SCOPE Magazine October 2014

OCTOBER 2014 VOL. 30, NO. 5 MASON GENERAL HOSPITAL & FAMILY OF CLINICS

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CT vs MRI

What is the difference?

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quality Radiology Chief talks about Hospital’s high-tech CT and MRI In the past 15 months MGH&FC has

added two state-of-the-art diagnostic imaging scanners that no other health care facility in the South Sound region can come close to offering patients – a low dose, large bore, high resolution CT; and a large, open, high resolution MRI. MGH&FC’s Chief of Radiology, boardcertified Radiologist Kevin Roscoe, M.D., and Michael Gray, director of Diagnostic Imaging, were instrumental in bringing these two scanners to MGH. Q - Dr. Roscoe, this is a very basic question for you – but what does “CT” mean?

A - CT is an acronym for Computed Tomography, often times referred to as a CAT (computer assisted tomography) scan.

Q - You stated that MGH&FC purchased this new CT scanner to “increase image quality while at the same time improving patient care, safety, and comfort”. Can you explain what this means to a patient?

A - First I would like to comment on the CT’s increased image quality, which is very exciting for me as a radiologist. The new

On the cover and above: Radiologist Kevin Roscoe, M.D., looks at a recent CT image (right) and MRI image (left) of the brain. MGH&FC recently installed the most advanced CT and MRI in the South Sound region. All diagnostic images at MGH - including mammograms and x-rays - are now digital. Cover photo by Cooper Studios, Shelton

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increments of acquisition, Toshiba Prime 80-Slice CT the scanner also allows for scanner has better very fast scan times – in the resolution than our previous order of just a few seconds.

16-slice CT scanner, and This warrants less concern is superior to the typical for a patient’s movements, 64-slice scanners in the area. i.e. breathing, etc. The Its higher resolution allows patient also spends less us to see more detail in the time on the table, and a scan to assure an accurate lower dose of contrast diagnostic study. This can be given for those model scans the body at scans that require contrast.

0.5 mm increments, which Kevin Roscoe, M.D., The scans are processed means increased capability Chief of Radiology, MGH& FC incredibly fast and can for scanning arteries of the be reformatted into three-dimensional head and neck, and peripheral arteries. rotating images for the physician and To improve ‘safety’, the new CT scanner surgeon. This occurs so instantaneously has the most up-to-date software that occasionally an emergency room package available in the new technology patient may have their images completed of iterative dose reduction. This means and interpreted before they are not only higher resolution, but lower transferred to their room. radiation exposure. So far, this is typically Q - What does MRI stand for? less than 50 percent of the previous scanner, and sometimes as low as 10 A - MRI stands for Magnetic Resonance percent. We are now starting to use the Imaging. ultra-low dose chest CT scanning features Q - The new MRI is called an “Open for following lung nodules on patients MRI”. Can you explain the benefits who require repeated scans. of this?

As for ‘comfort’, a patient can weigh up to A - The “open” design allows a wide-open 660 lbs. – and this is regardless of height. area to scan patients. The conventional The CT scanner’s center opening is the MRI scanner is a long, horizontal tube largest in the area at 78 cm in diameter, that the patient slides into on the table, compared to other models with openings with the imaged part of the body of 70 cm. This allows not only for larger positioned fully inside the tube. This can patients to fit more comfortably, but also be disturbing for patients who have a for lateral table movement to optimize tendency for claustrophobia – the fear positioning of the patient and alleviate the of being in a confined space. The new, feeling of claustrophobia during the scan. open MRI is a table with the cover above patient and all the sides open. The Q - Experts say the images of this magnetic center is in the middle of the new CT are “finer than any other table, allowing the patient to be moved scanner in Western Washington”. around and positioned at the center of Can you explain how that benefits the magnet, or the “sweet spot”. It can the patient? be directed over the specific area to be A - Besides the higher resolution of imaged, such as the knee or shoulder the 80-slice detector and its smaller

The Mason Vision We put patients first. We provide quality medical care to assist the individuals of our community to restore and preserve their health. We conserve patient and community resources through a sustainable, financially viable, coordinated system of health care delivery. or brain. The open design is so open, in fact, that infants and children can be scanned in their mother’s arms. That way the mother can hold and comfort the child while in the scanner. Previous open MRIs had trouble with image quality due to their low magnetic field strength. The new open MRI has high field strength and open design, with images of the same quality as the tube models.

Q - Again, image quality is superb with this new MRI. How does a CT image differ from an MRI image?

A - Images from a CT and an MRI scan may look similar, but they are produced by very different methods. Basically, an MRI scans where water molecules are in the body, creating images from the signals produced by water interacting with a magnet. A CT produces images by scanning variations in the density of tissues and the absorption of x-rays from iodine in the contrast.

Q - A CT scanner uses radiation, whereas an MRI does not. Can you explain the difference between radiation and magnetism?

A - The CT scan uses x-rays – the same as those in a conventional chest or wrist x-ray, except the x-rays are emitted from a tube rotating very quickly around the body, with detectors on the end of the x-ray tube collecting data and reconstructing images in a threedimensional display. This is a very fast imaging technology that can be done in a matter of seconds.

The MRI uses an incredibly strong magnet to excite tiny fractions of protons in the water molecules of the body, which then interact with a radio frequency, producing images from the data collected by very strong antennas. This is a rather slow process and therefore image acquisition may take 5 to 10 minutes per image, and an entire scan time of 30 minutes to an hour. Its very slow process makes it also susceptible to movement, and therefore the patient must remain as still as possible during the scan.

Q - When will a physician recommend a CT scan? MRI scan?

A - There are certain circumstances for both. Occasionally one may be substituted for the other, however, the decision is based on what type of data the physician needs. The CT scanner is very good at detecting blood in the brain and exquisitely sensitive for fractures, and therefore used heavily in the Emergency Room. It is also able to see the internal organs and bowel. The MRI is superior in imaging the soft tissues of the brain, spinal cord, and looking at ligaments and cartilage of the joints, such as the shoulder, knee, or hip. MRI also detects changes in the uterus and ovaries, and is often used by gynecologists.

Q - Are there concerns about having a child receive a CT and/or MRI? What should a parent look for when choosing a facility for an imaging study?

A - When imaging children, many factors need to be considered by the radiologist and the referring physician. The first priority is patient safety, and second is addressing the medical issue. Children and infants are more sensitive to the effects of radiation than older patients, and therefore prudent use of radiation

is mandated by the ALARA principle, which stands for ‘as low as reasonably achievable’. The CT dose reduction makes this more achievable than before and can be lifesaving. The MRI cannot replace the CT in this regard, but it can be used effectively if the patient can hold still for the scan. On occasion, a patient may require sedation in order to remain still; and as mentioned earlier, a child can be held by a parent.

Q - If a patient’s physician is not in Mason County, how can they be referred to MGH&FC for a CT and/or MRI? A - When a physician orders an imaging exam, the patient can take the order anywhere, as long as that particular scan is offered at the facility. So if your out-ofarea provider orders a CT or MRI – you can come to MGH to have that scan. We will send the results to them once the scan is complete. This is similar to a prescription being filled at any pharmacy that has the drug in stock. MGH&FC offers a number of imaging tests including CT, MRI, X-ray, ultrasound, nuclear medicine, and digital mammography. Patients and providers can call Mason General Hospital’s Diagnostic Imaging Department at (360) 427-9590 to schedule their exam.

Diabetics: morning rise in blood sugar requires attention About half of type 2 diabetes patients, even those who are keeping their disease under

control with diet and exercise, experience a morning rise in blood sugar known as the dawn phenomenon.

The rise occurs following changes in hormones, including cortisol and growth hormone, usually between 4:30 and 6:00 a.m. In a person without diabetes, insulin is released to control the blood glucose level and give the body a burst of energy to start the day.

When insufficient insulin is produced, the dawn phenomenon occurs, and it’s not easily controlled by oral medications. Sometimes, such patients require insulin treatment earlier than they otherwise might.

[SOURCE: Lisa Nainggolan, “Dawn phenomenon affects half of type 2 diabetes patients,” Medscape Medical News, November 7, 2013 (Diabetes Care, October 29, 2013)] SCOPE 3

quality Oakland Bay Pediatrics adds new services

Youngsters in the child-friendly Oakland Bay Pediatrics waiting area.

The outside entrance of Oakland Bay Pediatrics.

A sick child is no fun. To help parents through this difficult time, Oakland Bay Pediatrics is here to help – with a commitment to patient-centered care. Oakland Bay Pediatrics (OBP) is a kid-friendly clinic where providers and staff work together to meet the medical needs of all children, from birth to 18. Offering a complete range of medical services, OBP provides compassionate, quality treatment for a child’s injury or illness, helps manage chronic conditions, and works with parents to foster healthy lifestyles for their children. They also provide newborn care, immunizations, and school, sports, and annual physicals.

Tele-Pysch – A “remote” consultation service where a patient can meet live, onscreen with a mental health expert via TV monitor set up in the Clinic. This allows a face-to-face appointment with a mental health provider without having to travel out of the area.

According to Barbara Schmidt, clinic manager, OBP is adding services that will enhance patient care. “We are very excited to offer services such as the Reach Out & Read book program; a voice interpretative system (VIS); Tele-Pysch, which is coming soon (remote video counseling); and a transition system to adult care when a child reaches age 18,” stated Barbara.

Reach Out & Read – OBP is the only practice in the area that participates in this national program. At every well-child exam, children aged 6 months to 5 years are given a new, age-appropriate book to encourage reading at an early age. New book purchases are donated by community members and other entities that make the Reach Out & Read program possible.

Voice Interpretative System (VIS) – For non-English speaking patients and those needing sign language translation services, OBP now has the capability to translate English to almost any language through a live, onscreen translator, using VIS. During the patient visit with the physician, the translator is present on the voice/sign monitor to interpret the conversation between doctor and patient, allowing the patient to ask and answer questions and be informed about their care.

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Child-to-Adult Transitional Healthcare – At age 18, a child will graduate into adult medical care, and to help them make the transition, the providers and staff at OBP have created a system of core elements, or goals, to assist them in becoming responsible for their own healthcare. Between the ages of 12 and 14, OBP providers help children begin the transition by teaching them to participate in their clinic visits, be responsible for their appointments Rose Ann Rayos, M.D. and health issues, and to follow-up with their healthcare provider, when needed. The ultimate goal is to help the child take responsibility for their healthcare decisions by the time they turn 18. OBP would like to help make this a simple, seamless transition for everyone, as the parents’ involvement in their child’s healthcare diminishes.

Binod Tuladhar, M.D., F.A.A.P.

Therese Pizanti, A.R.N.P.

Pediatric healthcare providers who serve our area youth at OBP include board-certified Pediatricians Rose Ann Rayos, M.D., and Binod Tuladhar, M.D.; and board-certified Pediatric Nurse Practitioner Therese Pizanti, ARNP. Clinic hours are Monday through Friday, 8 a.m. to 5 p.m., and OBP is located close to MGH at 247 Professional Way in Shelton. To make an appointment call (360) 426-3102.

Hoodsport Family Clinic focuses on patient care and community

Margene Fields, ARNP; and Destiny Chesledon, medical assistant.

After running a private practice for 14 years at Hoodsport Family

Clinic, Margene Fields, ARNP, decided it was time to bring more medical resources to her patients by joining a hospital system. “We looked at our options and decided it was a natural fit for us to join Mason General Hospital & Family of Clinics because its values are in line with ours – ‘patient-centered’ care and ‘community’”.

“With the Affordable Healthcare Act, we knew we needed a strong support system to help us manage the business side of the Clinic, too,” added Dave Moore, office manager. By joining Mason General Hospital’s “Family” of Clinics, Hoodsport Family Clinic (HFC) now has collaboration in the areas of patient billing, electronic medical records, ordering of supplies, and employee benefits, to name a few. “With this support, Margene and staff can focus more on caring for our patients,” he said. The staff at HFC consists of Margene Fields, ARNP; Hilary Walker, ARNP; Destiny Chesledon, medical assistant; Dave Moore, office manager; and Receptionists Patty Sisson and Vickie Raisio. In addition to the business support, Margene and staff also receive patient care support by consulting with specialists and Emergency Department physicians at MGH&FC.

Upper left: Dave Moore, office manager. Lower right: Patty Sisson, receptionist. Center: MGH Hoodsport Family Clinic is scheduled for an external “facelift” this fall.

The HFC patient base includes Hoodsport, Lilliwaup, Brinnon, Union – and all parts in-between. Hoodsport Family Clinic is located at 24261 N. US Highway 101 in Hoodsport, and can be reached by calling (360) 877-0372.

CMYK

“We are also adding new services in 2015, and are very excited about bringing these new resources to our patients,” said Margene.

One new resource will be remote access to mental health services.

A mental health expert can consult live, onscreen with a mental health patient via a monitor set up in the Clinic. “This way they can have a face-to-face appointment without having to travel out of the area,” added Margene.

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get moving laughed Andrea, referring to Jiu Jitsu, but said her favorite workout is the CrossFit training. Her training periods last from 25 to 45 minutes.

Andrea (right) and Troy with children Dawson and Dylan.

Mom inspires the whole family to “get moving” When MGH & Family of Clinics’

Laboratory employee, Andrea Beman’s son was learning about shapes in preschool, he told his mom, “You’re shaped like a circle, and I’m shaped like the number one.”

“It was a really sweet moment – but it made me realize I didn’t want to be that shape,” said Andrea. That’s when her weight loss journey began.

“I started by walking a quarter of a mile each day – which kept me committed.

But I needed to join a gym to keep me accountable,” said Andrea. That realization led her to join the Northwest High Intensity Training Center in

Olympia, where trainers could monitor her progress.

Andrea’s two children, Dawson, 9, and Dylan, 8, joined her from the beginning. Her husband Troy jumped in two years later, when his afternoons became free. Now the family travels to Olympia twice a week to work out at the Center, which features Jiu Jitsu and CrossFit training programs. Andrea admits there is something new every time they go, which keeps their interest.

On the off days, they work out at home using the gym’s training techniques.

“Throwing a grown man over your shoulders is really great exercise,”

“What the kids really love about going is that they get to play. Because of the gym, we don’t do other things like go to the movies. As a result we have cut down on our cable bill, allowing us to afford the gym membership. The gym is truly family time,” said Troy.

Over four years, Andrea has lost 155 lbs., and in one year Troy lost 60 lbs. In addition to workouts, the couple uses the online program, ‘My Fitness Pal’ to count calories and practice portion control.

“As long as we stay within our daily calorie count, we can eat what we want,” said Troy. “And it’s helped us make healthier choices,” added Andrea.

Andrea went on to say that her children have better self-esteem and she has re-bonded with her husband. “It’s also a positive way to expend energy and build friendships, which in turn, gives you more energy,” she said.

For anyone wanting to live a healthier lifestyle, Andrea offers this advice: “Today is tomorrow – there is no waiting until tomorrow. You have good days, and you have bad days, but you keep going, and you tell yourself, ‘I’m stronger today than I was yesterday’”.

Don’t smoke during pregnancy

Living with a smoker dims vision

Women who smoke during pregnancy have an increased risk of

Smoking causes biological changes in the eye that may

giving birth prematurely, and premature babies are more likely than other babies to have eye problems.

cause or worsen age-related macular degeneration, cataracts, retinopathy and other eye disorders.

Problems include strabismus (crossed eyes), retinopathy and under-development of the optic nerve, a major cause of blindness in children.

If you live with a smoker, take note: these changes can also occur from being exposed heavily to second-hand smoke for five years or longer.

[SOURCE: Troy Bedinghaus, O.D., “How does smoking affect your eyes?” About.com Vision, updated May 19, 2014]

[SOURCE: “Smoking and eye disease,” Action on Smoking and Health Fact Sheet, May, 2014]

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news briefs Employee Focus

Live, learn and work at MGH&FC

Kris Gaa, RN, clinical coordinator, has worked at MGH&FC for the past 19 years, the last 13 years in the Birth Center at MGH. “I started in the medical/surgical/pediatrics unit before moving to labor and delivery. I have also had the good fortune to be able to float to intensive care, house supervisor, and emergency,” said Kris. “I love working here because of the comradery of the staff. We are a tight-knit group who take care of each other – just like a family would.” She went on to say she has worked in larger hospitals where employees are not as valued as individuals, and care is not as patient-centric. “There are a lot of jobs out there for experienced nurses, but I wouldn’t want to work anywhere else.

I choose to stay at MGH because I love working here,” she added.

Practitioner Program at Samuel Merritt University, Oakland, CA in 2014.

With special interests in preventative care, chronic disease management, and rural health care, Hilary believes that establishing a trusting relationship with her patients is critical to providing effective health care. She also believes that educating her patients empowers them to play an important role in their own health care.

Women’s Clinic has Evening Hours

MGH Mountain View Women’s Health (MVWH) is open late on Wednesday evenings until 7 p.m. Daytime office hours are Monday through Thursday from 8 a.m. to 5 p.m., and 8 a.m. to 2 p.m. on Fridays.

MVWH is a full-service medical clinic that provides medical treatment for women of all ages with gynecological and obstetrical needs. To schedule an appointment call MVWH at (360) 426-0955.

“Employee of the Month” Congratulations to MGH&FC “Employee of the Month” for September – Darlene Hersh, health information management; and for October –Terri Gushee, R.N., house supervisor/chronic care case manager.

Welcome Hilary Walker, ARNP

We are proud to be a

Tobacco Free

facility. Please – no smoking or chewing tobacco on our campus.

Thank you!

Gift Shop offers new items MGHF’s Auxiliary Gift Shop at MGH is open for your gift-giving needs – or if you just want to spoil yourself! New location, new merchandise, new everything! Also for sale is Carolyn Maddux’s book, Care: A Hospital for Mason County.

Give via CFC Mason General Hospital Foundation (MGHF) has joined several other community-based organizations to be a part of the Combined Federal Campaign (CFC). Being a member of the CFC allows federal employees to utilize payroll deduction for their philanthropic contributions. For MGHF, this means that all federal employees who would like to donate to the Foundation via payroll deduction can now do so. To set this up, a federal employee needs to contact their payroll office and provide MGHF’s CFC #27211.

Classes & support groups

MGH Hoodsport Family Clinic and MGH Shelton Family Medicine, along with Mason General Hospital, welcome boardcertified Family Nurse Practitioner Hilary Walker, ARNP, to their medical staff. Hilary is splitting her practice time between Hoodsport Family Clinic and Shelton Family Medicine.

“Living Well with Diabetes” class in November

Originally from Bainbridge Island, Hilary completed her college education in California, obtaining her Bachelor of Science degree in Physiology and Neuroscience from the University of California in San Diego; and her Master’s degree in Nursing from the Family Nurse

The First Aid/CPR/AED course size is limited to 16 per class, and an early, nonrefundable registration fee of $35 (exact cash or check) is required to cover the cost of books and materials. It is open to the entire community and a Spanish interpreter can be made available upon request. Comfortable clothing is recommended.

When: Thursday evening, November 13 from 5 to 9 p.m.

Where: MGH&FC Learning Center, next to McDonald’s on Olympic Highway North.

Registration: Advanced registration is required by November 1 by calling the Learning Center at (360) 427-3609.

A two-day class in diabetes self-management. .

When: Tuesday and Wednesday, November 18 & 19, 12:30 - 4:30 p.m.

Where: Pershing and Ellinor Meeting Rooms at Mason General Hospital Registration: Advanced registration is required by calling Sue Barwick, R.N., C.D.E., at (360) 426-1611, ext. 28941 (from Allyn (360) 275-8614, ext. 28941) Note: There is a fee for this class, however, diabetes education is a covered service under most insurance plans.

First Aid/CPR/AED course in November

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community Fresh ways to use your HOPE Garden employs local students garden veggies

– Recipes courtesy of HOPE Garden

Sometimes veggies can be a little dry, so it can be nice to combine them with a little dip. Not only will the dip make your veggies taste great, but it will have the added benefit of some healthy protein and fat to make your snack a balanced and healthy choice – not to mention, tasting great! The first step is to get a bunch of great veggies together – celery, carrots, radishes, kohlrabi, broccoli, cauliflower – the possibilities are endless.

Sesame Noodles Recipe HOPE Garden Coordinators Cece Watkins and Rachel Uberman are shown here tending the garden. Not pictured is Delphina Liles, one of the three coordinators of the HOPE garden project.

In 2009 Mason General Hospital loaned a section of its property for use as a community garden to promote healthy living through a sustainable, organic diet. This later became a very successful learning tool for youth from local schools, employing students several hours a week to tend the garden, learn to cook the produce, and sell it at the Shelton Farmer’s Market. Named the HOPE Garden for Hands-On Personal Empowerment, in 2013 that pilot project qualified for a federal SNAP-Ed grant as an after-school and summer employment program for students from Choice Alternative High School in Shelton.

Now, HOPE’s mission of “Empowering Mason County youth to develop healthy lifestyles and make positive choices through access to gardening, good food, movement, and community” extends well beyond gardening and food preparation into other areas that include workshops in effective communication, dispute resolution, job skills, and even yoga.

“It has been a really wonderful first year for our program,” said Rachel Uberman, nutrition educator on the threemember staff who run the HOPE Garden project. “This summer, an increase to twenty CHOICE students were employed to maintain the garden, sell and use the produce, and build raised beds – causing a ripple effect of good eating, health, and community building”.

For the full HOPE Garden story, go online to http://hopegardenproject.org/about/ 8 S C O P E

This is a really great warm weather recipe. It is eaten cold with lots of fresh vegetables. It’s also a great recipe to make for dinner with plenty left over for lunch the next day – and maybe the day after that, too.

Ingredients: ¼ cup of balsamic vinegar 1/3 cup of olive oil 1 tablespoon of hot chili sauce or cayenne pepper 8 cups of mixed, cut up veggies such as radishes, carrots, peppers, or bean sprouts 1 package of buckwheat soba (Japanese-style noodles), vermicelli noodles, or angle hair pasta

1 cup of cilantro leaves 3 scallions, thinly sliced 3 tablespoons of sesame seeds 2-4 tablespoons of toasted sesame oil ¼ cup of honey ¼ cup of soy sauce Optional ¼ cup of tahini

Directions: 1. Boil enough water to cook the noodles. Once the noodles are cooked, rinse in cold water.

2. Cut all of the vegetable into small (matchstick sized) pieces.

3. Combine all of the sauce ingredients and whisk or blend together.

4. Combine all of the ingredients in a bowl and toss with the cilantro and sesame seeds.

5. Enjoy now, or put in the fridge for later.

Buckwheat is actually the seed of a flowering fruit that is related to rhubarb and sorrel. It’s completely gluten-free and unrelated to wheat and all the grasses in the wheat family. So it’s a popular wheat substitute for those who are gluten-intolerant. It’s also very high in nutrients, and has even more fiber than oatmeal.

Buckwheat is good for your cardiovascular system. This means your heart and blood vessels. It is a good source of magnesium. Magnesium relaxes you, is really good for your blood vessels, and is the mineral responsible for the relaxation of the muscles. There is also research to say that buckwheat is good for blood sugar control.

Hummus

Honey Mustard Dip

Miso Tahini Dressing

Ingredients 1 8 oz. can of chickpeas (garbanzo beans) ¼ cup of fresh lemon juice (about one large lemon) ¼ cup of tahini 1 clove of garlic, minced 2 tablespoons of olive oil, plus more for serving ½ to 1 teaspoon of salt, depending on taste ½ teaspoon of ground cumin 2–3 tablespoons of water Dash of paprika

Ingredients ½ cup of mayonnaise ¼ cup of honey ¼ cup of mustard Pepper

Ingredients ¼ cup of tahini 1 tablespoon of miso 1 tablespoon of lemon juice ¼ cup or more of warm water Pepper, if desired

Directions In a bowl, blender, or food processor, combine tahini and lemon juice.

Process for 1 minute. Scrape the sides down and process for 30 seconds more.

Add the olive oil, garlic, cumin, and salt.

Process for 30 seconds. Scrape the sides down again and process for 30 seconds more. Open the can of chickpeas and drain out the liquid. Rinse the beans with water. Now, add half of the chickpeas to the blended mixture.

Process for one minute. Scrape down the sides and add the other half of the chickpeas. Process for 1-2 more minutes.

At this point the hummus will probably be very thick so very slowly begin to add the water until you have the desired consistency. Drizzle about 1 tablespoon of olive oil over the top of the hummus and sprinkle with paprika. The hummus can be stored in an airtight container in the refrigerator for up to one week.

Directions In a small bowl, stir together all of the ingredients. Enjoy with veggies or on a sandwich.

Ranch Dressing Ingredients 1-2 cloves of garlic, minced Salt to taste ¼ cup of flat-leaf parsley or ½ teaspoon of dried parsley 2 tablespoons of chives or ½ teaspoon of dried chives ½ teaspoon of dried dill ¼ teaspoon of onion powder Black pepper 1 cup of mayonnaise ½ cup of sour cream Milk, as needed for consistency White vinegar to taste, optional Directions In a bowl or jar, combine all of the ingredients and whisk together. Cover and refrigerate for 30 minutes before serving.

Directions In a jar combine the tahini, miso, and lemon juice. Mix well either by stirring vigorously or shaking if you have a lid for the jar. Slowly add the warm water while stirring, until you have the desired consistency. This dressing will thicken in the fridge so you will need to add more water over time.

Chronic or severe wound?

Don’t suffer any longer.

Stay close to home when your physician refers you to MGH&FC Wound Care Services.

Call (360) 432-3285.

Radiation protects against recurrence When ductal carcinoma in situ (DCIS)

How to research & compare plans for yourself and your family.

is removed through breast-conserving surgery, recurrence of either DCIS or invasive cancer is common in the first five years after treatment. When radiotherapy is added to the regimen, the risk of recurrence rate is cut in half, according to a study presented at the 8th European Breast Cancer Conference [Vienna, Austria, 2012].

At MGH&FC, we want you to be well-covered. So before registering for a health plan, please contact Lee Ayers, project supervisor at MGH&FC at (360) 432-7766, or email him at layers@masongeneral.com.

The protective effect against DCIS recurrence can still be observed 15 years later, but protection from invasive cancer is mostly in the first five years.

For more information go to: www.masongeneral.com & click on Healthplanfinder.

[SOURCE: Roxanne Nelson, “Radiotherapy after DCIS offers long-term protection,” Medscape Medical News, March 27, 2012]

Washington Healthplanfinder

A part of the Affordable Healthcare Plan

SCOPE 9

giving MGH Foundation thanks its supporters for a very successful 2014 Quality Care Open Golf Tournament!

The Foundation would like to acknowledge the tremendous support of all the sponsors, golfers, and volunteers for their generosity and for making this event possible. This year the Tournament generated more than $79,000 in cash contributions and in-kind donations. Funds raised will go toward the purchase of a new Telemetry System for Mason General Hospital & Family of Clinics.

Sponsors Title Sponsor

Cerner Corporation

Co-Presenting Sponsor Verizon Wireless

Co-Presenting Sponsor

Manke Lumber Company

Women’s Prize Sponsor

Christmas Village Mfg. Home Community

Men’s Prize Sponsor Squaxin Island Tribe

Tee Pack Sponsor Falcon Financial, Inc.

Prize Sponsor

Dynamic Collectors, Inc.

Tent Sponsor Electrocom

Banner Sponsor

Taylor Shellfish Company

Awards Dinner Sponsor

Mt. St. Helen Evergreens

Million Dollar Shot Sponsor Hiawatha Corporation

1st Place Handicap Prize Sponsor

Hoffman Construction Company

Tournament Patron Sponsor

Washington Casualty Company

3rd Place Handicap Prize Sponsor

Healthcare Management Administrators

Registration/Brunch Sponsor Valic Financial Advisors, Inc. - Joliet Osborne

Hospitality Carts Sponsor

Network Hardware Resale 10 S C O P E

Program Sponsor Jack Charneski

Hole Sponsor(s) Level A Cerium Networks Direct Matters-Promo, Print Mail Edward Jones, Eric Thompson, Financial Advisor Gastroenterology Associates John L. Scott Real Estate Karen Schade, Financial Advisor, Edward Jones Les Schwab Tire Center- Shelton MacEwen for State House Olympic Mountain Millwork Omnicell Our Community Credit Union Peninsula Credit Union Robert W. Johnson, PLLC

Hole Sponsor(s) Level B

Brady Trucking Cellnetix Pathology & Laboratories Community Financial Center - Mark Mager D.R. Gardner, CPA, PS DeMiero Enterprize Fidelis Communications First American Title Company Green Diamond Resource Company Hackney Family Dentistry HealthStream Heritage Bank Hood Canal Communications Jimini Construction Joe L. Snyder and Andrea L. Huff, Attorney at Law 360-426-9100 McCarty & Associates, Inc. “a marketing firm” NR Smith and Associates, PS

Olympic Panel Prudential NW Real Estate - Shelton Shelton Chiropractic Center Shelton Health & Rehabilitation Center Shelton Rotary Skookum Rotary Club Sterile Surgical Systems Wittenberg, CPA, PS

Hole-In-One Sponsors

Arnold Smith Insurance Gillis Auto Center

Steering Committee John Cruse Steve DeMiero Keith Geary Tom Hornburg Kathy Howe Paul Johansson Drew MacEwen Jeff McHargue Jack Stark, Committee Chair

Volunteers

MGHF Golf Steering Committee LakeLand Village Golf Club Staff MGH&FC CNS Staff MGH&FC Maintenance Staff Brent Ames Blake Ask Janene Bandes Jan Vigdor Bob Brady

Kristy Buck Marta Buran Darryl Cleveland Peggy Cleveland Michelle Corral Herbert Gofigan Jon Hornburg Alice Johansson Chris Koch, Designated Driver Angela Lewis Bill Nielsen Penny Nielsen Jennifer Owens Sara Perrott Stacey Scoles Judy Stark Ann Williams Bob Williams Lisa Woodard Nancy Wright

In-Kind Donors

Adele DuPont Alderbrook Golf & Yacht Club Alderbrook Resort & Spa Amy Corley/Seattle Mariners Angle Agency Insurance Anytime Fitness Arnold Smith Insurance Ayers Automotive Batdorf & Bronson Billy & Michelle Corral Cary’s Tire and Repair CDW Healthcare CenturyLink Claudia Cruse Columbia Bank

Darryl & Peggy Cleveland Direct Matters Domino’s Pizza Eclectia - Stacey & Marta Fir Lane Health & Rehab Food Services of America Heritage Bank Hood Canal Communications Hoodsport Winery Horseshoe Lake Golf Course Hunter Farms Inland NW Health Services Jack in the Box Jeff McHargue Jenipher Wallace Thirty One Gift Bags Jeri DeMiero Judy Nicholson Kathy Howe Key Bank L&E Bottling Lake Cushman Golf Course LakeLand Village Golf Club Land Title Company Little Creek Casino & Resort Lucky Eagle Casino & Resort Mary Anne Munson Mason County Rodeo MGHF Auxiliary Gift Shop MGHF Board Members Mountain Mist OAC Services, Inc. Pier 101 Gift Shop & Women’s Boutique

Roosters Salish Cliffs Golf Course Scott & Karen Hilburn Seattle Mariners Shelton Cinemas Shelton Health & Rehabilitation Center Simpson Door Company Tanya & Mark Frazier The Shopper The Strip Steakhouse Tom Hornburg Tozier Bros.

Treasures Thrift Store Union Square Deli- Jaime Taylor Verle’s Sports Center & Marine Wal-Mart Walter Dacon Wines

2014 Winning Teams Handicap Team

1st: Hiawatha Team 2nd: Key Bank Team 3rd: Christmas Village Team 4th: Jack Stark Team

Gross Handicap Team Eisenbarth Team

Non Handicap Team

1st: Manke Team 2nd: Skanska Team 3rd: Dynamic Collectors Team 4th: Electrocom Team

Visit MyMasonHealth.org for more information. For enrollment questions or general patient portal questions, please email patientportal@masongeneral.com. For technical questions, please call (877) 621-8014 between 8 a.m. and 8 p.m. EST, Monday - Friday (except holidays).

Please

MGH Foundation contributors memorialized MGH Foundation would like to acknowledge former contributors. Listed below are supporters, now deceased, the Foundation would like to recognize for their past support of our mission and work in the community. Please join us in acknowledging their support of the Foundation during their lifetimes.

Tom Creekpaum Warren R. “Bud” Earl Roberta L. Garrick Dorothy Gornick Harry Hillier

Alex H. Kuhr Ernestine Nicklaus Mary Jane Sund Ted Strozyk

Honorary and Memorial contributions made to MGH Foundation Mason General Hospital Foundation has received generous donations in honor and/or memory of the individuals listed below. Donors and memorialized individuals listed in this report reflect contributions made to the Foundation between June 23 and August 11, 2014..

Anonymous In Honor of:­ Wayne & Rebecca Haesel’s marriage Denis & Adele’s marriage Ron & Gerrie Bourke In Memory of:­ Bud Earl Harold & Joan Hanson In Memory of:­ Doris Keller Roger & Linda Hoff In Memory of:­ Ciqala Miller Travis Story Dortha Willour

Edith Borgny Jaques In Memory of:­ Dr. Norman Jaques Gordon & Marilyn Keller In Memory of:­ Jack Granger Thomas Muller In Memory of:­ Dortha Willour SHS Class of 1965 In Memory of:­ Connie Ells Banner Gary & Kendra Warner In Honor of:­ Wayne & Rebecca Haesel’s marriage

Please be advised that every effort has been made to ensure the integrity of this listing. If we have inadvertently omitted any names, please accept our apologies and most sincere thanks for your generosity and continued support of MGH Foundation.

use the enclosed envelope to make your tax-deductible donation to help support MGH&FC. To make a secured donation online go to www.MasonGeneral.com.

Ways to give to health care through MGH Foundation Mason General Hospital Foundation is very grateful for the support it

receives from the community in gifts of time, talent, and treasure. Our volunteers and contributors make it possible for the Foundation to fulfill its mission to provide financial support to Mason General Hospital & Family of Clinics. There are a variety of ways that you can make a gift to the Foundation.

Online contributions Please visit MGH&FC’s website at www.MasonGeneral.com. Look for the Foundation’s logo on the left side of the page and a header that says “Support the Foundation for MGH&FC”. Then click on the yellow “Donate” button below the logo to make a secure, online contribution through Paypal.

You can learn more about our annual Fantasy Forest event and online ticket sales by visiting us on the web at www.MasonGeneral.com Our Mission Mason General Hospital Foundation furthers the mission of Public Hospital District No. 1 of Mason County by providing financial support to Mason General Hospital & Family of Clinics.

Freedom to

move!

Conquer pain, restore function... and return to your favorite activities. That’s the goal at MGH Shelton Orthopedics, where board eligible orthopedic surgeons are committed to quality care and positive outcomes. With a full range of orthopedic specialties, including sports medicine and joint restoration and replacement, Shelton Orthopedics works toward finding a solution that will get you moving again.

To make an appointment at MGH Shelton Orthopedics call (360) 427-0663.

(360) 427-0663 939 Mountain View Dr, Ste. 130 Shelton, WA 98584 www.MasonGeneral.com

S C O P E 11

Fantasy Forest 2014 – Wednesday, Nov. 19 thru Saturday, Nov. 22 – Event Preview

Ticket sales close Nov. 10 so make sure you get your tickets now!

A Benefit for Mason General Hospital & Family of Clinics A Christmas on the Canal Wednesday, November 19

Sneak Peek & Holiday Shopping Experience Take advantage of this opportunity in the evening to meander through the beautifully decorated grounds of the Alderbrook Resort & Spa, and be the first to see the wonderful decorated designer trees for this year’s MGHF’s annual Fantasy Forest celebration and fundraiser. Be sure and stop in and see what this year’s MGHF Specialty Gift Shop has to offer as well as the many holiday vendors that will be on site. It is sure to get you into the holiday spirit!

Doors open at 4 p.m. and ends by 8 p.m.

Alderbrook Resort & Spa. Don’t miss this popular event... remember tickets sell out fast so don’t delay.

Doors open at 10 a.m., Silent Auction at 10:30 -11:30 a.m., Seating at 11:30 a.m. Lunch served at 12 noon with Fashion Show to follow. Event concludes at 2:30 p.m. Emcee: MGHF Board member, Jeff McHargue.

Ticket price per person $55, table of 10 for $550. Reservations required.

Event elements to include: Tree Auction, Silent Auction and Fund-An-Item.

Father – Daughter Dance

Admission by donation at the door, suggested amount $5 per person.

This year, be sure to invite your little princess to accompany you on a magical evening of dancing the night away amongst all the shimmering lights of the Alderbrook Resort & Spa. Let this year’s Fantasy Forest create an unforgettable evening. Alderbrook Resort & Spa is offering special resort overnight stay rates.

Thursday, November 20 Fashion Show & Luncheon Fantasy Forest just wouldn’t be complete without the annual Fashion Show! By popular demand Pier 101 will be back again this year to dazzle you with their unique style and incredible selection of fashions. What better backdrop than the grounds of the amazing

Doors open at 5:30 p.m., meal service begins at 6:30 p.m., event ends at 10 p.m.

Ticket price per person $50, open seating. Reservations required.

Event elements to include: Guest speaker, Eric Moll, MGH&FC CEO; Silent Auction, Fund-An-Item, and Special Raffle.

Here’s a peek at some of the Live Auction items...

Six-hour private Puget Sound Cruise Enjoy a serene cruise on board a 39’ trawler for four people though the scenic waters of South Puget Sound.

Guests will enjoy snacks, beverages and a meal while aboard the Lady M. The winning bidder will be able to choose from several Puget Sound destinations identified by Captain Burt Auseth!

– Generously donated by Burt & Michele Auseth and Rick & Joan Hayes.

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Additional Live Auction items to include: A Luxury Resort Condo anywhere in the world Hartstine Island Cabin Getaway for two with a Champagne Brunch Central Mason Fire District #5 - Home Service Hours Package

Special thanks to the following Sponsors: Co-Gala Sponsors: Heritage Bank and Hiawatha Corporation Program and Advertising Sponsor: Christmas Village

Alderbrook Resort & Spa at night.

Alderbrook Resort & Spa is a destination resort.

Fantasy Forest Week Guest Room & Cottage Special Event Rates: $99 -$149, plus tax (Use block code: Fantasy Forest). Based on availability. For reservations call (360) 898-2145. Please reserve by October 21, 2014.

Friday, November 21 Business Lunch & Confections Auction

The holidays are just beginning, so treat yourself to an afternoon escape at Alderbrook Resort & Spa for a relaxing afternoon on beautiful Hood Canal, or better yet, bring the entire office. This year’s Fantasy Forest will certainly get you in the holiday spirit, with over-the-top sweets to bid on, as well as a few beautifully decorated designer trees.

Doors open at 11 a.m., lunch service at 11:30 a.m., Auction 12 noon – 1 p.m. Event ends at 1:30 p.m.

Check out starts at 1 p.m.

Ticket price per person $50, Table of 10 for $500. Reservations required.

Event elements to include: Dessert Auction, Tree Auction, and Fund-An-Item.

Wine Tasting – A Toast to All of Our Community Supporters This year’s wine tasting promises to be the best one yet... What could be more romantic than enjoying your favorite wine, with your favorite date and being surrounded by the enchanting décor of the Alderbrook Resort & Spa during the holiday season This is a time when MGHF will celebrate and recognize all of our community supporters for their involvement and support of our mission!

Why not spend the night and enjoy breakfast on the beautiful Hood Canal? Alderbrook Resort & Spa is offering special resort overnight stay rates.

Saturday, November 22 Candy Cane Carnival

Santa Claus is coming to Alderbrook Resort & Spa and he hopes that you and your family will stop by so he can get a head start on his Christmas list! This is a favorite of our youngest supporters so don’t forget to get your tickets early as space is limited.

Doors open at 9 a.m., event starts at 9:30 a.m. and ends by 11:30 a.m. $10 per person, soft seating only. Event is free for children ages 3 years old and younger. Reservations required.

Event elements to include: Special Envelope Appeal for Fund-An-Item.

Grand Gala & Auction Eighteen years and look how far we have come... Mason General Hospital Foundation’s 18th Annual Fundraiser Fantasy Forest.

Consider making this year’s Fantasy Forest a must on your “To Do” list.

What better way to kick off 2014’s season of giving than by attending an enchanting evening on the Hood Canal at the Alderbrook Resort & Spa. This is an opportunity to catch up with old friends, show your support for MGH&FC and make a difference this year that touches the entire community. No Host Bar. Black Tie Optional. Alderbrook Resort & Spa is offering special resort overnight stay rates.

Doors Open at 5 p.m., Cocktail Hour & Silent Auction 5:30 – 6:30 p.m., Gala Auction Program begins at 6:30 p.m.

Gala Tickets are $175 per person, table of 10 for $1,750. Reservations required.

Ticket price per person $60. Soft seating only. Reservations required.

Premiere tickets are $200 per person, table of 10 for $2,000. Premiere table includes a large oval table for 10 guests with guaranteed front row placement. Premiere seating is limited.

Event elements to include: Tree Auction, Fund-An-Item and much more!

After November 3 single ticket purchases to the Gala & Live Auction must be purchased by calling the Foundation office at 360-427-3623.

Doors open at 5 p.m., event starts at 5:30 p.m. and ends by 8 p.m.

Deadline for all ticket sales is Monday, November 10 Important seating notes: If you have a seating preference, please make a note to seller when checking out through PayPal regarding seat assignments or call Meghan Lucas at 360-427-3623.

Please direct all calls regarding ticket sales to Meghan Lucas. Tickets are transferrable with 72 hour notice. Tickets are not refundable.

S C O P E 13

giving Trust donates $25K for breast & cervical cancer

Without straining your eyes.

Take it all in…

Mason General Hospital Eye Clinic provides expert eye care using state-of-the-art technology for the diagnoses and treatment of eye problems and visual impairment. Optometrist Jenni Aaseby, O.D., is available for routine eye exams and prescription lenses, with a specialty in contact lens fitting

The Karen Hilburn Breast & Cervical Cancer Fund, a chapter of Mason General Hospital Foundation, was presented – for the fourth year in a row – with a check for $25,000 from the Charitable Trust of Margery Jones, a former Shelton resident and cancer survivor. Miss Jones left her estate to be donated to charitable non-profits. This is the fourth consecutive year the Hilburn Fund has been a major recipient. Over the last four years Miss Jones’ estate has donated a total of $95,000. “We are so grateful for their continued support of our Fund,” said Founder Karen Hilburn. “This donation helps Mason County women that are underinsured or uninsured with their diagnoses and treatment of breast and cervical cancer.” Pictured here with Mrs. Hilburn is Miss Jones’ niece, Betty Temple (right), who has made the donation every year in her aunt’s memory.

Board-certified Ophthalmologist and Eye Surgeon Monica Vuong, M.D., provides treatment for conditions such as cataracts, glaucoma, and macular degeneration; and surgeries of the eye and eyelid, including laser procedures.

A full-service eye clinic is close to where you live. For an appointment call (360) 426-8717.

(360) 426-8717 2300 Kati Court, Suite C Shelton, WA 98584 www.MasonGeneral.com

The Mason Vision We put patients first. We provide quality medical care to assist the individuals of our community to restore and preserve their health. We conserve patient and community resources through a sustainable, financially viable, coordinated system of health care delivery.

MGH Ankle & Foot (360) 427-0366 MGH Eye Clinic (360) 426-8717 MGH Family Health (360) 426-3862 MGH Hoodsport Family Clinic (360) 877-0372 MGH Mountain View Women’s Health (360) 426-0955

MGH Oakland Bay Pediatrics (360) 426-3102 MGH Olympic Physicians (360) 426-2500 MGH Shelton Family Medicine (360) 426-2653 MGH Shelton Orthopedics (360) 427-0663 MGH Surgery Clinic (360) 426-4142

Mason General Hospital • 901 Mountain View Drive, PO Box 1668, Shelton, WA 98584 • Shelton (360) 426-1611, from Allyn (360) 275-8614, Toll free (855) 880-3201 • www.MasonGeneral.com • Equal Opportunity Provider • Translation Services Provided / Se habla español • Approved by the Joint Commission • Healthcare’s Most Wired Hospital for seven consecutive years!

14 S C O P E

Our whole team...

focused on patients first.

hola Mason General Hospital y Familia de Clínicas celebran

El Mes Nacional de Concientización del Cáncer del Seno con lo Siguiente Gratis

Un Evento de Salud para Mujeres

Como investigar y comparar los planes para usted y su familia.

Sábado, 18 de octubre del 2014 • 8 de la mañana hasta el mediodía Entrada Principal (Sur) del hospital

 Servicios Nutricionales  Información Sobre la Salud Cardiaca

 Masajes breves  Pruebas de diabetes  Información sobre el virus del papiloma humano VPH

 Refrigerio saludable

Únase a la diversión y…

“Tome el Control de su Vida” Exámenes de mamografía digitales GRATIS...

Para las primeras 50 mujeres que califiquen y que o no tengan seguro de salud o que no tengan suficiente seguro. Para información llame al (360) 432-7706.

¿NECESITA SEGURO DE SALUD?

¿No puede venir – pero necesita ayuda para encontrar un plan de seguro de salud? Llame a Lee Ayers, supervisor de proyectos, al (360) 432-7766, o comuníquese por correo electrónico al layers@masongeneral.com.

Patrocinado por

Parte del Plan de Seguro Médico Asequible

Mason General Hospital y Familia de Clínicas Mason General Hospital, 901 Mountain View Drive, PO Box 1668, Shelton, WA 98584.

De Shelton (360) 426-1611, de Allyn (360) 275-8614. Sin cargo al (855) 880-3201 www.MasonGeneral.com • Se Ofrece Igualdad de Oportunidades • Servicios de Traducción Provistos. Se habla españo • Aprobado por la Comisión Conjunta del Cuidado de Salud •¡El Hospital Más Conectado Tecnológicamente durante siete años consecutivos!

a or ble Ah oni Accede a sus historialesCMYK por internet sp Di

Desde Cualquier Lugar con facilidad y conveniencia.

Para más información visite a MyMasonHealth.org. Para hacer preguntas acerca de la inscripción o para hacer preguntas generales con respecto al portal de pacientes, favor de enviar un correo electrónico al patientportal@masongeneral.com. Para hacer preguntas técnicas favor de llamar al (877) 621-8014 entre las 8 de la mañana y las 8 de la noche, Hora Estándar del Este, lunes - viernes (excepto las fiestas).

Para más información visite a: www.masongeneral.com y haga clic en Healthplanfinder.

Washington Healthplanfinder

CMYK

¡Su equipo para ayudarle!

En MGH&FC, queremos que usted tenga suficiente cobertura. Así que antes de registrase para un plan de salud, favor de comunicarse con Susana Lopez, Patient Accounts Office, al (360) 427-3635.

Haz Clic Aquí

Vivir con un fumador atenúa la visión

El fumar causa cambios biológicos en

el ojo que podrían causar o empeorar la degeneración macular, la que se relaciona con la edad; las cataratas, retinopatía y otros trastornos oculares.

Si usted vive con un fumador, cuidado: estos cambios también pueden ocurrir por estar expuesto pesadamente al humo de segunda mano durante cinco años o más.

[SOURCE: “Smoking and eye disease,” Action on Smoking and Health Fact Sheet, May, 2014] S C O P E 15

CMYK

ECRWSS POSTAL CUSTOMER

Shelton

We put patients first. We provide quality medical care to assist the individuals of our community to restore and preserve their health. We conserve patient and community resources through a sustainable, financially viable, coordinated system of health care delivery.

A Emergency Entrance B Main Entrance 1 MGH Mountain View Women’s Health 2 MGH Eye Clinic

3 MGH Shelton Family Medicine 4 MGH Shelton Orthopedics 5 MGH Ankle & Foot 6 MGH Family Health

Ticket sales end Nov. 10

Benefit for Mason General Hospital & Family of Clinics

Purchase your tickets online at www.MasonGeneral.com.

119 Lake Cushman Rd

10

N

Tickets on Sale NOW!

Reserve your guest room or cottage at the Alderbrook Resort & Spa for the week of Fantasy Forest – Nov. 19 through 22 – by Tuesday, Oct 21 to receive the special rate.

To make a reservation call (360) 898-2145 and for the special rate, use code: Fantasy Forest.

Hoodsport

CMYK

101

lton

Published by: Mason General Hospital & Family of Clinics. Published six times per year.

Editor: McCarty & Associates, Inc. “a marketing firm”.

Business Office: Office hours: 8 a.m. – 5:30 p.m., Monday – Friday. Spanish Translator Available.

CMYK Located at Gateway Center, 2505 Olympic Hwy N., Suite 460, (360) 427-9547 Mason General Hospital: Visiting hours: 8 a.m. – 8:30 p.m., daily. Intensive Care Unit (ICU) visiting hours: special hours on a patient-by-patient basis, call for Unit hours. Located at: 901 Mtn. View Drive, PO Box 1668, Shelton, WA 98584-5001, (360) 426-1611, from Allyn (360) 275-8614, Toll free (855) 8803201. Serving the medical needs of Mason County since 1968. Accredited by The Joint Commission.

Translation Services Provided. Se habla español. Equal Opportunity Provider.

Administration: Eric Moll, chief executive officer; Micheal Keep, M.D., chief of staff; Don Wilson, commissioner/president; Nancy Trucksess and Scott Hilburn, commissioners.

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The Mason Vision:

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901 Mountain View Drive Shelton, WA 98584

NON-PROFIT ORGANIZATION U.S. POSTAGE PAID OLYMPIA, WA PERMIT NO 78

7 MGH Surgery Clinic 8 MGH Oakland Bay Pediatrics 9 MGH Olympic Physicians 10 MGH Hoodsport Family Clinic