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October 2013 • Vol. Vo ol. 35 No. 10

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: MICRA: Major Changes to Your Practice from Sacramento West Nile Virus Transmitted Through Blood Transfusion Medical Advances of the American Civil War


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

800-252-7706 www.CAPphysicians.com

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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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O C T O B E R 2 0 1 3 / V I TA L S I G N S


Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society October 2013 Vol. 35 – Number 10 Editor, Bonna Rogers-Neufeld, MD, FACR Managing Editor Carol Rau Yrulegui

Contents CMA NEWS ................................................................................................................................5 NEWS MICRA: A Major Challenge to Your Practice from Sacramento.....................................................8 BLOOD BANK: West Nile Virus Transmitted Through Blood Transfusion .....................................10 MEDICAL HISTORY: Medical Advances of the American Civil War ..............................................11 SAVE THE DATE: 33rd Annual Central Valley Cardiology Symposium..........................................14 CLASSIFIEDS ...........................................................................................................................19 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................12 • President’s Message • Walk With A Doc Recap and Upcoming Dates

Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD Kings Representative TBD Kern Representative John L. Digges, MD Tulare Representative Thelma Yeary

• Endless Horizon: Exclusive Planetarium Showing: October 8 • FMMS & FMMSA Reception: October 26 • Annual Installation & Awards Dinner Gala: November 6 • In Memoriam: Roger K. Larson, MD KERN COUNTY MEDICAL SOCIETY ............................................................................................16 • President’s Message • Call for Submissions to the Levan Humanities Review TULARE COUNTY MEDICAL SOCIETY.........................................................................................17 • Dr. Pandya Receives National Service Award • Save the Date: Holiday Dinner Event December 11 • Who Needs the AMA?

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.

Cover photography: Civil War Revisited, Fresno By Ning Lin, OD, MD See the largest reenactment west of the Mississippi at historic Kearney Park, Fresno, October 18-20, 2013.

Advertising Contact: Display: Annette Paxton, 559-454-9331 apaxton@cvip.net

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

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

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / O C T O B E R 2 0 1 3

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HEAL HEALTHCARE AL LT THCARE

REFORM R EFORM

Health care reform is in full-swing with the heftiest heftie legislation n set for 2014 — when health lth insurance w will become available vailable to mil millions of Americans who were previously uninsured.

THE THE BASICS F FOR OR IINDIVIDUALS NDIVIDUALS DID DI D YOU KNOW? Beginning January 1, 2014, new regulations provide most Americans access to affordable health insurance that covers essential care. The regulations that facilitate this include: tIndividual Mandate‰.PTUJOEJWJEVBMTBSFSFRVJSFEUPIBWFBOENBJOUBJOIFBMUI JOTVSBODFFGGFDUJWF+BOVBSZ 5IFSFBSFFYDFQUJPOTGPSDFSUBJOJOEJWJEVBMT tPenaltyy—*GZPVFMFDUOPUUPQVSDIBTFDPWFSBHF ZPVBSFSFRVJSFEUPQBZBQFOBMUZ  oJOUIFHSFBUFSPGJOEJWJEVBM QFSGBNJMZ PSPGJODPNF  o*OUIFHSFBUFSPGJOEJWJEVBM QFSGBNJMZ PSPGJODPNF  o*OUIFHSFBUFSPGJOEJWJEVBM QFSGBNJMZ PSPGJODPNF tGuaranteed issue‰*OTVSBODFDPNQBOJFTNVTUTFMMDPWFSBHFUPFWFSZPOF  SFHBSEMFTTPGQSFFYJTUJOHDPOEJUJPOT BOEDBOUDIBSHFNPSFCBTFEPOIFBMUIPSHFOEFS tHealth Insurance Exchange‰*OEJWJEVBMTXJUIPVUBDDFTTUPBGGPSEBCMF  FNQMPZFSTQPOTPSFEQMBOTUIBUQSPWJEFRVBMJGZJOHDPWFSBHFDBOFOSPMMJOQMBOTPGGFSFE FJUIFSUISPVHIUIFJOEJWJEVBMJOTVSBODFNBSLFUPSUISPVHI$PWFSFE$BMJGPSOJBXJUI DPWFSBHFCFHJOOJOH+BOVBSZ   0QFOFOSPMMNFOUDPNNFODFTPO0DUPCFS *GJOEJWJEVBMTEPOUFOSPMMXJUIUIF FYDIBOHFEVSJOHUIFJOJUJBMPQFOFOSPMMNFOUQFSJPE UIFZXJMMIBWFUPXBJUVOUJMOFYU ZFBSTPQFOFOSPMMNFOUQFSJPEUPPCUBJODPWFSBHF tSubsidies‰*OEJWJEVBMTBOEGBNJMJFTNBZRVBMJGZGPSGFEFSBMUBYDSFEJUTBOECFOFmU TVCTJEJFTPOMZUISPVHIUIFFYDIBOHF5BYDSFEJUTBSFBWBJMBCMFUPUIPTFXIPNFFUDFSUBJO JODPNFSFRVJSFNFOUTBOEEPOPUIBWFBDDFTTUPBGGPSEBCMFIFBMUIJOTVSBODFUIBUNFFUT NJOJNVNDPWFSBHFTUBOEBSETPGGFSFEUISPVHIUIFJSFNQMPZFSPSBOPUIFSHPWFSONFOU QSPHSBN&MJHJCJMJUZGPSUBYDSFEJUTJTCBTFEPOGBNJMZJODPNFBOETJ[F tPremiums‰1SFNJVNTDBOPOMZWBSZCZBHF HFPHSBQIZBOEGBNJMZDPNQPTJUJPO 5IFZNBZOPUWBSZCZHFOEFSPSIFBMUIDPOEJUJPOT tAnnual or lifetime limits‰*OEJWJEVBMBOEHSPVQQMBOTNBZOPUJNQPTFMJNJUTPO FTTFOUJBMCFOFmUT tOut of Pocket expenses‰-JNJUTPVUPGQPDLFUFYQFOTFTGPSDPQBZT DPJOTVSBODF  EFEVDUJCMFT FUDUP QFSJOEJWJEVBMUPBNBYJNVNPG GBNJMZBOOVBMMZ

Sponsored by:

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

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FOR MORE INFORMA INFORMATION, NFORMA ATION, TION, CALL A MARSH MARSH CLIENT CLIENT ADVISOR A DVISOR A AT T 800-842-3761. 800-842-3761. Marsh and the Societies’ do not provide tax or legal advice. Please consult with your own advisors to determine ne how the law’ law’s ’ss changes and your decisions impact your personal situation.

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CMA NEWS TRIAL ATTORNEYS RE-FILE ANTI-MICRA BALLOT INITIATIVE

On August 30, the trial attorneys re-filed their proposed antiMICRA ballot initiative with the Attorney General’s Office, a political maneuver that will buy them more time as they attempt to navigate around the organized opposition to the proposal. The revised initiative was filed only hours before the start of the long Labor Day weekend, an obvious attempt at keeping their proposal off the public’s radar as best they could. Despite the revisions, the central focus of this proposed initiative remains to be to more than quadruple California’s current $250,000 cap on non-economic damages in medical malpractice cases and create a cash windfall for the trial attorneys who calculate their fees based upon the size of the total jury award. If the trial lawyers are successful at undermining our state’s landmark professional liability reforms (the Medical Injury Compensation Reform Act, also known as MICRA), it would cause malpractice insurance rates for physicians to skyrocket, force the closure of safety net clinics and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. It’s unknown whether this will be the final revision to the trial attorneys’ ballot initiative proposal before they begin collecting signatures to put it on the November 2014 ballot. State law allows for as many re-filings as the backers see fit. Regardless of what the trial attorneys do next, the California Medical Association and its many coalition allies are working tirelessly to defend MICRA and to ensure that your ability to practice medicine is not threatened by this misguided effort. There is still no bill introduced in the Capitol. In our discussions with legislators, even among those who are not with us on MICRA, there is an acknowledgment that the trial lawyers do not have the votes in the Capitol to make any changes to MICRA. The Legislative Analyst Office, charged with providing the AG with a fiscal analysis of all initiatives, recently released their report. The LAO has indicated that they anticipate significant fiscal impacts, including costs associated with higher medical malpractice costs, likely at least in the low tens of millions of dollars annually, potentially ranging to over one hundred million dollars annually. DHCS TO IMPLEMENT 10 PERCENT MEDI-CAL CUTS BEGINNING IN OCTOBER

The Department of Health Care Services (DHCS) announced that it would begin to implement the 10 percent Medi-Cal physician payment rate reduction on October 1, 2013, for MediCal managed care and on January 9, 2014, for fee for service. DHCS also announced that it would be retroactively implementing the cuts for FFS providers to June 1, 2011, when the law authorizing the cuts went into effect. Specialty physician services in Medi-Cal managed care will not be subject to a reduction. CMA is working with the state to obtain additional information. The California Medical Association filed a lawsuit, CMA et al. v. Douglas et al., to stop the State of California from implementing the 10 percent cut included in the 2011-2012 state budget.

These cuts could not come at a worse time, as California is poised to expand Medi-Cal to 1.4 million more Californians under federal health reform and the demand for physicians is expected to rise. Currently, 56 percent of Medi-Cal patients report difficulty finding a doctor. If these cuts are not stopped, Medi-Cal will become nothing more than a broken promise of access to care.

LAUNCH OF EXCHANGE PROVIDER DIRECTORY DELAYED

Earlier this summer, the California Medical Association (CMA) reminded physicians to look for the release of Covered California’s central provider database, which exchange staff had previously said would launch at the end of July. Sadly, no such launch has taken place. Covered California has quietly delayed the launch of the database, allowing the previously stated deadline of late July to slide to the increasingly vague “by the end of August at the earliest.” The FAQ section regarding the provider enrollment database, which will serve as a way for physicians to check if they, or products with which they are contracted, have signed on to participate in the change, has been removed from the exchange’s website. While this delay is not encouraging, CMA staff will continue to monitor the issue and notify our members when the database is eventually launched. LEGISLATIVE UPDATE: Governor signs CMA-sponsored AB 1288 that will expedite physician licensure for practice in underserved areas Governor Jerry Brown has signed a bill (AB 1288) sponsored by the California Medical Association (CMA) that requires priority review status be given to the license applications of physicians who can demonstrate that they intend to practice in a medicallyunderserved area or serve a medically-underserved population. With California facing an uneven disbursement of physicians, increasing the physician pipeline to those areas to ensure delivery of safe, quality medical care will be crucial to the health of those communities. Scope Bills: • SB 491 – Nurse Practitioners: CMA had a great victory with the desired outcome of having SB 491 held on suspense. Essentially, the bill failed in committee and is done for the year. CMA expects that the author will re-introduce a scope bill next year. CMA is also being very vigilant about ensuring that there is no attempt to do a “gut and amend” at the end of this year’s session. • SB 492 – Optometrists: The optometrist scope expansion bill is now a two-year bill done for the year due to the fact that it did not have sufficient votes in the Assembly B&P Committee. • SB 493 – Pharmacists: CMA has removed its opposition after the sponsor agreed to our suggested amendments to limit furnishing to only nicotine based tobacco cessation prescription drugs, with the requirement that it be done under a protocol with a physician. After its agreement with CMA, the bill has been moving through the Legislature with bi-partisan support. Please see CMA News on page 6 V I TA L S I G N S / O C T O B E R 2 0 1 3

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CMA NEWS Continued from page 5

LEGISLATURE PASSES CURES BILL

The California Assembly has unanimously passed a bill (SB 809) that will provide $9 million annually to upgrade and maintain the Controlled Substances and Utilization Review and Evaluation System (CURES). CURES is an online database that allows authorized users, including physicians, pharmacists, law enforcement and regulatory boards, to access information about a patient’s controlled substance prescription history. The bill now heads to the governor’s desk. The mission of CURES is to prevent pharmaceuticals from falling into the wrong hands, while promoting legitimate medical practice and quality patient care. Registered users can access CURES to verify a patient’s controlled substances history before prescribing and the information can be used to help identify a patient who may be “doctor shopping.”

CMA STOPS EFFORT TO LOWER STANDARD OF PROOF FOR PHYSICIAN DISCIPLINE

In a victory for the California Medical Association (CMA), SB 670 failed passage on the Assembly Floor. CMA opposed a provision in the bill that would have given the Medical Board of California the authority to limit a physician’s ability to prescribe Schedule II, III and IV drugs when there was an allegation of inappropriate prescribing in violation of the Medical Practice Act and when there was risk of imminent public harm. The medical board would have been able to limit a physician’s prescribing authority based simply on “probable cause” that a violation occurred, a precedent-setting lowering of the standard of evidence for discipline against a physician. After the bill failed to get off the Assembly Floor, the author agreed to delete the provisions of the bill that established the new disciplinary authority. With this major deletion, the bill now gives the board a path to access medical records in cases where a patient has died and the next of kin cannot be found. It would also change the definition of unprofessional conduct for the repeated failure to meet with the medical board during an investigation. DID YOU KNOW: THE KEYWORD IN ANY APPEAL IS “APPEAL”

Thanks

to California Medical Association (CMA) sponsored legislation (AB 1455) and the resulting regulations, payors are required to establish a fast, fair and cost-effective dispute resolution mechanism (i.e., “appeal process”) to resolve provider disputes. Anytime a payor contests, adjusts or denies a claim, they are required to advise the provider of the availability of the appeal process and instructions for submitting the appeal. Payors are also required to acknowledge receipt of a written appeal within two working days for electronic appeals or 15 working days for paper appeals. They are also required to respond to written appeals submitted by providers within 45 days of receipt, and they must report to the Department of Managed Health Care, on an annual basis, the nature and volume of appeals received [28 C.C.R §1300.71.38 (e)(f)(k)]. To ensure your appeal is treated by the payor as an actual “appeal,” and not an “inquiry” CMA recommends the following: 6

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Clearly state in the subject line and first sentence of your letter that this is an “APPEAL.” Steer clear of the word “inquiry” in your appeal. Use of the word appeal leaves no doubt about your intention – to appeal the payment (or non-payment) of the claim. Make sure you are sending your written appeal to the correct address. Some payors, such as Blue Shield. If you send your written appeal to the claims address, it will most certainly be processed as an “inquiry” and not an appeal, which means you may not receive a written response, let alone the desired outcome of reprocessing of your claim. Clearly state your “ask,” ideally at the beginning and the end of your letter. For example, are you asking that the bundling edits be re-reviewed, are you asking for a medical necessity appeal to be reviewed by a physician of same or like specialty, or are you disputing the payor’s claim that the patient wasn’t eligible? Simply venting about your frustration with how a claim was underpaid or denied isn’t enough to communicate why you believe the claim was processed incorrectly. Look out for your written acknowledgement of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received your appeal. If you don’t receive the acknowledgement of receipt, there is likely a problem and a phone call to the payor may be in order. Look out for the payor’s written response to your appeal that should include the pertinent facts and reasons for its determination, which should arrive within 45 working days of receipt of the appeal. Contact: CMA reimbursement help line, 888-401-5911 or economicservices@cmanet.org.

PROBLEMS GETTING PAID?

The

California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff. Reimbursement Help Line: 888-401-5911 or economicservices@cmanet.org. One-on-one educational and reimbursement assistance to physician members and their staff.

CMA’S MEDICAL-LEGAL LIBRARY AVAILABLE ONLINE

The California Medical Association’s 24-hour online medicallegal library is the most comprehensive health law and medical practice resource for California physicians. The medical-legal library’s documents include most of the Center for Legal Affairs’ California Physician’s Legal Handbook (CPLH), as well as more specialized information on peer review and other subjects. These documents are available free to members at www.cmanet.org or by calling the member help center at 800-786-4262. Nonmembers can purchase CMA ON-CALL documents for $2 per page at www.cmanet.


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Weednesdayy, W February 5 Welcome elco Reception* Aboard Aircraft Carrier U.S.S. Midway An Award-Winning Floating Museum


MICRA A Major Challenge to Your Practice from Sacramento Virgil Airola, MD, CMA Trustee

Ever

wonder why some physician from elsewhere “dumped” that patient on you? Was it a Medi-Cal patient? It’s just business! Ask yourself how pediatricians keep their office doors open with an overhead of $115 per hour when Medi-Cal pays $22.90 for a 20 minute visit? And it’s the same in every specialty! Physicians are already Virgil Airola, MD forced to cherry pick among patients to stay in business. You probably have already found a place in your practice for some charity medical care – it's what doctors do. Now envision a dramatic increase in YOUR overhead – one that threatens your ability to avoid choosing between your paycheck and seeing any patient who needs your help. Trial attorneys are attacking in Sacramento! If they’re successful, your practice overhead, the local medical clinic's overhead and your hospital’s overhead will skyrocket with malpractice insurance premium increases and the unreimbursed cost of new mandated actions. Trial attorneys have initiated a two year battle to overturn the MICRA law that was developed in 1975 to insure that injured patients receive full payment of ALL (past and future) medical costs, all lost wages, punitive damages, and a reasonable “pain and suffering” payment. MICRA also limits attorney fees. Enactment of MICRA prevented a 400% increase in 1975’s physician malpractice premiums and prevented significant numbers of physicians from being declared “uninsurable.” Trial attorneys have filed a California Initiative, entitled “Troy and Alana Pack Patient Safety Act of 2014,” for the November, 2014 ballot that would: 1) Amend the MICRA provisions in the Civil Code relating to noneconomic damages to say: a. On January 1, 2015 the cap on non-economic damages shall be raised to reflect the increase in inflation based on the Consumer Price Index SINCE THE CAP WAS ESTABLISHED – a 480% increase! (NOTE: this will raise the cap to approximately $1.25 Million.) 2) The cap will be adjusted annually based on the CPI (a COLA) going forward. 3) The adjusted cap will apply to any action, which has not been resolved by final settlement, judgment, or arbitration as of January 1, 2015. 4) Requires a physician (and allows any person) to report to the Medical Board any information, which appears to show that a physician may be or has been impaired while on duty. 5) Requires a physician to report to the Board any physician responsible for care and treatment who failed to follow the standard of care when an adverse event occurs. 6) Hospitals shall conduct testing for drugs and alcohol on physicians: 8

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a. On a random basis for those with admitting privileges. b. Immediately upon the occurrence of an adverse event including those who treated or prescribed within 24 hours of the event. 7) The physician is responsible for being tested as soon as possible after learning of the adverse event. a. Failure to submit to testing within 12 hours after learning of the event may be cause for suspension of the physicians’ license. b. The hospital shall bill the physician for the costs of testing which cannot be passed on to patients or their insurers, should the Board direct a test to be completed. 8) Hospitals shall report any positive tests or refusal to submit to the Board which shall: a. Refer it to the Attorney General b. Suspend the physicians license pending an investigation and hearing on the matter c. Notify the physician and all facilities at which the physician practices that the license has been suspended. 9) If the Board finds the physician was impaired while on duty or during an adverse event, or the physician refused testing, the Board shall take disciplinary action which may include: a. Required addiction treatment b. Additional testing during probation and/or c. Suspension of licensure until the Board is satisfied the physician can return to work. 10) If the Board finds a physician was impaired during an adverse event, it shall notify the patient or family of a deceased patient of the finding. 11) The Board shall assess an annual fee on physicians to pay for the costs to the Board and the Attorney General for this program. 12) A physician shall be presumed negligent in any action who tests positive for drugs or alcohol or refuses to comply with testing in any action. 13) Prior to prescribing or dispensing a Schedule II or Schedule III controlled substance for the first time to a patient, the healthcare practitioner shall consult CURES database. The battle over MICRA will be expensive. Trial attorneys will spend $2 million just to collect qualifying signatures for their ballot initiative and much more later. Subsequently, costs to defend MICRA by a coalition of physicians, dentists, hospitals, community clinics, and insurance companies are expected to run about $60 million! The quality of California healthcare won’t increase with passage of the initiative! Access to physician-directed care will be reduced. Health care costs will rise substantially for virtually any person or institution providing medical or dental care. Trial attorney fees will rise dramatically. More frivolous malpractice lawsuits will occur as attorneys scramble to “cash-in.” Ultimately, your patients will find it harder to find and afford needed medical care. Please see MICRA on page 9


MICRA Continued from page 8 Do you want to know how to help preserve MICRA, help your patients, help your practice, and help your hospital? Contribute your time, influence and money to the fight for MICRA – be a part of Californians Allied for Patient Protection (CAPP) activities! Learn more about the issue at www.cmanet.org/issues-and-advocacy/ cmas-top-issues/micra and www.micra.org/ ballot-initiative/ballot-initiative.html. Educate your patient families. Advocate with your legislators. Open your wallet and contribute directly to fund this expensive battle that will define California medicine into the future – go to https://my.cmanet. o r g / C a l PA C / c g i - b i n / m e m b e r dll.dll/OpenPage?wrp= donations_NL.htm. If you have questions or want to talk with me about how you can help, please give me a call anytime at 559-449-4350 (ask for Dr. Virgil Airola) or 916-551-2570 (CMA staff: Brett Michelin or Nick Birteil). Contact Dr. Airola at: airola@comcast.net.

“SAVE THE DATE”

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: csrau@fmms.org or visit www.fmms.org

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BLOOD BANK West Nile Virus Transmitted Through Blood Transfusion Patrick Sadler, MD Central California Blood Center

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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 gstrasser@bakermanock.com www.bakermanock.com

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An immunocompromised Colorado man died from a West Nile virus (WNV) infection most likely transmitted through a blood transfusion, reported the Centers for Patrick Sadler, MD Disease Control and Prevention in an August 9 Morbidity and Mortality Weekly Report (MMWR). The patient, who had non-Hodgkin’s lymphoma, received a transfusion of blood that was reactive by mini-pool nucleic acid testing (MP-NAT) for WNV, but non-reactive by individualdonation NAT (ID-NAT). There have been no other cases of WNV transmission through a transfusion after the blood product was cleared by individual testing, according to CDC. “Although WNV is rarely transmitted through screened blood products, clinicians should consider WNV disease in patients with compatible symptoms who were recently transfused,” particularly those who are immunocompromised, wrote the MMWR authors. They added that the relative risks and benefits of different strategies for managing minipools that are reactive as a group but in which all of the component donations are negative on individual screening need to be evaluated further. In this particular case, “the blood collection and testing agencies involved have now decided to discard all constituent units of reactive minipools when an [individually] reactive donation cannot be identified,” said the report. The patient was admitted in August 2012 for chemotherapy and an autologous stem cell transplant. He was screened for subclinical infections 14 days before stem cell collection and no infections were detected. The transplant occurred on hospital days eight and nine. The patient developed gastrointestinal symptoms on day 18 and then fever and hypotension on day 28. A day later, he developed altered mental status, Please see Blood Bank on page 19


MEDICAL HISTORY Medical Advances of the American Civil War Nitin Sil, MD Reprinted by permission of the Marin Medical Society.

The

American Civil War has always been recognized by historians for its watershed effect on social and military evolution. History, however, has been less than kind with its perception of the era’s medicine. Images of amputation without anesthesia and surgery without respect to germ theory come readily to mind. Yet in reality the conduct of Nitin Sil, MD the Civil War had a profound effect on the art of medicine. More than 600,000 Americans died during the Civil War – more than every other war the country has fought before or since, combined. At the beginning of the war, a strained and outdated medical system was ill prepared for and quickly inundated by a seemingly endless stream of wounded. Over the war’s four long years, old ways were abandoned. Advances in procedures and medical doctrine rivaled advances in clinical thought. These advances combined to reshape the medical community. From this devastation arose what we perceive today as the foundation of modern medicine. On April 13, 1861, the bombardment of Fort Sumter by Southern forces sent both sides into a frenzy of enlistment. Yet despite the patriotic fervor, the medical system lay practically dormant. Most doctors of that time were rural family practitioners who did not need a state medical license or board certification. In many cases, their medical education was limited to one year of study with no formal residency or didactic learning. Teaching hospitals were nearly a nonentity, and even the Surgeon General, Dr. Thomas Lawson, considered medical books an “unnecessary extravagance.” Most medical dogma was rooted in the teachings of antiquity. Sickness was often felt to be based on humoral imbalances, and bloodletting was still one of the primary methods of treatment. Even surgery was considered taboo and rarely attempted. Boston’s Massachusetts General Hospital recorded on average 39 surgical procedures annually between 1836 and 1846. Ambulances and mass medical evacuation systems had not been organized or even considered. Germ theory was still 20 years in the future, and as thousands of men organized into base camps for war, no vaccination or sanitation systems were employed. As naive and unprepared as medicine was, its state of readiness only paralleled the state of military tactics. In July of 1861, a horrified nation learned of the death toll at the First Battle of Bull Run. Almost 3,000 soldiers gave their lives to inept and outdated methods of leadership based on tactics of the Napoleonic Era. The death toll at Bull Run was soon overshadowed by nearly every other major engagement, as military tactics lagged behind advances in weaponry. At the Battle of Fredericksburg in December 1862, 18,000 soldiers were killed, due in part to advances in the rifled musket that greatly extended its killing range. At the Battle of Antietam, earlier that year, more than

22,000 died in a single day – September 17 – largely due to the development of the Minie ball. This conical .63 caliber projectile was relatively quick to reload and on impact could shatter vast tracts of bone and tissue. A major culmination of the war’s destruction occurred at the Battle of Gettysburg on the first three days of July 1863. When the carnage was over, more than 50,000 soldiers were dead. The rise in casualties was soon matched by medical innovation. By the second year of the war, both sides had initiated calls for medical reform. Physicians were required to pass board examinations, and standards of practice were introduced. Recruitment camps were required to begin vaccination protocols, and soldiers were rejected on the basis of physical illness. Doctors were given the ability to hold military rank and could allocate orders to assist in the retrieval and care of patients stranded on the battlefield. In certain cases, these orders could supersede those of their officer peers. This innovation was further expanded when Dr. Hunter Holmes McGuire, a Confederate field surgeon, championed the idea that medical personnel were to be treated as noncombatants. His concept was later ratified by the Union Army and was soon integrated into the foundations of what would become the Geneva Convention. As Northern troops began to occupy the cities of the South, new methods of sanitation were introduced. When General Ben Butler assumed the command of occupied New Orleans in April 1862, he set up field hospitals, began a refuse disposal system, and vigorously employed the newly discovered drug, quinine. As a result, the years of Union occupation in New Orleans brought significantly lower levels of yellow fever and malaria. These changes in sanitation and treatment were paralleled by better systems of medical logistics. An ambitious hospital building program began, and by 1863, more than 400,000 medical beds were available. Facilities that specialized in various types of surgery and rehabilitation were constructed. Inspection systems were developed and then used to maintain standards of care. As a result, hospitals saw a mortality rate of less than 10%. Trains were formed with hospital cars that could accommodate the transfer of patients. Early horse-drawn ambulances were constructed with suspension systems for more secure transport, along with on-board medical kits to treat soldiers in the field. Ships that had been initially used for military cargo were refitted to hold the wounded. By 1863, vessels were designed from the keel up with operating rooms and isolation wards, and were staffed by nautical doctors and nurses. Surgery also experienced a renaissance. As the number of wounded increased, doctors had to create more efficient surgical methods. They devised new saws and chain devices, and they refined operating rooms, scalpels and instruments. By 1864, several subspecialties of surgery had emerged, including plastic, orthopedic, abdominal, thoracic, ocular and even neurological. For the first time, blood transfusions became ubiquitous, and prosthetic parts were created on a grand scale. Contrary to Please see Civil War on page 19 V I TA L S I G N S / O C T O B E R 2 0 1 3

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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

COSMOPOLITAN IMAGINATION AND THE NEW ECOLOGY OF MEDICINE AND GLOBAL HEALTH

website: www.fmms.org

I long, as does every human being, to be at home wherever I find myself. – Maya Angelou

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 Alan Birnbaum, MD S.P. Dhillon, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Ahmad Emami, MD Anna Marie Gonzalez, MD David Hadden, MD Joseph B. Hawkins, MD S. Nam Kim, MD Constantine Michas, MD Trilok Puniani, MD Khalid Rauf, 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 Trustee District VI Virgil Airola, MD Staff: Sandi Palumbo Executive Director

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We in the medical community are witnessing a phenomenal revolution in the ways we see and think about healthcare as we begin to traverse through the new ecology of medicine and global health. We now inhabit a moment of unimaginable possibility; with astronomical advances in communication technologies and the democratization of information in the digital age of the “Twitterverse” and Facebook. The ceaseless surge in the global flows and migrations of people, goods, capital and ideas across and within borders has rapidly altered both our individual and collective sense of identity, time and space. In an era of hyper-globalization where the world is increasingly becoming more interdependent and interconnected, we can no longer afford to think through the texts of anachronistic parochialisms. We must embrace our cosmopolitan imagination. Cosmopolitanism is a worldview and a practice grounded in an understanding of our common shared humanity, whereby communities recognize their mutually constitutive existence in an interdependent world, where shared risks between communities provide the incentives to peacefully co-exist and cooperate. Cosmopolitan imagination calls for a fundamental paradigm shift in our traditional ways of relating with one another as individuals and communities. It challenges us to establish a new locus of responsibility with our neighbors; to recognize that we now exist in what British social theorist, David Held calls “overlapping communities of fate.” Indeed, meeting the challenges to global health in the 21st century will require all of us to be bold and imaginative in the pursuit of this spirit. We now live on a planet where two-fifths of the world’s people lack access to proper sanitation, where 1.1 billion people lack access to fresh drinking water and where 6,000 children die from waterrelated illnesses such as diarrhea and malaria on a daily basis. According to Amnesty International, global maternal mortality rates are on the rise, where “around the world, one woman dies every 90 seconds in pregnancy or childbirth” and women in the United States “have a higher risk of dying of pregnancy-related complications than those in 49 other countries.” Though there has been notable progress in meeting the anti-poverty agenda of the United Nations Millennium Development Goals, which expressed global resolve to cut extreme poverty in half and reduce the incidence of HIV/AIDS, malaria and other preventable diseases by 2015, much work remains to be done in combating these complex challenges to global health. In consonance with cosmopolitan sensibilities, the medical community must undergo a metamorphosis in praxis in order to address these challenges. As we witness the convergence of the interests of the local and the global, and the ubiquity of information and technology, physicians and caregivers must learn to adapt to the needs of the new ecological terrain of global health and citizenship. These radical changes present us with a tremendous opportunity to re-imagine new, more fluid and nuanced understandings of community and of our responsibilities at both the local and global levels. As physicians, we are bound together in our pursuit to make the world a better place and we accept the magnitude and scope of our work with every patient we treat and with every community we serve. But we must now broaden our horizons to meet the myriad complexities of medicine and global health in the 21st century and a cosmopolitan approach offers the medical community with a unique conduit for addressing the health needs of communities both locally and across the globe. Contact Dr. Rajpal at rsrajpal@gmail.com.

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Fresno-Madera

ROGER K. LARSON, MD 51-year member

Roger Larson, MD, a retired internist, died peacefully in his home in San Louis Obispo on August 26, 2013, at the age of 89. Dr. Larson was born in Michigan in 1924, He received his medical degree from the University of Illinois College of Medicine in 1947, did his internship at Cook County Hospital in Chicago and completed his residency at Kern General Hospital in Bakersfield. After his medical training he served as Captain in the U.S. Army for two years in Japan and Korea. He returned to California and joined the faculty of the new UCLA School of Medicine, where he pursued his interests in pulmonary disease and cardiology. In 1957 Dr. Larson was recruited by Valley Children’s Hospital, and along with Dr. Thomas Eliason, established the first cardiac catheterization and blood gas lab in the San Joaquin Valley and provided technical support for their new open-heart surgery program. He then became the Medical Director of the Fresno General Hospital, serving as the first full-time director of its small training program in internal medicine. This training program grew under his charge from a nonuniversity-affiliated program of nine residents and one full-time faculty to a university-affiliated program of 50 residency positions and 20 full-time faculty positions. He retired from this position as Chief of Medicine in 1989. He continued a part-time medical practice and served as a part-time medicolegal consultant until 1992. During this time, he also served as the medical director of a large federal AIDS professional education and training grant for four Western States. Other appointments during his career included the Board of Directors of the Tuberculosis and Health Association of California, Chairman of the Pacific Southwest Regional Medical Library Advisory Committee and member of the Editorial Board of the Western Journal of Medicine. He authored and co-authored many publications in medical and scientific journals. Dr. Larson’s medical recognitions and awards include: Distinguished Service Award from the American Heart Association; the Henry Kaiser Teaching Award from UCSF, the establishment of the Roger K. Larson Distinguished Visiting Professorship CME program and the Laureate award of the American College of Physicians. In addition, in 1989, the FMMS honored Dr. Larson with that year’s Lifetime Community Service Award. Dr. Larson was an active member of FMMS, serving on its Board of Governors and various committees. He most recently served on the FMMS Community Health Committee and participated in its Air Quality program prior to his move in 2011 to San Luis Obispo. For over three decades, Dr. Larson was an avid, knowledgeable and well-known book collector on California and the West, in addition to writing and publishing several books on these topics. Portions of his book collection – and other items were donated to Fresno State’s Henry Madden Library and a major portion was sold in a series of four auctions in San Francisco. Included in his collection was a signed, first edition of author William Saroyan’s first book and the personal diary of pioneer Fresno physician Dr. Chester Rowell. Dr. Larson was known to many as a man of uncommon humility, humanity and altruism. Dr. Larson is survived by his wife, four children, six grandchildren and six greatgrandchildren.

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

Oct. 26 & Nov. 16 9:00-10:00am Registration begins at 8:45am at Woodward Regional Park Sunset View Shelter WHO CAN ATTEND: Participation is open to anyone interested in taking steps to improve their health. 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 receptionist@fmms.org.

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

Find us on Facebook: Fresno-Madera Medical Society http://www.facebook.com/pages/Fresno-MaderaMedical-Society/107731015917068

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Fresno-Madera ENDLESS HORIZON: PLANETARIUM SHOWING EXCLUSIVELY FOR FMMS MEMBERS Spend a relaxing evening viewing this family-oriented program, which offers a historical perspective of the events that paved the way for the modern exploration of the planets and the cosmos.Join narrator Patrick Stewart on this explanation of mankind’s drive to reach out towards the unknown. This exclusive FMMS showing is at the Downing Planetarium, a 74-seat Star Theater under a 30-foot hemispherical dome located on the CSU, Fresno campus. This show is designed for audiences grade 5 to adult. Tuesday, October 8, 2013 Downing Planetarium, CSU, Fresno Doors Open: 6:30 pm • Show time: 7:00 pm Star Gazing: 8:15 pm (weather permitting) No charge, FMMS members • $6, non-FMMS member Information: 224-4224 x 118 or csrau@fmms.org No food or drinks allowed in theater LIMITED SEATING • MUST RSVP TO ATTEND Reservation Form Checks payable to FMMS, PO Box 28337, Fresno, CA 93729 Cost: ___ No Charge, FMMS member ___ $6 each, Non-FMMS member and guests NAME PHONE EMAIL FOR CONFIRMATION

May fax registration to: 559-224-0276 Tickets & parking passes held at door. Confirmation & directions will be emailed.

FMMSA RECEPTION AT FRESNO STATE’S LIBRARY The FresnoMadera Medical Society Alliance is partnering with Henry Madden Library at Fresno State to host a reception and special after-hours tour of the Library’s “Valley Firsts!” exhibition, which showcases world-class innovations, inventions and accomplishments originating in the San Joaquin Valley. Saturday, October 26 • 6:00-8:00 p.m. Henry Madden Library, Fresno State campus Cost: Members of FMMS or FMMSA: $20/couple, $10/person. The event is free to any member of the FMMS Alliance who brings a person who joins the Alliance at the function. Physicians-in-Training and their spouses/partners/guests are free. Hors d’oeuvres and beverages, includes Fresno State wines, will be served. RSVP by October 21 to Susie Bartlett: swbart43@gmail.com; 2764 W. Robinwood Lane Fresno, CA 93711; or telephone 559-431-3879. Campus parking is free for this event.

2013 Annual Installation & Awards Dinner Gala Wednesday, November 6, 2013 Roger Rocka’s Dinner Theater

Congratulations to the 2013 Physician Community Service Award Honorees: Kenneth L. Jue, MD Alexander Sherriffs, MD Dinner • Door Prize Drawings Installation of FMMS Officers and Prahalad Jajodia, MD 2014 FMMS President Treat your family, employees, colleagues and friends to a fun, treat-filled evening! Includes dinner and show: “Shrek the Musical” Sponsorship opportunities: Contact spalumbo@fmms.org MUST RSVP TO ATTEND Reservation Form Checks payable to FMMS, PO Box 28337, Fresno, CA 93729 Cost: ___ $60 each, includes open seating dinner/show NAME GUEST NAME Charge my ___ MasterCard ___ Visa Credit Card Number: | Exp Date Name on card

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Billing Zip Code Total amount $

Signature: Date RSVP by Nov. 1, 2013 • Information: 559-224-4224 ext. 118 May fax registration to: 559-224-0276

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Kern

Kings WILBUR SUESBERRY, MD PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581

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

President’s Message

website: www.kms.org

ACKNOWLEDGING DR. NORMAN LEVAN: BAKERSFIELD DERMATOLOGIST AND EDUCATIONAL PHILANTHROPIST KCMS Officers 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

Dr. Norman Levan was still seeing patients once-a-week at the age of 96. He attended USC Medical School and later returned to USC as their first professor of dermatology. He retired from his Bakersfield dermatology career in 2012. Although retired from active practice, Dr. Levan continues with his educational philanthropic involvement. In March 2011, Dr. Levan donated nearly $14 million to Bakersfield College, adding to his previous donation of $5.7 million. His donation broke the record for donations to a community college at that time. Most of the nearly $20 million was used for scholarships for students. In addition, the donations established the Norman Levan Center for the Humanities and the Norman Levan Center for Life-Long Learning. The director of the Norman Levan Center for the Humanities, Dr. Jack Hernandez, stated that “the college and community is very appreciative of the generosity of Dr. Levan.” His generosity enhances and promotes broad intellectual interest for the college and the community. The Levan Center is a 4,400 square foot facility that houses a 1,450 square foot seminar hall at Bakersfield College. Dr. Levan has also donated to St. John’s College in Santa Fe, New Mexico where he obtained a Masters of Arts in Humanities after he had already been practicing medicine. Contact Dr. Suesberry kyholl@sbcglobal.net.

CMA Alternate Delegates: Lawrence Cosner, Jr., MD

Call for Submissions to the Levan Humanities Review

Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Administrative Assistant

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Portia Choi, MD

The Norman Levan Center for the Humanities published the premier issue of the Levan Humanities Review in April 2013. The Review is an online journal for the community of Kern County, to provide a venue for reflection on the humanities, including relevance of the humanities to the lives of individuals and communities. The premier issue can be accessed online. The Review is seeking submissions for its second issue. Prose submissions are for articles, essays, and book reviews on topics in the humanities, the humanities and science, and the humanities and medicine. These submissions are not to exceed 5,000 words, can be interdisciplinary, and should be accessible to readers outside the field. All submissions should be in a Word document, along with a brief bio of the author. Poetry submissions are not to exceed three poems and 30 lines per poem. Submissions are accepted only from faculty and staff of local colleges, schools, hospitals, and professionals. The deadline for submissions is December 1, 2013 questions should be emailed to the editors at jhernand@bakersfieldcollege.edu. Contact Dr. Choi at ssportia@aol.com.

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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


Tulare Dr. Pandya Receives National Service Award for Volunteer Work Tulare Medical Reserve Corps (TMRC) is pleased to announce that Gaurang Pandya, MD, Immediate Past President of the Tulare County Medical Society, and his Pandya Family Foundation was selected as The Outstanding Medical Reserve Corps Partner Organization for 2013. The award honors MRC partner organizations that supported MRC units in carrying out their missions and provide MRC units with opportunities to participate in public health preparedness and response activities. There were 71 nominations from across the country, and after an extensive review, awardees Dr. Pandya with Rear Admiral Boris Lushniak, were selected from each category. Awardees received MD, Acting Surgeon General and Captain Rob their recognition during the Late Spring Seasonal Tosatto, R.Ph., Director of the Civilian Volunteer National MRC Leadership and Training Summit at The National Conference Center, in Leesburg, Va., on June 6. Dr. Pandya and The Pandya Family Foundation have been working with Tulare Medical Reserve Corps since October 2011. He is a general surgeon in Porterville, Calif. He is the Immediate Past President of the Tulare County Medical Society and in that capacity he informed physicians in the county about TMRC. He also contacted all three hospital medical staff presidents to request a presentation to their respective medical staff members, and the TMRC Coordinator made those presentations to about 200 MDs. He personally led the recruitment of physicians at the Sierra View District Hospital where six other MDs and the Medical Staff Coordinator joined TMRC and received extensive training in emergency preparedness. He personally contacted over 30 additional community and faith based organizations to inform them about the Tulare Medical Reserve Corps. He helped develop a mass vaccination training/exercise for the Porterville SIKH Temple where 39 people received seasonal flu shots. The exercise utilized the Incident Command System (ICS) taught by the TMRC Coordinator. Dr. Pandya led the Emergency Preparedness information campaign at Holy Cross Catholic Church where over 300 parishioners participated in an all day Sunday event. He continues to promote TMRC to schools and other faith based/community service organizations in the greater Porterville area. His foundation also gave a substantial financial gift to TMRC when it helped fund an educational presentation to healthcare professionals in Visalia on the National Institute of Health publication: “Crisis Standards of Care.� Dr. Pandya is a tireless supporter of Tulare Medical Reserve Corps. TMRC congratulates Dr. Pandya for his outstanding community service through the Tulare Medical Reserve Corps. Any physician who would like to know more about the Tulare Medical Reserve Corps can contact Dr. Pandya or Steve Chambers, Coordinator, at 559-624-8496 or schambers@tularehhsa.org.

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

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

Holiday Dinner Event SAVE THE DATE!

TULARE COUNTY MEDICAL SOCIETY

Wednesday, December 11, 2013 Visalia Convention Center

Please RSVP to Dana Ramos (559)734-0393 or dramos@tkfmc.org V I TA L S I G N S / O C T O B E R 2 0 1 3

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Tulare Who Needs AMA? James T. Hey, MD; Robert E. Hertzka, MD; Albert Ray, MD; and Lisa S. Miller, MD

The majority of U.S. physicians aren’t members and apparently ask that question. At times, so do many of us who are members and who are active in the organization itself. We don’t always agree with each other and we don’t always agree with the conclusions, but we decide collectively rather than letting someone else decide for us. Nonmembers let others decide for them. The recent November meeting of AMA’s House of Delegates (HOD), which prompted this article, produced few things that would make the headlines or stimulate nonmembers to join. But the overwhelming need for physicians to be united on the things that matter to us and to our patients creates an absolute requirement for an organization that speaks for all physicians. Let’s look at why. LEGISLATIVE AMA still is the voice of medicine for Congress and the White House. Our specialty societies represent our more parochial interests and professional needs, but only AMA speaks for the entire profession. Every legislator knows that. When we differ on policy or turf issues, everyone loses. When we speak with one voice, we don’t always win, but our chances improve substantially. While the SGR cliff is infuriating evidence of Congress’ inability to resolve serious fiscal issues, that fact that we haven’t fallen off that cliff yet is certainly due to the extremely strong objection Our AMA raises every year. The delay in implementation of ICD-10 is also to AMA’s credit and for now saves each of us not only the hassle of that transition, but also its significant cost. Adopted at this HOD was a report with extensive policy to strengthen Medicare for current and future generations, and for which AMA will now be advocating on Capitol Hill. It outlined the provisions necessary for Medicare to transition to a “defined contribution” instead of a defined benefit plan as it is currently structured and whose rising cost has the potential to bankrupt the country. Those provisions include, among others: • Enabling beneficiaries to purchase insurance from a wide variety of plans all subject to appropriate oversight and regulation. • Preserving traditional Medicare as one of the options. • Requiring participating plans to meet guaranteed issue and renewability requirements and prohibit cancellation except in the case of outright fraud. • Applying risk adjustment to the defined contribution to be sure the older and sicker can afford them. And adjusting the contributions annually based on the true changes in the cost of healthcare. • Requiring the baseline defined contribution to be the cost of traditional Medicare. Also adopted at this meeting were California resolutions to: 1) “Decouple” Social Security recipients from the mandate to participate in Medicare – in other words, to give those who wish to stay with their own health plan the right to do so 2) Outlaw “Pay for Delay” policies that many pharmaceutical 18

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companies use to keep their branded, more expensive drugs from competition be generic companies 3) Oppose general CMS audits of E&M codes without due cause. All these are issues we want Our AMA to “win” for us, and should matter to each and every doctor in the country.

LEGAL AMA has an extensive and powerful legal team that goes into action when needed. California need look no further than the story at San Buenaventura Hospital, where a new CEO sought to impose hospital bylaws and hospital-chosen physician leadership or an unwilling medical staff. CMA asked AMA’s legal team to assist in the fight, and together we not only reserved this outrageous assault on self-governance, but followed up with passage of a California law now guaranteeing medical staff selfgovernance by statute. That fight was won in large part due to the intersession of Our AMA. More recently, AMA partnered with two state societies in a successful lawsuit settled for a $350 million return to the physicians who were systematically underpaid for their out-ofnetwork services by United’s use of its Ingenix coding software. And just this past December, Aetna, which used the same United-owned Ingenix software, settled a similar lawsuit by AMA and several other state societies and will be returning $120 million to physicians, including those of us in California. Perhaps even more importantly, United has ceased its use of Ingenix, and AMA continues in its lawsuit to see that Aetna does likewise.

POLITICAL Not only does AMA, through its PAC, engage in political campaigns to assist candidates who believe physicians are part of the solution instead of part of the problem (Bob Hertzka’s favorite criteria), but they also conduct a campaign management school and one for candidates themselves to help physicians and their family members prepare to enter public office. It is no small feat that there are now 17 physician members of the House of Representatives, and three physician senators.

NETWORKING Rank-and-file physicians don’t care how any part of organized medicine does its work, I’m sure, including whether we have a house of delegates or councils or committees. We care about the results – specifically, about how well they make physicians’ lives better and help doctors help their patients. All of organized medicine should be judged by those criteria. However, effectiveness is totally dependent on who is represented and if they have a voice in the process. Meetings like the HOD allow us to hear what is happening elsewhere in the country and what others have done to be successful in their states or specialties. Since all specialties and all states are represented at AMA, it can be said that nearly all doctors belong to one or another of the components that come together there. Please see AMA on page 19


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

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.

ANNOUNCEMENT

FOR LEASE OR RENT

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.

1 lg or 2 separate suites; 1,200sf & 1,300 sf. 3 exam rms. Lab space; waiting rm, 1 bathrm & private office. Good storage; close to SAMC. 1095 E. Warner #102 & #103. 559-905-9233. Office space at Cedar/Alluvial. 3,075 sf. Call 559-287-3279.

PHYSICIAN WANTED P/T or Locum work for local occupational clinic. Sprain/strains and employer physicals. Call Su Rosenthal at 559-287-0172 or Su@PalmMedical.com. Avecinia Wellness Center is hiring board certified FP/IM physicians for its integrative medical practice. Visit www.avecinia.com and email questions/cvs to aamer@ awcmgmt.com.

KERN

PHYSICIAN WANTED Part time physician for weight loss clinics in Bakersfield. Possible buy-in. Established practice with potential. Fax CV to 805-6447943 or email: swhitcomb@pro-weight-control.com.

Blood Bank

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somnolence, and respiratory distress. A cerebrospinal fluid sample taken on day 30 was negative for various bacterial and viral infections, but was not tested for WNV. The patient’s mental status did not improve and he ultimately died on day 47. Diffuse encephalitis was revealed on postmortem evaluation. After the fact, WNV was detected in patient serum that had been collected on day 43, and in brain and spinal cord tissues collected during autopsy. During subsequent investigation, retrospective testing of the implicated unit showed discrepant ID-NAT results and evidence of WNV-specific immunoglobulin M (IgM) and neutralizing antibodies. Frozen plasma thawed after storage from the implicated unit was reactive for WNV on four of five replicate Cobas TaqScreen WNV tests, but WNV RNA could not be detected by conventional Taqman RT-PCR. The report can be viewed at www.cdc.gov/mmwr/pre view/mmwrhtml/ mm6231a2.htm. Source: CDC MMWR, 8/9/13 from ABC Newsletter, August 16, 2013) Contact Dr. Sadler at: psadler@donate blood.org.

popular media, anesthesia was used and documented in over 80,000 surgeries. Medical literature even recorded the comparison trials of different types of anesthesia. Compared to their 1861 counterparts, surgeons in 1865 had gained unprecedented advantages in medical knowledge, experience and treatment options. Two percent of the population of the United States died during the Civil War; two-thirds died from disease rather than battlefield injuries. While initially unprepared, the medical system was able to adapt over a period of four years. By war’s end in 1865, newly built hospitals continued to provide services to thousands of wounded. The wartime innovations of hospital ships, ambulances and hospital trains continued to develop. Perhaps most importantly, medical professionals began to appreciate and expand on their wartime education. Medical dogma that had previously restrained advancement was questioned, and the need to discover, refine and evolve became the new paradigm. Dr. Sil is a hospitalist at Kaiser San Rafael you may email him at: nitin.a.sil@kp.org.

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 sf. 9330 Stockdale Hwy. – 5,754 rsf. 9900 Stockdale Hwy. – 2,085 sf. 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. 3535 San Dimas – 1,598 sf. 9508 Stockdale Hwy. – 455 sf. Lab Space 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. 3015 Calloway – 1,465-10,318 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-2,265 rsf. 9900 Stockdale Hwy. – SOLD OUT! 3535 San Dimas – 6 Buildings For Sale 3941 San Dimas St. – 9,000 rsf.

AMA Continued from page 18 However, if a physician isn’t participating, his or her voice is lost to the discussion. Objecting to the direction Our AMA has taken used as an excuse to not belong merely cedes the battlefield to the enemy. So in these very difficult times, “Who needs the AMA?” Every American physician and every one of those physicians’ patients. That’s who.

CONTACT US, PARTICIPATE Your AMA local delegates want to hear from you: • Dr. Ron Morton: rmorton@goldenstateeye.com • Dr. Thomas Daglish: daglish@sbcgobal.net Contact the authors: Dr. James T. Hay, jthay@ncfmg.com; Dr. Robert E. Hertzka, bob@hetzka.com; Dr. Albert Ray, albert.x.ray@kp.org; and Dr. Lisa S. Miller, 858-467-1899.

V I TA L S I G N S / O C T O B E R 2 0 1 3

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A N O R C A L G R O U P C O M PA N Y

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

2013 October  
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