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2011 Lifetime Award Recipient

Dr. James Morrissey Summer Issue 2011 SUMMER 2011



The San Joaquin Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000! Now is the time to take a good look at the SJMS/CMA plan if:

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*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 51518 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • •


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Volume 59, Number 3 • June 2011


22 38 51 56 SUMMER 2011


2011 Lifetime Achievement Recipient


A new member benefit debuts

28 IN THe NeWS

New Faces and Announcements


2011 Young Physician Recipient

DeDICATeD CARegIVeR Doreen Bestolarides, RN


A Trusted Friend and Advocate

34 PRACTICe TOOL: Handling Email


Disaster Preparedness

62 THe TIC:

A Memoir by Moris Senegor



Helping doctors treat and patients heal. The Advanced Imaging Center

James Halderman, MD President

at Lodi Memorial Hospital offers Board certified radiologists, comprehensive diagnostic services, and a convenient location for patients.

George Khoury, MD President-Elect Lawrence R. Frank, MD Past-President Thomas McKenzie, MD Secretary-Treasurer Board Members

High Field MRI Breast MRI Digital X-ray (walk-ins welcome)

Shiraz Buhari, MD Ramin Manshadi, MD Javad Jamshidi, MD

Moses Elam, MD Wendi J. Dick, MD Raissa Hill, DO

Trinh Vu, MD James J. Scillian, MD Kristin M. Bennett, MD

Medical Society Staff Michael Steenburgh Executive Director Debbie Pope Office Coordinator Gena Welch Membership Coordinator

(209) 333-7422 Frank M. Hartwick, M.D. Majid Majidian, M.D. R. Brandon Rankin III, M.D. Grant W. Rogero, M.D. Roger P. Vincent, M.D.

Committee Chairpersons MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations to be appointed

Communications Moris Senegor, MD

Legislative Jasbir Gill, MD

Community Relations Joseph Serra, MD

Audit & Finance Marvin Primack, MD

Member Benefits Jasbir Gill, MD

Nominating Hosahalli Padmesh, MD

Membership to be appointed

Public Health Karen Furst, MD

Scholarship Loan Fund Eric Chapa, MD

NORCAP Council Thomas McKenzie, MD CMA House of Delegates Representatives Robin Wong, MD Patricia Hatton, MD

Lawrence R. Frank, MD James J. Scillian, MD Roland Hart, MD

James R. Halderman, MD Peter Oliver, MD

CMA House of Delegates Representatives - Alternates Kwabena Adubofour, MD



Gabriel K. Tanson, MD

Ramin Manshadi, MD SUMMER 2011

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MeSSAge > executive Director MeSSAge > executive Director

Cause forwe are “A Individually, one drop, but together Celebration! we are an ocean.”

What a great time of year June is! The heat of summer is rising and pulling us out of the office more (hopefully) and giving us more reasons to be thankful we live in such a wonderful area as the central valley. Another wonderful thing about June is we take an evening to gather and honor very special people here at the medical society in the form of our Lifetime Achievement and Young Physician Awards. is year’s honorees numerousSan nominations from Medical our membership Those wordsTh were spoken by Dr.received Susan Kaweski, Diego County Society’swhich new speaks well of the respect they receive from their fellow peers. Up until the time I met with Jim Morrissey, president during her recent installation ceremony. She further stated, “and united we must be, our LTA recipient and noted cardio-thoracic surgeon to photograph him for this magazine profile, I can especially in these tumultuous times” to which I couldn’t agree more. These are difficult times honestly say we had only briefly met. Having now had the opportunity to spend an entire morning for physicians and the medical community as a whole. Far-reaching changes are happening with him, I can say I was equally at a break-neck pace in Washington, D.C., and at our own state capital. As Dr. Kaweski so impressed with his humble demeanor, eloquently states, we need solidarity amongst our ranks like never before. One voice may be quick wit and wonderful story telling ignored and no one notices, but when a chorus sings in harmony – it’sIprett y hard to not take4 hours EXCLUSIVE MEMBER BENEFIT ability. learned much in those notice. about the life of a physician and his deep commitment to his profession and Membership is often perceived as a non-essential cost of doinghis business. Something youyou sign community. I believe will find up for out of habit or peer pressure. Some see it as a duty, havinghisjoined early interesting in their medical story quite and a great career and never taken the opportunity to become more involved seek any of on ourpage services reador(check it out 22). and so sadly, never truly see the value of membership because theirDr. own is skewed Jeffperception rey Ing, a local secondtowards it being something of little or no value. Nothing couldgeneration be further Ophthalmologist from the truth. and our YoungaPhysician Award Membership not only provides you extensive personal benefits,2011 but opens wide array of winner is equally fascinating person. Devoted services to your practice managers and staff as a whole. Beyondanthat, we could fill several pages to his faith, family and serving others, his with the extensive list of services CMA provides as well. story is nothing short of inspiring and worthy of our recognition. Check To truly appreciate membership, you have to experience it or atsoleast appreciate the extensive out his story on page 38. lobbying taking place every day on your behalf in both Sacramento and D.C. For those to this year’s Annual members who have had to call us and request assistance with a Unique collection, billing, coding, Membership Dinner, we will also be contract or personnel issue, membership value is easy to comprehend and seldom enters honoring local Attorney Don Riggio, a very special member of our community and a loyal friend to their thoughts after help has been rendered. For those that have attended our annual House many of our physician members. Don was instrumental in forming our medical review committee of Delegates or yearly visit to the capital for Legislative Day, value is again securely reinforced decades ago and has represented countless physicians over the years with the highest level of integrity because they see first-hand impact our recaps unifiedhis voice hasforinus these arenas and professionalism. Dr.the Moris Senegor career on page 56.of thought. And lastly, I wish to draw your attention to a very unique membership benefit we are launching this My month hope is–you have had theThopportunity to seeapp first-hand value of your membership DocBookMD. is unique iPhone containsthe information on every one of ourand members feel and positive contribution making in the future of medicine by being a part manyabout otherthe resources as well. you’re And due to a complete sponsorship by Norcal Mutual, it’sofentirely something biggerRead thanmore yourself. Possibly even free to allmuch members! about it on page ocean.

All the Best! All the Best!

Mike Steenburgh Executive Director Mike Steenburgh Executive Director


Moris Senegor, MD Moris Senegor, EditorMD Editor editorial Committee Editorial MorisCommitt Senegor, ee MD Shiraz Buhari, MD MD Kwabena Adubofour, KwabenaMike Adubofour, MD Steenburgh Robin Wong, MD Michael Steenburgh William West Managing Editor Managing Editor Sherry roberts Creative Director Michael Steenburgh Contributing Editor Contributing Writers Sherry Roberts Carmen Spradley Creative Director/Graphic Designer Cheryl England Tom Gehring William West Contributing Sources California Medical Association Contributing Sources California Medical Association Los Angeles County Medical Association Los Angeles County MedicalMedical Association San Diego County Society San Diego County Medical Society The San Joaquin Physician magazine is published quarterly by themagazine Th e San Joaquin Physician San isJoaquin Medical Society published quarterly by the San Joaquin Medical Society Suggestions, story ideas or completed stories Suggestions, story ideas or writtcompleted en by current stories San Joaquin Medical Society writt en by current members San Joaquin Medical Society are welcome and members will be reviewed by the Editorial Committ are welcome and will be ee. reviewed by the Editorial Committee. Please direct all inquiries and submissions Please direct all to: inquiries and submissions to: San Joaquin Physician Magazine 3031 March Lane, Suite 222W SanW.Joaquin Physician Magazine Stockton, CA 95219 3031 W. March Lane, Suite 222W Phone: 209-952-5299 Stockton, CA 95219 Fax: 209-952-5298 Phone: 209-952-5299 Email Address: Fax: 209-952-5298 Email Address: Medical Society Office Hours: Monday Friday Medical through Society Offi ce Hours: 8:00 AM to 5:00 PMFriday Monday through 8:00 AM to 5:00 PM

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From The President < MeSSAge

Contracts, Call Schedules, Good Samaritans, and EMTALA. How can our “duty to treat” affect the way we practice medicine?

It seems like a simple question that would have a simple answer. After all, we ponder with the most common scenarios of this “duty” almost every day; especially doctors who work in emergency rooms. We have all heard of the usual ways that we can run afoul of this duty. We do not turn away our patients with whom we have an established relationship unless another doctor is available to take over their care. We also do not turn them away unless they make themselves impossible to treat. There are many ways to get into trouble if one is not aware of the laws. Here are a few of them. The San Joaquin Medical Society can help doctors access resources to keep themselves on the straight and narrow.

Contracts What about contracts? How can that be a problem? We understand our duty but we do not always know where it lurks. More than a few doctors have been surprised to learn


that when they signed on the dotted line with a healthcare insurer that they also consented to participate in other networks that are included under that HMO or IPA. That secondary pool may be poorly compensated or include hospitals where the doctor is not privileged to work. The burden of knowing about these shadow patient pools is on us; and this can cause liability. What if the healthcare insurer goes out of business? Then we do not get paid above and beyond the co-pay but we still have a duty to the patient. The best advice is buyer beware when we sign up to become a provider. California is what is known as a “corporate bar state”. A doctor can only be self-employed or be employed by another doctor or a group of doctors. In other states, however, many doctors have sold their practices to hospitals for various reasons. What if the hospital commands its physician employee to breach the duty to treat in some

What if the healthcare insurer goes out of business? Then we do not get paid above and beyond the co-pay but we still have a duty to the patient. The best advice is buyer beware when we sign up to become a provider.

ABOUT THE AUTHOR – Dr. James Halderman is President of the San Joaquin Medical Society and practices at Sutter Tracy Community Hospital as an Anesthesiologist.



Message > From The President

way in order to save money? Who is going to take the ethical hit with the authorities? You guessed right if you thought that it is the doctor’s problem. This is exactly the opposite of what would normally happen in an employeremployee relationship. As “learned professionals” we have a special ethical duty that supersedes our duty to an employer.

Call Schedules Dr. John Bonner of Fresno says, ”In my day, if the hospital called, I went in. It didn’t matter if my name was not on the board in the ER that day.” What an admirable work ethic! He implied two principles in that statement. First, is the expectation by the public that we will never leave them in jeopardy. Second, is the very fact that if a

doctor’s name is not “on the board” then there is no duty to treat a stranger because there is no prior existing doctor-patient relationship. The people at large are not well aware of this legal principle and are surprised when they learn about it. Litigation has been brought against doctors who refuse to oblige a plea for help from a stranger, but the precedent is well established in numerous courts of law.   Many doctors no longer take call at the hospitals where they are privileged. Those who do take call usually work in the essential cardiac and surgical fields and demand compensation for their commitment. The reason is that hospitals in the United States also have a legal duty. That is the “duty to provide” doctors for the patients that show

”In my day, if the hospital called, I went in. It didn’t matter if my name was not on the board in the ER that day.” - Dr. John Bonner of Fresno

up in their emergency rooms. If a doctor signs on to cover the ER then he will also have to sign off to avoid breaching his “duty to treat” if he desires to leave ER coverage. This lack of exuberant desire to cover the emergency rooms on the part of our doctors has gone noticed by the public and the politicians. There are already grumblings circulating in the newspapers over this limited access. Policy makers in various government agencies are already exploring ways to mandate pro-bono work by physicians as a condition of licensure. The States of Maryland and South Carolina have even gone to such degrees as exploring the possibility of conscripting their licensees into a quasi state-run medical corps to ease the access problem; and amazingly without providing financial compensation for probono services rendered. Some doctors take pause when they consider applying for a license in these states.

Good Samaritans Just when you thought it was safe to go outside, you find someone hurt who needs medical attention. That means your medical



attention. Every state has some sort of legislation in place that was meant to encourage doctors and other healthcare experts to render aid and comfort to sick or injured persons. The fear of subsequent litigation frightens away the good Samaritans. For the most part these laws work as intended and work well. However, there are pitfalls. The Good Samaritan cannot be compensated for his service in any way whatsoever. To accept compensation implies a doctor-patient contract. A medical expert cannot deviate from accepted practice other than simply lacking possession of the tools of his specialty. Lastly, and obviously, no one can act recklessly or negligently while attempting to render aid.   Is the matter as simple as it appears? Not quite so. Some jurisdictions, including one in the State of California, have ruled that rendering medical aid is certainly protected by the law. However, they have also ruled that performing other acts, such as moving a victim from one place to another, in order to facilitate the aid constitutes a separate act that is not considered medical aid and is not protected by the Good Samaritan law.



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Message > From The President

Fortunately, these legal flaws can be remedied with new legislation. However, we are running up against vested interests among the victims’ advocates who have no desire to see potential liability eradicated.   There is another little known element connected to this Good Samaritan legal principle. In almost every nation in Europe and North America, there exists the “duty to rescue” principle. We can think of it as the Good Samaritan law swinging its door in the opposite direction. Where there is a protected opportunity to render aid, there simultaneously exists a mandated responsibility to rescue a victim in need. This principle dates back all the way to Ancient Greece. In a few states, such as Ohio, if a licensed medical expert happens upon a




victim in need, then there is a regulatory requirement to render as much skilled aid as possible until more definitive treating personnel arrive on the scene. Many of us would stop and do so anyway. It is important to understand that if a medical expert were to find a victim in need and abscond without rendering aid or at least notifying the authorities, then that person might receive a public sanction upon his license if his dereliction is discovered. In many states, such as California, and in every non-English speaking nation in Europe, the duty to report is a matter of law and steep fines can be imposed anyone who fails to report or call 911.

EMTALA Last, but certainly not least, is a word about



opportunity to render aid, there simultaneously exists a mandated responsibility to rescue a victim in need. ” - Dr. James Halderman



the Emergency Medical Treatment and Active Labor Act. About thirty years ago a sizable number of voters and politicians decided that it was unethical to turn away any patient in need who could not pay. The unfortunate situation had always existed in hospitals since the beginning of time when charitable funds ran low. Now, though, a national legislative measure was created that compelled hospitals to board any patient in need and locate a doctor for that patient whom appeared in the emergency department. The laudable intent of this measure was successful in preventing the dumping of patients from one hospital to another (or to nowhere) when the original facility could have provided the care. However, there are unintended consequences. When hospitals must provide care, someone somewhere must pay for that care. The cost is shifted to patients who have money. Doctors charge more for call stipends because their services are now not only needed, but they are required. Costs of medical care go up.   There is a perverse incentive that few in government are willing to admit publicly. With EMTALA there is the incentive for patients with

sufficient money to forgo medical insurance because they know that they cannot be turned away from the hospital. They believe, as do some politicians, that if they show up in the emergency room, that someone will be there to see them. That is true to a certain point. There is a doctor in the ER, but he is probably not a specialist. What if the patient needs a specialist? Most specialists do not take call anymore because of the increasing number of patients who lack insurance and refuse to pay what they can afford. Thanks to the prohibition on balanced billing in California, they do not have to pay either. Even if the patient wishes to pay for a balance, it is against the law for the doctor to collect it. This is a losing proposition for everyone.   Such is the world of over-regulated medical care. When all parties involved have something to gain, great principles can sometimes be advanced. When one party tweaks the law in order to gain an advantage within the system, the sacred trust between the doctor and the patient breaks down and away with that goes the sense of “duty to treat.”





Message > From The Editor

Principal Of Uncertainty, Beyond Physics ”Heisenberg’s principle of uncertainty applies to social situations.” In an age when all doctors are being placed under increasing scrutiny by numerous entities, hospitals, payors, and internet raters, to mention a few, the Heisenberg principle becomes a sobering concept. The more doctors are scrutinized, the more they are likely to change in reaction.

ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.



Say what? Revelations come in unexpected moments. This one happened on I-5 travelling between County Hospital and St. Jo’s while I was making rounds. Werner Heisenberg was a Nobel Prize winning physicist whose famous theory had already broken beyond the boundaries of quantum mechanics, becoming the symbol of an era. Some refer to the 20th century as the “age of uncertainty”. In fact the composer Leonard Bernstein created a symphony by that very same name, ostensibly referring to this troubled century. But the author I was listening to on an audio book in my car, was writing about the Columbine School massacre of 1999. How on earth could quantum mechanics apply to the sociology of a traumatized community in the aftermath of a bloodbath?   Heisenberg was researching subatomic particles when he proclaimed that the very act of studying the likes of electrons,

protons etc. alters them. The means used to observe their behavior, such as X-ray beams, impart energy into them and change their “natural” state. The particles, as they appear to the observer, are in a different state, one influenced by the observer. The latter can never know what their “natural” state is with certainty. The author Dave Cullen, writing about Columbine, points out that sociologists have discovered that the same phenomenon applies to groups of people.   Columbine was an event that shocked the nation, provoking intense media scrutiny directed at the school and the town of Littleton, an affluent suburban community outside of Denver. Since the killers, two seniors in the same school, committed suicide and could not explain their motives, numerous hasty theories were advanced by the media, some within hours of the tragedy, as to why they did it. Some of you may remember these: the killers


were avenging bullies who had tormented them; they were of being observed. It is only in this way that the entertainer “Goths”; they were gay outcasts; they belonged to a group can escape the predicament of Heisenberg’s particles. But is of outsiders known as the “trench-coat mafia” who became that really so? Doesn’t the very process of creating a “zone” murderous in reaction to their ostracization. These have all alter the nature of the act? Does anyone truly know, what the turned out wrong over the ensuing decade as sealed police “natural” performance of a Yo-Yo Ma or Itzhak Perlman is? records were gradually released. Dave Cullen’s revelation then took me to another situation   It is no surprise that TV and print media presented wild, I know well, and I suspect so do my readers. It is a doctor unsubstantiated theories as fact. It happens all the time. under scrutiny. Having spent over a decade in medical staff What Dave Cullen found peculiar was the frequency with leadership I have seen doctors in such situations, sometimes which countless witnesses, under my own watchful eye. At locals who lived in the other times I have been on community, validated these the other side of the fence theories, and thus appeared being observed. I thus have a to accept what was reported first- hand knowledge that the Columbine was an event that as reality. Previously a quiet, situation breeds anxiety and shocked the nation, provoking quintessentially “Middle focuses a doctor’s attention on intense media scrutiny America” school, under the the entity under observation. directed at the school and the powerful limelight of the Of all the details in a practice media “Columbine came that require attention, the one town of Littleton, an affluent to embody everything under study all of a sudden suburban community outside noxious about adolescent looms high above others like of Denver. - Senegor America.”, says Dave Cullen, a mountain to surmount, unjustifiably so. When always there. The doctor stating that Heisenberg’s worries about how to make uncertainty principle applied this activity look good, how to this community, Cullen to put proper make-up on it, was referring to the intense media examination of Littleton how to manipulate the process so that it appears favorable to which resulted in a rapid change in the community’s image, outside observers. Depending upon their personalities and not to mention its own self-perception. “Heisenberg’s what I call their “professional ego strength”, different doctors uncertainty principle had played out in full force….Littleton deal with such situations differently. Some get defensive or was observed beyond all recognition”, concludes Cullen. appear hurt by lengthy inspections. Others act like they are   My first reaction to this revelation that observation can hiding things, or conversely they lash out at the observer change a subject was to recall a personal experience. I started thinking that the best defense is a good offense. Yet others taking piano lessons at age 42, and continued for about 8 stay quiet and explore the margins of honesty in the way they years despite being obviously inept at it. In the process I engage the clinical activity under study, sometimes straying discovered that there was a difference between rehearsing to the other side. a piece versus playing it to an audience. In rehearsal I   From the standpoint of the observer , the activity is no was more or less, in a “natural” state, unobserved. Those longer in its “resting state”. Once target doctors are aware of who heard me didn’t care, for they were not an audience. the spotlight aimed at them, they alter the way they behave in They went about their business as usual. I played my daily the clinical setting being studied. In an age when all doctors rehearsals with no pressure, no performance anxiety. But are being placed under increasing scrutiny by numerous give me any audience, even one person, and a piece that I entities, hospitals, payors , and internet raters, to mention a thought I was good at came out poor on performance. In few, the Heisenberg principle becomes a sobering concept. that situation I was more concerned with how I was being The more doctors are scrutinized, the more they are likely to perceived, and the resultant apprehension altered my change in reaction. presentation. In this way I discovered what most seasoned   The principle applies even more to medical institutions. performers know well, namely that one has to be in a certain Currently there is an ever expanding effort to define and “zone” while performing in front of an audience, a “zone” observe quality in medical services, usually aimed at large that psychologically insulates the performer from the fear entities such as hospitals, medical groups and other such




Message > From The Editor

providers. I have in the past gone on record with my view transparency between institutions, so patients can make that no matter how objectively one aims to define quality, more knowledgeable choices, as they do buying cars or the matter remains subjective and susceptible to error, not to other consumer goods. However, financial consequences mention manipulation. Dave Cullen’s revelation about the attached to report cards, favorable or adverse, are around uncertainty principle strengthens this opinion. the corner, and these will raise the stakes for the institutions Anyone who has served in a hospital quality committee involved. One can safely bet that some organizations knows that at a large institution, the process of responding will engage in dishonest practices in attempts to appear to scrutiny is a well planned, well beurocratized endeavor better. Their likelihood of crossing the line is likely to be involving a team, “a “quality proportional to their profit team” (doesn’t that sound motive. Therefore, for profit just wonderful), which organizations and publicly aims at manipulating traded companies are more My other problem with intense the process at all stages at risk of succumbing to the outside scrutiny of large medical of its life, with the goal temptation. of making it look good   Such shady institutions is the impetus it provides to outsiders. Take manipulations of the system for dishonesty, especially if it results in congestive heart failure are already occurring in reimbursement changes . - Senegor or pneumonia, the Medicare coding, with treatments of which various forms of “upcoding” have been targets of to increase reimbursement, quality analysis since some strikingly absurd, the inception of the trend. repeatedly in the news. A small army of hospital employees go around reviewing Recently the San Francisco Chronicle expressed surprise charts, talking to physicians and ancillary staff, and leaving at the high incidence of starvation being reported in certain forms in medical records to be filled related to these entities. California counties, some as affluent as Huntington Beach. It They thereby heighten awareness of the issue among all, and turns out each one of these locales has a hospital belonging inject a sense of purpose, of urgency, to the need to appear to the same for-profit chain which has been upcoding what good under scrutiny in “report cards” related to CHF and I presume to be patients with low BMI’s into exaggerated pneumonia. Statistics are then compiled by another element “starvation” categories that draw better reimbursement. They of the same army and fed back to everyone involved. Thus an even billed Medicare for kwashiorkor, an African pediatric endless cycle is created, aiming to improve the activity under starvation variant, with surprising frequency. You can safely scrutiny. Does all this alter the “natural” way in which CHF bet that such abuses will rapidly cross over into the area of or pneumonia are approached by that hospital? You bet! quality statistics if financial screws are applied to institutional My big problem with this process is not the attempt to providers in concert with their report cards. Translated to improve performance in the entity being studied. It is the my paradigm, outside scrutiny with financial consequences inevitable consequence that many other clinical activities not would result in more energetic Heisenberg responses in under scrutiny will be ignored. After all, hospitals and other target entities. large organizations have limited budgets and personnel. If   Dave Cullen’s book “Columbine” contains a strong they devote their resources to a handful of treatments preindictment of the national news media for the way they designated for careful outside scrutiny, i.e. if they allocate altered Littleton and its high school. He makes the case substantial energy to mount a Heisenberg response to that this was undeserved. Do we as physicians, and the what’s being observed, one can reasonably conclude that institutions we associate with deserve the same treatment there won’t be much left over to provide “natural” quality from numerous outside entities scrutinizing us? Is our improvement in entities not under observation; and these, reactive change to such observations justified? In the case despite current trends, vastly outnumber those scrutinized. of the observers one can be certain that entities which My other problem with intense outside scrutiny of large engage in holier-than-thou ventures, be it the media, Federal medical institutions is the impetus it provides for dishonesty, Government, or medical payors, never doubt their missions. especially if it results in reimbursement changes . Currently As for us, our behavior, natural as it seems in light of the most “report cards” are being issued to create comparable Heisenberg revelation, remains morally murky.




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A revolutionary communication tool for SJMS physicians Communication between physicians can be inefficient at times and patient care can be delayed, resulting in frustration for everyone. These frustrations, however, may be shortlived. Two physicians from Texas have created a tool to help solve these communication delays — DocBookMD and now every member of San Joaquin Medical Society has free access to it. “We wanted to change the way physicians communicate. We wanted to make it easier, more efficient, and more secure,” says orthopedic surgeon and DocBookMD co-founder Tim Gueramy, MD. “We created a program that will allow physicians to talk to one another with new technology.” Dr. Gueramy created DocBookMD with his wife, family physician Tracey Haas. DocBookMD is a physicians-only iPhone app that allows physicians to: • send HIPAA-compliant text messages and photos; • assign an urgency setting to outgoing text messages; • search a local pharmacy directory; and • search the San Joaquin Medical Society directory “DocBookMD allows you to look up another doctor at the point of care. You can then either call the physician or send a text message with room numbers, medical record numbers, even pictures of wounds and x-rays. And all of this is sent securely and in a way that meets HIPAA requirements,” says Dr. Gueramy.


  The DocBookMD app is now available to every San Joaquin Medical Society member free of charge due to the sponsorship of DocBookMD by Norcal Mutual Insurance. Only physicians who are members of the society can access DocBookMD, and the app is currently only available for Apple’s iPhone. An Android version is expected in the summer or fall of 2011. Messages can then be sent using the app’s messaging priority system. Physicians can assign each message a 5-minute, 15-minute, or normal response time. “If the recipient does not answer the message within 5 minutes or if the message does not get to the doctor, you will then get a message back stating that it did not make it,” says Dr. Gueramy. “You can see and hear that the message you receive is different from any other text.” Using the DocBookMD directory, physicians can look up other physicians in their county society by first or last name or by specialty. Physicians can then contact other physicians by messaging, office phone, cell phone, or email. The pharmacy directory allows physicians to search for a local pharmacy alphabetically or find a pharmacy by zip code. Users can also create a “favorites” list of physicians or pharmacies that they contact most frequently. To register or for more information on DocBookMD, please visit www. or call the San Joaquin Medical Society for more information.


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n, CA 95219 rch Ln, Stockto nter, 3120 W Ma Ce ch ar 49 se 22 Re 2. Therapeutic 40, FAX: 209.47 TEL: 209.472.22 TherapeuticRese SUMMER 2011

SJMS Is Proud to Announce an Exclusive Benefit for Its Membership – Prescriber’s Letter Online, Mobile Access, and 25+ hours of CME... Dear SJMS member,

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And now I am so pleased it is a reality. Not only that, but we were able to get our members the highest level of service Prescriber’s Letter offers – its VIP Member level. VIP stands for “Very Informed Prescriber” and that speaks volumes about the special nature of this member benefit. Other physicians throughout the nation pay $250 for this service, and it is now included in your SJMS membership, at no additional fee to you.

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Some experts are backpedaling on aspirin • Take CME-in-the-letter CME-in -i -the-letter -in Some experts are backpedaling on aspirin • View your CME history to prevent heart disease. • View your CME history to prevent heart disease. We know that aspirin is beneficial for SECONDARY that aspirin prevent is beneficial for Colleagues Interact We know • Read Messages recurrent cardiovascular events.... read Colleagues Interact SECONDARY prevent • Start a Discussion more... • Read Messages recurrent cardiovascular events.... read Table of Contents of Current Issue • Account Start a Discussion Manage My Previous Issue more... • View/Change My Information Table of Contents of Current Issue • Change Email Notifications Search Issue Manage My Account Previous • Simple New Drugs• View/Change My Information • Browse • List of New Drugs • Change Email Notifications • Advanced Search

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You now get online access to each and every Prescriber’s Letter drug therapy recommendation as soon as they are posted. You also get all the evidencebased details behind each recommendation, and other practice tools such as the PL Drug Formulary Comparison tools, PL Patient Handouts in English and Spanish, Treatment Guidelines, and all the other PL Detail-Documents. You can access all of this on your computer, or mobile device of your choosing, including iPhones and Android phones. We were also able to reserve every SJMS member a space on the monthly webinars where the Prescriber’s Letter Editorial Board deliberates and decides upon the Recommendations to be published. Plus, if your schedule does not allow you to listen to these sessions when they are offered live, you will have access to listen to the archived recorded sessions whenever you want. Through this new arrangement with Prescriber’s Letter, your SJMS membership now includes more than 25 CME credits per year at no fee to you. You can get these CME credits from reading the Recommendations – from getting your clinical questions answered online at the Prescriber’s Letter website – and by participating in the live webinars or listening to the recorded webinars. To begin taking advantage of this members-only benefit, visit our website at and click on the Prescriber’s Letter logo located on our homepage, or you can just call our office (209-952-5299) and we’ll handle the entire subscription process for you. All the Best!

Mike Steenburgh Executive Director SUMMER 2011

Prescriber’s Letter Is Now a Member Benefit of the



The Achievement of a Lifetime:

Dr. James D. Morrissey If you were a stranger to town, and you just happened to notice the tall, mature man in a long white lab coat as he crossed California Street, you might say to yourself: “Ah, he must be a doctor.” And you would pride yourself on your detective skills, having noted the gleaming white facade of St. Joseph’s Medical Center raised behind him, and his attire; you might note his friendly demeanor, having caught a flash of a quick smile as he strides past you, disappearing into a medical building on the other side.





nd you would be right, for this man is Dr. James Dell Morrissey, “Jim” to his many friends, family and colleagues. He is the Chief of Cardiothoracic

Surgery at St. Joseph’s Medical Center, and the founding engine of the hospital’s cardiac program for the past thirty-nine years. He is well-known to the California Heart Association, having served as its leader; and to St. Joseph’s Foundation’s board of directors, having served there; and to scores of schoolchildren, having served as an educator and presenter in “Heart Labs” for Stockton’s elementary and secondary schools; and to the American Heart Association. you could say all that. Still, having said it, you will have left out so very, very much. Perhaps if you had seen him when he was ten years old, standing in front of the ticket master at Penn Station. It is about eight o’clock on a Saturday night in 1946, and young Jim had slept past his stop after a long day of fishing. He is all alone, and starting to get a little upset. He needs a new ticket, and he has no money. By Carmen Spradley Photography by Mike Steenburgh




Dr. Morrissey

Bottom left photo - Taken at Dampush Pass in 1973. Dr. Morrissey states, “We had just spent 72 days over 19,000 feet and were returning from a successful ascent of Dhaulagiri, the 6th highest mountain in the world. The red long-johns I’m wearing I had not taken off for 3 months. From that point it was the first time in almost 3 months that we were able to see green trees”. Top right photo – Dr. Morrissey in surgery at St. Joseph’s Medical Center. Bottom right photo – Dr. Morrissey with climbing partner, Sir Edmund Hillary.




Feature > Dr. James D. Morrissey “Well, do you have anything to trade for it?” the ticket master asks.   “I have a couple of really nice trout here,” young Jim says, holding up his day’s catch.   “Well, that would be good enough,” the ticket master answers.   And he takes the fish, and gives young Jim a ticket. Or, if you’d been there in 1954, when Jim was eighteen, already a veteran “director of fishing” at a boy scout camp, sitting in the fishing tent, tying and untying fishing knots, when one of the other scouts steps in.   “The doctors up at the medical cabin want to talk to you. Can you come up?”   The three doctors are med students. One of them, a young Stuart Rae, is bent over some kid’s foot, stitching up a big laceration. He is halfway through, and the suture is tangled. Jim’s fishing skills are about to pay off again.   “Do you think you can get this out?” the med student asks.   “I think so,” Jim answers, and quickly works the knot out.   Impressed, Stuart throws out a line of his own.   “You want to finish sewing this kid up?”   Jim answers, “Sure!” and finishes the job the med student had started.   The kid surveys his stitched foot.   “Are you a doctor?”   “No.”   The kid looks up, and locks his gaze on Jim.   “You know, maybe you should be.”   Perhaps you can almost see the thoughts flashing through young Jim’s head.

  Of course, if you were to stick around later that summer, you’d see Jim hiking along a Wyoming national park trail with his friend, Roger. Here is your chance to see another

side of Dr. Jim Morrissey. The two teens have set out from their group’s camp early that morning, determined to warm up after a long cold night sleeping outdoors. The hiking leads to climbing, and the climbing leads to more climbing – up and up and up, until they scale the Grand Teton itself – a nearly 14,000foot summit. The boys have no ropes, and no guide. But they make it there, and back again. And perhaps you can almost see more thoughts flashing through young Jim’s head.   Here is the part where you see the future Dr. Morrissey go off to college with his best pals, Vince Cerny and Art Mittelstedt. But you discover it is not a college you could ever guess, not if you stood there at California Street for a million years. It is the only college the three can agree upon---the New York State College of Forestry.   That first year of college, Jim’s father dies. Thinking of his mother’s diminished resources and his sister still at home, Jim declares himself financially emancipated, and takes on a load of odd jobs to support himself. The lesson learned at age ten, of knowing that one way or another, he can navigate through his life, even when resources are quite small, has stayed with him.


But the idea of a life as a doctor persists.   Jim goes to see his dean. The man is very understanding.   He says, “Let’s do this. Let’s try to find a curriculum.”   There are seven different curriculums at the college. One of them is called “Pulp and Paper Engineering and Plastics.”   “Why don’t you go into Pulp and Paper? That will give you the calculus and organic chemistry and all those things that you are going to need.”   Jim agrees, not knowing just how rigorous the curriculum will turn out to be. Three years of calculus, seventy-two semester hours of chemistry, including organic, advanced organic, physical chemistry, and advanced physical chemistry. It is a killer curriculum. Jim does fine, but no straight A’s, not by a long shot.

  Jim graduates. It is 1958. He applies to the only medical school he wants, the State University of New York, at Syracuse. He is turned down. Jim has neither the temperament nor the money to sit still and contemplate his

setback. He had spent the summer of his third year of college, up in Prince Rupert, British Columbia, working in a paper mill’s research lab. It had been a spectacular summer; he’d done a lot of ice climbing, living in a world of ropes and crampons and ice axes. He would go back there. He calls his friend, Phil Nye, and tells him he needs a job, and wants to get into med school. And Phil says, “Come out to BC, and we’ll see what we can do.”   So here’s where Jim’s story gets really wild. He has to get to British Columbia, but he has very little money. So he snags a ride with a friend as far as Fargo, North Dakota. He needs money, and he needs to get up north. A trucking company is advertising for truck drivers. They need someone to haul two truck cabs piggyback on an 18-wheeler, all the way to Omak, Washington. Jim has never driven a big truck like that in his life, but doesn’t see the problem. Just the opportunity. He applies, and they hire him.   It takes about eight weeks, but Jim gets to Omak. He’d had only one near collision. Somewhere along a major highway – deserted – Jim broke a cardinal rule known to actual truck drivers. He tried to gear down while going downhill. He was caught between gears, and nearly crashed. He ended up at the side of the highway, in a cloud of dust. He decided to view the episode as a learning experience. He got into gear, eased back onto the highway, and traveled on.   British Columbia did not let him down. Jim found himself with a very lucrative job as chief chemist in a paper company there. But the idea of a life of medicine persisted. Two thirds into his first year with the company, Jim resigned and left for New York. An adviser he’d had at the College of Forestry agreed to make him his graduate assistant, and to make sure Jim could take two more courses towards med school. “We can get you reapplied to some schools,” his adviser told him.   But Jim didn’t want to go to any medical school. Though he was accepted at others, the place he really wanted – State University, Syracuse – put him on a wait list. >>



Feature > Dr. James D. Morrissey

Dr. Morrissey prepares pig hearts for an annual presentation to local elementary students – a project he has led for decades to introduce young students to the marvels of medicine and the human body.

Jim writes a letter to the admissions officer. Within days, he is summoned to a meeting of the admissions committee. Every committee member is sitting in front of a copy of Jim’s letter.   The admissions officer turns to Jim.   “You say here that we’ve turned you down a second time, and that this is a mistake. Why do you think we’ve made a mistake?”   So Jim told them. He knew he could handle the academic load, because there was no way medical school could be as hard as the College of Forestry. The committee, of course, was insulted.   So Jim told them of his strong drive, and his unwavering desire to become a doctor. He talked with a conviction that can only come from sincerity, and with a passion that remains in him today. Up to that moment, Jim had lived a life propelled by his own power; with plenty of assists and cooperation by friends and strangers, of course, but always with the feel of the reins in his own two hands. This time was different. A group of people he didn’t know held the fate of his most fervent desire.   He got in.   If you could have seen Jim during those years, you wouldn’t need the benefit of his recent accomplishments to appreciate his stamina. Jim not only handled medical school, he also served in the Naval Reserve Ensign Program, played sports with characteristic gumption, and traveled to Malawi, in southeastern Africa. Jim graduates med school. It is 1964. He signs up for the Peace Corps. While he waits for assignment,



he works in a year’s internship in general surgery at Barnes Hospital in St. Louis, Missouri.   In July, 1965, Jim arrives in Tanzania, East Africa, to work as a Peace Corps volunteer. He returns to the States in 1967, and begins his second internship at Barnes that July as assistant resident in general surgery. In 1969, during a break from his residency, Jim joins an expedition to Dhaulagiri, a 26,794-foot mountain in Nepal, Asia. Jim is the team physician. It is an illfated expedition. Seven of the fourteen members are wiped out by an avalanche, including the team leader. After the mountain quiets, no one seems to know what to do. The remaining seven climbers mill around.   “Okay, obviously somebody has to make some decisions around here. So I’m going to make a decision,” Jim says to the group. He takes charge, leading the remaining members on a search for bodies. Nothing can be found but backpacks and ropes. The climbers make their way down Dhaulagiri. Jim and his friend, Louis Reichardt, have already resolved to return to the mountain. The two make their pitch to the Nepalese government for a permit on a second climb, to be attempted four years hence. They get their permit before they leave Nepal. They would climb Dhaulagiri again.   Jim’s assistant residency ended in June of 1971. He spent one more year at Barnes Hospital, as chief resident of cardiothoracic surgery. He left in June of 1972, and began laying plans to relocate to a city in California, despite having just completed


his indoctrination into the St. Louis Medical Society. Stockton, California seemed ready for an energetic young cardiovascular surgeon. Jim communicated back and forth with a Dr. Hebert there, who gave the young doctor a clear picture of Stockton’s possibilities.   The new doctor in town quickly established his place within Stockton’s medical community. Before 1972 ended, Dr. Morrissey became the chief of cardiothoracic surgery at St. Joseph’s Medical Center, and in early February of 1973, was unanimously elected to active membership in the San Joaquin Medical Society. Besides the hours spent setting up cardiac service at St. Joseph’s, Dr. Morrissey spent yet more time conducting research at his lab at San Joaquin General Hospital.   Of course, the 37-year-old Morrissey still planned on climbing Dhaulagiri again. He met Dr. Joseph Serra, a Stockton orthopedic surgeon, and the two quickly became friends. Serra found it impossible not to get caught up in the excitement of the upcoming climb. Morrissey left for his Dhaulagiri expedition with two of the original Dhaulagiri climbers, John Roskelly and Louis Reichardt. The three climbers summited Dhaulagiri. By 1977, Dr. Serra had fully acquired the climbing bug. Dr. Morrissey left for a reconnaissance trek to K2, the world’s second-highest mountain, located on the Pakistan-Chinese border. Dr. Serra went with him.   “That was a great adventure,” Dr. Serra recalls now. “We took 16 clients all the way to K2 base camp.” Later that trip, Morrissey met up with Galen Rowell, a world-class nature photographer and expert climber, John Roskelly and a climber named Kim Schmitz. Morrissey and the three other men climbed Trango Towers, a group of granite spires on the north side of the Baltoro Glacier in Pakistan. They were the first Americans to ascend Trango Towers.   One of Dr. Morrissey’s favorite restaurants in those days was the Alustiza Restaurant, a family-owned place about a block away from the original On Lock Sam’s restaurant in downtown Stockton. That is where he met Jack, one of the younger members of the Alustiza family. Jack had been a football player at Stanford, a big guy who had remained friends with his old football teammate, Jim Plunkett. Morrissey had begun to run marathons by that point, and his enthusiastic recounts of hitting the roadways inspired Jack Alustiza to start running marathons, as well. Jack ran sixteen marathons, and gave Plunkett a push into marathon running as well. Morrissey’s power to get people moving had become exponential.   And it was a good thing, too. In 1980, Morrissey got a call from his old friend Louis Reichardt. Lou had been asked to be climbing leader for an expedition up Mt. Everest, organized by Richard Blum, San Francisco financier and husband to the city’s mayor at the time, Dianne Feinstein. Reichardt needed another man on the team he knew he could really count on. He insisted Blum make Morrissey deputy climbing leader.   The goal was to conquer the east face of Mt. Everest, the most dangerous and technically challenging section of the summit. Sir Edmund Hillary had summited the peak from


the Nepal side in 1953, an approach Hillary himself described later as much less challenging than the east face, which is on the Tibet side of the mountain. Hillary is invited to join the 1981 expedition.   The team reaches 22,000 feet, or just above the daunting rock wall of Everest’s east face, when a storm forces the vanguard of the group to turn back. Morrissey reaches 17,000 feet. Twice. The 62-year old Hillary had become ill, and Morrissey carried him down to the 14,000-foot level to recover. Morrissey tended Hillary for nine days, until Hillary improved. The two climbed back up to the 17,000-foot level. Hillary became ill again, more seriously this time. Morrissey took him down to 14,000 feet again. After more than 2 weeks of rest and care, Morrissey escorted the older gentleman back over a 17,600-foot pass and down to a place called Carter, where Hillary was placed into a truck and taken farther down, to a hospital.   The image of Morrissey with Sir Edmund HIllary at Everest in ‘81 is perhaps our most revealing look at Jim. Don Wiley, the president of St. Joseph’s Medical Center, has described Morrissey as “bigger than life.” That may be one of the better descriptions of Morrissey. For as much as he felt driven to scale that mountain with the others back in ‘81, he felt more compelled to help the ailing Hillary. Whatever the circumstance of his life, Morrissey seems to expand it beyond its expected confines.   Dr. James Dell Morrissey went on to lead the successful 1983 effort to become the first team to summit Everest from the Tibetan side. He credited teamwork for their success. One could also credit the trust and respect that comes from deep friendship, which Morrissey seems to engender so well. From his Stockton friend Jack Alustiza, who served as camp cook, to old friends like Lou Reichardt, the ‘83 Everest team, and their conquest of the eastern face, has become the symbol of Morrissey’s larger kind of life.   Since Everest, Morrissey has continued with his characteristic potency. His practice continues, with patients and staff that feel real affection for him. He still lends his support in one way or another for the Wilderness Medical Society, a group of physicians who advance education in the world of medicine and the outdoors. He is active with the Himalayan Rescue Association and the American Himalayan Foundation.   Now, Dr. Jim Morrissey is recognized with the San Joaquin Medical Society’s Lifetime Achievement Award. The community he adopted, and improved, is taking the time to look at how Jim has led his life. In doing so, we come to realize why we celebrate people like Jim. People who climb mountains, whether real or metaphorical, not only show how great an individual can be, but also how much our small kindnesses and help, the reciprocation of friendship and cooperation that we give to another, really matters in this world. When we swap a train ticket for a pair of trout, or give a kid a job shoveling snow to help pay for college, we help to create a spectacular life. That’s the achievement of a lifetime.






Providing staff, physicians and patients with relevant & up to date information

Janine Hawkins, Dameron Hospital’s CNO is pictured Dameron Hospital Hosted Sepsis Training Center for San Joaquin County Sepsis is an infection that is one of the leading causes of hospital deaths. In an effort to reverse this national trend, Dameron Hospital hosted a portable Sepsis education and training facility: The Medical Simulation Corporation (MSC) SimSuite Simulation Lab.   Five other San Joaquin County hospitals participated in this specialized physician and nursing educational program May 16th through May 20th. The MSC Sepsis program was provided to San Joaquin County area hospitals through the Hospital Council of Northern & Central California’s Patient Safety First Initiative. Other California Hospitals who have participated in sepsis educational programs have seen a 40% average drop in hospital deaths due to this common, but potentially deadly infection in which bacteria overwhelms the body’s natural immune system.   Sepsis can begin as a normal infection in people of all ages, but is particularly dangerous in newborn infants and the elderly. When the



infection enters the body’s bloodstream, it can result in a deadly outcome. Sepsis is a serious issue facing all healthcare professionals since over 200,000 people die annually from Sepsis infections in the U.S.   “We were quite pleased that Dameron Hospital was chosen to be the central location for sepsis training in this county” said Janine Hawkins, Dameron Hospital’s Chief Nursing Officer. “We benefitted from this new training and assistance to not only our internal hospital staff, but to all our local hospital and healthcare colleagues. This is something that will directly result in saving lives and something our whole community benefitted from”.   The MSC SimSuite Training facility uses simulated mannequins that are amazingly lifelike in every detail, including switching gender and age. Each year Sepsis in some manner strikes 750,000 people in the U.S. alone. Sepsis is the 10th most common cause of death and is the leading cause of death for critically ill hospital patients in the U.S. ________________

Sutter Gould Medical Foundation Acquires Gastroenterologists and Endoscopy Center in Stockton Sutter Gould Medical Foundation

SimsSuite Mobile Lab


news < COMMUNITY   (SGMF) is pleased to announce that two highly respected Stockton gastroenterologists, George Rishwain, M.D. and Sohan Singh Mahil, M.D., have joined the Gould Medical Group. Their practices, and the Stockton Endoscopy Center located at 415 E. Harding Way, Suite E, were acquired by SGMF on March 1, 2011.    Both doctors will continue to see patients at their current N. California Street locations as well at the endoscopy center on Harding Way. Patients may also be seen at SGMF’s Hammer Lane location at 2545 West Hammer Lane.   Drs. Rishwain and Mahil have practiced gastroenterology in Stockton for almost 30 years and are highly regarded for their quality and service to patients.   Dr. Rishwain said “Aligning with an organization like Sutter Gould Medical Foundation ensures our patients receive the highest quality care. Sutter Gould shares the same commitment to health care and the community as we do.”   “The addition of these two respected physicians and the endoscopy center keep us on our strategic plan to provide comprehensive services to our patients in San Joaquin County,” said Dr. Paul DeChant, M.D., CEO of Sutter Gould Medical Foundation. ________________ San Joaquin General Hospital Installs New Mammography Unit San Joaquin General Hospital’s Diagnostic Imaging Department has recently installed a new, state-of-the-art digital mammography unit, complete with CAD (computer-assisted detection). The mammography room has been relocated within the Imaging department and remodeled to create a beautiful, soothing, patient-friendly suite.   The mammography service is accredited by the American College of Radiology and the FDA. It provides comprehensive, courteous and efficient service for all patients. The department has greatly expanded its mammography scheduling capabilities yet offers the same expertise and thoroughness. For symptomatic patients or patients you notice are due for their routine screening exams, same-day or next-day appointments are readily available.


Staff of SJ General Hospital’s Diagnostic Imaging Dept   In addition to the excellent routine mammography services, the department offers the option of allowing necessary follow up diagnostic imaging to be done in one visit. For example, a patient who presents with a lump may receive the necessary additional views and/or a breast ultrasound during the same visit versus the need to schedule additional appointments. Staff radiologists, certified in digital mammography, are on site and available for immediate consultation.   The Diagnostic Imaging Department at San Joaquin General Hospital is very proud and excited to offer this level of service and invites you to send us your mammography referrals. Our normal business hours are 7:30am – 4:00pm weekdays, and appointments may be scheduled by calling (209) 468-6221. ________________

St. Joseph’s Medical Center Leads the Way in Environmental Excellence St. Joseph’s Medical Center has received the highest environmental achievement award presented by Practice Greenhealth, a national membership organization for health care facilities committed to environmentally responsible operations. The facility was named a member of the Environmental Leadership Circle, Practice Greenhealth’s most prestigious award. These competitive awards are given within the healthcare sector to institutions for outstanding programs to reduce the facility’s environmental footprint.   “All of our members are committed to improving health care’s environmental performance, but there is an illustrious group of facilities setting the highest standards,” said Practice Greenhealth





NEWS Executive Director Anna Gilmore Hall. “They are the best of the best, the recipients of our top award. St. Joseph’s Medical Center has introduced extensive environmental strategies into health care and is committed to achieving further improvements.”   The Environmental Leadership Circle recognizes healthcare facilities that exemplify environmental excellence and are setting the highest standards for environmental practices in health care. Award winners are chosen by the Practice Greenhealth award review team from the top Partner for Change applicants. To be considered, facilities must meet the criteria for the mercury-free award, recycle at least 25 percent of their total waste stream, have implemented numerous other innovative pollution prevention programs, and are leaders in their community.   This is the sixth year in a row that St. Joseph’s Medical Center has attained the Environmental Leadership Status! St. Joseph’s has been part of the Environmental Leadership Circle since its inception in 2007. Each year, the hospital strives to achieve the highest level possible of environmental awareness and conservation integration. The many recycling programs ongoing at St. Joseph’s include green waste, batteries, cans, bottles, wood pallets, hospital products such as blue wrap and shrink wrap, baby bottles and energy efficient laundry washers.   “We take pride in being an environmental leader within the health industry and are dedicated



to continuously striving to improve our environmental performance,” said John Kendle, St. Joseph’s Director of Operations, Support and Services. “The Environmental Leadership Circle is only going to get more crowded as more health care facilities make a commitment to reduce the health and environmental impacts associated with health delivery.”   St. Joseph’s Medical Center has also implemented the use of 100% postconsumer waste recycled paper for the entire hospital, reusable isolation gowns, reusable sharps containers, and initiated onsite vermicomposting for wet kitchen scraps. St. Joseph’s also has a partnership with MedShare, which acts as a recycling and distribution center for surplus medical supplies and equipment. They redistribute donated product to healthcare facilities in our community and in economically developing countries that have little or no medical resources.   The Practice Greenhealth

Drs. Pankaj & Sudevi Thaker

Environmental Excellence Awards in eight categories were presented in Phoenix, AZ, in conjunction with CleanMed 2011, a global conference for environmental leaders in health care. ________________ Drs. Pankaj & Sudevi Thaker Announce Opening a New Office Dr. Pankaj Thaker, MD FACOG and Dr. (Mrs.) Sudevi Thaker MD, FACOG are certified by the American Board Of Ob Gyn and provide a full range of services for Women’s Health Care Including Pregnancy, High Risk

SJMS Legislative Delegation meet with Assemblywoman Galgiani


news < COMMUNITY impact to local physicians and access to care for patients.   In addition to meeting with Senator Lois Wolk, Assembly members Bill Berryhill and Cathleen Galgiani, the group enjoyed an entertaining presentation from Governor Brown and Lt. Governor Newsom during the morning session. ________________ Avon Breast Health Outreach Program Awards Grant to St. Joseph’s Foundation The Avon Breast Health Outreach Program has awarded a $55,000 one-year grant to St. Joseph’s for an outreach project through St. Joseph’s Mobile Mammography Program (MMU). St. Joseph’s will partner with three Southeast Asian community organizations to develop a comprehensive breast cancer screening program that is culturally competent, including dedicated staff with specific language skills and trusted members of their own specific communities to advocate on our behalf. All of these dynamic Asian groups are dedicated to increasing the health status of their members and are committed to bringing health services to their communities through an Meeting with Senator Wolk and Assemblyman Berryhill extended partnership with St. Joseph’s. It is the fourteenth year Pregnancy, Infertility , Colposcopy, SJMS Physicians Visit State that St. Joseph’s has received Surgical and non surgical treatment Legislators and Hear from funding from the Avon Foundation for Urinary incontinence, Uterine the Governor for Women to support its work on Prolapse, etc. During the annual CMA Legislative this important health issue, and in   Dr. Pankaj Thaker is also a trained Day held this past April 5, several recognition of the program’s excellence. Hypnotherapist and will be providing local physicians and members of the   In partnership with our Southeast Hypnotherapy and Emotional local Alliance visited with each of our Asian community partners - Asian Freedom Technique (EFT) related state representatives and their staffs Pacific Self-development And services for Weight Reduction, to discuss a myriad of issues facing Residential Association (APSARA), Smoking Cessation , Chronic Pain, California physicians. Top on the list Lao Family, Hmong Women’s Anxiety and Phobias. of course was MICRA reform which Heritage, and Lao Khmu - the MMU   Both are accepting new patients is being pushed this year by the trial will provide culturally appropriate from most of the insurance programs attorneys. Each of our representatives education and educational material and can be reached during normal expressed support on this important about breast cancer early detection business hours at 209-467-1007. The issue and appreciated hearing our and breast health to underserved new office is located at 415 E. Harding personal concerns and its potential women. The outreach will reach ladies Way Suite I, Stockton CA 95204-6118




John H. Kim, M.D. in their communities and consists of door-to-door contact, house parties, and helping the women communicate with their care providers. Further, the project will assist in physician contact and obtaining referrals for mammograms.   Through this program, 4,000 women will be reached through educational and outreach efforts pertaining to the importance of proper breast health practices, including clinical breast exams, breast self exams, and screening mammograms. Additionally, 700 women will receive screening mammograms and clinical breast exams.   Breast cancer is the most common form of cancer in women in the U.S., and the leading single cause of death overall in women between the ages of 40 and 55. According to the American Cancer Society, 22,115 new cases of breast cancer will be detected in California this year and 4,170 lives will be lost. Nationwide, there is a new diagnosis every three minutes and a death from breast cancer every fourteen minutes. While advances have been made in prevention, diagnosis, treatment and cure, early detection still affords the best opportunity for successful treatment. Programs such as St. Joseph’s CDP help ensure that all women have access to early detection information and options, even poor



and medically underserved women.   “We are proud that the Avon Foundation shares our mission and has chosen to support our program. With these funds we will be able to provide life-saving breast cancer detection and breast health services to women in need within the Southeast Asian population in our community,” says Theresa Weaver, R.N., M.S.N., Program Manager, St. Joseph’s Medical Center.   Since 1993, the Avon Foundation has awarded more than 1,425 grants to community-based breast health programs across the United States, including the Cancer Detection Program at St. Joseph’s Foundation. These programs are dedicated to educating underserved women about breast cancer and linking them to early detection screening services. ________________ John H. Kim, MD, Reproductive Endocrinology and Infertility Specialist, joins St. Joseph’s Medical Staff St. Joseph’s Medical Center is pleased to announce the addition of John H. Kim, MD, FACOG, to the hospital medical staff. Dr. Kim comes to the Stockton area with over seventeen years of experience in Obstetrics and Gynecology. Most recently, Dr. Kim practiced Obstetrics, Gynecology, and Infertility at Essentia Health in Fargo, ND. He obtained his medical degree at the Rosalind Franklin University of Medicine and Science at Chicago Medical School in North Chicago, IL. His postgraduate training includes an internship and residency in Obstetrics and Gynecology at Brown University School of Medicine, and a fellowship in Reproductive Endocrinology and Infertility at the University of California in San Francisco.   “I became an infertility specialist because of the rewarding experience of helping patients achieve their dreams of becoming pregnant. I am aware of how stressful infertility can be and I am committed to providing compassionate and expert care for my

patients.”   Dr. Kim specializes in reproductive endocrinology and infertility. In addition, he brings years of experience and expertise in non-invasive surgery such as laparoscopy and hysteroscopy for infertility and all types of gynecologic problems. In the future, he is working to bring robotic surgery for women. Dr. Kim is board certified and a Fellow of the American College of Obstetricians and Gynecologists. He is a member of the American Society for Reproductive Medicine and the San Joaquin Medical Society.   Dr. Kim has joined the growing group of OB/GYNs at P. Gill Obstetrics and Gynecology Medical Group, Inc. For more information, please call P. Gill Obstetrics and Gynecology Medical Group, Inc. (209) 466-8546. ________________ CMA Foundation Seeking Leadership Awards Nominations Nominate an Outstanding Colleague for the CMA Foundation Leadership Awards The CMA Foundation is accepting nominations for the 2011 Leadership Awards, which celebrate the efforts of individuals or organizations that make a difference in the health of Californians. The Robert D. Sparks, M.D., Leadership Award, the Ethnic Physician Leadership Award, and the Adarsh S. Mahal, M.D., Access to Health Care and Disparities Award recognize the compassion and commitment of California’s health care professionals. The deadline to submit nominations is June 23. Nomination information and packets for each award can be accessed by visiting the Leadership Award page under the “About Us” section of For more information, please contact Carol Lee, 916/779-6622 or clee@


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I Hate Email Taking Control of Your Inbox

By Tom Gehring ,,• CEO of the San Diego County Medical Society

I hate email! No, I love email. No, I hate email! Sound familiar? Love it or hate it, physicians today no longer have the option of ignoring email. On an average day, I receive between 100 and 150 non-spam emails. How to deal with the onslaught? First, read the email tech manual. The book Send: The Essential Guide to Email for Office and Home by David Shipley and Will Schwalbe is probably the best description of how to effectively use email and avoid its many pitfalls. I have given it to every member of my staff and every physician in our society leadership — that’s how good it is.



  Email is divided into two broad categories: reading and sending. Here’s my routine for an email reading session:   First, I go through every email in my queue and read every subject line, ruthlessly deleting — without opening or reading the text — every email that looks like junk or appears irrelevant, based only on the sender, the subject line, or both.   Then, I triage every incoming email into one of four categories: requests for action, information for me, requests for information from me, or scheduling. If it does not fit into one of those categories, it’s most likely junk, and I will delete it.   Now I go back to the top and open each email (most recently received first) and ruthlessly apply the 4Ds: Do, Delegate, Delay, or, my favorite, Delete. If, when I open the email, it turns out to be junk, that’s easy: I delete it.   If it’s information for me, I read it, assimilate it, then either delete it or move it to a folder (see below on folders). I’m ruthless — I don’t leave it in my inbox.   If it’s a request for action (sometimes embedded in information emails), I then do it, delegate it, or delay it. Once I do it, I delete it from my inbox. If I delegate it, then I move it to a folder for the individual for whom I’ve delegated it. If I delay it, then I either assign it as a task or as an event, at which point I move it to a folder labeled “Pending.”   If it’s a request for information, see item above. If it’s scheduling, then I respond and move it directly to my calendar — I do not leave it in my inbox. I have a simple metric for my inbox: If it’s empty, that’s fabulous. If it has between three and five extremely high priority current items, that’s OK. If it has more than 10 items, then I need to go back to the triage cycle.


I’m a big fan of this simple rule: Touch every email exactly once. Hard to do in practice — and there will be exceptions — but, in general, if you follow the rule, you’ll stop wasting time.   Develop a useful hierarchy of folders, including in each several broad categories: actions you’ve delegated to others, actions you’ve delegated to yourself (pending items), event-driven folders (e.g., CMA’s next House of Delegates), and broad categories of information.

Here are some suggestions for sending emails: Prior to sending an email, ask yourself before anything else, “Is this email really necessary?” Then ask the same question again. Keep it simple. Keep emails totally — and I mean absolutely totally — free of negative emotions. If you’re using adjectives or adverbs that are pejorative, that’s a great indicator that you should not be sending the email. Check your tone: Is this what you would say and how you would say it if you were face-to-face with the recipient? Check your recipient list: Got everyone? Got too many? With one exception, never blind carbon copy (BCC). It’s a recipe for disaster. The exception to not BCC’ing is if you want to ensure privacy for the email addresses for a large group of recipients. If there’s action requested, say so in the subject line, e.g., “Action Requested.” Make sure the subject line is clear and compelling. Use dates, not “tomorrow” or “today” or “yesterday.” Spell check. Syntax check.

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Read the email from beginning to end at least twice before sending. Make sure the attachments, if there are any, are attached. Before you hit the Send key, ask yourself what would happen if this email were published verbatim in The Stockton Record. If there is any doubt in your mind, then listen to the voice in the back of your head and reconsider the email. A short note on PDAs, iPads or similar devices and the habit we’ve gotten into of sending emails from them. Many busy professionals now have a portable device that allows them to download their emails continuously while they are away from their desks. I use my iPad to keep me informed and to ruthlessly delete anything that is junk so that when I get back to my computer, I am able to rapidly take action as above.


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2011 Young Physician Award – Dr. Jeffrey Ing

Serving Others is his Passion One could say that his is a life which tilts toward accumulative achievement and an ever-increasing regard from others. But that wouldn’t really capture what Dr. Ing is all about. The young ophthalmologist has already found a pleasing approach to life, one that has meaning and relevance for him right now; one which embodies a repeating pattern of living symmetry that reaches outward just as much as it moves forward; an elegant kaleidoscope of family, of work, and of service. By Carmen Spradley

Dr. Ing heads a successful practice of general ophthalmology and corneal surgery at Delta Eye Medical Group, which has offices in Stockton, Lodi, and Tracy. He celebrates his sixteen-year marriage to Helen, who is a registered nurse, and mother to their three children, Ryan, 14; Jessica, 10; and Jared, age 8. The couple share a thoughtfully structured family life, and travel as medical partners in missions overseas. Dr. Ing reached this orbit of work, family and purposeful travel quite logically. His pattern extends from his father’s. Dr. Clarence Ing worked as an ophthalmologist and missionary throughout Jeffrey’s growing years. When Jeffrey was four, the elder Ing moved the family from Glendale, California to the west coast of Puerto Rico in order to serve at a mission hospital there. Until the age of eight, Jeffrey gained his first, informal education on the beach, at home, or with friends, learning the practical way, through a kind of apprenticeship in construction and shade-tree mechanics. His parents delayed his start in first grade by two years, believing in what they’d read: that it was better to start children in school at a later age, for in doing so, a child would be less likely to be bullied, more likely to excel academically, and more likely to lead, rather than be led. When Jeffrey was 12, his family moved back to the States. They lived in Georgia for about three years, then moved to the Marshall Islands. Next was Singapore, where Jeffrey spent his time in high school, graduating after only three years. Jeffrey returned


to the States to attend Pacific Union College, a parochial school operated by Jeffrey’s church, Seventh Day Adventist. Next came Loma Linda University, a Christian institution, for medical school and residency, and an internship at Kettering (Wright State University). Jeffrey met Helen, introduced by a mutual friend who knew of their shared interest in mission work. They married. Jeffrey began and eventually completed his fellowship at the Mayo Clinic. The couple, now with a new baby, made plans to begin mission work in Puerto Rico. They would live in the same house Jeffrey had grown up in, and Jeffrey would work in the same hospital in which his dad had worked years before. Then came the news that their first-born baby had a severe neurological condition. Should they go ahead with their plans?   They did, but they didn’t stay. Before their mission post was complete, the couple made the decision to return to the States. Here, their son would be allowed the resources to explore his potential. Leaving early meant having to pay back the financial support the post had afforded to Jeffrey’s medical education. They paid it back. By the time the young family reached Stockton, they had very little money.   “We moved to Stockton,” Dr. Ing says, “and I thought, well, we’ll just check it out for a year or two. But we checked into the services here, and we found out that the Valley Mountain Regional Center here is very active.” >>




day. Both were completely blind from cataracts. When you are blind from cataracts, you can’t even see shadows. You can only tell when the Dr. Ing is planning to go back to Honduras again soon, with a Christian sun is up or when it’s down, or when service organization named Canvasback, in January. “When we go, I the light is on or off. Th is couple had not seen each other in years. When (plan to) take a resident, someone in training with ophthalmology. we took off the patches the next day, they embraced each other. It was one of the coolest experiences I’ve ever had. I’m hooked.” Mission work has taken Dr. Ing (The VMRC provides and coordinates services for the and Helen to Honduras, Belize, the Philippines, and Africa. And developmentally disabled, and support for their families.) The along the way, the doctor discovered another component of couple quickly found they’d come to an ideal place for the benefit service. “When we were in Belize, there was a (young) lady out of their special-needs son. there whose mother was a nurse. Her mom came in to help with Stockton was also a good fit for Dr. Ing’s medical expertise. surgery. Th is daughter had no interest in her mother’s profession.” “There were no corneal specialists in the valley. There were a few But Dr. Ing had built in a unique learning opportunity to that would come and spend a week or two, but no one wanted his work there. When all her friends were introduced to the to live in the Valley. So I found myself immediately becoming surgical suite, and got to scrub and watch surgery, the young very busy with corneal transplants, and really helping. I could woman started taking interest in what her mom was doing, and go to San Francisco and there would be ten or fi fteen corneal she wanted to come in and join them. “It changed the motherspecialists. I could go to Sacramento and there would be another daughter relationship in that family.” The young woman is now in five or six corneal specialists. But in Stockton, Lodi, Tracy, a nursing program. Manteca, and even Modesto, there were no corneal specialists. Dr. Ing is planning to go back to Honduras again soon, with So when I saw that, I thought, well, I’m doing stuff that I like...and a Christian service organization named Canvasback, in January. helping people...and we just stayed on and on and on. I bought “When we go, I (plan to) take a resident, someone in training with into the practice, and we’ve been enjoying our time here. It’s been ophthalmology. Because when we take one resident out there, and good for us.” they come and work with us, then we create in them that desire to Stockton’s location has been another blessing for the Ing give of themselves to service.” Th is is the outward arc of Dr. Ing’s family. Dr. Ing loves the outdoors. “We’re about an hour and half life kaleidoscope. It is that compounding of one good deed to from Yosemite, a couple hours from Tahoe; I love to ski, I like to create new ones, like growing cells. It is taking what one has, and climb, and camping. And for diving I go to Monterey.” The doctor making it exponential. learned to dive at age eight, when he was living with his family in Dr. Ing is forty-four years old. His onward and outward reach Puerto Rico. in life will only grow. His thoughtful, positive approach will Stockton became the new hub of Dr. Ing’s dedicated efforts. continue to help and inspire others. He will pursue his dedication “When I left my mission post, (in Puerto Rico) and we moved to improvement in his practice, in his surgical technique, giving here...Helen and I had a conversation. And I said, ‘you know, I’m rein to an internal passion. going to be in private practice, and I’m going to be making more The doctor is always interested in learning the newest ways to money than we did as missionaries. I want to dedicate a certain perform a surgical procedure for better results. “Once I fi nd amount of my money and my time to service. Helping other something that is better, even if I don’t get reimbursed the same, people.’” even if it takes longer, even if it is more difficult, I have a hard time In 2000, the couple went on a mission trip to Fiji. “We found justifying doing it the easier way. How could I do that? I couldn’t this litt le mission. We did cataract surgery in this old building, live with myself. That is what my passion is about. I don’t do open room. We had a Fijian translator there, who would hold anything halfway,” he says. He smiles. “Except golf.” the hand of the patient with one of his, and with his other, a fly Forty-four. Many years lie ahead. The kaleidoscope slides swatter, swatt ing fl ies. Ing’s surgical sterile techniques worked, outward and onward. Perhaps one of Dr. Ing’s favorite quotable nevertheless. “We never had an infection there,” Ing says. personalities said it best: Dr. Ing’s connection with service is reinforced with every “We make a living by what we get. We make a life by what we experience he has. It is a kind of benign cycle. He is compelled give.” to act, and those actions create results which are compelling. ---Sir Winston Churchill “In Fiji, I operated on a couple, a husband and wife, on the same




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Amit Parekh, MD Cardiology Kaiser Permanente 7373 West Lane Stockton CA Office: 476-6219 Seth GS Medical College: 2000

Sean Anderson, MD Anesthesiology 700 Mtn Ranch Road, Ste C1 San Andreas CA Office: 754-4334 Univerisyt of Arizona: 2002

Trieu Pham, MD Family Medicine Kaiser Permanente 7373 West Lane Stockton CA American University of The Caribbean: 2005

Suttisak Chavalithamrong, MD Family Medicine Sutter Gould Medical Foundation 600 Coffee Road Modesto CA Office: 524-1211 Chulalongkorn University: 1998 Man Duong, MD Internal Medicine Kaiser Permanente 7373 West Lane Stockton CA American University of the Caribbean: 2006 Crisoforo Garza, Jr., MD Obstetrics and Gynecology San Joaquin General Hospital 500 W Hospital Road French Camp CA Office: 468-6600 University of California School of Medical - L.A.: 1985 Robert Ote, MD Family Medicine Kaiser Permanente 7373 West Lane Stockton CA University of the City of Manila: 1999


James Saffier, MD Internal Medicine San Joaquin General Hosptial 500 W Hospital Road French Camp CA Office: 468-4081 Northwestern University Medical School: 1983 Jonathan Schafer, MD Family Medicine Sutter Gould Medical Foundation 1300 W Lodi Ave, Ste P Lodi CA Office: 369-7493 University of South Dakota: 2005 Baowei Tang, MD Rheumatology Kaiser Permanente 7373 West Lane Stockton CA Office: 476-5228 Nanjing Railway Medical College: 1989

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With 50 years of experience and roots dating back to 1953, Gill Obstetrics has a rich history of serving generations of women throughout San Joaquin County. We offer clinical expertise and compassionate care in a welcoming environment where women can feel comfortable and secure, knowing that we put our patients’ needs first.

Jasbir S. Gill, M.D.


Lynette Bird

Catherine Mathis, M.D.

After all… each woman's needs are unique and you deserve special care!

Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 • 435 E. Harding Way (209) 464-4796 Param K. Gill, M.D.

With 50 years of experience and roots dating back to 1953, PRENATAL & POSTPARTUM CARE Gill Obstetrics has a rich history of serving generations of HIGH RISK PREGNANCY women throughout San Joaquin County. We offer clinical INFERTILITY, INVITRO FERTILIZATION expertise and compassionate care in a welcoming environment where GYNECOLOGY women can feel comfortable and secure, knowing that we put our patients’ needs first. ENDOMETRIOSIS

Peter G. Hickox, M.D. Patricia A. Hatton, M.D


David Eibling, M.D. Vincent P. Pennisi, M.D.

Harjit Su

Thomas Streeter, M.D. Vijaya Bansal, M.D.

Meena S

2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800 Linda Bouchard, M.D.

Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209) 334-4924 After all… each woman's needs are unique and Manteca: you deserve special care!1234 E. North St., Ste. 102 – Ph. (209) 824-2202

Darrell R. Burns, M.D.

Jasbir S. Gill, M.D.

URINARY INCONTINENCE OVARIAN CYSTIC DISORDER LAPAROSCOPY Tonja Harris-Stansil, M.D HYSTEROSCOPY PRENATAL & POSTPARTUM CARE& TREATMENT OF CERVICAL, DIAGNOSIS Patricia A. Hatton, M.D HIGH RISK PREGNANCY UTERINE & OVARIAN CANCERS INFERTILITY, INVITRO FERTILIZATION Jennifer Phung, M.D. GYNECOLOGY ENDOMETRIOSIS Harjit Sud, M.D. OSTEOPOROSIS DETECTION CENTER URINARY INCONTINENCE We are proud to announce the opening of The Osteoporosis Detection Center using state of the art DEXA Vincent P. Pennisi, M.D. imaging. DEXA scanning is now recognized to be the most accurate predictor of fracture risk in women. OVARIAN CYSTIC DISORDER LAPAROSCOPY Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 • 435 E. Harding Way (209) 464-4796 2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800 HYSTEROSCOPY Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209) 334-4924 ViLinda cki PatBouchard, terson-LamberM.D.t, R.N.P.C. DIAGNOSIS & TREATMENT OF CERVICAL, Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202 UTERINE & OVARIAN CANCERS

ourewebsi l We are proud to announce the opening of The Osteoporosis Detevictsioint Cent r using tsteatate ofwww. the argt iDEXA imaging. DEXA scanning is now recognized to be the most accurate predictor of fracture risk in women.

KeviDr. nRiE.neRine, M.D.

Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 • 435 E. Harding Way (209) 464-4796

Denise Mor

Meena Shankar, M.D. Jennifer Phung, M.D.

Lynette B

Kevin E. Rine, M.D. Dr. Rine

Denise M

2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800

Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209) 334-4924 Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202

visit our website at

John Kim, M.D.

Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 435 E. Harding Way (209) 464-4796 • 2509 W. March Ln., Ste. 250 (209) 957-1000 Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209) 334-4924 Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202

visit our website at www.gil

visit our website at

Vicki Patterson-Lambert, R.N.P.C.

Denise Morgan, M.S.N. - N.P.

Jennifer Phung, M.D.

Denise Morgan, M.S.N. - N.P.

Lynette Bird, R.N., B.S.N. Lynette Bird, R.N., B.S.N.

Benefits < Membership

Know Your Rights:

Managed care contractual protections Legislation sponsored by the California Medical Association (CMA), AB 1455 and SB 324, require that all health plan contracts with physicians be fair, reasonable, and consistent with California law and regulations. Contractual clauses that are specifically prohibited cover the following:

• Claims filing deadlines that are inconsistent with the law (See “Unfair Payment Practice: Timely filing denials” at • Financial incentives to deny, reduce, limit or delay care; • Gag clauses; • Hold harmless/exculpatory clauses; • Clauses imposing undue financial risk; • Clauses allowing for unilateral amendments by health plans (See CMA’s “Contract Amendments: An Action Guide for Physicians,” and medical-legal On-Call document #1070, “Managed Care Contractual Protections.”) • Clauses requiring physicians to comply with undisclosed QI or UM programs; (See medical-legal On-Call document #1020, “Disclosure by Managed Care Plans and their contracting Medical Groups/IPAs”) • Clauses requiring submission of medical records that are not reasonably relevant for the adjudication of the claim. (See September 2010 issue of CPR and medical-legal On-Call document #1170, “Health Plan Access to Medical Records.”)

Gena Welch Membership Coordinator (209) 952-5299

Briefly Noted Know Your Rights: Managed Care Contracts Steps to Evaluating Relationships and Preparing for Negotiations Medi-Cal processing

Physicians who believe their contracts violate any of these laws are urged to contact CMA’s Center for Economic Services (CES) at (888) 501-4911 or

claims using NCCI edits

OFFICE MANAGERS FORUM: Join Gena Welch each month at Valley Brew for a lively seminar attended by dozens of other office managers who enjoy a complimentary lunch and some great networking as well. For more info or next month’s topic, call Gena at 952-5299 to be added to our guest list. Every second Wednesday from 11:00 - 1:00




Membership > Benefits Managed Care Contracting Resources

Payor contract negotiations can be difficult. CMA offers a number of free resources and services to help members and their staff to simplify the contract review and negotiation process.    CMA’s Center for Economic Services provides one-on-one education and coaching on managed care contracting issues. Contact CMA’s reimbursement help line at (888) 401-5911 or Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations – A Focus on Payor Contracting.”

This toolkit provides physicians and their office staff with practical tips and tools to assist with the negotiation, implementation and ongoing management of complex managed care contracts. The toolkit includes sample forms and letters that may be customized for each medical practice. Contract Analyses. CMA provides objective analyses of several

health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician’s attention to issues which may warrant further inquiry or clarification. Contract Amendments: An Action Guide for Physicians.” This

guide is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy or procedure. Financial Impact Calculator. It is important that physicians

understand how a fee schedule can affect their practice’s bottom line so that they can make informed decisions about participation in a health plan before contracts are signed. CMA has developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on physician practices based on commonly billed CPT codes. Payor Profiles. CMA’s payor profiles include information for each of

the major payors in California, including important contact numbers, addresses, and links for quick reference for payor interactions. Best Practices: A guide for improving the efficiency and quality of

your practice.” This toolkit offers a series of proven steps that solo and small group practices can take to improve many facets of their practice. Chapter IX, “Surviving Out of Network: One Physician’s Experience,” offers practical advice, including tips on developing an out-of-network strategic plan. To access these resources mentioned above, see Medical-Legal Library (formerly CMA On-Call). CMA’s

Medical-Legal Library includes several documents that address managed care contracting, including but not limited to the following documents: #1070, “Managed Care Contractual Protections” #1055, “Contract Termination by Physicians and



Continuity of Care Provisions” #1099, “Contract Termination or Exclusion: Action Plan for Physicians” #1040, “Exclusivity Provisions and Membership Requirements in Contracts” #1020, “Disclosure by Managed Care Plans (and their Contracting Medical Groups/IPAs)” CMA Contract Analysis Service. Physicians who are interested in personal legal advice and representation with respect to a specific contract or other physician business matters should contact their personal attorneys, or may contact the law firm that provides CMA’s contract analysis service. For more information on CMA’s contract analysis service and the discounts available to CMA members, see medical-legal On-Call document #1705, “CMA Contract Analysis Service.” TIP: Physicians do not have to accept substandard health plan contracts. You can and should negotiate your contracts. Contact: CMA Reimbursement Help line (888) 401-5911 or Medi-Cal processing claims using NCCI edits

As required by the Affordable Care Act signed into law in March 2010, all state Medicaid programs, including Medi-Cal, began applying National Correct Coding Initiative (NCCI) edits for claims processed on or after March 28, 2011, with dates of service on or after October 1, 2010. The Centers for Medicare & Medicaid Services (CMS)

developed NCCI edits in 1996 to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Medicare Part B claims. NCCI code pair edits are developed based on coding guidelines defined in the American Medical Association’s CPT book, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice.    NCCI edits are pairs of CPT codes that are not separately payable except under certain circumstances. The edits apply to services billed by the same physician for the same patient on the same date of service.   While the vast majority of billing and payment policies listed in the Medi-Cal Provider Manual follow AMA CPT coding guidelines and, by default, NCCI code pair logic, it is advisable for physicians to familiarize themselves with these rules to ensure accurate coding and avoid denials, costly rework, and appeals. NCCI edits consist of two types:

Procedure-to-procedure (Column1/Column2) edits that define pairs of HCPCS/ CPT codes that should not be reported together for a variety of reasons; and Mutually Exclusive Edits/Medically Unlikely Edits, which are units of service edits, that define for each HCPCS/CPT code identified, the allowable number of units of service; units of service in excess of this value are not feasible for the procedure under normal


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Membership > Benefits conditions (e.g., claims for excision of more than one gall bladder or more than one appendix). More information about Medi-Cal’s policy on NCCI code pair edits can be found at the Medi-Cal website, or on the CMS website, Contact: CMA Reimbursement Help line (888) 401-5911 or

Due to the retroactive effective dates of these provisions and the fee schedule corrections, a large volume of claims will be reprocessed. It is expected that this reprocessing effort will take some time. Reprocessed claims will be slowly worked into the payment process to ensure that new claims coming into the Medicare program during this time are timely and accurately processed.   Most physicians won’t need to take action to receive any applicable adjustment. However, any claim submitted with billed charges lower than the revised 2010 fee schedule amount will need to request a reopening from Palmetto using the Redetermination/Reopening Request form. Include copies of the EOBs, and identify the corrected billed charge. CMS is extending the normal one-year time period to request a reopening of these claims, as necessary. Still, physicians are encouraged to submit their requests quickly.   This reprocessing of claims may result in underpayments or some overpayments. Physicians who have claims that result in additional payment will receive a payment and EOB showing the correction. Medicare claim corrections that result in an overpaid amount will appear as a corrected claim showing a negative payment amount. Palmetto will issue overpayment letters and will follow the normal process for handling overpayments that occur.   Physicians may choose to collect the additional co-payment that may be due, or waive it. The Office of Inspector General has developed favorable policy related to waiving beneficiary costsharing amounts attributable to retroactive increases in payment rates resulting from the operation of new federal statutes or regulations. View the notice released by CMS at www.

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Doreen Bestolarides R.N.,

dedicated caregiver to undersireable patients

Throughout the history of medicine there have been “undesirables” needing treatment, lepers or Colonial Era Africans come to mind, and few who have provided the necessary care. Nonetheless, those that rose to the challenge have received admiration from their societies. Thus, legendary names like Father Damien or Albert Schweitzer have arisen. Here in our obscure little corner of the U.S. a fledgling effort is under way to pioneer better treatment for such a population, considered “difficult” by doctors and nurses alike. And who to better administer it than a unique individual who harbors such a patient in her own family. As with all such stories, there are silent partners behind the scenes contributing to the individual’s success.




COMMUNITY > Dedicated Caregivers

Throughout the history of medicine there have been “undesirables” needing treatment, lepers or Colonial Era Africans come to mind, and few who have provided the necessary care. Nonetheless,



The group in question is the developmentally disabled. They are mostly adults who have recurring problems with respiratory ailments, neurologic conditions, various organ system failures, and demand a higher level of attention than typical patients. To the average caregiver these patients appear “alien”, literally and metaphorically. They often cannot communicate their needs like ordinary people and misunderstandings abound. They seem to engage in unruly conduct, and are rapidly labeled a “behavioral problem”. Their nutritional, ambulatory and transportation needs are often puzzling and time consuming. Many end up with multiple repeat hospitalizations for a set of recurring conditions. They have longer lengths of stay than comparable non-delayed patients, thus utilizing a larger share of resources. This in turn becomes a source of frustration for administrators who also see the developmentally delayed as an “undesirable” group.   Doreen Bestolarides R.N., a 25 year veteran at St. Joseph’s Hospital has entered this fray in an official capacity and created a vital role for herself as a “special Needs R.N.” to coordinate the care of these patients and educate caregivers on their unique treatment needs. Doreen steps into this role at what should be the prime of any nursing career with an impressive C.V.: a vast ICU and CCU experience, rising to the level of supervisor; administration of a Cardiac Cath Lab; Clinical Management Specialist for open heart surgery. This is about the time when such careers head up towards directorships or other senior positions. Instead Doreen has chosen to enter an unchartered area of care, for which there is precious little precedent or obvious advancement opportunity. Her special reason for this path is Danny, her own developmentally delayed son.   Danny, now age 21, has Down’s Syndrome and autism. He was also born with Tetralogy of Fallot, a heart defect, which required open heart surgery to correct as a newborn. Caring for Danny has given Doreen not only the motivation to attend the needs of those like him, but also the unique knowledge of resources available for help such as Valley Mountain Regional Center, United Cerebral Palsy, Walton Developmental Center, Shriner’s Hospital and others. Along the way she has also acquired a vast experience in hospitalizations and their glaring deficiencies. In one awful instance, septic and non-verbal, Danny was sent home thrice from the E.R. until he went into disseminated intravascular coagulation from untreated sepsis. He ended up spending a month at a university hospital in San Francisco, and lost his spleen as a consequence of the delay in treatment.   As the years have gone by Danny’s problems and therefore his needs have increased. Currently Doreen grapples with his poor ambulation due to unique knee problems, recurrent pneumonias, other upper respiratory issues, a lumbar pars defect causing back problems,


persistent aortic insufficiency, easy fatigue and chronic bowel problems that are endemic to patients like him. Danny has his own special communication problems. For instance he cannot cry, or shed tears, therefore it is difficult for caregivers to detect pain when he has it. Having seen her son frequently in and out of the same hospital where she works, and at times dissatisfied with his care, Doreen has become her son’s best advocate. Over the years this has caused her to informally engage in the hospital based care coordination and education that was to eventually become her new job. Doreen was not the only dissatisfied mother of a developmentally delayed child. A benefactor who prefers to stay anonymous also had major issues with the care given to her now deceased offspring with cerebral palsy. Instead of complaints or lawsuits, this special person approached St. Joseph’s Hospital with an offer of assistance in improving care to such patients. The offer included funding for educating caregivers. Doreen describes this person as a “sweet, quiet, under the radar lady; very intelligent”, who has given to numerous other charities connected to this cause. With Danny’s needs now interfering with Doreen’s full time career, already driven towards staff education for special needs patients, the unexpected appearance of this benefactor was a well timed blessing. St. Joseph’s Hospital administration knew that they had a difficult problem in with their developmentally disabled patients. On the one hand, in an era when patient satisfaction matters more, the challenging care needs of this population and their consequent propensity to dissatisfy their families was a conundrum. Furthermore, their persistent and seemingly intractable length of stay was an added blemish on the hospital’s record, not to mention their financial performance. Identifying the personal career needs of Doreen Bestolarides, a trusted, well liked employee, and coupling them with the donation from a unique benefactor in creating an unconventional new job position, was nothing short of a stroke of genius. Thus the “Special Needs R.N.” position came to being. At the time there were no other donor funded positions in this vast organization. Doreen’s main mentor in this position turned out to be Dr. James Popplewell, long time medical director of Valley Mountain Regional Center, and specialist in the care of the developmentally disabled. Having known him for years as a staff physician at St. Joseph’s, Doreen discovered a different side to this physician at a regional symposium she organized in O”Connor Woods. There, she had assembled numerous vendors and treaters involved in the care of the developmentally disabled. “It was the first time they had all seen each other”, she recalls. In this first of what was to become multiple subsequent faires, Dr. Popplewell spoke, and she was impressed with his deep fund of knowledge on the subject. A new relationship between them developed thereafter, and the two began making regular rounds on such patients. She soon discovered that the friction problem and communication deficit between the hospital staff and special care patients also extended to Dr. Popplewell. His methods were misunderstood, his motives were questioned. Doreen made an effort to identify “ where Dr. Popplewell was coming from”, as she puts it. She discovered that he viewed these patients as


Valley Mountain Regional Center A Hub Of Resources For The Developmentally Disabled And Their Families VMRC is a private, non-profit corporation, under contract with the State of California. It provides or coordinates services for developmentally disabled children, adults, and their families. Developmental disability is defined by law to include: cerebral palsy epilepsy autism mental retardation; and any other condition closely related to mental retardation that requires similar treatment. The condition must originate before the age of 18, be expected to continue indefinitely, and constitute a substantial handicap. How To get Started 1. Call the VMRC office for your county. Eligibility assessment is free. 2. Basic background information will be taken over the phone. 3. An Intake Coordinator will be assigned, and a meeting scheduled, to discuss needs. 4. VMRC services will be explained. 5. Assessment(s) and a comprehensive social history will be gathered to determine eligibility. 6. If eligible, an Individual Program Plan (IPP), or Individual Family Service Plan (IFSP) for younger children, will be developed and updated regularly. 7. Intake may take up to 120 days to complete. San Joaquin County: 209.473.0951 Stanislaus County: 209.529.2626 Amador, Calaveras, and Tuolumne County: 209.754.1871



COMMUNITY > Dedicated Caregivers

of the benefactor. The position is here to between hospitalization and community adult humans, and demanded that they stay. “We’ve seen the value”, says Charos. resources needed to keep patients in be treated with the same dignity afforded Furthermore, the Doreen’s work did improve optimal health afterwards. Nursing to all humans. She learned from him the the length of stay of these patients, confirming education to teach care givers how to importance of knowing the “baseline that this parameter is merely a symptom of a communicate with these patients and performance” of each patient, this deeper problem, and it cannot be improved how to look for signs of trouble was being highly variable and individualized unless the ills provoking it are profoundly another contribution. Often the cues between patients. addressed. are not the same as typical patients. The goal of treatment was always to When I asked Doreen if there are national Signs such as hyperactivity, sudden return the patient to their own unique organizations or other such baseline. For example groups of caregivers specializing most such patients can’t in hospital based care feed themselves. The job coordination of these patients, of feeding them invariably “To the average caregiver these patients she indicated that none exist. gets assigned to the least appear “alien”, literally and metaphorically. Thus she finds herself a true sophisticated individual pioneer in a field of specialty that in the care team, such as They often cannot communicate their needs has yet to be recognized. Doreen a nurse’s aide. From the like ordinary people and misunderstandings indicates that she would love standpoint of the team, abound. They seem to engage in unruly to see her project extended to expeditious conclusion of St. Joseph’s parent organization such a task is paramount. conduct, and are rapidly labeled a Catholic Healthcare West But what if that person’s “behavioral problem” which encompasses numerous baseline is 45 minutes hospitals in California and to complete their meal? Arizona. There are no such No one seemed to know, moves afoot yet according to or care. “He was silently Ray Charos. frustrated by the nurses”, In a tragic twist of fate, after three years as a sitting, unwillingness to sit, hands and says Doreen about Dr. Popplewell. “They Special Needs R.N., Doreen Bestolarides now fingers in the mouth and many others, all wanted PEG tubes” as a solution to the finds herself alone in the care of these patients. are clues to underlying symptoms or feeding problem. Dr. Popplewell hated Dr. Popplewell, “my guru, my mentor” as she diseases. Caregivers have to be specially this as a quick, impersonal, pragmatic puts it, is ailing with a terminal condition, trained to recognize these. Teaching solution to a time consuming problem, and no longer able to provide care. Doreen which he felt was a way of treating these them how to get these patients to respond still regularly visits him. In a tone of resigned patients like animals. The difference is another challenge. “There are very few dismay, she indicates that there will be no one in approach to the feeding problem developmentally disabled who are totally stepping into the void Dr. Popplewell vacated, exemplified the gap that needed to be unresponsive. They all respond in some who will take on the challenge with the zeal bridged between day to day hospital way or another”, says Doreen. Educating and sense of purpose this unassuming, long caregivers, and advocates of the caregivers on how to elicit a response became serving, and poorly appreciated physician has developmentally disabled. part of her job. In this regard, “it’s a bit like displayed. “Now, everything is hospitalists”, Doreen found herself coordinating the being a veterinarian”, she quips. she muses. It suddenly dawned on me, as she care of some 12 to 18 developmentally Ray Charos, Vice President and Chief made this remark that Doreen Bestolarides disabled patients per month in her Nurse Executive at St. Joseph’s Hospital herself has now taken the baton by default. now unique hospital based position. confirms that the Special Needs R.N. position “You realize Doreen, that from now on, you Eventually, as she became better known, has been successful. Initially instigated are Dr. Popplewell”, I remarked. The Doreen was also called upon to counsel by a grant from the dissatisfied donor, the thought had not occurred to her. She families of newborns with birth defects. position has now been “operationalized”, i.e. smiled back, with a bittersweet expression She feels that her main contribution the hospital is now putting its own financial in her face. has been to create a continuum of care resources to fund it, in addition to that




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A Trusted Friend of the Medical Society is Recognized for a Lifetime of Service

By Moris Senegor, MD We have many accomplished citizens here in San Joaquin County who, unlike their big city counterparts, live quiet unassuming lives. If you run into them in theaters or grocery stores they look like any other average person, bearing no hints of their status.

Often their accomplishments do not happen in big, dramatic leaps, but rather in day-today, year-after-year dedicated, quality work. San Joaquin Medical Society is about to honor such a person who has recently faded into retirement, and his profession, you may be surprised to hear, is one which many doctors find distasteful. Don Riggio is a lawyer who retired six weeks ago. He is not just any lawyer. Don spent his career, thirty-five plus years, here in Stockton, defending physicians in malpractice lawsuits. And he was good at what he did. Anyone who meets Don, a diminutive, bespectacled, soft-spoken, polite man, would never guess what a powerhouse he was in malpractice defense. I knew, for he defended me once, many years ago. The secret to his success, as I saw it first hand, was unadulterated professionalism, meticulous attention to the details of his case, and thorough, realistic client preparation. Don was no showboating TV attorney. Having since encountered this breed on many



occasions, I can attest that in California, within a MICRA environment, such theatrics don’t amount to much. Don himself confirmed this for me in a recent interview. “You don’t have to fear runaway juries”, he said, referring to a MICRA environment. The cases are much more predictable, and consistent both for the plaintiff and defense. With no temptation to go for broke with a jury susceptible to theatrics, settlements are much easier, and professionalism reigns supreme over charlatanism. Don came to Stockton in a roundabout way. Born in Newark, New Jersey to a father who was an engineer for Esso. He spent his formative years moving through numerous cities in the U.S. and Europe, including Bedford in Massachusetts, Lyndhurst in England, Rome in Italy, and Rotterdam in Holland, eventually receiving a high school degree from Seton Hall Prep School back in New Jersey. He then continued on to Boston University and Rutgers, receiving a law degree from the latter in 1967. Having done ROTC, Don’s early career, formative as it would later prove, was in the JAG Corps of the U.S. Armed Forces, initially at the

DMZ in Korea. Having served in a hardship post, he then got to pick a plum post, the Presidio in San Francisco where he met his wife Kathleen, a Manteca girl. Thus not only did he acquire valuable litigation experience in the Army, but he also found a wife who drew him from the East Coast to the West. Don settled in San Joaquin County in 1972, initially working as County Counsel and Stockton Unified School District attorney. In his latter role he was chief labor negotiator for the School Board. As it so happened, during his term there was a teacher’s strike, and they picketed his house. “That’s how good I was as a negotiator”, he now chuckles. His wife was not amused. Soon Don found himself searching for a new job. Joe Diehl was looking for an attorney with litigation experience and in 1975 he jumped ship to his firm which at the time consisted of only four lawyers, Diehl, Steinheimer, Pearson and Riggio. Medical malpractice defense was a large part of Don’s practice from the get go, the work already comprising nearly 50% of the small firm’s business at the time. The rest was general liability work. By the 1990’s the firm had grown to 30 attorneys and 15 partners, and was well recognized for its malpractice defense work. Don Riggio was now exclusively engaged in this area. When the


firm broke up in 1999 after Joe Diehl’s retirement, Don partnered with Mordaunt and Kelly to form a smaller firm, one of many such which emerged from the mother ship, and he continued in his field of expertise until six week ago when he retired. When I asked him how many cases he thinks he handled in his career Don was stumped; “oh, I have no idea”, he said, “thousands?”. He then went on to tell me that his big joy with malpractice defense work was the continuous learning opportunity it afforded. “It never got stale”, he said. Every day there were new medical issues to learn, new experts to be acquainted with, and new circumstances to litigate. “People actually paid me to educate myself”, he quiped, still amazed at this fact. Don is particularly effusive with his praise for Norcal Mutual, which he considers a sterling insurance carrier. He indicates that this company made it easy for him, as a defense attorney to relate to his two clients, the doctor being defended and the insurance company paying the bills. While most malpractice lawsuits are defensible, Don pointed out that occasional mishaps happen, as they do in any profession, and Norcal was always realistic about settling such cases. Most importantly, Norcal always allowed him to mount an “all out defense”, as he calls it, never questioning this deposition or that expert witness as a potential extravagant cost. Unlike other insurance companies, “they gave you carte blanche to do what’s necessary to defend the doc”, he says. In addition to his professional contribution to us doctors, Don’s other gift to our community was his 23.5 years of service, 6 re-elected terms, as a member of the Stockton Unified School District. For his service, his peers in the School Board chose to honor him by naming a school after him. Don reports this with the same unassuming, soft spoken style, downplaying the monumental accolade as if he had won a bowling trophy. Still busy in retirement, Don indicates that every week he makes lists of things to do, and he has a hard time completing them all. These include chores and projects as might be expected. But then there are those piano lessons he always dreamed of taking, but never had time for, because he could not practice. And then there is volunteer work at his grandkid’s schools. Contributing to schools remains a lifetime passion for Don. If Don Riggio becomes half as good at playing the piano as he was defending us doctors, he would have yet more reason to receive a standing ovation from us. But for the time being our gratitude for everything he has done is worthy of an ovation to last multiple curtain calls.




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2011 Lifetime Achievement Award Recipient


Dr. James Morrissey and our 2011 Young Physician Award Recipient Dr. Jeffrey Ing

with a special tribute to Don Riggio, Esq.

Sunday, June 26, 2011

Cocktail Reception 6:00pm / Dinner 7:00pm

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Additionally, we will honor the passing of the gavel from President James Halderman, MD to President-Elect George Khoury, MD





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CANCER SYMPOSIUM for Clinicians and Medical Staff

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8:00 a.m. to 2:30 p.m. September 17, 2011 Registration $20 Continental Breakfast and Lunch included. Please watch your USPS Mail. More information will be mailed directly to your office.










In the late 1960’s, while a student in Ortaokul (middle school) at the

English High School for Boys of Istanbul I developed a tic. It was a peculiar contortion of my upper lip, raised high up, and draping the underside of my nostrils. By necessity

my entire

lower face distorted during the act, and my mouth took on a strange, puckered, rounded appearance. In

the decades to come I was to study neurology and learn the precise definition

of a tic: a sudden, repetitive, non-rhythmic, stereotyped motor movement. Classified as a variant under the heading of “movement disorders” (such conditions as Parkinson’s disease), tics differ in that they are, as neurologists say, semi-voluntary, i.e. the owner of the tic can partially control it. At the onset of my tic, aged around 13, I was still far away from such formal definitions which might have sanitized my act as some sort of medical condition. In the Istanbul of the 1960’s however, no-one, my own parents included, viewed this mysterious contortion of my face as justifiable. It was repugnant to all and insulting to some.




doing a prett y good job. I have since encountered grown ups with more revolting, I remember when this habit fi rst started. It was instigated by “semi-voluntary” habits. When I was a medical student at my uncle Albert, married to my mother’s sister Victoria (yeah, the University of Chicago, doing my Junior Year Obstetrics no kidding, I had a Victoria & Albert in my family; decades & Gynecology clerkships, my small team of students was later my fi rst wife’s parents in Salinas, California were to assigned to a rather disheveled Chief Resident, who was acquire two dogs named Charles & Diana, but that’s another pleasant enough to work with and, unlike many others of her story). Albert once asked me if I could curl my lip up like that. I rank, did not give us much hard time. She would have been tried, I did, and I never again stopped. In fact a more satisfying quickly forgettable were it not for her peculiar habit of picking form of the tic, a “super-charged” version her nose while she was reading medical if you will, was when I lathered records, and then licking the products my upper lip with a good, on her fi nger as though they were ice thick layer of saliva cream – the crunchy kind - and from my tongue, and chewing down her own buggers. “Tics may increase then curled the wet Th is she did in full view of anyone as a result of stress, mass onto my nostrils, she happened to be near, and deeply inhaling the without any inkling that it might be fatigue, boredom, or satisfactory smell disgusting to those who witnessed it. high-energy emotions, of my own oral In fact she was usually so absorbed secretions, Dr. Schraut in her reading that I was certain which can include be damned. Thus, I her actions were semi-conscious, a negative emotions, had a dry version of behavior she probably acquired in such as anxiety.” the act and a wet one. early childhood, and retained into “Tics may increase potential embarrassment now as as a result of stress, an adult, a doctor nonetheless. As fatigue, boredom, or highmedical students we were at the very energy emotions, which can bottom of the packing order and thus include negative emotions, such as anxiety.” (Wikipedia) dared not say anything to this woman about her habit. I am Now you tell me! Yes…All of the above was probably at play sure others did, but I never witnessed them. as my daily repetitions of the act became more prominent A yet higher-up person, also from my medical school days in Ortaokul. “Immediately preceding the tic onset, most was a German general surgeon by the name of Dr. Schraut. individuals are aware of an urge that is similar to the need He was a young attending physician, a protégé of Dr. George Block, one of the most illustrious senior Professors on the staff, to yawn, sneeze, blink or scratch an itch”, continues the defi nition. A tension builds up, and it has to be released, as if specializing in bowel fistulas (for those who don’t know what the possessor of the tic “had to do it”. That’s exactly the way it this is, I recommend that you not research it; suffice it to say was. But why did those grown ups not understand this at the that it involves bowel contents creeping to body parts where time? they don’t belong). A short, rather handsome dark haired man My parents, who correctly identified my behavior as a with a thick German accent, Dr. Schraut had the physique and tic, and labeled it as such, were horrified that their beloved agility of a striker in a German soccer team. His rather gross son, the one who was going to that most prestigious school habit was that whenever he conducted a rectal examination, and of whom they were therefore so proud, could engage in and this he did multiple times a day, he brought out his such a repulsive contortion of his face multiple times a day. gloved fi nger and smelled it. It was a brief smell, not much to Aside from making numerous negative remarks about it, it, but noticeable nonetheless. None of us students had been and imploring me to quit, they did nothing else. I suppose educated in the diagnostic potential of smelling stool, and nowadays, in the U.S. the same act would have precipitated an indeed, to our knowledge, no one else practiced this art. We excursion through numerous doctors and specialists in search made fun of him behind his back, speaking in a fake German accent, imagining what he thought as his fi nger approached his of a remedy, and possibly administration of some psychiatric drug. In the Turkey of the ‘60’s no one went to a doctor unless nostrils, “hhmmm, shtool; smells gut!” they were deadly ill, and there was a strong stigma associated These ghastly habits that were to make my rolling upper lip with seeking psychiatric help, especially for one’s children. look flowery by comparison were no consolation for me in my teenage years as my tic took over my life and promised to make Every adult in my world, the Europeanized, secular, affluent Istanbullus, lived vicariously through the accomplishments it more miserable than my early teen angst that was already




it no matter how hard I tried. of their children, and openly seeking such remedy, in other My embarrassment reached its peak with a male teacher words, admitt ing there was something nutt y-the-matter with who eventually noticed it. His name was Mehmet Ali Akyol, your kid was near social suicide. Eventually my parents got and he taught us history. He was a stocky man with a dark tired of repeated admonishments and learned to live with my complexion and pencil-thin moustache. He carried himself tic. with the high dignity of a mid level Ottoman bureaucrat Th is is about when my teachers at the English High School who demanded more respect than his rank deserved. We began noticing it. In those days we all sat in class behind old found him intimidating, as we did with most male teachers. fashioned desks, lined in multiple rows. I never sat in the front He had a natural aura about him that of the class where one was an easy target induced discipline in us teenagers for oral quizzes. Nor did I sit otherwise prone to anarchy. He at the very back with the also had a special gift for sarcasm, slackers and clowns. I of the Turkish kind, which he preferred the safety “I still pucker my lip freely unleashed on us students. of an obscure middle to this day, but no These usually happened during desk, preferably interminable oral exams when a with plenty of mates one notices any more. single hapless kid stood in front blocking the teacher’s Maybe I do it less of the whole class and fielded line of sight. I was questions from him. Those who thus able to conceal frequently, or maybe were ignorant, and especially those my emerging tic for I have learned to who attempted to B.S. their way quite a while, in a better conceal it.” out of their obvious cluelessness, way I could not do at received the most humiliating home. Eventually the sarcasm at their own expense in inevitable happened. It front of their peers. Th is was a fate was fi rst noticed by several worse than physical punishment which female teachers, some Turkish, was also quite common in Ortaokul. A slap on one’s body, some British. The females were at a disadvantage in our school, and I suppose in our society, because, by virtue of their or even the strike of a wood blackboard pointer used as a whip hurt for a few minutes. The tongue lashing unleashed gender, they automatically commanded less respect. Th is by Mehmet Ali Bey, and the resultant disgrace, could last for they knew well, and they were very sensitive to any sign of days, indeed for some, a lifetime. disrespect. Unlike my unsophisticated parents, who despite And so it was that Mehmet Ali Bey eventually came their lack of education, correctly identified my condition, to notice my curling upper lip, as I attempted to conceal it these female teachers took personal offense at my curling lip behind my classmates in those middle row seats. Since he and protruding mouth. They thought I was sending them taught us history for several years, it was eventually bound some kind of personal message. Nowadays, as an adult, I can to happen sooner or later. Unlike his female colleagues he just imagine what they must have thought. These women did did not take the cowardly route of confronting my parents. not react to me in open class. Instead they called my parents In his usual direct, unabashed style, he took me on in front of and complained that I was making faces at them, that they the whole class. One day he interrupted his lecture, looked were outraged and insulted. My disrespectful behavior had to directly at me and told me, much to the amusement and stop immediately. laughter of my classmates, that what I was doing made my Each such complaint resulted in a new eruption at home face resemble a horse’s ass right before it was about to defecate. from my parents who, exhausted and disappointed as they In those days horse driven carriages were still quite were, - puzzled too - had no recourse other than talk me out common in Istanbul, especially in the Princess Islands where of what was now an impossibly entrenched tic. All this did motor vehicles were not allowed, and the main transportation was embarrass me further, hopeless as I was, and try to invent consisted of donkeys or rickety carriages known as a excuses for why I felt the compulsion to smell my upper lip. “payton”(phaeton).. If one rode next to the driver, and us kids My most common excuse was, “but, it smells good!”. Th is loved doing that, one inevitably encountered horses that threw them into more frenzy. No amount of complaining or defeacated copiously as they trotted along, pulling the heavy lecturing could stop my now compulsive act. And so I went carriage. There was not one kid in our class who had not through years of Ortaokul and then Lycee curling my lip and witnessed a horse raising its tail and puckering its anus as it experiencing the consequences, ashamed and unable to stop




got ready to do the act. Thus Mehmet Ali Bey’s imagery struck a funny bone in everyone. Needless to say, my face being likened to a horse’s anus was the height of embarrassment. It would have been humiliating at any age, but it especially stung in those sensitive, angst ridden teenage years.   Somehow my parents discovered about Mehmet Ali Bey’s comment, and they found it even more amusing than my

classmates. Having been frustrated by the non-ending tic for much longer than anyone in the school, they could not have put it to words any better than my self-important history teacher. They repeated the “horses ass” image to me for many years to come, well into my adulthood as my tic persisted. In the meanwhile I kept curling my upper lip, and puckering my mouth helplessly, because I needed to, regardless of how anyone reacted. I learned to develop a thick skin and deflect derisive mockery at my expense from everyone, including my closest family, not that it did not hurt. It was to serve me well in years to come as I went through a surgical residency where public humiliation and dressing-down by superiors was an integral part of the order, a military-like experience. To this, I suppose, I have my tic to thank for.   I still pucker my lip to this day, but no one notices any more. Maybe I do it less frequently, or maybe I have learned to better conceal it. No one has commented on my residual tic, nor has anyone taken offense in many years. I no longer ride horse driven caring support carriages. But on those rare guidance occasions, usually on vacation choices somewhere, where I encounter a defeacating horse, I can’t help but think of Mehmet Ali Bey. In a strange way the imagery that he attacked me with has now come around, to be associated with his own visage. It is his well groomed, seriously moustachioed face I see as the horse lifts its tail in that special, determined way that presages the coming of farts and feces. There in the smelly droppings of the beast lies an almost holographic image of this influential man from my past, silently glaring at me as the feces fall to the ground.

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As a rule of thumb, adopting a new technology is never easy or foolproof. Even Microsoft is famous for not getting products right until the second or third try. Why then should health information technology be any different? Granted, the advantages that a well-done system could offer are impressive. Electronic medical records could follow a patient around from physician to physician, saving time and helping to prevent errors. The stacks and stacks of paper-based records found in physician offices and storage warehouses would be a thing of the past. Medical alerts and reminders could be automated, errors due to illegible handwriting would be eliminated and customized views and reports could be easily generated. And while you can probably grasp easily that EHRs might take a while to mature due to all the complexities inherent in patient care from a variety of clinicians, youâ&#x20AC;&#x2122;d think that e-prescribing systems would be vastly simpler to implement. You might be wrong.




On the Other Hand E-prescribing has often been promoted as one key answer to improved patient safety. In an e-prescribing system, physicians enter a prescription on a computer or handheld system and simply e-mail it to a participating pharmacy. This set-up eliminates errors due to illegible handwriting or missed drug-to-drug interactions among other items. The system is also more efficient—phone calls between physicians and pharmacists are greatly reduced and refill authorizations can be automated.   And the system is purported to reduce health care costs. In one example, according to the Centers for Medicare & Medicaid Services, Medicare beneficiaries experience as many as 530,000 adverse drug events every year due in part to negative interactions with other medication or lack of information about a patient’s medical history. The e-prescribing initiative has been predicted to save Medicare $156 million by avoiding adverse drug events.   The problem, as with so much in health care, is the potential for abuse of the e-prescribing system by insurers. Health insurers already use protocols such as prior-authorization to delay care and those protocols are having a significant impact on physicians. The American Medical Association recently released a membership survey on preauthorization which found that more than half (58 percent) of physicians experience difficulty obtaining approval from insurers on 20 percent or more of preauthorization requests for drugs. (For more on the study see “Preauthorization Policies Impact Patient Care” on page 17 of the February 2011 edition of Southern California Physician).Insurers have financial incentive to shape e-prescribing policy and delivery mechanisms to ensure that prior-authorization remains an onerous process for physicians, and that information available to physicians at the point of care remains limited.   There are other problems as well. Not every plan and its formularies



are covered by the software. And, even if they were, formularies change frequently making software updates a challenge and a hassle. Likewise, not all pharmacies participate in e-prescribing, which limits choices for both physicians and patients. Potential Pitfalls Nothing illustrates the potential pitfalls of e-prescribing better than a recent pilot project by the California Public Employees’ Retirement System. The pilot program launched in June of 2009 and continued through June of 2010. Co-sponsored by health plan partners Anthem Blue Cross, Blue Shield of California and Medco Health Solutions, the goal of the program was to accelerate the use of e-prescribing technology in large physician groups, and track results such as the number of identified preventable adverse drug events, use of e-prescribing, and generic drug and formulary prescribing rates. Five physician groups representing more than 12,000 doctors participated in the pilot—San Jose Medical Group, John Muir Physician Network, North American Medical Management of California, Sante Community Physicians and Hill Physicians. On the surface, the pilot program showed some impressive results—new e-prescriptions and e-renewals more than doubled and all of the participants believed that e-prescribing increased drug safety for patients. In fact, 50 percent of prescribers made changes due to drug alerts from the system. And 67 percent claimed to have improved efficiency during the patient visit with the system.   The problems, however, are a little more insidious. First, the CalPERS e-prescribing software contained an algorithm that automatically replaced a brand name drug with a generic drug when available. Certain brand name drugs were excluded completely from the algorithm, which could be a serious problem for patients that may have interactions with a generic version of the medication. The end result was that at

the end of the study, CalPERS generic dispensing rates were 7 percent higher with e-prescribing, reaching 77.4 percent of those who used e-prescribing versus those who did not during the second quarter of 2010.   Prescribers also had a long list of complaints about the pilot. For example, they cited issues with performance, lack of routine database updates, lack of transparency on true capabilities, workflow, reporting capabilities and the limited number of pharmacies enrolled among others. Cost was also mentioned as a factor. AllScripts, for example, charges $20 per month per doctor for the service.   Coming to a Theater Near You Like it or not, e-prescribing is coming to you faster than you may realize. Starting back in 2009, the Medicare Improvements for Patients and Providers Act of 2008 authorized the Centers for Medicare & Medicaid Services to pay a bonus to physicians for successful e-prescribing. In 2009 and 2010, physicians who successfully used e-prescribing received a bonus payment of 2 percent of their overall Medicare reimbursement.   In 2011, however, the reward for e-prescribing is beginning to phase out, while a penalty for not e-prescribing begins in 2012. The e-prescribing bonus payment will be 1 percent in 2011 and 2012, and 0.5 percent in 2013. The penalty for not e-prescribing will be a reduction in Medicare reimbursement by 1 percent in 2012, 1.5 percent in 2013, and 2 percent in 2014. Doctors who e-prescribe infrequently or who can demonstrate a hardship adopting e-prescribing might not be eligible for the bonus payments or penalties. The challenge for California legislators will be to institute patient privacy protections and set standards for e-prescribing that will preserve the physician-patient relationship and prevent insurers from exploiting HIT initiatives such as e-prescribing to further deny, delay, or hinder patient access to care.


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