Spring 2011

MINDS on the

EDGE

Spring Issue 2011 SPRING 2011

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While incremental changes are made along the way, you’ll still need to continue to make important decisions about health insurance for you and your employees, especially when it comes to managing premium costs.

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* Marsh and the Association do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.

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SAN JOAQUIN PHYSICIAN

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Volume 59, Number 1 • March 2011

{FeATUReS}

22 34 50 56 SPRING 2011

CAISSON DISeASe

Its origin and the Brooklyn Bridge

RISK MANAgeMeNT

{DePARTMeNTS} 28 NeW FACeS AND ANNOUNCeMeNTS 38 CMA FOUNDATION ReSOURCeS

Tips for lowering Ambulatory-Care Risks

40 PUBLIC HeALTH UPDATe

MINDS ON THe eDge

60 CMA WeBINARS

Mental Health Issues

2011 Vaccination Requirements

64 ALLIANCe NeWS SJ COUNTY NAMI

A practical resource

66 IN MeMORIAM

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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

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Gabriel K. Tanson, MD

Ramin Manshadi, MD SPRING 2011

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MeSSAge Message>>executive ManagingDirector Editor

the Wagons “Circle Individually, we–are MICRA is under Attack! one drop, but together we are an ocean.”

A fight is brewing in the state legislature, and like many fights, this one is over money. But this one involves insurers, legislators, trial attorneys, and, at the core, our physicians. Since the passage of the Medical Injury Compensation Reform Act over thirty years ago, many attempts have been made to modify or strike down MICRA, especially its cap on non-economic damages, which remains at $250,000, the same as it was at its passage.

The last major to change MICRA occurred in 1999, with the introduction Th ose words were legislative spoken byattempt Dr. Susan Kaweski, San Diego County Medical Society’s new of AB 1380, which took aim at revising the non-economic damages cap upward, and then continue president during her recent installation ceremony. She further stated, “and united we must be,to adjust the cap by referencing the Consumer Price Index. This time, lawmakers are being approached especially in these tumultuous times” to which I couldn’t agree more. These are difficult times by trial lawyers in an education for physicians and the medical community as a whole. Far-reaching changes are happening attempt aimed at convincing at a break-neck pace in Washington,“A D.C.,study and at our state capital. As Dr. Kaweski sononbyownCalifornia’s former them that the cap needs to be eloquently states, we need solidarity amongst our ranks like never before.

One voice may be raised. And while Gov. Brown partisan state legislative analyst found ignored and no one notices, but when a chorus sings in harmony – it’s prett y hard to not take has not taken a stance on the notice. issue, he has stated that he’d that merely doubling the non-economic be willing to consider raising cap to $500,000 willyouincrease Membership is often perceived as a damages non-essential cost of doing business. Something sign the cap. up for out of habit or peer pressure.

Some see it as a duty, having joined early in their medical Many attorneys and healthcare costs in California by $9.5 career andorganizations never taken take the opportunity to become more involved or seek any of our services attorney and sowith sadly, never truly see the valuebillion of membership because their owntrickle-down perception is skewed issue MICRA’s $250,000 annually.

The non-economic cap,of little or no value. Nothing could be further from the truth. towards it beingdamages something bebenefi devastating.

Healthcare noting that if not it had been Membership only provides you effect extensive will personal ts, but opens a wide array of indexedtoforyour inflation, it would services practice managers and staff as a whole.

Beyond that, we could fi ll several pages premiums will increase. Fewer people be just $1,000,000. with theover extensive list of services CMA provides as well.

Consumer Attorneys of will be able to afford insurance.”

California states thatmembership, patients To truly appreciate you have to experience it or ofatCalifornians least appreciate the extensive Lisa Maas, executive director who have legitimate claims lobbying taking place every day on your in both Sacramento Alliedbehalf for Patient Protection (CAPP)and D.C. For those are unable to find attorneys to members who have had to call us and request assistance with a collection, billing, coding, take their cases. contract or personnel issue, membership value is easy to comprehend and seldom enters Insurers maintain that MICRA’s major provisions have kept premiums lower, increased access their thoughts after help has been rendered. For those that have attended our annual House to health care (especially through self-insured public institutions who provide care to uninsured ofpatients), Delegates or yearly visit to the capital for Legislative Day, value is again securely reinforced and has resulted in early and fair settlements (with fewer frivolous lawsuits going to trial). because they seephysicians first-handare thecaught impact unifiedasvoice in prepare these arenas thought.staying Meanwhile, in our the middle bothhas sides to testofMICRA’s power. Physicians and clinics fear that if MICRA is changed, rates will rise, and doing business in My hope iswill youbehave themore opportunity California thathad much difficult. to see first-hand the value of your membership and feel positive about the contribution making the future of medicine a part of Your SJMS/CMA membership has you’re never been moreinneeded or valued by bothbyofbeing us. Without your something yourself. Possibly even an ocean. support wemuch cannotbigger beginthan to adequately counter this threat and without our strategic alliances, MICRA will likely be radically changed.

All the Best!

All the Best!

MikeSteenburgh Steenburgh Mike Executive Director Executive Director

66 SAN SANJOAQUIN JOAQUINPHYSICIAN PHYSICIAN

Moris Senegor, MD Moris Senegor, MD Editor Editor Editorial Committee Editorial Committee Moris Senegor, MD Shiraz Buhari, MD Kwabena Adubofour, MD Kwabena Adubofour, MD Mike Steenburgh Robin Wong, MD Michael Steenburgh William West Managing Editor Managing Editor William@sjcms.org Sherry Roberts Creative Director/Graphic Designer Michael Steenburgh sherry@sjcms.org Contributing Editor Contributing Writers Sherry Roberts William West Creative Director/Graphic Designer Carmen Spradley sherry@sjcms.org Cheryl England Sharless Hand Contributing Sources California Medical Association Contributing Sources Los Angeles County California Medical Association Medical Association Los Angeles County San Diego CountyAssociation Medical Society Medical San Diego County Medical Society The San Joaquin Physician magazine is published quarterly by the The San Joaquin Physician magazine San Joaquin Medical Society is published quarterly by the San Joaquin Medical Society Suggestions, story ideas or completed stories Suggestions, story ideas or written by current completed stories San Joaquin Medical Society written by current members San Joaquin Medical Society are welcome and will be reviewed by members the Editorial Committee. are welcome and will be reviewed by the Editorial Committee.

Please direct all inquiries and submissions to: Please direct all inquiries and submissions to: San Joaquin Physician Magazine 3031 W. March Lane, Suite 222W San 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: gena@sjcms.org Fax: 209-952-5298 Email Address: gena@sjcms.org Medical Society Office Hours: Monday through Friday Medical Society Office Hours: 8:00 AM to 5:00 PM Monday through Friday 8:00 AM to 5:00 PM

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From The President < MeSSAge

Are you a physician or a nurse?

Will The Real Doctor Please Stand Up Decades ago there was a popular television game show known as “What’s My Line?” The object of the game was for the contestants to ask questions of the “mystery guest” who was a well-known celebrity or perhaps an average citizen.

The mystery guest would hide among several decoy guests in hopes of concealing his occupation (meaning his line of work) or his identity.

The questions could only be answered with “yes’ or “no” answers and the decoys were also giving answers designed to confuse the contestant. Once the contestant offered up what he thought was the correct identity, the host of the show would then say, “Will the real ‘Mystery Guest’ please stand up?”

I thought of “What’s My Line” today as I read that a new degree program in nursing known as the Doctor of Nursing practice may soon open at the University of California. It seems that nowadays there are so many professionals in many different fields of work that have taken to calling themselves “Doctor.”

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There are scientists in industry and in academia who hold the Doctor of Philosophy. Lawyers used to earn the Bachelor of Laws degree but now it is know as the Juris Doctorate. Interestingly, the master’s level law degree is still known as the Master of Laws degree.

In our own health care arena there are many paraprofessionals who hold doctoral level degrees such as optometrists, chiropractors, audiologists, dentists and so on. Each of these pertains to certain specialized areas of practice. There are many other fields with doctoral level degrees such as engineering and veterinary medicine and even divinity.

I heard that one of my cousins had recently graduated from the University of Central Arkansas’s program in Physical Therapy. >>

An MD or DO will have twelve years of education after high school just to get started in an independent practice. A DNP will only have eight years after high school in a non-medical school program, yet that nurse is supposed to also practice independently.

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

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Message > From The President

JOIN THE FIGHT

TO PROTECT MEDICINE Every cause needs a powerful champion. This spring, you have an opportunity to become a champion for medicine and your patients, when more than 400 physicians, medical students, and CMA Alliance members come to Sacramento for CMA’s Annual Legislative Leadership Conference.

At the conference, you will hear about the issues facing medicine in Sacramento from an impressive array of experts who live and breathe the politics and policy on these issues. Armed with this knowledge, you will then head to the Capitol to meet with legislators to make sure the voice of doctors is heard in Sacramento.

WILL YOU JOIN US? Call the San Joaquin Medical Society at (209) 952-5299 to RSVP We will provide free shuttle service from the society office departing at 7:00am and make arrangements for us to meet with each of our state representatives following the luncheon and be back to Stockton by 5:00pm.

C A L I F O R N I A M E D I C A L A S S O C I AT I O N

37th ANNUAL LEGISLATIVE LEADERSHIP CONFERENCE Tuesday, April 5 • Sacramento • Sheraton Grand Hotel

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What was the degree she earned after three years of study?

You guessed right if you thought Doctor of Physical Therapy. I’m not knocking my cousin’s hard work in school.

These therapists have to earn a baccalaureate degree before entering the physical therapy program.

Now, correct me if I’m wrong, but when I hear of physical therapists earning a doctorate in their field, I am starting to feel suspicious that there is some credentials inflation going on here. After all, they are not diagnosticians; and besides, how many decades of training does one need after high school to judge the effects of the treatment process?

For decades now, schoolteachers have moved on up the training ladder to earn the Doctor of Education degree.

What does this degree mean and why is it necessary? Jack Gourman who was a Professor of Political Science at California State University asked this question for most of his career and could not find a valid reason for compelling a teacher to undergo so many years of graduate school for the privilege of evaluating the education process. In fact, some as coining the phrase “piled higher and deeper,” in reference to the Doctor of Philosophy degree, which later spawned the Doctor of Education degree, has credited Dr. Gourman.

Last year Dr. Larry Frank, our Immediate Past-President introduced us to Dr. Nurse. This Dr. Nurse was Dawn Bucher. She was profiled in the Wall Street Journal as a recent graduate of a doctoral program in nursing at Columbia University. This new nursing degree known as the DNP or Doctor of Nursing Practice is designed to train nurses to function as diagnosticians with full prescribing authority and hospital admitting privileges. The entry criteria are a suitable GRE score and possession of a Nurse Practitioner degree or a similar background. Nursing schools have, for decades, awarded the Ph.D. to nurses who completed a rigorous research oriented program and planned to perform clinical research. This Ph.D. degree is well respected in academic circles. However, there is a growing criticism of the Doctor of Nursing practice credential because it would allow a nurse to function identically to a primary care physician. Susan Chase and Rosanne Pruitt are two nurses who hold advanced practice degrees in nursing and are well respected in the academic community. They jointly wrote an article in the Journal of Nursing Education criticizing the DNP degree as unnecessary for a nurse who already holds the Nurse Practitioner credential. Furthermore, the authors stated >>

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Message > From The President that nursing school is not an acceptable alternative Mart and Walgreens stand to earn huge profits by background for a medical diagnostician. Diagnostics opening clinics that are staffed by nurses with the constitutes the practice of medicine, according to inexpensive DNP degree. We can expect to see a big Chase and Pruitt. push to get more nurses out in the field with this new An MD or DO will have twelve years of education degree. after high school just to get started in an independent What happens when legal restrictions against practice. A DNP will only have eight years after nurses practicing medicine are lifted? This has already high school in a non-medical school program, yet happened in the Midwest states via the Medicare optthat nurse is out provisions. supposed to When also practice advanced independently. practice nurses The right to prescribe is the key to the The clinical are granted purse in both private paying insurance ramifications legal parity with of these physicians, the and in Medicare and Medicaid. alternative nurses quickly Since most states do not bar the practitioners move out of corporate practice of medicine, on medical their traditional care are jobs in the many retail chains such as Wal-Mart obvious to medical care and Walgreens stand to earn huge physicians. machine and profits by opening clinics that are The patients displace the on the other primary care staffed by nurses with the inexpensive hand may doctors from DNP degree. We can expect to see have no idea their practices a big push to get more nurses out in who is treating and drive them them. The completely out the field with this new degree. patient may of the market. only know Nurses are not what he sees, subject to the and what he does corporate bar and see is a person in a white coat calling himself doctor. can be employed by hospitals and even businesses Fortunately, in California and in a few other states, with little medical care experience while earning a tidy there are “truth in credentialing” laws in the works that profit for their employers. The financial windfall can will mandate a clinician to wear a nametag that clearly be huge and the political pressures on government indicates that clinician’s education background. These regulators are obvious. laws were not easy to pass and in the future we can The future of medicine under this scenario is clear. expect legal challenges and heavy political lobbying on If a patient is wealthy enough and willing to spend his behalf of the alternative professionals who hold these own hard earned money on a real physician then he dubious credentials. can choose to do so. On the other hand, if the patient The right to prescribe is the key to the purse in has only modest means or is enrolled in a government both private paying insurance and in Medicare and sponsored medical plan, then that patient will have to Medicaid. Since most states do not bar the corporate settle for the nurse who merely calls himself “Doctor.” practice of medicine, many retail chains such as Wal-

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Message > From The Editor

Reflections on Medical Staff Leadership What Machievelli Can Teach Us

The following, the second in a series of essays reflecting on the Medical Staff , was presented on the occasion of my farewell Quarterly Staff Meeting as St. Joseph’s Chief of Staff, in 2008. It took many years to formulate my ideas, and nearly nine months to prepare the speech I delivered on that occasion, even tough that day I appeared to be talking off the top of my head. For those who recall the meeting, I apologize for the déjà-vu. For those not there, I hope it presents their experiences in a new light.

As humans, regardless of our age, education or social class, we are bound by the same psychological rules that govern our lives, and as it so happens sometimes, those of the common laboratory rat and pigeon.

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.

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As a young physician observing Medical Staff activities, I was initially a spectator and from the very beginning, sensed a political process that seemed akin to our society at large. We had elections, votes, some semblance of parliamentary procedure, and a seemingly democratic process. However as I became more involved, differences emerged from general government.

For instance Medical Staff elections seemed largely pre-determined; there were no campaigns, and no formal political parties. I eventually joined the Medical Executive Committee (MEC) and witnessed behind-thescenes governance. Now the process seemed yet more idiosyncratic, and more different from government at large.

The largest difference I noted was that the Medical Staff did not contain the three distinct branches of national government:

executive, legislative and judicial.

Instead, executive and legislative were fused into one body, the MEC and its subsidiaries, with hospital administration an uneasy partner in the process. The judicial body was conspicuously absent as an independent entity, with some fragments also mainly in the domain of the MEC. This was a prominent source of frustration among physicians who, when seeking recourse against MEC decisions, had to appeal to none other than the same MEC itself for reconsideration. In my many years of service, I witnessed several impassioned appeals and never once did the MEC reconsider or change its actions in question.

To be sure, there are clauses for due process in all hospital bylaws which can activate a judicial body, usually when action is taken against a physician’s privileges. These are seldom invoked; in my decade in

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the MEC I never witnessed such a hearing. For judicial like the Medici family of his time. The third is the people recourse physicians have to step out of hospital governance at large. If any of these three access uncontrolled power, and appeal to society at large and its legal system. This is also we end up with a deranged form of government. In the rarely used due to its cost in money and time. case of a king or a strong-man, such absolute power leads So exactly how did the Medical Staff reflect society at to tyranny. In the case of the aristocratic class, unchecked large, and why did it have to do so? I accidentally stumbled power results in oligarchy. Finally with the people at large, on an answer in the first few months of my term as Chief of their uncontrolled power leads to mob-rule, the worst form Staff, and it came from an unlikely source that I happened of government. In Machiavelli’s opinion a republic is a blend to be listening to at the time. It was a Teaching Company of these three elements, a cocktail if you will, where each is course on CD about Nicollo Machiavelli (1469-1527), the checking the other’s tendencies for absolute power. Different Florentine philosopher and political scientist. societies can devise different blends of these three elements, In current times thus resulting in republics Machiavelli is as diverse as the U.S., considered a villain China or Korea. for his advocacy of As I studied When us modern Americans think of a inhumane ruthlessness Machiavelli, it dawned “republic” we think of it as a reflection in consolidating and on me that this of ourselves, a democratic society with exercising power, fundamental concept duly elected members of government formulated in his of blended power is famous book “The indeed the way in which whose sole purpose is to serve the Prince”, a ubiquitous hospital Medical Staffs society. But what about the People’s College staple. What reflect their parent Republic of China, the Republic of North most people don’t society. To translate know is that this work to Machiavelli’s Korea, or the United Soviet Socialist represents only one side definitions, for an Republics (USSR). How do they fit of Machiavelli, the one absolute leader we can in?

How can they call themselves a exploring tyrannical substitute a “Chief”, “republic” and get away with it? rule. He was also a be it Chief of Staff, student of republics, Chief of a department, - Moris Senegor, MD modeled especially after or CEO of a hospital. the pre-Empire Roman Such “Chief”’s are Republic, and wrote a generally vested with much larger work on this subject, lesser known to college enormous powers, and thus have a threatening potential students because it is not as succinct as “The Prince”. In this for tyranny. The analog of aristocrats in the Medical Staff work labeled “Discourses on Livy”, or “Discourses” in short, are those who serve in important Committees. Taking away Machiavelli outlines the notion of a “republic” as he sees it. traditional inheritance as a source of aristocratic title, such When us modern Americans think of a “republic” we physicians otherwise are curiously similar to the traditional think of it as a reflection of ourselves, a democratic society gentry. In any body-of-physicians there are a select few that with duly elected members of government whose sole indefinitely rotate through Committees, the remainder being purpose is to serve the society. But what about the People’s politically apathetic. They become a group of self-appointed Republic of China, the Republic of North Korea, or the elite by default, and their actions can be viewed as elitist and United Soviet Socialist Republics (USSR). How do they fit potentially oligarchic by the rank and file. Finally the “people in? How can they call themselves a “republic” and get away at large” are those apathetic physicians who occasionally with it? attend quarterly Staff meetings, have no inkling of how the Machiavelli provides a unified definition which fits all the political process runs, and thus act as the “common person above. According to him there are three elements in a society in the street”. They are the ones most apt to complain about with potential for political power. The first is an absolute the inappropriate or unjustified power of the other two monarch, like a king or dictator. Next is the aristocratic class, groups when confronted with policies they dislike. Releasing

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Message > From The Editor the reins of power to them ( I literally used to call them “the bodies, is at the top of the enemies list. Then there is the mob” when I was Chief of Staff), can be disastrous. As our much despised and feared Joint Commission, the hospital Founding Fathers knew well, there had to be a powerful elite accrediting body, with its seemingly arbitrary, faddish, and body, in our case a Senate, to check the potential for mob cumbersome rules. Medicare, Medi Cal, private insurance rule. Someone had to issue unpopular or unpleasant rules for companies, hospital parent companies such as CHW, the ultimate benefit of the disgruntled recipients, the people Kaiser, Tenet etc., all populate the list of external threats at large. with their unpopular demands upon the Medical Staff, at If one now applies these analogies to the day-to-day times threatening to end certain physician practices. These functioning of the Medical Staff, all of the fault lines in threats, unsavory as they are, remain essential in keeping hospital governance cohesiveness within the suddenly become Medical Staff. There is no clear. The sources easier way to resolve heated of tension in this debate on an issue of policy So what are we to make of my opinion world are those very than by saying, “well, that’s that us physicians who practice in same checks and what the Joint Commission balances that keep demands we do!”. hospitals reflect our parent society as a the political system All three elements of mirror republic? Shall we stop bickering in equilibrium. the hospital Medical Staff with each other and engage in “love “Checks” are not intrinsically realize that pleasant to those “united we stand, divided thy Chief” or “love thy CEO”? Shall we on the receiving we fall”, and thus in most quit complaining about policies issued end who would healthy Medical Staffs the by our MEC? Shall we ignore external rather take their inherent tensions of the regulators and their pesky irritations? power further than micro-“republic” remain it should go. We see restrained, and held back The answer is no, no and no. this phenomenon from turning the system - Moris Senegor, MD regularly in our into a house of cards. I parent society with submit to you that if these countless debates external threats were to about the limits of disappear, unrestrained Presidential power for instance. In the Medical Staff, Chiefs tension would explode like a volcano and there would be no issue edicts, manipulate meeting agendas, and engage in way to keep the Chief, aristocrats and mob from engaging behind-the-scenes politicking in attempts to expand their in the equivalent of civil war. This, I hear occasionally does power. The potentially oligarchic elite as a collective body happen in certain hospitals, but I do not know of any local issue policy decisions from say the MEC, which are received examples current or historic, within our County, where such by howls from the rank-and-file on staff who scream that dysfunction has occurred. the MEC has no such power or authority over their hospital So what are we to make of my opinion that us physicians practices. They then attempt to vote themselves out of who practice in hospitals reflect our parent society as a political predicaments or unpopular policies. Chiefs and mirror republic? Shall we stop bickering with each other and CEO’s are accused of tyranny (usually with alternative engage in “love thy Chief” or “love thy CEO”? Shall we quit terms), the “aristocrats” forever rotating through the complaining about policies issued by our MEC? Shall we committees of elitism; and these leaders in turn retort by ignore external regulators and their pesky irritations? The telling the physicians-in-the-street that they do not know answer is no, no and no. What we should do is continue the what’s for their own good. same way as we always have, but instead of wondering what’s Societies remain cohesive for various reasons, a major wrong with us, realize that existing tensions within the Staff one being enemies or external threats. Medical Staffs are no are healthy, and “that’s the way it is”. Not to mention, “that’s different. The U.S. Government and its various regulatory the way it should be”.

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We are Seeking Your Lifetime Achievement and Young Physician Award Nominations Don’t miss the opportunity to recognize a fellow colleague who has inspired or mentored you in your own medical career. Each year our society recognizes two outstanding physician members who have demonstrated exemplary care – not just for their patients, but also their community and the world in which they live.

We will accept nominations via fax or mail for each of these awards up to Friday, March 18, 2011. Please provide us detailed information on your nominee’s accomplishments and community involvement.

The Young Physicians Award is exclusive to physicians under the age of 45. Nomination Forms are available online at www.SJCMS.org and have also been mailed directly to each member.

Our Nominating Committee (consisting of all past presidents and past LTA recipients, some of which are pictured here) will evaluate all submitted nominations for each of these awards.

The following criteria will be taken into consideration for these prestigious awards: • Dedication to high standards of medical practice.

• Dedication to the care and well being of the patients of their community.

• Dedication to the support of physician colleagues in the medical community.

• Involvement in humanitarian activities.

• Involvement in community civic activities.

• Leadership in the medical and/or civic communities.

Your input in this process is very important. To submit your nominations for the Lifetime Achievement Award and/or the Young Physicians Award please fax them to 209-952-5298 or, should you have any questions please call 209 952-5299.

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Dear SJMS member, l of having a nationa

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tions, databases, ana da en m om ec l r ca ini cl We create unbiased ive webinars. d l an s, am gr ro CME p ccreditations rned it the highest a ea as

y h vit cti bje d o ysicians and evidence‐base bscriptions from ph Prescriber’s Letter’s su nd s a cie en ag to provide our E accrediting tanding relationships from the major CM g‐s on e l av e h . W er worldwide h institutions as Kais medical institutions credited CME to suc ac rary of or Lib ns al tio ion da at en N m D, scape, WebM unbiased recom ed M s, kin op s H hn plo ians em yed by derson, Jo ealth Canada, physic nationwide, MD An , H DA , F lth ea H of Institutes d now SJMS. Medicine, National lus many others – an , p .K. U he d t an lia Austra the governments of n Steenburgh, so whe

cutive Director, Mike xe r E e ou er r y w fo we rd s, ga gh re ysician We’ve always had hi fit for San Joaquin ph n to provide a bene tio ho have been sa s w er an nv ici co ys d a ph te he initia any San Joaquin e m th t Browne, te cia re pp e a of our Board: Rober rs be em pleased to do so. W M as rs ea ri, hing for so many y Ted Lee, Darius Noo integral in our publis k, Raymond Wong, ac rim ss Steele. n P Ru re nd Da i, a y, um oll oz nn ark, John Mor M ey Jerry Jones, John Co Gu o, ag rs ea Stadtner and y Sheela Kapre, David ysicians, all San ese San Joaquin ph th

of ns tio bu tri on rk, and the c rescriber’s Letter Thanks to Mike’s wo

to get the unbiased P le ab be w no embership in SJMS. ill s w h year, as part of m ac Joaquin physician s e dit re E c CM lus over 25 recommendations, p o know each sed that we will get t ea

pl m I a e. im g t ors for a lon e we can help.

We’ve been neighb o contact us anytim e t fre el Fe r. te et other even b

Editor‐in‐Chief Jeff Jellin, PharmD,

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95219 Ln, Stockton, CA , 3120 W March er nt Ce ch ar 49 se 2.22 Therapeutic Re 40, FAX: 209.47 TEL: 209.472.22 ch.com ar se Re tic eu ap Ther SPRING 2011

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SPRING 2011

Caisson Disease Its Origins and the Brooklyn Bridge

Moris Senegor, MD

Author’s note: The fascinating history of the discovery of decompression sickness summarized below is forever associated with the Brooklyn Bridge in the United States, even though there were other precedents. I became interested in the subject after reading a book entitled “The Great Bridge” by the historian David McCullough. The account below closely follows Mc Collough’s book, and at times quotes him directly. For those interested in the subject I strongly recommend that they read the much more detailed story recounted in this book. - Moris Senegor M.D.

W

e are all familiar with decompression sickness (“the bends”) as a condition that affects deep sea divers. It is also known as caisson disease. Has anyone wondered what the word “caisson” means? Frankly, for all the years I have been a doctor I presumed that it was the name of some then famous, now obscure, probably French physician that described the condition. Nothing could be further from the truth. “Caisson” is a civil engineering term, initially associated with bridge building in the 19th Century, especially the Brooklyn Bridge, which at the time of its construction was viewed as the latest wonder on earth, to rival the classics of Herodotus.

To briefly review the disease, decompression sickness afflicts those who are subjected to high ambient pressure

SPRING 2011

whether it be air or water. When these individuals return to normal atmospheric pressure they are at risk for forming gas bubbles within their blood vessels, leading to ischemia in the distribution of whatever vessel is affected. Thus there are a variety of symptoms associated with the condition ranging from muscle cramps, joint pain, and skin changes like mottling, to pulmonary symptoms such as cough, chest pain and shortness of breath. It is however, the neurologic symptoms that are most dangerous. They range from headaches and dizziness to paralysis and death, depending on how badly the brain is afflicted. The onset of symptoms varies from a few minutes to around 24 hours, most within the first three hours of decompression. >>

SAN JOAQUIN PHYSICIAN

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Feature > CAISSON DISEASE

The pathophysiology of the condition has to do with inert gasses, mostly nitrogen, being driven into tissues during the period of compression, which then dissolve back to the bloodstream during decompression. The likelihood and severity of occurrence depends upon the duration of exposure to compression, and the speed with which decompression occurs. Avoidance of the condition, i.e. prevention by slow decompression, is the best cure. For those who do experience what is also known as “the bends”, the treatment is hyperbaric oxygen, or if this is not available, recompression, with subsequent slower decompression. Decompression should be achieved at or slower than 20 minutes for each atmosphere of extra pressure encountered to prevent the condition.

Mainly a diver’s disease, decompression sickness can also afflict flyers in unpressurized aircraft and spacewalking astronauts. Every year around 1000 divers are estimated to experience symptoms of the bends, around 2.8 cases per 10,000 dives. When first encountered in the 19th Century however, the disease initially hit construction workers in devices known as pneumatic caissons. These were ingenious devices, still in current use, to dig and create deep foundations for large structures, many under water.

A caisson in essence is a large air-sealed box with an open bottom. In the 19th century, construction crews entered and exited the box through an airlock connected to the outside

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world via a staircase. The caisson chamber was filled with pressurized air. Construction crews inside the caisson dug earth from its open floor, and debris was removed through another tube. Progressive digging literally pulled the floor from under the box, causing it to descend into the earth. Naturally the rate of descent was quite slow, a few inches a week for rocky soil, faster for sandy soil. The caisson thus gradually descended to whatever depth was deemed necessary for the project, anywhere from 70 to 150 ft. below ground. Then its interior was filled with concrete, thus forming a foundation for the structure to be supported.

As a pneumatic caisson descends, the air pressure within it is progressively increased with air compressors so it can withstand the exterior pressure bearing upon it. Thus conditions within a caisson eventually mimic those of a deep sea dive. When exiting a caisson workers are at risk for developing decompression sickness. The condition was first recognized in Europe where caisson technology was developed in the mid 1800‘s. It became much more prominent when it tragically afflicted countless workers in two large American bridge projects, one over the Mississippi in St. Louis, the other, the more illustrious Brooklyn Bridge in New York.

The St. Louis Bridge built by James Buchanan Eads, and named after him, broke new ground in U.S. civil engineering

SPRING 2011

when it became the longest arch bridge in the country, first to of the prestigious Rensselaer Polytechnic Institute of use steel for such a large construction, and also first to employ upstate New York, and a distinguished Civil War veteran. the cantilever method in construction, which allowed barge Washington had also built several bridges for the Union Army traffic uninterrupted while the project was completed between during his service. John Roebling sent his son to Europe to 1867 and 1874. It was also the first U.S. project to engage the acquire knowledge in the latest bridge building technology. newfangled European pneumatic caisson technology in the Washington spent time in England, France and Germany building of its foundations. The sandy soil of the Mississippi visiting numerous engineering projects and bridges, recording allowed easy digging and rapid descent of caissons, which his impressions and relaying them back to the U.S. By the would eventually reach a depth of 136 feet. This project was time he returned home he was well informed with the latest to record yet another, more infamous American first, this one on caisson technology and ready to assist his father with the in medicine: the first fatality from decompression sickness. It hitherto never before attempted scheme. Initially appointed happened after Eads’ caisson descended below 75 ft. By then Assistant Chief Engineer for the East River Bridge project, numerous mysterious cases of the bends had already occurred, Washington Roebling subsequently received a promotion to some disconcerting, none disastrous. On March 19, 1870 Chief Engineer through a tragic stroke of bad luck. a worker named James Riley died suddenly fifteen minutes In July 1869, his father John unexpectedly died of tetanus after emerging from a two after his foot was crushed hour shift in Eads’ caisson between a ferry and a dock chamber. By the time the on the New York City project was completed a side of the future bridge Th e St. Louis Bridge built by James Buchanan total of 15 were to die, and tower. He was 64 years Eads, and named after him, broke new ground 77 severely afflicted. old. From here on what Simultaneous with came to be known as the in U.S. civil engineering when it became the the Eads project in St. Brooklyn Bridge would longest arch bridge in the country, fi rst to Louis, a more ambitious be more associated with effort was under way to Washington its builder, use steel for such a large construction, and construct a much awaited than John its creator. At also first to employ the cantilever method East River bridge between the time Washington in construction, which allowed barge Manhattan and Brooklyn was 32 years old. The in New York. The project 13 arduous years it took traffic uninterrupted while the project was was conceived by John A to construct the edifice, completed between 1867 and 1874.

Roebling, a German born 1870-1883 took its toll engineer who initially on its Chief Engineer, undertook farming upon both psychologically and emigration to the U.S. physically, leaving him a and subsequently returned to engineering, the profession for cripple by the end. Among many afflictions that were to render which he was trained in his native country. He had already Washington frail, the most prominent would be caisson built several prominent bridges including the Ohio River disease, which would not only affect his crew, but also injure Bridge in Cincinnati which bears striking resemblance to its the Chief Engineer himself. “bigger brother” in New York, and is now named the “John The two caissons designed for the East River Bridge were A Roebling Bridge”. Assigned Chief Engineer for the project the largest ever built in the world. They were giant wooden in 1867 by the State of New York, Roebling came up with boxes, the Brooklyn caisson measuring168 ft long, 102 ft wide, a daring design for what was to be the largest suspension with 9.5 ft of headroom inside. They each were the size of an bridge in the world, crossing the river in one, uninterrupted average train station. They were built of timber, with 15 ft central span, supported near each shore by two 268 ft., seven thick roofs that had to withstand the increasing weight of the story towers, themselves taller than most structures in the earth bearing upon them as the caissons descended. They city at that time. Built into the water, these towers were to be were built in a nearby shipyard like a fort, and then launched set on enormous foundations dug into the earth employing into the East River like a ship. They were then towed downcaisson technology. The depth to which these were to be river to their precise locations and sunken. The first caisson, sunk remained uncertain, for the exact geological location of on the Brooklyn side, was launched on 3/19/1870, ironically bedrock at each side of the river was unknown. on precisely the same day the Eads Bridge in St. Louis Assisting Roebling in his gargantuan undertaking was encountered its first death from caisson disease. his son, Washington Roebling, also an engineer, graduate Work within the Brooklyn caisson turned out to be more

“

“

SPRING 2011

SAN JOAQUIN PHYSICIAN

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Feature > CAISSON DISEASE

John Augustus Roebling arduous than that in St. Louis because of the abundance of boulders in the Brooklyn soil, that had to be painstakingly removed. The caisson thus descended slowly, at a rate of six inches a week. Work within the caisson occurred round-theclock, with 112 workers in the two day shifts, and 40 at night.

It was damp, dirty, hard work in bad air. Only the least skilled laborers of New York sought employment in the project.

Eventually a decision was made to blast the rocks within the caisson, and this increased the rate of progress somewhat.

One pound of air pressure equals two feet of water. As the caisson descended the pressure within was progressively increased. Initially since the rate of descent was slow, there seemed to be little trouble from caisson disease. Washington Roebling knew well of the troubles encountered both by Eads and French predecessors. Eads had hired a Doctor Jamison to oversee medical safety and treatment in his project and the

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latter published his work. By late 1870, when the New York project was at its infancy, Eads had already lost more men to the mysterious illness and restricted work within his caissons to one hour shifts per man.

In November 1870 construction began on the New York caisson, which was to be slightly larger than its counterpart sinking in Brooklyn. A month later, the Brooklyn caisson, down at a depth of 43 feet, had a fire on its roof. It was started by the careless handling of a candle by a worker within. Fires in high pressure environments do not burn like those in normal atmospheric pressure. There are no flames, and the fire erodes through the wood like a giant termite colony or a hidden cancer, slowly destroying it. The resultant crisis caused Washington Roebling to spend an extensive amount of time within the caisson directing efforts to detect and fight the fire. Upon emerging from the structure, Roebling became paralyzed in his legs, his first encounter with the dreaded mysterious illness. It was painless, and after a few hours began to resolve. Despite residual weakness, Roebling continued to descend into the caisson in the days to come to deal with the crisis. It took over three months to repair the damage caused by the fire which ate through nearly half the ceiling of the caisson.

Roebling was left permanently weakened by the effort, but did not suffer any repeat episodes of the disease during this effort.

In December 1871 digging began inside the New York caisson, the project being delayed by the troubles in its cross-river counterpart. The soil here proved easier to remove and the caisson descended faster, at an average rate of 2 ft/week, but sometimes as fast as 6-11 inches per day. In the meanwhile,

by January 1872 the Brooklyn caisson had reached 51 ft of depth and had 24 pounds of extra air pressure within it. At this point Roebling decided to hire a New York surgeon and physician from the Manhattan Eye and Ear Hospital for a position he entitled “Surgeon to the New York Bridge Company”. His name was Andrew H Smith, and he was to achieve prominence nine years later as one of the doctors tending to the slow death of President Garfield, assassinated with a bullet to the spine.

However his pioneering work on decompression sickness was to be his greater contribution to U.S. medicine.

Smith started with the experience acquired in St. Louis, documented by Dr. Jaminet, and imposed the rules of the Western project upon the workers in New York. He then went on to carefully examine and document the medical problems

SPRING 2011

he saw in the East River project. He noted that upon entry into the pressurized caisson the men’s pulse temporarily increased, and then returned to normal in an hour, but was “small, hard and wiry”. Upon emergence from the caisson the workers were pale for the first 20 minutes, and had shrunken hands with shriveled fingertips. Body temperatures inside the caisson were one to two degrees above normal. He conducted experiments with dogs and pigeons which he took in and out of the caisson, but could not come to any conclusion.

Smith was the medical director of the project for about 5 months, and in this time treated 110 cases of decompression sickness. As the caissons descended, the suffering of the labor force seemed to clearly increase, especially with the intensely painful muscle cramps of “the bends”. He treated the men with ergot or atropine, made them comfortable with whisky and ginger, or in more severe cases, morphine. He thus allowed them to endure the two hours an average attack lasted. Assisting Smith in the record keeping and treatment of these workers was a colleague he recruited at the Brooklyn City Hospital. A young intern at the time, Dr. Walter Reed found these cases fascinating and kept extensive notes on them.

Smith never used the term “bends”. He referred to the condition as “caisson disease”. He recognized, as had the French before him, that the condition was dependant on pressure, and always occurred after emergence, never within. “Indeed”, he wrote, “it is altogether probable that if sufficient time were allowed for passing through the lock, the disease would never occur”. He never realized how close he had come to solving the puzzle. The men emerging from the caissons first went through an airlock. They were usually sick and tired of the deplorable conditions within, eager to emerge as soon as possible and head to the pubs. Smith prescribed that the men emerging from the New York caisson spend an extra 5 minutes in the lock for each additional atmosphere of pressure. His rule was rarely observed.

Smith never figured out the true pathophysiology of the disease, and speculated on various theories from special predisposition, to alcohol use, to the time spent in the caisson. Nonetheless his prescription of slow decompression for prevention was the correct one. Unfortunately his numbers were off . The emerging workers had to spend 4 times the amount of time in the lock than he had prescribed to effectively prevent the condition.

A French doctor and physiologist at the Sorbonne, Paul Bert discovered the true cause of the bends about the same time as Smith was conducting his research. He published his results in August 1872, after Smith had resigned his post. When Smith learned of Bert’s opinions, he decided Bert was mistaken.

A special issue of contention was a recommendation by the Frenchman that sending an afflicted worker back to the caisson immediately was the best treatment. This option, at the time labeled “the heroic mode”, appeared foolhardy to both Smith and Washington Roebling. In any case, such arguments were, by this time, irrelevant, for the caisson work had been terminated by

SPRING 2011

order of the Chief Engineer.

The first death of the East River project occurred at the New York caisson in April 1872 at 71 ft of depth. On May 18, 1872, after 3 more deaths and several severe cases of the bends Washington Roebling ordered the digging of the caisson to stop at 78 ft 6 in. He decided not to go to bedrock as originally intended, for the human toll of the project was getting too high.

Curiously Eads had not suffered any death until his caisson reached 94 ft with an air pressure of 44 pounds. Going to bedrock, estimated Roebling, might cost 100 lives. And thus the Manhattan tower was left with a questionable foundation on account of the toll taken by decompression sickness.

There was still more work to be done in filling the caisson with concrete. All the while Roebling had been in and out of the structure countless times, supervising the project. At this point he suffered his second attack of the bends since the roof fire of 1872. This time he was in excruciating pain, and was blind and paralyzed as well. Even though over the years he gradually improved, from here on Roebling was to become a permanent invalid. He suffered from chronic fatigue, near blindness, pain and depression. He directed the remainder of the project from his home, using his wife Emily as an intermediary between himself and the construction site. She executed her new role with uncanny skill.

In the spring of 1873 Dr. Smith submitted a formal report reflecting on his experience as the Chief Surgeon of the New York Bridge Company in which, for future projects, he recommended a “hospital lock” for workers exiting pneumatic caissons. Had this been installed in the New York caisson earlier all the cases of the bends, not to mention the deaths of laborers, and chronic illness of the project director Roebling could have been prevented.

The Bridge opened on May 24 1883 with much fanfare.

President Chester Arthur and New York Mayor Franklin Edson, accompanied by Emily Roebling, crossed the bridge and shook hands with Brooklyn Mayor Seth Low, with celebratory cannon fire in the background. Washington Roebling, still feeble, neurasthenic and drug addicted, did not attend the ceremony.

He stayed home and held a small reception of his own to celebrate the occasion, attended by the President and other dignitaries. From then on he rarely visited the bridge that had become the centerpiece of his life. Despite his frailty Roebling lived on to a ripe old age of 89 in Troy, New York where he had gone to school. He died in 1926.

The number of men killed during the construction of the bridge is unknown. The Bridge Company did not keep official figures, and this was not unusual for the times. Estimates vary from 20 to 40. There is no question however, that the construction of this iconic landmark had the unintended consequence of bringing caisson disease into the medical consciousness of the United States.

SAN JOAQUIN PHYSICIAN

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COMMUNITY > news

IN THE

NEWS

Providing staff, physicians and patients with relevant & up to date information She was a resident and surgical pathology fellow at the University of California, San Francisco, and St. Mary’s Hospital. She belongs to the American Society of Clinical Pathology; the American Society of Cytopathology; the College of American Pathologists; the South Bay Pathology Society; and the San Joaquin County Medical Society.

Dr Milano Elvira Milano, MD, is new LMH Chief of Staff Elvira Milano, MD, became Lodi Memorial Hospital’s new chief of staff in January. She will hold the post for a two-year term.

Dr. Milano is a graduate of Tulane University, School of Medicine. She received her Bachelor of Science, biology, from Colorado State University. Dr. Milano has been the medical director of the LMH clinical laboratory since 2005. Most recently, Dr. Milano has overseen the development of a new morgue project for Lodi Memorial Hospital.

Dr. Milano is board certified by the American Board of Pathology in both clinical and anatomic pathology.

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SAN JOAQUIN PHYSICIAN

St. Joseph’s Medical Staff Announces 2010 Physician Champions Physician Champion awards were presented to Drs. Steven Goldberg and Dean Sloan during a recent physician recognition ceremony.

Steven L. Goldberg, MD, a general surgeon, was named Physician Champion of Quality. Dr. Goldberg has been a well-respected surgeon in this community for over 30 years, esteemed by his colleagues, and well-liked by staff and patients. Dr. Goldberg has taken on leadership roles for various Medical Staff Committees throughout his tenure, including the Credentials Committee, Surgery Committee, Surgery Trauma/QC, and most recently on the Surgical Services Committee in which he was

Don Wiley and Dr. Steven Goldberg

SPRING 2011

news < COMMUNITY instrumental in the implementation of various improvement projects in the operating room.

Named Physician Champion of Community, Dean Sloan, MD, has participated in the leadership of multiple Medical Staff Committees at St. Joseph’s, providing wise advice and direction for colleagues on the medical staff. He has been extremely active as a leader in the Surgical Residency Program at San Joaquin General Hospital, both as

and demonstrate excellence in two categories: Quality and Community.

Dr. Steven Laviola Joins Lodi Memorial Clinics The Lodi Memorial Hospital clinics welcome cardiologist Steven LaViola, MD. To their staff. Dr. LaViola graduated from the University of Bologna School of Medicine, Bologna, Italy. He completed a residency program in internal medicine at Cook County

physician’s referral. Most insurances are accepted. Call 339-7625, in Lodi, or 948-0808, in Stockton, for appointments.

Sahdev Saharan, MD, Board Certified Rheumatologist Opens Private Practice in Stockton and Joins St. Joseph’s Medical Staff St. Joseph’s Medical Center is pleased to announce the addition

Drs. Jensen and Sloan

Dr. Laviola

Dr. Saharan

a mentor for the surgical staff and as an academic lecturer providing necessary education and training to those who provide for our community’s neediest patients.

“We had several deserving nominees in both Physician Champion categories,” said Susan McDonald, Vice President for Medical Affairs, St. Joseph’s Medical Center. “It was great to have so much physician involvement and enthusiasm for nominating, and voting for, their colleagues.”

St. Joseph’s initiated the Physician Champion award program in 2009 to recognize and honor individual physicians who pursue

Hospital in Chicago and a fellowship in cardiovascular medicine at UC Davis Medical Center. He is certified by the American Board of Internal Medicine in cardiovascular disease and internal medicine and by the International Board of Heart Rhythm Examiners as a certified cardiac-device specialist.

Dr. LaViola will see patients at the Lodi Memorial Hospital Ham Lane Clinic, located at 845 S. Fairmont Ave., Ste. 8, in Lodi, and at the Lodi Memorial Community Clinic – Trinity, at 10200 Trinity Pkwy., Ste. 102, in Stockton. Current patients can call for appointments, and new patients are welcomed with a

of Sahdev Saharan, MD, FACR, CCD, to the hospital medical staff.

Dr. Sahdev comes to the Stockton area with specific training in the treatment of arthritis and various autoimmune diseases. Most recently, Dr. Saharan completed a fellowship and gained further work experience at the University of Mississippi Medical Center and VA Medical Center in Jackson, MS. He obtained his medical degree at Pandit B.D.Sharma PGIMS in Rohtak, India and completed his Residency at Creighton University Medical Center in Omaha, NE. He has also participated in research specific to his specialty at Stanford University.

SPRING 2011

SAN JOAQUIN PHYSICIAN

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COMMUNITY > news

IN THE

NEWS “Healing is an art and compassion is the most important tool to help a physician complete this art,” says Dr. Saharan. “Patient centered care is my motto and I am ready to run my practice with a great deal of hard work and knowledge. I look forward to years of service in this community.”

Dr. Saharan is board certified with the American Board of Internal Medicine and the American Board of Rheumatology. He is a member of the American College of Physicians, the American

Dr. Thomas Sorbera College of Rheumatology, the San Joaquin Medical Society, and the California Medical Association. His special interests

30

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in the field include Rheumatoid Arthritis, Lupus, Sjögren’s Syndrome, Gout/ Pseudogout, Dermatomyositis, Spondyloarthropathies, Autoimmune Myositis Conditions, and Autoimmune Connective Tissue Disorders.

Dr. Saharan’s practice is located at 2800 N California Street, Suite 5, in Stockton. To make an appointment, call (209) 462-7246.

or 948-0808, in Stockton, to schedule an appointment.

For more information on the Lodi Memorial Community Clinics, providers and other services offered by Lodi Memorial Hospital, visit the hospital’s website, www.lodihealth.org.

Dr. Thomas Sorbera joins Lodi Memorial Community Clinics The Lodi Memorial Community Clinics welcome urologist Thomas Sorbera, MD. Dr. Sorbera graduated from University of Texas at Houston School of Medicine and completed residency programs in both general surgery and urology. He is certified by the American Board of Urology.

Dr. Sorbera will see patients at the Lodi Memorial Community Clinic – Vine, located at 1235 W. Vine St., Ste. 22, in Lodi, and at the Lodi Memorial Community Clinic – Trinity, located at 10200 Trinity Pkwy., in Stockton.

Current patients can call for appointments, and new patients are welcomed with a physician’s referral. Most insurances are accepted. Call 334-8520, in Lodi,

John Yarbrough, MD, MBA, Specialist in Behavioral Medicine and Psychiatry, Joins St. Joseph’s Medical Staff St. Joseph’s Behavioral Health Center is pleased to announce the addition of John Yarbrough, MD, MBA, to the hospital medical staff. Dr. Yarbrough completed a fellowship in Forensic Psychiatry and was also the Chief Fellow in Child and Adolescent Psychiatry, both at the West Virginia University School of Medicine. He obtained his medical degree at the George Washington University School of Medicine and Health Sciences in Washington, DC. Dr. Yarbrough has extremely unique training and expertise in both forensic psychiatry and child and adolescent psychiatry.

He received the America’s Top Psychiatrists Award from the

Dr. Yarbrough

SPRING 2011

news < COMMUNITY Consumers’ Research Council of America twice, and has a special interest in the treatment of abusive parents with mental illness.

Dr. Yarbrough is a member of the American Academy of Psychiatry and the Law, the American Academy of Child and Adolescent Psychiatry, Christian Medical and Dental Association – Psychiatry Section, and the American Psychiatric Association.

To contact Dr. Yarbrough, call St. Joseph’s Behavioral Health Center at (209) 461-2000.

Amod Tendulkar, MD, Cardiothoracic Surgeon Joins St. Joseph’s Medical Staff St. Joseph’s Medical Center is pleased to announce the addition of Amod Tendulkar, MD, to the hospital medical staff. Dr. Tendulkar comes to the Stockton area with experience most recently as Chief Resident of the Cardiothoracic Surgery department at University of Maryland, Baltimore, School of Medicine. He obtained his medical degree at Saint Louis University, School of Medicine, in MO. Dr. Tendulkar is board certified in General Surgery. He is a member of the American College of Surgeons. While a resident at the University of California, San Francisco – East Bay Surgery Program, Dr. Tendulkar received the Excellence in Research Award from the American College of Surgeons’ Forum on Fundamental Surgical Problems.

Dr. Tendulkar has joined the practice of Drs. James Morrissey and Jerome McDonald at

SPRING 2011

room, a new main lobby and a healing garden. The hospital is a nonprofit, acute-care hospital, owned by the Lodi Memorial Hospital Association.

Dr. Tendulkar

Dr. Yavrouian

Stockton Cardiothoracic Surgical Group in Stockton.

LMH selected as Business of the Year

by Local Chamber of Commerce The Lodi Chamber of Commerce honored Lodi Memorial Hospital as its 2010 “Business of the Year” at the chamber’s annual meeting Jan. 27.

LMH is Lodi’s second largest employer, with a staff of 1,400 and a $147 million operating budget.

In late 2009, LMH opened a $157 million, state-of-the-art, inpatient wing with 90 new medicalsurgical beds, a new emergency

St. Joseph’s Medical Group Announces New Colon and Rectal Surgeon Robert G. Yavrouian, MD St. Joseph’s Medical Group of Stockton is pleased to welcome surgeon Robert G. Yavrouian, MD, to their medical group of Family Practitioners, Internal Medicine Specialists, and General Medicine Practitioners. Dr. Yavrouian has joined the practice of Colon & Rectal Specialist Peter Tuxen, MD, with their Stockton office.

“Dr. Yavrouian brings fresh ideas and the latest treatment options to this community,” said Peter Tuxen, MD, Colon & Rectal Specialist. “I consider myself lucky to have a new physician with his skill and expertise working with me. He is an excellent addition to the group of physicians at St. Joseph’s Medical Group.”

Most recently, Dr. Yavrouian completed his Colorectal Surgery Fellowship at the University of Southern California. Before that, he completed a General Surgery Residency at San Joaquin General Hospital, where he was Chief Resident. Dr. Robert Yavrouian attended medical school at Drexel University College of Medicine (formerly MCP Hahnemann University) in Philadelphia, PA. He is a member of both the American College of Surgeons and the American Society of Colon and Rectal Surgeons, as well as the San Joaquin Medical Society.

SAN JOAQUIN PHYSICIAN

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Dr. Zheng LMH Outpatient Services moves to New, Convenient Location Lodi Memorial Hospital has consolidated its outpatient services to a new, more convenient location. Lab, X-ray/diagnosticimaging and cardiopulmonary services relocated to LMH’s old emergency room. Outpatient surgeries will register there as well. Outpatient laboratories in the Conrad Building and Lodi Medical Plaza have closed, and all laboratory tests are now conducted in the main hospital building. The old ED-parking lot will now be available strictly for outpatients.

The economies of scale offered by this move will also allow LMH to reduce prices for most lab and diagnostic services.

St. Joseph’s Medical Group Announces Addition of Urologist Wei Zheng, MD St. Joseph’s Medical Group of

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Stockton is pleased to welcome fellowship-trained urologist and endourologist Wei Zheng, MD, to their medical group of Family Practitioners, Internal Medicine Specialists, and General Medicine Practitioners. Wei Zheng, MD, brings years of experience and unique expertise to St. Joseph’s Medical Group patients.

Dr. Wei Zheng received his medical degree from McGill University in Montreal, Canada, and completed his residency in General Surgery and Urology there. He completed an Endourology (minimally invasive surgery) Fellowship at the University of Western Ontario in Canada.

Dr. Zheng is Board Certified in Urology and Endourology, and is a member of the American Urological Association, the Royal College of Physicians and Surgeons of Canada, the California Medical Association, as well as the San Joaquin Medical Society.

“My philosophy of care is to serve my patients with integrity, quality and excellence,” says Dr. Zheng.

Dr. Zheng has over 10 years of experience, speaks Chinese as well as English, and has special interests in cancer, stones, urinary incontinence and minimally invasive surgery. Call 209.475.5500 for an appointment.

Hill Physicians Adds Government Programs Director Hill Physicians Medical Group is adding a Government Programs department to support its

enrollment growth in Medicare, Medi-Cal, Healthy Families and other public programs funded by federal, state or local governments.

“These programs are an important safety net for community health,” said Steve McDermott, CEO of Hill Physicians. “The new Government Programs department works crossfunctionally on outreach, network development, compliance and compensation so that we better meet the needs of members who come to us through a governmental health program.”

Jennifer Pereur has been hired by PriMed Management Consulting, the management services organization that supports Hill Physicians, to lead the new function. “It’s an exciting opportunity at a challenging time,” said Pereur. “Millions of Californians rely on governmental programs like Medi-Cal, Healthy Families and Medicare, and each of these is changing in response to tight budgets and the healthcare reform process.”

Hill Physicians has served members enrolled through Medicare Advantage, Healthy Families and AIM (Access for Infants and Mothers) for many years, in addition to its commercial HMO enrollment. In 2008, the independent physician association began providing care for MediCal enrollees in Sacramento, subsequently expanding those services to residents in San Francisco and San Joaquin counties. Hill Physicians currently offers care to more than 63,000 members of various governmental programs.

SPRING 2011

Dr. Jeffrey Ing Visits Remote Island of Chuuk to Provide Modern Cataract Surgeries As soon as her surgery was completed, Erna sat up and began to sing a song of praise.

“I have been blind for three years and unable to go outside my house. When I woke up this morning, there was a song in my heart because I knew today I would see,” she exclaimed.

Erna was one of the 107 patients who received eye surgery on a recent ophthalmology trip to Chuuk, an island in the Federated States of Micronesia. Jeffrey Ing, MD, practices general ophthalmology and corneal surgery and is President of Delta Eye Medical Group (Stockton, Lodi, Tracy), together with James Bainer, MD (Kaiser, Riverside, CA) were recruited to lead the eleven person team and travel 9,500 miles to provide cataract surgery on an island where ophthalmic care is practically non-existent.

“Chuuk is a challenging place to work. There is no running water in the hospital to scrub hands, wash instruments or flush toilets. Most of the water is in buckets or basins as the water is off much of the day.

The power would go out right in the middle of microscopic surgery and flashlights were brought out to finish at least one surgery. In other cases, we had to wait for the generator to “kick in,” then restart all of our specialized ophthalmic surgical equipment.

Dr. Ing recruited his wife, Helen, who is a nurse and his father, Clarence Ing, MD, also an ophthalmologist (Weimar, CA), as well as several others from outside the region.

“It was cool to have my dad help us on this mission trip. My dad was a missionary ophthalmologist and I grew up around eye care. I use to assist my father in surgery as a teenager, now he assists me. I also got a chance to take my dad SCUBA diving –he taught me to dive when I was eight

SPRING 2011

years old. Now I’m taking him diving and introducing him into the world of digital underwater photography.” Ing has done underwater photography all over the world and produces an annual calendar. His website is ingsocean.com.

Patients lined the hallway and waited for days to see the doctors – over 550 patients were examined – over 450 pairs of eyeglasses were dispensed. One man had come from his remote outer island, traveled 130 miles by motor boat, and waited for two months for the team to arrive.

Medical officer Kiki Always wrote of this man, “My uncle walked outside the hospital smiling and happy. For he has not been able to see for many years and stayed home for that reason. It is a miracle for him that he can see again.”

Ing feels a calling to share his

talents in areas where medical care is not available. He goes on a medical mission nearly every year. This was his third Canvasback trip and he shared, “Chuuk was indeed one of the most challenging places to work.

My heart was extremely touched by seeing a little girl who was born with no eyes and a little boy who was blind as a result of an infection when he was young.”

Canvasback Missions is a nonprofit organization located in Benicia, CA. The organization operates a Diabetes Wellness Center in the Marshall Islands, where over 50% of the adult population is diabetic. The organization sends medical teams specializing in ophthalmology, orthopedics, otolaryngology, obstetrics and gynecology, urology and dentistry. For more information on how you can volunteer, please contact: www. canvasback.org.

Dr. Yarbrough

SAN JOAQUIN PHYSICIAN

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PRACTICE MANAGEMENT > Ambulatory-Care Risks

Managing Professional Risk

Tips for Lowering Ambulatory-Care Risks Risk Management, PMSLIC Insurance Company and the NORCAL Group Karen D. Davis, MA, CPHRM Among the factors that influence the safety of ambulatory care and the liability risk levels of office-based physicians, three of the main ones are: The level of communication with other healthcare providers about patients’ care; the effectiveness of office follow-up processes; and the attention given to documentation of telephone calls.

The following tips may help physicians and office staff members increase patient safety and lower liability exposure related to these factors.

Communication with Other Healthcare Providers When you refer a patient to another physician, have some mechanism in place to determine whether your referral recommendation has been carried out and the patient has been seen by the recommended consultant (or another physician of the patient’s choice).

Communicate in writing with the consultant about the requested consultation.

An effective way to convey significant details

to another physician is to prepare a “fact sheet” with the patient’s clinical information and your impression.

After your patient is seen by a consultant, you and the consultant should establish who is responsible for which aspects of the patient’s care and who will order further testing and consultations if necessary. If there is a question about what you or the consultant will do, you should take the time to communicate physicianto-physician and to document the understanding you reach in your discussion.

Effectiveness of Follow-up Processes Systematically monitor compliance with appointments. Establish a process whereby a designated staff member reviews all no-show appointments to determine which patients must be called and rescheduled. Document no-shows, along with the steps taken to contact the patient and reschedule the visit.

When you refer a patient to another physician, have some mechanism in place to determine whether your referral recommendation has been carried out and the patient has been seen by the recommended consultant (or another physician of the patient’s choice).

When a patient is advised to undergo a test, three areas of concern require follow-up: Has the patient complied with the recommendation? Have test results been received and reviewed by the ordering physician? Has

1Teno, JM, Connor, SF, Referring a patient and family to high-quality palliative care at the close of life.

Journal of the American Medical Association, 2009, (301), No 6; 651–658.

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SPRING 2011

the patient been notified about the results? An appropriate follow-up system provides answers to these questions.

Patients should not be solely responsible for making appointments for tests, to see consultants or for calling the office to obtain results.

You should assist patients in making appointments in order to be assured that the appointment has been made. It is also prudent to notify all patients of all test results (rather than just reporting abnormal results). Such a policy helps close each testing loop and reduces the possibility of patient information “falling through the cracks.”

Your follow-up system for tests should not only confirm receipt of test results but also ensure that you review the results.

The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it. Without such a method, a positive result can be accidentally misplaced or filed away before you review it or the patient is notified. If the patient later alleges that harm occurred as a result of a delay in diagnosis and treatment, the mishandled test result may well be viewed as concrete evidence of negligence.

Documentation of Telephone Calls Generally, the types of telephone calls from patients that should be documented include: clinical questions and what advice was given, calls for prescriptions or renewals, after-hours calls, and calls to an on-call physician.

Calls to patients that should be documented include: calls to share test results, calls to contact no-show patients, calls to give patients instructions or to advise about further access to care, and unsuccessful attempts to contact patients.

SPRING 2011

Telephone contacts should be documented in the appropriate medical record.

If your office simply keeps a call log, information about a specific call can be difficult to retrieve. The facts surrounding a call are not readily available if they are recorded in a call log; thus, using a log can be detrimental if a malpractice claim is filed and your office must produce information about the patient’s interactions with the practice.

You should have a system for documenting all afterhours phone calls.

You can use telephone call forms or a tape recorder or dictation machine to record patient name, time of and reason for the call, and your advice or action. When the call is from a patient, the information should be added to the patient’s chart as soon as possible.

Giving clinical or medical advice over the telephone without timely, face-to-face follow-up increases your liability exposure. Prescribing over the phone is also risky, as it requires you to assess the patient sight unseen.

You should not prescribe for a patient unknown to you without seeing the patient. It is also prudent to have established parameters as to when prescriptions will be renewed by phone.

Consider developing the preceding suggestions as policy and including them in a policy manual.

Make sure all employees review your policy and consider asking them to sign off yearly that they have been advised of the policy and understand it.

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/cme.

SEMINAR FOR PHYSICIANS AND PRACTICE MANAGERS Sat, April 16 • 8:30-11:00am Brookside Country Club

Allied Health Professionals: “Who’s Practicing Medicine in Your Office”?

Learning Objectives: • Differentiate and apply varying levels of physician supervision

• Implement administrative strategies to reduce professional liability exposure as demonstrated through written job descriptions, standardized procedures, protocols, delegation of services agreements, as well as other communication and documentation practices.

Seminar Includes: Discussion of risk management exposures associated with physician supervision (e.g., breach of duty, vicarious liability, and unauthorized practice of medicine).

Highlights a variety of allied health professionals: MAs, LVNs, RNs, NPs, PAs. Case scenarios are used to illustrate risks.

CME Will be Provided Buffet Breakfast will be served Call the medical society to RSVP

(209)952-5299

SAN JOAQUIN PHYSICIAN

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37

PRACTICe MANAgeMeNT > CMA Foundation

CMA Foundation Quarterly Update

By Carol A. Lee, Esq., President and CEO Partnerships to Promote a Healthy and Active Lifestyle for Children The CMA Foundation’s Obesity Prevention Project continues in its work to reduce the prevalence of overweight and obesity in children and their families and carries out its purpose by working with Regional Physician Advocates.

A goal of the Project is to facilitate partnerships between schools and physicians for ongoing collaborations in support of the Safe Routes to School (SRTS) Program. Walking and bicycling to school is an easy and effective way for children to get their daily physical activity.

Unfortunately, only 30% of California school children walk or bike to school in a typical week. Health care providers around the state can take steps to promote safe “walking and rolling” to school among their patients and their families. Providers can encourage parents to walk or bike to school with their children in order to ensure both children and adults get their daily physical activity.

Providers can also lend a strong and respected voice to community efforts to prevent pedestrian and bicycle injuries and deaths to children.

Contact your local public health department to learn if your community has a Safe Routes to School program or a child safety coalition and how you can lend your expertise to these efforts. Learn more about statewide efforts to promote Safe Routes to School and Walk to School at www.CAactivecommunities.org/safe_routes. html and www.cawalktoschool.com.

The CMA Foundation’s Obesity Prevention Project has launched a new resource to raise childhood obesity awareness. The Project’s monograph, Inspiring Change in our Communities: Physician Champions Making a Difference provides a snapshot of the innovative programs implemented

by Physician Champions throughout California. The work of each of these physicians is aimed at serving their communities, particularly low income and underserved communities, in a variety of settings. Each of these physicians was inspired by a patient, an incident, or a movement. Some have dedicated months and years while others could only spare a few hours; 38

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and each has changed behavior to break the cycle of childhood obesity by empowering patients to take control of their health.

Please visit the Obesity Prevention Project section of the CMA Foundation’s website at www.thecmafoundation.org/ projects/obesityProject.aspx to access the Inspiring Change in our Communities: Physician Champions Making a Difference monograph and other additional Project resources. For more information, please contact cmaf@thecmafoundation.org or 916.779.6620.

New Resources for Diabetes and Cardiovascular Disease The California Medical Association (CMA) Foundation is pleased to announce the release of two new practice-based resources for diabetes care. They are the web-based version of the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2009-2010 and the patient education handout Diabetes and Your Nerves.

SPRING 2011

The PRG first became available in hard copy format earlier this year. It was developed with the support and expertise of 33 physicians and health care leaders from a variety of physician associations, medical groups, health plans and other organizations dedicated to the prevention and management of diabetes and its complications.

The PRG includes information on: • Screening, diagnosis and management of type 2 diabetes, dyslipidemia and hypertension • Preventing and managing acute and long term complications • Effective patient communication techniques • Health care provider and patient education resources We are currently recruiting physicians to help update the content for the PRG’s next edition. We expect to finalize and release the next edition by mid-2011. We encourage you to lend your experience and expertise to help make the PRG an invaluable resource in the primary care setting. Please contact us if you are interested in participating in the PRG update.

Diabetes & Your Nerves In collaboration with the UCSF Neuropathy Center, the CMA Foundation has completed a patient education handout for patients who have Diabetic Peripheral Neuropathy (DPN) called “Diabetes and Your Nerves”.

The handout aims to educate patients so that they can recognize symptoms of DPN and other forms of neuropathy, seek professional help, and take action to prevent further nerve damage. The handout is available in both English and Spanish.

Both of these resources can be accessed by going to our website at www.thecmafoundation.org, then click on “What’s New”.

For more information on these resources, please contact Senely Navarrete, MPH, Diabetes QI Project Director at (916) 779-6638 or email snavarrete@thecmafoundation.org.

SPRING 2011

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COMMUNITY > Public Health

Pertussis/Whooping Cough Alert – New School Requirement for 2011 ALL 7th - 12th graders MUST have proof of a Tdap shot before starting the 2011-2012 school year.

Avoid the June Rush…Get Your Patients Ready for School, NOW! Pertussis (whooping cough) cases have been widespread in California during 2010. This disease is highly contagious and can be fatal to infants.

Parents, grandparents, health care workers and anyone who works with pregnant or post-partum women, or cares for, infants or young children should be immunized. Adults and teens need “Tdap” booster shots, as immunity from prior vaccination or natural disease fades over time.

Contact your healthcare provider to get updated on immunizations for you and your children.

A new California law (Assembly Bill 354), now requires all 7th -12th graders to be immunized against pertussis (whooping cough) and show proof of Tdap vaccination, before starting public or private school as of July 1, 2011. Parents are encouraged to get their child vaccinated now.

For more information or resources: San Joaquin County Public Health Services Immunization Program (209-468-3481) Sounds of Pertussis: http://www.sjcphs.org/Disease/pertussis.htm Shots for School: http://www.shotsforschool.org California Vaccines for Children: http://www.eziz.org/

7TH – 12TH Grade Immunization Chart - What Shots Do My Adolescent Patients Need?

REQUIRED vaccine for ALL 7th – 12th graders 2011-2012 school year Tdap (Tetanus, diphtheria, acellular pertussis)

Additional Notes for the Health Care Provider

What this means for YOUR patient Whooping cough or pertussis continues to be widespread in California and parts of the U.S. For the 2011–12 school year only, all children entering 7th–12th grade will need proof of a Tdap shot before starting school. For 2012-13 and beyond, only students entering 7th grade will need proof of a Tdap shot.

• Clearly state the name of the pertussis containing vaccine that was administered on the yellow Immunizations Record (“shot card”), i.e., Adacel, Boostrix.

• If a pertussis containing vaccine was administered on or after the 7th birthday, that will satisfy the new rule for schools.

• There is no minimum interval between administering Td and Tdap vaccine.

RECOMMENDED vaccines for 7th – 12th graders Human Papillomavirus (HPV)

Meningococcal

Chickenpox (Varicella)

Hepatitis A (Hep A)

Seasonal Flu

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What this means for YOUR patient This 3-shot vaccine series is recommended for girls to help protect them from cervical cancer later in life. Boys ages 9 to 26 years may also receive the vaccine.

Meningococcal meningitis is easily spread by kissing, sharing drinks, coughing, or sneezing.

Protects against Neisseria meningitidis Groups A, C, Y and W-135.

Chickenpox is usually worse for adolescents and adults than for kids. Two doses of chickenpox vaccine are needed if your patient has never had chickenpox.

Two doses administered 6 months apart are recommended for children 2 years and older who are at increased risk for infection, or for whom immunity against hepatitis A is desired.

This year’s vaccine protects against 3 strains: A/2009 H1N1, A/H3N2, & Influenza B.

SPRING 2011

The practice of medicine is about to undergo revolutionary change. Are you prepared?

The Next Step: Successfully Negotiating Health Reform 14th Annual California Health Care Leadership Academy June 3-5, 2011 Renaissance Esmeralda Resort and Spa Indian Wells, California

• Restructuring of Medical Practice and Payment • Physician-Hospital Alignment: Definitions, Elements, How to Assess Integration Offers • The (Ongoing) Politics of Reform • Health Reform and Health Care Quality: Burden or Opportunity?

• HIT: Interoperability, Meaningful Use, Quality Measurement and Reporting • Health System Reform and the Physician Workforce • Practice Management: Reengineering Your Practice for Survival • Managing Change Effectively • Physician Leadership in the Era of Reform

Featured Workshops: • Strategies for Independent Physicians to Compete • Learning from Disney: Cultivating and Sustaining Patient Loyalty • It’s Official: ICD-10

SPRING 2011

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PHYSICIAN 43

OVARIAN CYSTI C DISORDER HEALTHYMadhavi Ravipati, M.D. 75,000 BABIES DELIVERED LAPAROSCOPY GILL OBSTETRICS &Matters GYNECOLOGY Experience HYSTEROSCOPY OSTEOPOROSIS DETECTION CENTER We are proud to announce the opening of The Osteoporosis Detection Center using state of the art DEXA 75,000 HEALTHY DIAGNOSIiSmagi& nTREATMENT g. DEXA scanningOFis nowCERVI recogniCAL,zed to be the most accurate prediMalcatoAshok,r ofM.fDracture risk in women. JMeenaenniferShankarPhung,,M.M.DD. .

BABIES DELIVERED Experience UTERI NE & OVARIAMatters N CANCERS

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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.

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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

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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 obgyn.com 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.

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Denise Mor

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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.gillobgyn.com

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

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

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

Benefits < Membership

Having payor problems?

CMA’s Center for Economic Services is here to help The California Medical Association’s Center for Economic Services (CES) is staffed by practice management experts with a combined experience of more than 125 years in medical practice operations. Our goal is to empower physician practices by providing resources and guidance to improve the success of your practice. Assistance ranges from coaching and education to direct intervention with payors or regulators.

Access to CMA’s practice management experts is a members-only benefit.

When should I call CES? SJMS/CMA members can call on CMA’s practice management experts for one-on-one help with contracting, billing, and payment problems.

It might be time to call CES if you answer “yes” to any of the following questions:

• Are your claims not being paid in a timely manner?

• Are you not being paid according to your contract?

• Are your claims being denied after obtaining prior authorization?

• Are you receiving unreasonable requests for medical records or untimely requests for refunds?

• Are you having difficulty obtaining fee schedules and/or payment rules?

• Are your claims denied for untimely filing?

• Have you been presented with a managed care contract and you’re not sure if the terms are consistent with California law?

• Call CES today and we’ll arm you with the knowledge you need to identify and fight unfair payment practices.

• What can CES do for me and how much will it cost?

Access to our advocates is a free member benefit and includes: Education and guidance on reimbursement and contracting related issues Advice on best practices for improved practice viability Information on your rights and responsibilities under California law and regulations Sample letters, forms, and toolkits

Gena Welch Membership Coordinator (209) 952-5299 gena@sjcms.org

Briefly Noted Having payor problems?

CES is here to Help!

Medicare releases new fee schedule changes for 2011 2011 Payor updates Educational tools Available to SJMS/CMA Members

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

SPRING 2011

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Membership > Benefits Intervention directly with the payor when necessary Assistance with filing a formal complaint with the regulator.

Guidance on managed care contracting Information on identifying and preventing payor abuse How do I access CES services?

Phone: Reimbursement Helpline 888/401-5911 E-mail: economicservices@cmanet.org Web: www.cmanet.org/ces TIP: For a list of unfair payment practices, see Know Your Rights: Identify and Report Unfair Payment Practices at www.cmanet. org/ces.

Medicare releases new fee schedule changes for 2011

Services (CMS) recently released a revised 2011 physician fee schedule.

The 2.2 percent update that took effect on June 1, 2010, was the starting point for the 2011 payment update. The Medicare and Medicaid Extenders Act of 2010, signed by President Obama in December, established a payment update for 2011 of 0 percent, which means that the 2.2 percent update from last June continues throughout 2011. This payment update replaces the 25 percent pay cut that otherwise would have been imposed due to the sustainable growth rate formula.

Although the physician payment rates are not being cut, the final rule included a reweighting of practice expense relative value units (RVUs), malpractice RVUs and work RVUs. Other modifications that affect payment are relative values for services that were identified as misvalued, updated data being used in the geographic practices cost indices and multiple procedure payment reductions for therapy and imaging services.

In order to maintain budget neutrality, the numerical value of the conversion factor was set to $33.9764.

These changes may affect the payment physicians will see for 2011 and

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may result in increases or decreases to individual codes. Some specialties may see more of an impact, as reflected in the impact table from the 2011 final rule, found at www.cmanet.org/news/cpr.

Physicians are encouraged to use the California Medical Association’s Financial Impact Worksheet (www. cmanet.org/ces) to determine the impact the RVU and other factors will have on your practice. Medicare fee schedules for 2010 and 2011 are posted on Palmetto GBA’s website, www.palmettogba.com/ j1b, and can be used for the calculations.

Additional information about these changes is explained in a CMS transmittal sent to contractors along with the updated files. A copy of the transmittal can be found at www.cmanet.org/news/ cpr. Contact: CMA Reimbursement Help line 888/401-5911 or economicservices@ cmanet.org.

Payor updates

Aetna: Aetna recently notified contracting physicians that effective April 4, 2011, Aetna will no longer provide physicians with paper EOBs. In order to continue to receive paper EOBs, physicians must complete and return Aetna’s Request for Exclusion from Paper Shut-Off form found at www.cmanet. org/news/cpr. Physicians are reminded that they will need to complete a new opt-out form to be excluded from paper shut-off in 2011, even if the physician signed an opt-out form in 2010.

Anthem Blue Cross: The insurer notified contracting physicians in a notice dated Jan. 5, 2011, of new and revised medical policies and clinical UM guidelines, which will be effective April 8.

New or revised medical policies include, but are not limited to, IMRT, genetic testing, brachytherapy, skin related cosmetic and reconstructive services, and transcatheter heart valves.

A copy of the Blue Cross notice can be found at www.cmanet.org/news/cpr.

The complete list of Blue Cross’ Medical Policies and Clinical UM Guidelines can

be accessed on the Blue Cross website, www.anthem.com/ca, select “Provider,” and then “Medical Policies and Clinical UM Updates.”

CIGNA: CIGNA recently announced in its electronic provider bulletin that effective Feb. 22, CIGNA is revising its modifier 25 and modifier 59 policies.

Specifically, CIGNA has reduced the list of code combinations that require documentation with the use of the modifier. The modifier 25 list has been reduced from 79 to 57 code combinations.

Modifier 59 has been revised from 79 code combinations to just four.

The list of code combination requirements can be found on the secure CIGNA for Health Care Professionals website, www.cignaforhcp.com, by going to “Resources,” then “Clinical reimbursement Policies and Payment Policies,” and selecting “Modifiers and Reimbursement Policies.”

United: UnitedHealthcare recently announced changes to the procedure code list for the plan’s Radiology Notification and Prior Authorization programs. Claims with dates of service on or after Jan. 1, are subject to these changes. Specifically, United added three CPT codes and six HCPCS codes to the notification and prior authorization list.

The full list of procedure codes requiring notification or prior authorization for 2011 can be found on the United website, www. unitedhealthcareonline.com, by going to “Clinician Resources,” then “Radiology,” then “Radiology Notification & Authorization,” and selecting the “Resources: Reference Materials section.”

Contact: CMA Reimbursement Help line 888/401-5911 or economicservices@cmanet. org.

Educational tools Available to SJMS/CMA Members

The California Medical Association’s Center for Economic Services publishes several guides and toolkits to assist >>

SPRING 2011

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SPRING 2011

(209) 371-8700 www.endoscopyoflodi.com

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physicians and practice managers, including the following: Payor 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.

Medicare Internet-based PECOS Enrollment Guide for Physicians

This guide walks physicians through the process of PECOS enrollment, from determining if they are in PECOS to accessing the Internet-based PECOS enrollment system.

2010 Guide for Medicare Consultation Code Reporting

Private retirement and estate planning for physicians and affluent entrepreneurs The Stull Financial Group provides: Specialized Knowledge Extensive Resources Focused Experience customized analysis Extraordinary customer care a Substantial network of Seasoned Professionals Stull Financial 5637 n. Pershing avenue Stockton, ca 95207 (209) 956-1673 dstull@htk.com www.stullfinancial.com

This guide provides guidance regarding coding for consultative services.

CMA Managed Care Consultation Code Quick Reference Guide CMA surveyed the major payors in California to find out which of them plan to follow Medicare’s lead and eliminate payment for consultation codes. The results are outlined in this document.

LaVida Medical Group – Important Changes: What They Mean to Your Practice

This guide was created to help physicians understand the impact the changes with LaVida Medical Group may have on their practice. Included is information on DMHC approved transition plans, names and contact numbers for the receiving IPA/medical groups, planspecific continuity of care policies, and other important information for physician practices.

Cal-Net IPA Physicians Guide

This guide provides physicians with details on the Cal-Net IPA closure and subsequent bankruptcy and includes plan-specific transition plans, the names of the receiving medical groups/IPAs, continuity of care information, and other important information for physician practices.

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Payor Solvency Checklist

This checklist was developed to help physicians monitor the financial health of their contracted payors.

Updated Payor Profiles These profiles contain important contact numbers, addresses, and links for quick reference for payor interactions for major managed care and government payors.

Blue Cross Important Changes:

What They Mean to Your Practice In late 2009 and early 2010, Anthem Blue Cross announced several changes that impact physician practices. To help physicians understand the impact these changes would have on their practices, CMA published this tool kit, which contains information on each of the changes, including important dates and links to important documents and sample letters.

Know Your Rights: Identify and Report Unfair Payment Practices

This document summarizes California’s Unfair Payment Practices legislation.

Know Your Rights: Quick Guide for Appeals

This document lists some of the more common types of denials and a brief description on how to respond to these denials.

Know Your Rights: Timeframes for Appeal

This document provides a summary of timeframes to appeal PPO, HMO, ERISA, Medi-Cal, Medicare, Workers’ Compensation claims.

Know Your Rights: Timely Payment

This document provides a summary of when payors must pay claims and the penalties associated with late payment.

How do I access these tools and resources?

Phone: Reimbursement Helpline 888/401-5911 E-mail: economicservices@cmanet.org Web: www.cmanet.org/ces

SPRING 2011

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SPRING 2011

MINDS on the

EDGE Mental illness is every bit as serious as heart disease or diabetes, yet it often is not treated on a par with those conditions.

Here are the basics.

WHEN 22-YEAR-OLD Jared Lee Loughner opened fire at a political meeting in Tucson in early January killing six people and injuring twenty, a stunned nation asked “Why?” Why didn’t someone realize that Loughner was dangerous? And if they did realize it, why didn’t they seek help for him? >>

Reprinted from Southern California Physician

BY CHERYL ENGLAND

SPRING 2011

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Cover Article > MENTAL HEALTH Similarly, after 23-year-old Seung-Hui Cho killed 32 people and wounded many others before killing himself in a shooting massacre on the campus of Virginia Tech in April 2007 it was revealed that he had a history of mental instability. Worse, several professors had reported disturbing behavior and he had been investigated for stalking two female students. Why didn’t anyone connect

coverage; there’s discontinuity of care; and sometimes there are complicating issues such as substance abuse.

The issues surrounding treatment for mental health illnesses are so vast and complex that we are able to only touch on some of the key concerns in this article— mostly the issues surrounding stigma and parity. Entire articles could easily be written on subsets on the issues—for

My son would stand in the kitchen and say ‘Thoughts, thoughts are going by and I can’t catch them. the dots? Why wasn’t he being treated for mental illness? Why was he allowed to be the architect of the deadliest shooting incident by a single gunman in United States history, on or off a school campus.

All good questions, albeit ones that are not easy to answer. When it comes to mental illness treatment, there’s a tangled web of complications. The list ranges from the stigma, shame, and isolation that sufferers and their families may feel; there’s a lack of education and training for recognizing symptoms—and knowing what resources are available for help; there’s the cyclical nature of the disease, making it hard for physicians to diagnose; there are issues getting patients to comply with treatments; there’s lack of insurance

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example, mental illness in adolescents or different ethnicities, mental illness treatment in the prison and jail systems, treatment for military personnel and much, much more. So, while this article is by no means definitive, hopefully it will give you a small taste of what your patients and psychiatrist cohorts are possibly up against.

Julia’s Story

Julia Robinson Shimizu’s story illustrates many of the points about what is wrong with mental health care in the United States. Seven years ago Shimizu’s 18-yearold son “got sick” shortly after the start of his freshman year in college. He stopped eating, stopped talking and stopped

going to classes. The college sent him home, stating that he needed clearance from a physician to return. “I was literally on my knees begging him to please go see a therapist,” says Shimizu. “He wouldn’t go. But since he wanted to go back to school, I had that on my side.”

Since the school did not require clearance from a mental health professional, Shimizu’s son went to his childhood pediatrician. “When he went to the pediatrician his health was OK and he was doing well enough to be articulate,” continues Shimizu.

The pediatrician cleared him to return to school—where he promptly fell apart again. In a twist of irony, Shimizu decided to go to a therapist to help her deal with her son’s problems.

The therapist was the first person to diagnose her son as schizophrenic based on her descriptions of his symptoms. Even then, Shimizu and her husband struggled for years to get help for her son—and to get him to accept that he needed it.

Resources and help were difficult to find. Insurance wasn’t willing to pay for treatment. “We got a very nice letter from our private insurance company,” says Shimizu. “It said they’d be glad to help once my son was medication-free and symptom free for 5 to 10 years. I had even heard of insurance providers who limited other families to six sessions with a therapist—that won’t get you far.”

Eventually, their son’s doctor helped Shimizu apply for Medi-Cal funding.

And she was directed to NAMI, the National Alliance on Mental Illness, where she currently serves on the Board of Directors. “It was a horrible time. We were so lost,” says Shimizu. “NAMI offered help and support.”

Now, at 25 years old, Shimizu’s son has been in treatment for a bit over a year.

SPRING 2011

It’s been a very, very long journey,” says Shimizu. “He’s now very compliant with his medication. But medication alone won’t do the trick. Medication and talk therapy is known to be effective. When a person gets ill, they lose lots of years— talk therapy can help.”

Lag Time

Unfortunately, Shimizu’s story is more the rule than the exception. ‘The real tragedy is that we don’t recognize mental illness early in the onset,” says Rusty Selix, Executive Director and Legislative Representative for the Mental Health Association in California.

“On average, it is six years after the onset of a mental illness before it is identified and a treatment set.”

Eerily true to form, it took six years for Shimizu to begin getting treatment for her son.

More than 20 percent of the U.S. population— 44 million people— experience a mental disorder in any given year, but almost half of these individuals do not seek treatment according to a 2002 report from the U.S. Department of Health and Human Services, 2002. “My son would sometimes stand in the middle of the kitchen and say ‘Thoughts, thoughts, thoughts are going by and I can’t catch them’. He knew something was wrong but he was still resisting help,” she says.

Without treatment, people with mental illness develop additional problems— and develop them faster than do people without a mental illness.

One Medicaid survey, for example, showed that people diagnosed with mental illness have five times the rate for all major illnesses—diabetes, hypertension, and heart disease—than those without a mental illness. And,

SPRING 2011

according to the Centers for Disease Control and Prevention, people who suffer from chronic, untreated depression may die up to 25 years earlier than the average lifespan.

Untreated mental illness is also costly. Serious mental illnesses cost $193.2 billion in lost earnings per year, according to findings in a 2008 issue of American Journal of Psychiatry. And people with untreated mental illness are swamping emergency rooms, straining the system. Out of 95 million visits made to emergency rooms by adults in 2007, 12 million, or 12.5 percent, had to

do with mental disorders, a substance abuse problem, or both according to a recent report from the U.S. Agency for Healthcare Research and Quality. Of those 12 million visits, about 66 percent involved patients with only mental disorders. Almost 41 percent of those 12 million visits resulted in the patient being admitted to the hospital, which is more than 2.5 times the rate of hospitalizations for other conditions.

The Stigma Sticks

Most mental health experts agree that the stigma attached to mental illness is a

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Cover Article > MeNTAL HeALTH

It’s a Catch-22 WHILE SOME PEOPLE voluntarily check themselves into a hospital for mental health care, many others are involuntarily committed. A person can be placed on an involuntary hold and be treated in a mental health facility if they are determined to be mentally ill and meet one of three criteria: imminent danger of self harm, imminent danger of harm to others, or grave disability.

Law enforcement officers have the authority to place a person on involuntary hold as do physicians and mental health professionals who have been trained and certified by the Department of Mental Health. If a person is placed on an involuntary hold and committed to a Department of Mental Health designated facility, a physician has a minimum of 72 hours to evaluate the person and determine if more treatment is needed. “It can be very difficult and frustrating to try to help those with serious mental illness,” says Daniel Suzuki, MD, Medical Director at Las Encinas Hospital, which specializes in behavioral health care. “A person who has a schizophrenic illness, is actively delusional and is homeless may still not meet the criteria of grave disability for involuntary commitment if they can find shelter underneath a freeway overpass and panhandle for money.”

Even if a person is hospitalized, he or she cannot be forced to take medications. There is some recourse but it’s not pretty. If the treating physician believes that a patient who is refusing medications does not have the capacity to make such a decision, the physician can petition the Superior Court to request a hearing. Within two days from the time the doctor requests the capacity hearing, the patient will be contacted by an attorney from the Public Defenders Office or, in some counties, a Patients’ Rights Advocate to prepare for the hearing. The patient is then scheduled for a hearing where a hearing officer or judge from the Superior Court will decide the issue of capacity to give or withhold consent to medical treatment.

Unless there is an emergency, the patient cannot be medicated without giving consent until the hearing takes place. Then, if the court decides that the patient is not capable of giving informed consent, the doctor will be given authority to medicate the patient despite his or her objections.

Unfortunately, at times, people whose mental illnesses are acutely treated in the hospital and stabilized relapse due to noncompliance with outpatient treatment. In many cases outpatient resources for the chronically mentally ill without insurance is very limited. “Without mental health treatment centers and social support systems to encourage medication compliance and help with the psychosocial stressors that accompany mental illness, relapse rates can be high,” says Dr. Suzuki. “The good news is we have more effective psychotropic medications that are more tolerable and have fewer side effects.

For example, we have new long-acting injectable antipsychotic medications that can help prevent rehospitalizations if we have systems to provide them to patients.”

For people who have insurance coverage and voluntarily seek inpatient treatment, options are greater, although not without challenges. In a typical insurance scheme of fail-first policy, patients must first fail to improve with outpatient treatment before they can go to the hospital for inpatient treatment.

After acute stabilization, the patient then transitions to a partial hospitalization program where they receive treatment during the day and go home in the late afternoon.

“The mental health care delivery system in the U.S. is still very underfunded and fragmented,” says Dr. Suzuki. “I remain hopeful, however, that if physicians, hospitals, insurance companies and the public sector work together, then ultimately quality of care can succeed in a cost effective environment. And that is good for everyone, most importantly the patient.”

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key reason that more people do not get help. “There is huge discrimination against people with mental illnesses,” says Selix.

“What can we do to change the stigma associated with mental illness? We don’t have the answers.”

While Shimizu’s son is on a good path currently, the family’s ordeal is still not over. Feelings of shame still linger. “For the longest time we didn’t want to tell anyone,” says Shimizu. “My husband still has people he hasn’t told. We’re not bad people; we didn’t make him sick.”

Why do mental illnesses continue to be stigmatized?

For one thing, the term “mental illness” implies a distinction from “physical” illness, although the two are intimately coupled.

For example, schizophrenia is a progressive disease—the longer it is left untreated, the more brain cells a person actually loses. Some mental health advocates propose switching to less stigmatized terms, such as behavioral health or brain disorders.

In addition, we tend to say that people we do not like are “crazy” or “mental.” The media often portrays mentally ill individuals as comic. Some people also believe that if you have a mental illness, you must be dangerous and unpredictable.

In fact, the opposite is generally true—mentally ill people are more likely to be the victims of crime because their odd action may provoke attack.

For someone with mental illness, the consequences of stigma can be devastating. Some people with mental illness don’t seek treatment for fear of being seen as less than other people. They believe that once family and friends fi nd out about their illness, they’ll be scorned. They may try to hide their symptoms and not stick to treatment regimens.

Some people with mental illness become socially isolated. “With a physical illness, a person gets cards, balloons, phone calls, and offers of help. My son got none of that,” says Shimizu. “It isolates a person. You often lose friendships. People don’t know what to do to welcome someone with mental illness back into the fold.”

Indeed, statistics back up those feelings. In 2004, Mental Health Connection of Tarrant County and Community Solutions of Fort Worth, TX

SPRING 2011

conducted a public attitudes survey on mental illness. Among the findings: • More than 50 percent believe major depression might be caused by the way someone was raised, while more than one in five believe it is “God’s will.”

• More than 50 percent believe major depression might result from people “expecting too much from life,” and more than 40 percent believe it is the result of a lack of will power.

• 60 percent said an effective treatment for major depression is to “pull yourself together.”

Parity: A Multi-level Issue

Close behind stigma as a key reason that people do not seek treatment is the issue of cost. Many people cannot afford care and, in many cases, health insurance coverage of treatment for mental illness is inadequate and far more limited than that for physical illnesses, such as diabetes or high blood pressure. Only 6.2 percent of current U.S. health care spending is devoted to the treatment of mental disorders. Although there is some legislation in place to help resolve the parity issue, it is often hard to enforce and new laws are difficult to get passed.

In March 2008, the U.S. House of Representatives passed the Mental Health Parity and Addiction Equity Act of 2008, a federal law that would require equal health insurance coverage for mental and physical illnesses, when policies offer coverage for both. The law came into effect on July 1, 2010 and, although a start, the law is not perfect.

First, it applies only to group plans sponsored by employers of more than 50 people. State and local government employee plans may opt out of the federal parity law. Further, if a plan does not already cover mental health benefits, even in a limited fashion, the law would not

SPRING 2011

pertain.

“Our number one concern is that despite the new Federal parity law, we have seen a reversal in insurance trends,” says Randall Hagar, Director of Government Affairs for the California Psychiatric Association. “Blue Shield and Blue Cross are being more restrictive. It’s cheaper for them if people are discouraged from psychotherapy and just get medications.

So now they are beginning to use controls on outpatient psychotherapy— for example, requiring new approvals every couple of months. If you increase the hassle factor, people will give up.”

Prior to the Federal law, California passed Proposition 63, Mental Health Services Act, in 2004. This statute, which was authored by Selix and then-Assemblyman Darrell Steinberg, levied an additional 1 percent state tax on incomes of $1 million or greater to fund mental health service programs beginning in 2005. The program generated additional revenues of about $800 million in 2006-2007 alone. Much of the funding is provided to county mental health programs.

Other statutes, however, have not proven as easy to get through the legislative process. Assembly Bill 1600, Mental Health and Substance Abuse Parity, would expand mental health coverage requirements for certain health insurance policies issued, amended, or renewed on or after Jan. 1, 2011. Basically, the bill broadens the list of conditions to receive parity from a handful to all disorders included in the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association. “The bill closes the loop on the effort started over 10 years ago to eliminate insurance discrimination against people with mental illness,” says Hagar.

Unfortunately, former Gov. Schwarzenegger vetoed the bill, claiming it would add costs to insurance premiums for individuals and would raise costs in employer supplied benefits. Hagar says those claims are unfounded. “Our data shows it’s really pennies per month for premiums,” he says. “The data comes from calculations of the California Health Benefits Review program at state universities.” And, he adds, “the argument about employers is specious.

Plans give employers a price and then look at utilization data for the company.

Employers who offer fewer mental health benefits have more costs in health services. We believe this bill will decrease employer costs.”

Suggestions Suggested

Selix thinks that the medical home model might help. In his view, this integrated approach would allow the appropriate professional to deal with the patient immediately—a patient could avoid the issues of stigma, the care would be covered and easily approved and the patient would be spared the strain of finding a therapist. “Most physicians do not have a relationship with a mental health specialist,” he says. “A patient gets a list of therapists and an 800 number to call and then they are on their own. That’s a disincentive.”

Shimizu believes that physicians should stress that mental health is important, too, and offer to refer the patient to a therapist if they need to talk about something. “I would like to see us accept that people who are overcoming mental illness are worthy of attention and they are not contagious,” she says.

“Mental illness is simply a part of human life—you’re still a person.”

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COVER ARTICLE > Mental Health

Practical Resources for Physicians and Patients San Joaquin County NAMI (National Alliance for the Mentally Ill)

By Kari Khoury, RN

More than 26 percent of Americans suffer from a diagnosable Mental Illness. Our county Mental Health Services care for patients who are in crisis needing hospitalization as well as those dealing with chronic mental illness needing outpatient care. Family practitioners and Internists may not be aware that there is a grassroots, nationally recognized and extremely effective organization called NAMI (National Alliance for the Mentally Ill) right here in our community. NAMI can assist them in caring for their patients who suffer from major mental disease.

My family has been dealing with severe mental illness for 24 years now, and NAMI has provided us with crucial, supportive and educational programs to help us understand mental illness, become aware of community treatment programs, and most of all learn how to interact, care for and support our mentally ill family member. My brother is diagnosed with schizoaffective disorder.

Now 42, he is living on his own but receives significant support from the local health care system. I am grateful for the care he receives

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from his Case-Worker and Psychiatrist.

However it was the local NAMI group that offered programs such as “Family To Family”, “Peer To Peer” and “NAMI Provider Education Program”, which enabled our family to cope successfully with his disease.

Family to Family is a series of 12 weekly classes taught by trained volunteer family members who know what it is to have a relative dealing with mental illness. Current information and research on such major mental illnesses such as schizophrenia, depression, bipolar disorder, panic disorder, obsessive-compulsive disorder, addictive disorders and borderline personality disorder are covered. During special workshops for listening, problem-solving and communication techniques, attendees will also acquire strategies for handling crisis and relapse. Family members will be given information about medications, side-effects and ways to help their loved one remain compliant with their meds. Care-givers will learn stress reducing coping skills and how to avoid emotional overload. Participants

My family has been dealing with severe mental illness for 24 years now, and NAMI has provided us with crucial, supportive and educational programs to help us understand mental illness, become aware of community treatment programs, and most of all learn how to interact, care for and support our mentally ill family member. My brother is diagnosed with schizoaffective disorder.”

SPRING 2011

will learn about community services and support systems in their area.

Peer to Peer is a support program taught over a ten week period and run by two trained “mentors” and a volunteer support person. Each has personal experience at living “well” with their mental illness. Participants are encouraged to share their traumas and feelings surrounding their mental disease. As they learn about stress, symptom triggers and positive coping skills, patients fi nd out that they share many of the same problems and successes with their classmates.

At the end of the 10 weeks, patients leave with a binder full of resources, and a “relapse prevention plan” that helps to identify thoughts or events that may predict an impending relapse. Steps to organize care, calm feelings and strategies that enable the person to cope with family, the public and their health care providers are all survival skills gained during the Peer to Peer program.

The NAMI Provider Education Program, also a 10 week series, is designed specifically for physicians, nurses and health care workers dealing with patients with severe and chronic mental illnesses. The course presents an in-depth, subjective view of mental disease by way of two trained Family to Family mentors, two patients with knowledge of their own mental illness and well on the road to recovery, and one mental health professional who is also a consumer or family member. Participants gain “lived experiences” and deep insight into the lives of patients and their families.

Th is enables the professional to deliver comprehensive care involving the social, personal and medical aspects of mental illness. They will realize the hardships patients face and the courage and persistence needed to recover.

I was recently talking to a physician friend when the topic of conversation turned to mental illness. I was surprised to fi nd out that he had not heard of NAMI. It would be great for the doctors and health care providers to have all the “tools” available to them when caring for mentally ill patients and there families. Participants in the support and educational groups provided by NAMI can gain a multitude of skills that help patients and families survive major mental illness. NAMI was a great asset to my family. I encourage all doctors to explore these fantastic programs.

A very comprehensive website, nami.org is a great place to refer your patients for more in-depth information. Here in SJC, Gayle Henderson is the NAMI/SJCBHC Family Advocate. Her cell phone number is 209.594.7920 and the NAMI office number is 209.369.2594. Feel free to call her.

SPRING 2011

NAMI CAN MAKE A POSITIVE DIFFERENCE IN THE LIVES OF YOUR PATIENTS! The NAMI Provider Education Program will start its spring 2011 series of 10 weekly classes soon.

Spring Family to Family class will start Feb 12, 2011. Eleven Saturdays 10- 12 Noon, 530 W. Acacia St. Second floor, (across from Dameron Hosp.)

Stockton: Support group Sharing and Caring is held the 1st Thurs of the month: 6pm 1212 N. California St. Conference room A Lodi: Support group Sharing and Caring is held on the 4th Thurs. of the month: 6pm Lodi Ave Baptist Church, 2301 W. Lodi Ave. Stockton: Support group Sharing and Caring is held on the 4th Sat. of the month: 10 am 1212 N. California St. conference room A Tracy: Support group Sharing and Caring is held every Monday 7 pm and Wednesday 10:30 am Sutter Healthy Connections Resource Center 35 E. 10th St. Suite C San Joaquin County NAMI P.O. Box 448 Stockton Ca. 95201 Phone: 209.468.3755 Office hours: Mon, Tues, Thurs, Fri. 1-3 pm Submitted by: Kari Khoury RN

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8 JOAQUIN PHYSICIAN 58SAN SAN JOAQUIN PHYSICIAN

FALL 2010 SPRING 2011

SPRING 2011

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59

CMA

Webinars Available Online!

CMA is excited to announce that we will be hosting a series of live monthly webinars to educate physicians on a range of topics from health information technologies to reimbursement issues.

Space is limited so register soon by going to http://cmanet.org/calendar/ and following the simple instructions.

If you need help with your CMA user name or password, simply call CMA’s member help line, (888) 233-2937 or call your county medical society and they will assist you.

We b i n a r s m a r k e d w i t h a n a s t e r i s k ( * ) a re P M I C E U C re d i t A p p ro v e d

March 2 12:15pm-1:15pm

CMA MEMBERS ONLY: Meaningful Use for your EHR

*Mar 16 (Wed) Keyincentive Financial Ratios to In order to receive payments for Increase electronic Practice health records (EHR) implementation, physicians will have to demonstrate “meaningful use” of that Profitability — 12:15PM - 1:15PM

system.

Thewill Federal recently released a draftprofit/loss rule that will define This webinar teach Government critical skills in analyzing the practice “meaningful use,” including which quality measures physicians will have to statement for overhead expense ratios, accounts receivable ratios, staffing report. This CMA Webinar will walk physicians through the proposed rule, and ratios and how to access specialty comparison norms for benchmarking.

offer practical tips for physicians who are gearing up for incentive payments in 2011.

*Apr 6 (Wed) Coding for Medical Necessity and Quality March 3 12:15pm-1:15pm Care — 12:15PM - 1:15PM and also 6:00PM - 7:00PM

CMA MEMBERS Documentation – necessity as a deciding Medicare and private ONLY: payers all recognize medical Medi-Cal Fraud and Abuse Series factor for claims payment and it is important that all practices know the In this Medical Consultant with the Department of rules.

Thiswebinar, session Bruce will beTarzy, led byMD, Mary Jean from Sage Associates.

Health Care Services will describe the importance of documenting medical services provided to Medi-Cal recipients. And, impact of fraud and abuse to *Apr 20 (Wed) Implementing a Compliance Program the Medi-Cal program.

a Practical Perspective *March- 1:15PM 10 12:15pm-1:15pm 12:15PM and also 6:00PM - 7:00PM

Medicare – Newprograms, Year, Fresh Formal compliance whileStart a very good idea, have not been manThis webcast is designed as a Medicare refresher course, covering a variety of datory until recently when health care reform legislation passed containtopics including the call inquiry process, filing an appeal and reading ing a provision making compliance plans mandatory for certain providers. your remittance advice.

Implementing a compliance program in a physician’s office does not have to be a daunting task. Mary Jean from Sage Associates will lead this inforMarch 18 12:15pm-1:15pm mative session.

HIPAA Overview and Compliance – How to Be Compliant with Recent Changes

*May 4 (Wed)Act Dealing Sensitive Personnel Issues The HITECH of 2009with mandated additional guidelines for HIPAA 12:15PM - 1:15PM impact HIPAA compliance, breach and penalties. In this webinar,

which David Ginsberg will give a brief overview of HIPAA and security This programofisPrivaPlan, an informative discussion of state and federalprivacy laws, and rules, highlight the changes to HIPAA affecting security breach notification and best practices managers may use for handling difficult employee issues. business associate agreements, and provide resources to help physicians Debra Phairas, President of Practice and Liability Consultants, will review and comply with the new HIPAA regulations. theunderstand dos and don’ts for avoiding lawsuits.

April 7 12:15 pm-1:15pm *May 4 (Wed) Dealing with Sensitive Personnel Issues Resubmit, Reopen or Appeal?

6:00PM 7:00PM This presentation will help you navigate the appeals process and answer all of

This program is an asked informative discussion of state and federal and your frequently questions regarding: Reopening vs.laws, Redetermination.

What form do I use and where send it? And, responding the Additional best practices managers may use do for Ihandling difficult employeetoissues.

Documentation Requests (ADR). and Liability Consultants, will review Debra Phairas, President of Practice the dos and don’ts for avoiding lawsuits.

*April 21 12:15 pm-1:15pm Medicare Top 10 Billing Answers Errors to Your Legal Questions in *May 18 (Wed) Finding Presented by Catalina Ramirez, Ombudsman, Palmetto GBA. This presentation 5 Minutes A Guide to CMA’s Amazing Legal Library is designedortoLess: increase provider awareness and understanding of the most common claim denials. It will also provide you with the appropriate information 12:15PM - 1:15PM on how to avoid or resolve common denials.

CMA’s Center for Legal Affairs these will walk physicians and their staff through navigating and utilizing CMA’s invaluable Medical-Legal Library.

*May 12 12:15 pm-1:15pm Medicare Preventive Services *Jun 1 (Wed) ICD-10 — 12:15PM - 1:15PM

Are you and your patient’s getting the most out Medicare Part B benefits? Did

This informative webinar will be presented by Practice Management you know that Medicare Part B covers sixteen (16) Preventive Services? Learn Institute. what they are and how to bill correctly for them in this informative webinar.

*Jun 15 (Wed) Best Practices for Working your Account *May 26 12:15pm-1:15pm CMA MEMBERS ONLY: Receivable Reports Evaluation & Management and Documentation 12:15PM - 1:15PM and alsoCoding at 6:00PM - 7:00PM

In this maximum member’s reimbursement only webinar, with Dr. quick ArthurAccounts Lurvey, Receivable Medical Director for Receiving (A/R) PalmettoGBA, offers and in-depth training for documenting and coding turnaround is a goal of every medical practice. Using A/R reports effectively out-patient and in-patient E&M services. allows the billing department, manager and physician to keep on top of this consistently.

This informative session will be led by Mary Jean from Sage June 9 12:15pm-1:15pm Associates.

CMA MEMBERS ONLY: The Art of Training, Evaluating and

Retaining Qualified Personnel for Today’s Medical Practice

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SAN JOAQUIN PHYSICIAN

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SPRING 2011

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medical society > Membership

25 New

Members in the Past 60 Days!

...and even more on the way.

Mala Ashok, MD Obstetrics and Gynecology P Gill OB/GYN Medical Group 435 E Harding Way, Ste 1 Stockton, CA 95204 Office: (209) 464-4796 University of Madras: 1981 Jai Autar, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2080 Fiji Medical School: 1984 Raymond Chang, MD Cardiology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-3737 University of California School of Medical â&#x20AC;&#x201C; LA: 1990 Yu-Lian Chang, MD Family Medicine Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377

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Office: (209) 839-3300 Institute of Medicine I: 1998 Debby Chao, MD Urology Kaiser Permanente 1789 W Yosemite Ave, Ste 2F Manteca, CA 95337 Office: (209)858-7770 University of California School of Medical â&#x20AC;&#x201C; LA: 2002 Nusrat Chaudhry, MD Internal Medicine 200 Cottage Ave, Ste 103 Manteca, CA 95336 Office: (209)624-5811 University of the Punjab: 1994 Maria de Guzman, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-3368 University of Santo Tomas: 1988 Charles Denman, MD Internal Medicine Kaiser Permanente

7373 West Lane Stockton, CA 95210 Office: (209) 476-2000 University of Rochester School of Medicine & Dentistry: 2007 Veena Devarakonda, MD Pulmonary Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-23300 Seth GS Medical College: 2000 Esther Fine, MD Head & Neck Surgery Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2171 University of Washington: 2004 Rajnish Gupta, MD Dermatology Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 Office: (209)957-3821 Vanderbilt University: 2004

Dean Kelaita, MD Family Medicine Silver Oak Medical Office 702 Mountain Ranch Rd San Andreas, CA 95249 Office: (209)754-0870 Albany Medical College of Union University: 1993 John Kim, MD Gynecology P Gill OB/GYN Medical Group 1617 N California St, Ste 2A Stockton, CA 95204 Office: (209)466-8546 Rosalind Franklin University: 1990 Chris Krpan, DO Orthopedic Surgery 1300 Kurt Drive Angeles Camp, CA 95222 Office: (209)736-1147 Western University: 1999 YanYan Li, MD Family Medicine Kaiser Permanente 1721 W Yosemite Ave Manteca, CA 95337

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Office: (209)824-5004 Qingdao Medical College: 1990

Office: (209) 476-2000 Institute of Medicine I: 1998

Shahryar Masouem, MD Obstetrics and Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2080 Ross University School of Medicine: 2004

Lily Pang, MD Pathology St Joseph’s Medical Center 1800 N California St Stockton, CA 95204 Office: (209)467-6491 Medical Center of Fudan University: 2004

E Oluwakemi Ogunjimi, MD Obstetrics and Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-3023 Wright State University: 2006

Daan Ren, MD Family Medicine Sutter Gould Medical Foundation 2151 W Grant Line Rd Tracy, CA 95377 Office: (209)832-0535 Medical Center of Fudan University: 1995

Htun Oo, MD Geriatric Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210

SPRING 2011

Sahdev Shaharan, MD Rheumatology 2800 N California St, Ste 5 Stockton, CA 95204

Office: (209)462-7246 Maharshi Dayanand University: 1996 Gary Shrago, MD Radiology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2111 University of Oklahoma: 1967 Konrad Thomas, MD Obstetrics and Gynecology Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Office: (209) 839-3300 Howard University: 2001 Sanjeev Vaishampayan, MD Cardiology Stockton Cardiology Medical Group

415 E Harding Way, Ste D Stockton, CA 95204 Office: (209)832-0343 Wayne State University: 1989 Robert Yavrouian, MD Colon & Rectal Surgery 1805 N California St, Ste 409 Stockton, CA 95204 Office: (209)948-0578 Drexel University College of Medicine: 2004 Peter Yip, MD Family Medicine Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 Office: (209)954-4040 University of California School of Medical – Davis: 2001

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SPRING 2011

In Memoriam < COMMUNITY

Eric Marc Braunstein, M.D.

the guard should take the apple that he had in the trunk, even though the guard said it was fine. The deciding factor that day was not the guard’s standard, but the doctor’s.

That trip was essentially an express trek.

The three of us drove straight back from Chicago. We didn’t stop to sleep. And here is why: Dr. Braunstein missed his wife and wanted to be back with her.

May God bless his soul. Our prayers are with him.”

Dr. Braunstein is survived by his wife, Wendy; his father, Dr. Richard Braunstein, of San Carlos, CA; brothers Robert Braunstein of Seattle, WA, and Kenneth Braunstein of Humble, Texas. He also is survived by his aunt Elaine Light and two nieces, Alexandra Braunstein and Sara Braunstein. He was preceded in death by his mother, Nina Braunstein.

August 17, 1958 – November 22, 2010

With the passing of Dr. Eric Marc Braunstein, Stockton has lost a wellrespected cardiologist, colleague, friend, husband and family member.

Dr. Braunstein was a member of the San Joaquin Medical Society and the California Medical Association for nearly twenty years, and served on the Medical Practices Committee and the Medical Review Committee.

A colleague, Dr. Ramin Manshadi, formed his strongest impression of Dr. Braunstein at a most memorable time in our nation’s history, September 11, 2001: “We were at the cardiovascular board review course in Chicago. Everything was in standstill. There were no cars, planes, or trains available to get us back. Luckily, I had a rental car. We decided to drive back together along with one of my colleagues from UC Davis.

We had many interesting conversations as we drove, about our respective faiths, and how each allowed room for our friendly triad. Why, we wondered together, was there so much hate in the world?

When we finally crossed California’s checkpoint, Dr. Braunstein insisted that

SPRING 2011

R. James Schmitt, M.D. June 27, 1923 February 9, 2011

Dr. R. James Schmitt passed away on February 9 at St. Joseph’s Medical Center. Dr. Schmitt worked in Stockton as an obstetrician/gynecologist for

30 years, most notably with Schmitt, Gallagher & Cobb. He was a member of the San Joaquin Medical Society and the California Medical Association for more than fifty years, and served on several medical committees, including as board director for the Bureau of Medical Economics.

In his nearly ninety years of life, the doctor traveled far from the bureau drawer bassinet he lay in as a baby. From New Mexico, to Colorado, to Nebraska and New York, Dr. Schmitt lived his life with vigor.

It was in Colorado, in 1948, where he met his wife, Collette. To help pay for medical school, he worked for Colorado Ice & Cold Storage, loading 300-pound blocks of ice. He met Collette, then an x-ray technician, when an ice block fell on his foot. They married a year later.

The doctor and his wife moved to California; the doctor completed two residencies, served in the Army, and worked in Public Health in Detroit and Puerto Rico. After many productive years as a physician, Dr. Schmitt retired in 1987.

Dr. Schmitt will be remembered by many from his affiliation with the Stockton Sailing Club and the Stockton Golf & Country Club, and from his active service to the Knights of Columbus Presentation Council #10478. He was Past Grand Knight, Past Faithful Navigator with the Fourth Degree, and Past Chapter President.

He also chaired the Respect Life Committee, and was a member of Presentation Church.

He is survived by his wife of 61 years, Collette; brothers Bill Schmitt and Vincent Schmitt, and children Sue Schmitt, Jean Johnston, Taffy Piper, Chris Chan, and Jim Schmitt. He was preceded in death by his sister Patsy.

Dr. Schmitt is also survived by grandchildren Damon Tighe, Jenny Johnston, Heather Johnston, Christy Piper, Dale Piper, Tevin Schmitt and Harrison Schmitt. A great-grandson, Landon Piper, was born on January 2, 2011.

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COMMUNITY > In Memoriam

Dr. Thomas Coleman Werner M.D.

Ronald Allison, remembers the doctor’s contribution to others: “Dr. Werner was very experienced and well-trained in primary and urgent care.

He also helped thousands of residents in Rehabilitation Care Centers deal with end-of-life issues, keeping their families informed and reassured.

He helped found Emergency Service at Dameron Hospital in 1972. In 1977, he trained the Stockton Fire Fighters in emergent care so they could serve as paramedics. That training made possible the saving of many lives.”

Dr. Werner is survived by his two sisters; Dee Lawrence of Houston, Texas, and Ann Johnson of New York, his five children; Kimberly Little of Stockton, Heidi Werner of Stockton, Kelley Roach of Manteca, Gia Werner of Folsom and Justin Werner of Stockton; by fourteen grandchildren; and two great-grandchildren.

Sept. 7, 1937 Dec. 11, 2010

Dr. Thomas Coleman Werner passed away at his home on December 11, 2010. The doctor’s contribution to the health and well-being of Stockton area patients, to education and the improvement of medical care, spanned more than thirty years.

Dr. Werner joined the San Joaquin Medical Society and the California Medical Association in 1970, and served on many committees. Dameron Hospital appointed him chief of staff in 1977, a position he held for more than ten years. After serving as medical director of Student Health at the University of the Pacific, the doctor turned his attention to geriatric medicine, offering his years of experience to help nursing home patients and their families.

Dr. Werner’s friend and colleague, Dr.

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for 40 years, passed away on December 16th at St. Joseph’s Medical Center in Stockton. He was 93 years old.

The doctor was a member of the California Medical Association and also the San Joaquin Medical Society, where he served on several committees, and as board director for the Society and for the Bureau of Medical Economics. He also served as president of the San Joaquin Medical Society in 1976-1977.

Dr. Roeser was a Nebraska native, educated at the University of Nebraska, who served his internship and residency at the Presbyterian Hospital of Chicago, Illinois.

In 1950, he moved to Stockton with his wife, Eva. It was the beginning of a forty-year surgical practice, eventually assuming the position of Chief of Surgery and Chief of Staff for St. Joseph’s Medical Center. He retired in 1985.

Dr. Roeser was known throughout the community for his service as an elder in the First Presbyterian Church of Stockton and as a charter member of the North Stockton Rotary Club. The doctor also served as one of the Stockton Symphony Association’s first presidents, and was influential in its founding.

Erwin Roeser is survived by his wife of 67 years, Eva; his sister, Arline Abell of San Diego; seven children, Cherrie Roeser of Stockton, Susan Sather of Stockton, Mary Hammond of Fair Oaks, Janey Jones of South Lake Tahoe, William Roeser of Fresno, John Roeser of Pleasanton, and Thomas Roeser of Elk Grove; twelve grandchildren, and three great-grandchildren.

Erwin Heldt Roeser, MD Sept. 5, 1917 Dec. 16, 2010

Dr. Erwin Roeser, a Stockton surgeon

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ALLIANCe UPDATe > Member of the Year

Bune Primack Name 2011 Alliance Member of the Year Bune’s loyalty and contributions to the Alliance over her many years of membership is outstanding. She embodies the best of what the Alliance stands for….dedication to her family, friends and her community.

Bune served as Alliance president from 1974-75 and held numerous offices and worked on many committees. She has hosted the senior luncheon with Greta Hermann and Barbara Wegner and appears to have the lifetime appointment of bridge chair.

In the community, Bune has been active at Children’s Home of Stockton serving on the board for nine years and president for two. At Temple Israel you will fi nd her at the numerous bakery workshops leading up to the annual Food Fair and serving as treasurer the day of the event.

Bune was a member of Junior Aid and served as treasurer and bridge coordinator, was active in PTA while her children attended school and has supported many of her grandchildren’s activities as well. Bune was treasurer for Joan Darrah’s campaign and term of office (1990-96) and has also served on the Grand Jury.

Bune and her husband Marv have been active in the medical community for many years and have added much to our community. They are the parents of four children, two of which have returned to Stockton to practice medicine.

MEMBER OF THE YEAR LUNCHEON Please Join us to Present the Award to Bune Thursday, March 24 11:30 a.m. Papapavlos, Lincoln Center, Stockton

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Please RSVP by March 17 Send To: Greta Hermann Mail check for $25 (SJMA) 9564 Trenton Way, Stockton 95212 LEGISLATIVE DAY IN SACRA MENTO Tuesday, April 5, 2011 Here is an easy & fun way to get involved in our state legislation.

Meet at the S.J. Medical Society at 3031 W. March Lane #222W at 8:00am and we will return around 4:30pm (lunch is provided).

Groups of transportation will be provided to the event.

Let’s show our support & share our concerns with the legislature!

Please call the Medical Society to make reservations.

209-952-5299 ALLIANCE PICNIC HONORING 50 YEAR MEMBERS Thursday, April 14 at 12:00 Noon Home of Judy Yecies, 6455 St. Andrews Drive, Stockton RSVP: Judy Yecies with $15 payment made to SJMA (gratis for 50 year members) jyecies@comcast.net or 209-951-3184 PLEASE JOIN US FOR A “WINE AND WHINE” CASUAL GET TOGETHER THURSDAY, MARCH 31, 2011 5 - 7 pm HOME OF FRA N MEREDITH, 4925 St. Andrews (Brookside, off of March Lane) Bring your favorite wine. Light snacks provided Spouses Welcome!

SPRING 2011

â&#x20AC;&#x153; individually, we are one drop, but together we are an ocean. â&#x20AC;? united ... and

we must be, especially in these tumultuous times.

Dr. Susan Kaweski, President San Diego County Medical Society

two organizations one mission together with

Join us and

to serve you.

we will make some waves.

For more information or a membership application: visit www.sjcms.org or call us at 209.952.5299

• • • •

Business Records Storage Media/Vital Records Vault Certified Document Destruction Document Imaging Services

Mike Long, Director of Marketing

209-320-6618

email: mlong@pacificstorage.com www.pacific-records.com

Stockton Golf & Country Club tradition • private setting • heritage 3800 W. country club blvd • stockton, ca

Call for special membership pricing (209) 466-4313

State of the art fitness center

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SAN JOAQUIN PHYSICIAN

Swimming Pool and Clubhouse

Clubhouse Amenities: - Grand Ballroom for events - Casual & Formal Dining Rooms - Grill Room overlooks 18th Green - Locker rooms with Spas/Steam Room

SPRING 2011

STOCKTON MRI & Molecular Imaging Medical Center, Inc. 2320 N. California Street • Stockton, CA 95204 PHONE 209-466-2000 • Fax 209-466-2600 w w w. s to c k to n m r i . co m

The Most Advanced and Comprehensive Medical Imaging Center in San Joaquin County Just Got Better with the Addition of the Central Valley’s only 128 Multislice CT Scanner with Lowest Radiation Dose Imaging Services Include: • • • • •

The first PET-CT since 2003 Full service of Nuclear Medicine Most advanced G. E. High Field MRI (1.5 Tesla) Full service of Digital Radiography and Fluoroscopy Siemens Ultrasound Units

All Board Certified Radiologists with fellowship: Javad Jamshidi, MD Jack L. Funamura, MD Francis P. Isidoro, MD Oscar Isidoro, MD Brij J. Kapadia, MD

The Fastest 128 Multislice High Resolution CT in community practice:

Siemens Somatom Definition AS+ (128) SPRING 2011

SAN JOAQUIN PHYSICIAN

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PRSRT STD. U.S. POSTAGE

San Joaquin Medical Society 3031 W. March Lane, Suite 222W Stockton, California 95219-6568

PAID

Permit No. 60 Stockton, CA

RETURN SERVICE REQUESTED

You invested everything in building your practice and reputation.

For 35 years, we’ve defended your investment.

Our passion protects your practice

Many personal injury lawyers have learned the hard way not to bring non-meritorious claims against NORCAL Mutual policyholders. Drawing on 35 years of experience, we defend to the standard of care in your area.

To learn more about NORCAL Mutual’s products and services, please contact: >

NORCAL Mutual is proud to be endorsed by San Joaquin County Medical Society as the preferred medical professional liability insurer for its members.

Ken Stacey, Senior Account Executive Phone: 800-652-1051, ext. 2054 Fax: 415-735-2353 E-mail: kstacey@norcalmutual.com

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License #: 0A00400