were halfway done! But even using published crisis checklists as our templates, the project seemed huge. So we organized ourselves into teams of physicians, nurses, and others to review background materials and tailor our checklists to our patients. This reduced our heavy lifting, and our volunteers made the project their own – improving our chances for successfully adding checklists to our toolbox in a crisis! Our original goal was to make Children’s a safer place even during an infrequent medical crisis. This project promises to be a major step forward! Later this year surgeons, anesthesiologists, nurses, and technicians will practice using these checklists in simulated crises during our regular daytime OR schedule because practiced use is the final key step to improving our performance during a real crisis. Appended is one of our checklists, “Cardiac Arrest: Asystole/PEA”, followed by our cover page: 1 Ziewacz JE, Arriaga AF, et al. Operating Room Crisis Checklists. J Am Coll Surg 2011; 213 (2): 213. 2 Arriaga AF, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013; 368: 246-53. 3 Mulroy MF. Emergency Manuals: The Time Has Come. Anesthesia Patient Safety Foundation Newsletter 2013; Spring-Summer: 10. V I TA L S I G N S / A U G U S T 2 0 1 3


Fresno-Madera RANJIT RAJPAL, MD Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1040 E. Herndon Ave #101 Fresno, CA 93720 559-224-4224 Fax 559-224-0276 website: FMMS Officers Ranjit Rajpal, MD President Prahalad Jajodia, MD President Elect A.M. Aminian, MD Vice President Hemant Dhingra, MD Secretary/Treasurer Sergio Ilic, MD Past President Board of Governors S.P. Dhillon, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Babak Eghbalieh, MD Ahmad Emami, MD Anna Marie Gonzalez, MD David Hadden, MD S. Nam Kim, MD Constantine Michas, MD Trilok Puniani, MD Khalid Rauf, MD Mohammad Sheikh, MD CMA Delegates FMMS President A.M. Aminian, MD John Bonner, MD Michael Gen, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Shazia Maghal, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Praveen Buddiga, MD Surinder P. Dhillon, MD Don H. Gaede, MD Peter T. Nassar, MD Trilok Puniani, MD Oscar Sablan, MD Dalpinder Sandu, MD Mickey Sachdeva, 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


ADDRESSING SOCIAL DETERMINANTS OF HEALTH IN THE CENTRAL VALLEY In the time of your life, live – so that in that good time there shall be no ugliness or death for yourself or for any life your life touches. Seek goodness everywhere, and when it is found, bring it out of its hiding-place and let it be free and unashamed. – William Saroyan

When I came to the Valley over three decades ago, I was immediately drawn to its wondrous landscapes and the indefatigable spirit of the people of the Sierra – I knew instantly that I was home. This Valley of ours is a special place; rich with a diversity of people from all walks of life, who are driven by a unique passion and dynamism to make positive impacts in their communities. We now stand at a transitional moment in the history of our Valley, as our voices and stories begin to move from the periphery of “the other California” to the core, to reflect the emergent realities of the modern Californian polity. Though it is true that we have made extraordinary progress and advancements, the fact also remains that the health of our Valley is not reflective of what it can and should be. The air quality of our cities is consistently rated among the most polluted in the nation, too many of our children are afflicted with obesity, we are faced with an impending fresh water crisis, poverty and unemployment rates are mounting, gaps in access to healthcare, quality education and housing stability persist; the challenges we face as a community are varied, complex and multi-faceted. It is, therefore, of paramount importance that we, as a society broaden our scope and understanding of what it means to have a healthy community. All too often we focus solely on generic markers associated with good health in the popular parlance of the medical community. But the measure of an individual or a community’s overall health cannot be determined only by traditional and standardized health diagnostics, and it is not solely a function or a reflection of the efficacy of the medical community. Rather, our health is determined at the confluence of medicine and various fields such as law, education, business, agriculture, engineering and urban design. Reputable health advocacy organizations, including the World Health Organization have placed special emphasis and consideration on the social determinants of health – the underlying conditions in our social, physical, political, cultural and economic environments and relationships which directly impact our overall health, quality of life and epidemiological integrity. I strongly believe, that as advocates for public health, our Medical Society must forge greater collaborations within the community and seek to implement and inculcate the theory and praxis of a social determinants of health approach when addressing healthcare problems in our Central Valley. We need bold and innovative solutions and we must activate our individual and collective agencies to engage our policy-makers to cohere around public policy geared towards fostering a healthful and sustainable Central Valley. We need to adopt a holistic public health vision which recognizes that securing essential human security needs and fostering relationships of equality and respect are central aims which will help our communities close these gaps in health. We have the necessary tools and resources to create this positive change and the members of our medical community and the people of this great Valley have the courage and determination to fight for our health. This is our home, and I am inspired by the power and possibilities of our collective participation and engagement in meeting the challenges and opportunities which stand before us.

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Fresno-Madera June Walk With A Doc Program

Fresno-Madera Medical Society Hosts Free Community Health Walks

WALK WITH A DOC COMMUNITY OUTREACH PROGRAM 'Walk with a Doc’ strives to encourage healthy physical activity in people of all ages and reverse the consequences of a sedentary lifestyle in order to improve their health and well-being.

GRAB A FRIEND AND HEAD TO THE PARK 2013 SATURDAY DATES: August 24 • September 28 7:30-8:30am Registration begins at 7:15am at Woodward Regional Park Sunset View Shelter WHO CAN ATTEND: Participation is open to anyone interested in taking steps to improve their health.

Photos courtesy of Alan Birnbaum, MD

ENCOURAGE YOUR PATIENTS TO PARTICIPATE! In addition to the health benefits of walking, you will receive: • Healthy Snacks • Healthy Lifestyle Tips/Resources • Chance to Talk with a Doc FURTHER INFORMATION: Contact the Fresno-Madera Medical Society at 224-4224, ext. 110 or at

Thank you for the support of the July Walk With a Doc

Find us on Facebook: Fresno-Madera Medical Society

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2013 PHYSICIAN “LIFETIME ACHIEVEMENT” AWARD I nominate ________________________________________, MD Please give specific and detailed examples for your nomination:

The Medical Society will bestow an award recognizing a physician who has gone beyond the call of duty in providing for the health and welfare of our community's residents during his or her lifetime. All nominees must be FMMS members. Criteria for this award includes: •Extraordinary service and dedication to patients, the community or to the profession •Uncompensated services performed •High quality of care provided to patients Previous award recipients: Drs. James Caffee, Roger Larson, Gilbert Roth, Robert West, Ronald Smith, Dwight Trowbridge, Lauren Grayson, Harold Hanson, John Murray, Max Millar, Ed Defoe, Thomas Eliason, Fred Cooley, Robert Peters, Jack Schiff, Burton James, Donald Knapp, Sathaporn Vathayanon, Jack Thorburn, Kenneth Jue, Joseph Woo, Steven Parks, John Conrad, Bjorn Nelson, Theodore Steinberg, Malcolm Masten and John Bonner. Nominations from the past three years will be considered. The recipient is selected by the FMMS Historical Committee and approved by the FMMS Board of Governors. The award will be presented at the Medical Society's November 6, 2013 dinner meeting. Please complete and return this form by September 1, 2013. “We make a living by what we get, but we make a life by what we give.” – Winston Churchill

FRESNO-MADERA MEDICAL SOCIETY 2013 PHYSICIAN COMMUNITY SERVICE AWARD SPECIAL PROJECT OR SERVICE Dear FMMS member: Recognize a Deserving Colleague! The Medical Society will bestow an award recognizing a physician who has gone beyond the call of duty to devote his or her time to a one-time or on-going special project or service either locally, statewide, nationally or internationally, that served(s) to promote the welfare and healthcare of the community or the medical profession. All nominees must be FMMS members.

Submitted by____________________________ Phone_________ Return by September 1, 2013 Mail to: Fresno-Madera Medical Society, Historical Committee P. O. Box 28337, Fresno CA 93729-8337 or Fax to: 559-224-0276

2013 “SPECIAL PROJECT OR SERVICE” AWARD I nominate ________________________________________, MD Please give specific and detailed examples of your nominee’s project or service:

Previous award recipients are: Drs. Marc Lasher, Richard Whitten, Jr., Walter Byerly, Chun. C. Chan, David Pepper, Chun-Wai Chan, Lee Snyder, Women’s Imaging Specialists in Healthcare, Mohammad Arain, John Telles and Joan Voris. Nominations from the past three years will be considered. The recipient is selected by the FMMS Historical Committee and approved by the FMMS Board of Governors. The award will be presented at the Medical Society's November 6, 2013 dinner meeting. Please complete and return this form by September 1, 2013. “It is well to give when asked, but it is better to give unasked, through understanding.” – Kahlil Gibran


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Submitted by____________________________ Phone_________ Return by September 1, 2013 Mail to: Fresno-Madera Medical Society, Historical Committee P. O. Box 28337, Fresno CA 93729-8337 or Fax to: 559-224-0276


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

President’s Message



There will be a celebration of life for Dr. Hans Einstein on Saturday, August 10, 2013, 10:00am to 1:00pm at the Kern County Museum, Pioneer Village, 3801 Chester Ave. Bakersfield, CA 93301. All are welcome to pay respects to Dr. Einstein. A KCMS member stated that Dr. Einstein was a “Great physician – yet a very humble human being.” He was instrumental in the continuing effort toward the development of a vaccine for coccidioidomycosis (Valley Fever). Music will start at 10:30am with the Masterworks Choral singing several selections from a medley of Dr. Einstein’s favorite songs and several classical pieces. The Bakersfield Jazz Singers will sing several of his favorite swing tunes. Spoken tributes to Dr. Einstein will start at 11:00am. This is a time to share your stories, or come to listen. Bring your lunch. Music, refreshments and licorice will be served. The Celebration of Life will follow the People and Pets Walk for Valley Fever, hosted by the Valley Fever Americas Foundation. Go to

Wilbur Suesberry, MD President Alpha J. Anders, MD President-elect Eric J. Boren, MD Secretary Ronald L. Morton, MD Treasurer Joel R. Cohen, MD Immediate Past President Board of Directors Bradford A. Anderson, MD Lawrence N. Cosner, MD John L. Digges, MD J. Michael Hewitt, MD Susan S. Hyun, MD Mark L. Nystrom, MD Sameer Gupta, MD Edward W. Taylor, MD CMA Delegates: Jennifer Abraham, MD John Digges, MD Ronald Morton, MD CMA Alternate Delegates: Lawrence Cosner, Jr., MD Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Administrative Assistant

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Tulare Two Rare Conditions Manifesting as Sinus Disease Kulraj S Dhah, MS II Medical Student, A.T. Still University School of Osteopathic Medicine in Arizona and Bruce Hall, MD FACP Internal Medicine, Visalia Medical Clinic, Lindsay, CA

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

A 46-year-old male presented to the office with 1 week history of daily headaches. Focus of pain was website:

TCMS Officers Steve Cantrell, MD President Thomas Gray, MD President-elect Monica Manga, MD Secretary/Treasurer Gaurang Pandya, MD Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Pradeep Kamboj, MD Christopher Rodarte, MD Antonio Sanchez, MD Raman Verma, 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 Thelma Yeary Executive Assistant Dana Ramos Administrative Assistant

over left frontal sinus. Initial differential included sinus infection. Further history taking revealed unilateral supraorbital pain with lacrimation of left eye, nasal congestion and drainage, occurring around the same time every day for the past seven days. Episodes lasted between one to four hours. No previous history of allergies reported. Patient had failed on OTC antihistamines and pain medications. Physical exam was unremarkable. Based on the classic presentation, a diagnosis of cluster headache was made. Cluster headache is classically characterized by attacks of severe unilateral orbital, supraorbital, or temporal pain, accompanied by autonomic phenomena. Unilateral autonomic symptoms must include at least one of the following: ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion and are always ipsilateral to the pain. According to the International Headache Society, most headache episodes last 15 to 180 minutes. In the episodic form, attacks can occur daily, usually 1 to 8 times a day for some weeks, followed by a period of remission. The chronic form of cluster headache lacks sustained remissions1. It has been termed “suicide headache” as some sufferers have been driven to suicide due to the pain or anticipation of the pain4. The prevalence of cluster headache is less than 1 percent and mostly affects men1. In a metaanalysis of 16 population-based epidemiologic studies, the following observations were reported2: • The overall male to female ratio was 4.3:1 • The lifetime prevalence of cluster headache for adults of all ages was 124 per 100,000 (95% CI 101-154), or 0.124% • The one year prevalence of cluster headache was 53 per 100,000 (95% CI 26-95) First-line treatments for acute cluster headache attack are subcutaneous sumatriptan and oxygen inhalation3. Verapamil is the agent of choice for the preventive therapy of cluster headache. Other agents that may be effective include glucocorticoids, lithium, topiramate, and methysergide1. A 51-year-old patient presented to the office with 10 day history of nose pain. The unilateral, periodic, sharp pains initiated in the left nostril and interfered with sleep. After two days of pain unrelieved with home remedies, patient sought treatment at an Urgent Care facility and was prescribed Augmentin (amoxicillin/clavulanic acid) for suspected bacterial sinus infection. After two more days without relief, the patient developed sharp pains in the left mandible and scheduled an emergency visit with a dentist. The dental exam, including x-rays, was negative. The dentist attributed the pain to a sinus infection and advised the use of pain medication adjuvant to the antibiotic. Pain pattern and frequency was not relieved by the prescribed regimen. Patient presented to the PCP ten days after initial pain. On physical exam, patient appeared in moderate to severe distress holding pressure against her left nose in an effort to occlude the left nares. No abnormalities of the ear, nose and throat were seen. Based on the classic presentation of pain involving the second Please see Sinus on page 17 1 May, A., Cluster headache: Epidemiology, clinical features, and diagnosis., UpToDate, Last updated 5/9/2013 2 Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia 2008; 28:614. 3 Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology 2010; 75:463. 4 Kumar, R., Blanda, M., Cluster Headache. Medscape. Last updated 10/18/2012 5 MacDonald BK, Cockerell OC, Sander JW, Shorvon SD. The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000; 123 ( Pt 4):665. 6 Bajwa, Z., Ho, C., Khan, Sajid., Trigeminal Neuralgia. UpToDate, Last updated 1/5/2012. 7 Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008; 71:1183.


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Sinus Continued from page 9 and third divisions of the fifth cranial nerve, the patient was diagnosed with Trigeminal Neuralgia. The annual incidence of Trigeminal Neuralgia (TN) is 4 to 13 per 100,000 people5. Approximately 15,000 new cases occur in the United States each year6. TN is one of the most frequently seen neuralgias in the elderly. The incidence increases gradually with age; most idiopathic cases begin after age 50, although onset may occur in the second and third decades or, rarely, in children6. The male to female ratio of TN is about 1:1.5. It is hypothesized that this slight female predominance may be related to the longer average lifespan of women compared with men6. A systematic review and practice parameter published in 2008 from the American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS) concluded that carbamazepine is most effective medication for controlling pain in patients with classic TN, oxcarbazepine is probably effective, and baclofen, lamotrigine, and pimozide are possibly effective7. Conclusion: The common occurrence of sinus ailments, including allergies and infections, in the Central Valley can influence our clinical judgment to the potential detriment of our patients. The two cases above illustrate diagnoses that could easily be mistaken for sinus conditions. A thorough history and physical exam are essential to arriving at the correct diagnosis and beginning proper treatment.

2014 Coding Book News It is that time again to start purchasing coding books. Order your 2014 editions of CPT, ICD-9, ICD10, and HCPCS thru us. We are offering extraordinarily discounted rates and free shipping directly to your office. Please contact Dana Ramos, Provider Relations to order or obtain more information; 559-7340393 or

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 KCMS Officers Jeffrey W. Csiszar, MD President Vacant President-elect Mario Deguchi, MD Secretary Treasurer Theresa P. Poindexter, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Thomas S. Enloe, Jr., MD Ying-Chien Lee, MD Uriel Limjoco, MD Michael MacLein, MD Kenny Mai, MD CMA Delegates: Ying-Chien Lee, MD Staff Marilyn Rush Executive Secretary

UPCOMING DATES TO REMEMBER • August 26, 2013: Part A of Noridian Medical MAC Implementation • September 16, 2013: Part B of Noridian Medical MAC Implementation • September 18, 2013: TCMS – ICD-10 Workshop/Training • September 19, 2013: TCMS – ICD-10 Workshop/Training • September 22, 2013: TCMS – Family Day • December 11, 2013: TCMS – Annual Holiday Event

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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, 559224-4224, Ext. 118. FRESNO/MADERA



Dr. Ahmad Emami announces his Man of the Year campaign benefiting the Leukemia & Lymphoma Society. Tax-deductible donations to his campaign can be made at: ami. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 559-320-0580.

Medical office space; 1476 W. Shaw Ave. between Fruit & West. 1200sf, great location. Call Shannon Mar, Guarantee Real Estate, 999-6165, Medical office; 1046 E. Shields, 1,331 sf, close to Fwy 41 & Manchester Mall. Call Shannon Mar, Guarantee Real Estate, 9996165, Brand new (model) home near Willow Intl. campus. 2,760 sf, numerous upgrades, 5 bdrms/3bths. Available early to mid August. Call: 559-273-5336.

PHYSICIAN WANTED LQMG Medical Group is seeking Board Certified, Internal Medicine physicians to join its group. Call 559-450-5703.




Complete suite of office furn. 1 desks w/return & file draws; 2 guest chairs; 10 exam rm. chairs; 9 rolling stools for exam rms; 6 footstools; 8 desk chairs; 4 exam rm tables. Call 559-432-7700.

Nanny available for your children. Dr. Stanic’s wife, Katarina, knows a right person for your home. Contact: Call Sequoia Dental Office; 559-635-7186, ask for Katrina or (indicate NANNY) under subject)

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

MEDICAL OFFICES FOR LEASE Crown Pointe Phase II – 2,000-9,277 rsf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 rsf. Meridian Professional Center – 1,740-2,265 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf. 2323 16th St. – 1,194 rsf. 2323 16th St. – 1,712 rsf. 2323 16th St. – 2,568 rsf. 4939 Calloway Dr. – 1,795 sf. 3941 San Dimas St. – 9,000 rsf. SUB-LEASE 1902 B Street. – 1,698 sf. 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 rsf. Adm. & Billing – 6,613 rsf. FOR SALE 1911 17th Street – 2,376 sf. 2019 21st Street – 2,856 sf. 2204 Q Street – 4,600 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-2,265 rsf. 9900 Stockdale Hwy. – SOLD OUT! 3941 San Dimas St. – 9,000 rsf.


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Transfusion Medicine Continued from page 15

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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.


NORCAL Mutual is owned and directed by its physicianpolicyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact your broker or call 877-453-4486 today. Visit for a premium estimate.


N O R C A L M U T U A L .C .C O M

2013 August