November-December 2014 by SMCMA

S a n M at e o C o u n t y

November/ December 2014

Physician

in s id e

S a n M at e o C o u n t y M e dic a l Ass o ci at i o n

Volume 3 Issue 10

Transgender and Political Correctness in a Changing World

Treatment Options for Sleep Apnea

An ICD-10 Christmas Tale

Member Benefit News: Open enrollment for the San Mateo County Medical Associationsponsored dental plan has started! You and your family are eligible to enroll in the SMCMA-sponsored dental plan only during open enrollment periods. Apply by December 31, 2014! To be eligible for coverage, applications must be received during the special open enrollment period ending on December 31, 2014.

For more information... Call a Client Advisor at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

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S a n M at e o C o u n t y

Physician Editorial Committee Russ Granich, MD, Chair Uli Chettipally, MD Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership Vincent Mason, MD, President; Michael Norris, MD, President-Elect; Russ Granich, MD; SecretaryTreasurer; Amita Saxena, MD, Immediate Past President Alexander Ding, MD; Manjul Dixit, MD; Toby Frescholtz, MD; Edward Koo, MD; Alex Lakowsky, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Kristen Willison, MD; Douglas Zuckermann, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

November/December 2014 - Volume 3, Issue 10 Columns President’s Message: What’s in a name? ...........................................4 Vincent Mason, MD

Feature Articles Transgender and political correctness in a changing world.. ...........6 Marci Bowers, MD

Treatment options for sleep apnea. . ..................................................8 Mehran Farid-Moayer, MD

An ICD-10 Christmas tale. . ................................................................10 Gerry Wieder, RN

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

Of Interest Member updates, Index of advertisers.......................................... 14

On the cover: “Winter Landscape with Bird Trap, detail, by Pieter Brueghel the Younger, late 1500s to early 1600s, oil on panel - National Museum of Western Art, Tokyo - DSC08414” by Daderot - Own work. Licensed under Public domain via Wikimedia Commons - http://commons.wikimedia.org.

President’s Message by Vincent Mason, MD

What’s in a name?

grew up in a small southern town in the 60s, when your name was part of your identity (internally and externally). It defined you in so many ways. I learned to be proud of my name as a youngster. Then the 70s came along and things changed: I went from an elementary school in my neighborhood, to an

elementary (middle school) about a mile from my house. I didn’t understand why and asked my mom. Her response (another new word for me): “This is all about integration and a better education for you.” At that school my external identity was impacted. I was no longer Vincent but a derivative: Vince, Vinnie, Vincenzo. This was perplexing to me. Culturally, I’d never encountered a situation where, when asked “what’s your name?” the person would reply with some different, somewhat similar, but not the same as what I said to them: Vincent.

In the 80s and 90s, my identity became even more complex (again more external, than internal). People would ask: How do you like to be called? I would respond: “Vincent is fine,” but what they were asking me was how I identified in society: Are you black, Afro American, African American? I’d heard far worse as a youngster and would respond: “Whatever makes you feel comfortable.” It mattered, but it didn’t. In this issue of San Mateo County Physician, we get to read a thoughtprovoking article from Marci Bowers, MD, an OB/GYN who specializes in Gender Confirming Surgery. Her article will speak to identity, both internal and external. Our community is fortunate to have her on the staff at Mills Peninsula Hospital. We also have an informative article on treatments for sleep apnea by sleep specialist Mehran Farid-Moayer, MD, and a fun tribute, in verse, to the phenomenom known as ICD-10.

“

As the season ends, we all get to celebrate something: Winter Solstice,

“

Christmas and New Year, Lunar New Year, Hanukkah, Kwanza, Three Kings Day, and more. During the final quarter of the year, people get to reflect on past experiences and gear up for the year ahead. For all practicing physicians in California, 2014 has been a tremendous year. Most notably, Proposition 46 was soundly defeated in November, upholding the protections of MICRA (Medical Injury Compensation Reform Act of 1975) to ensure that we physicians still have the ability to provide access to patient care in this great state. Defeating this deceptive ballot measure involved a tremendous commitment from SMCMA and CMA, dozens of specialty societies, Community Clinics and Health Centers, labor unions, and other groups throughout California. This is also the time of year when we look forward to the future, reexamine what’s most important to us, and resolve to make the coming year one that has meaning and purpose.

This is also the time of year when we look forward to the future, re-examine what’s most important to us, and resolve to make the coming year one that has meaning and purpose.

4 San Mateo county physician | November/December 2014

How will you give back in the coming year? Again, here is where a name is important. During the No on 46 campaign, were you identified as a volunteer, financial supporter, activist, or advocate? Perhaps you didn’t even know what Proposition 46 was about before now, but you can still show your support. While this latest victory is sweet, it certainly won’t be the last time MICRA comes under attack. When it does, SMCMA will be there, fighting to protect your interests. We will always have opponents to MICRA. We will also have physician-advocates who understand that it is imperative to preserve quality patient access and care in California. The defeat of Proposition 46 is an example of what physicians can do when they work together. Please continue fighting with us, side by side, to protect your interests. Here’s to a great 2015! ■

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November/December 2014 | SAN MATEO COUNTY PHYSICIAN 5

Transgender and political correctness in a changing world by Marci Bowers, MD

arrival at Mills-Peninsula Hospital in 2010 was not easy. Despite having performed more than 1,000 male-to female (MTF) sex change surgeries and 1,500 transgender surgeries overall, as well as more than 20 years of post-residency experience, I was denied privileges at one South Bay hospital. They told me I was “not qualified.” Fact is, there is no definitive training available for my line of work—transgender surgery—and there is no certified fellowship anywhere in the world that certifies individuals to do the work I do. Although things will hopefully change, transgender surgery remains largely a work of surgical specialty training followed by experience combined with an apprenticeship. Mine was with Dr. Stanley Biber, a general surgeon and true father of transgender surgery in the U.S. Doc, as he was affectionately referred to, practiced in Trinidad, Colorado, the one-time “sex change capital of the world.” I built upon my dozen years of experience as an ob/gyn surgeon in Seattle and upon the fact that the MTF

prototype surgical procedure was, as many advances in surgery have been, designed and invented by a gynecologist, Dr. Georges Burou. (Dr. Burou practiced in Casablanca, Morocco from the late 1950s until the early 1970s.) At the time of my application for privileges for transgender surgery, I thought about how difficult it is for the surgeon who goes first—there are so many examples in medicine. As a colleague once said to me, “You can tell the true pioneer by the arrows in their back.” And so it has gone for me for a very long time. I recall awaiting judgment outside the rejecting hospital’s boardroom and overhearing the Executive Committee of the hospital staff giggling and talking to one another about me. Contrast that experience with the extraordinary and visionary treatment I have received from the professional staff at Mills-Peninsula. But it wasn’t easy taking over for Doctor Biber in Colorado in 2003, and it has not been easy here. And true, both of those experiences have toughened me for the fight for the women who have been victims of Female Genital Mutilation (FGM).

SMCMA MEMBER STORY

MARCI BOWERS, MD Marci Bowers, MD is a Pelvic and Gynecologic Surgeon with more than 25 years of experience. She is a former Department Chairperson at Swedish Medical Center (Providence) in Seattle, where she practiced as Obstetrician/Gynecologist, delivering more than 2,200 babies while there.

In 2003, Dr. Bowers relocated to Trinidad, Colorado, following in the footsteps of legendary surgeon Stanley Biber, MD. As the only gynecologist in the area, she served the local women of Southern Colorado for nearly eight years. During her time in Trinidad, she also acted as overseeing physician for the Trinidad Planned Parenthood, a much needed resource in the small town

for low-cost mammograms, birth control, and cancer screening. Dr. Bowers then relocated to the Bay Area of San Francisco in October 2010, where she practices general gynecology and surgery. She is a recognized expert in her field of specialty. She is also the first North American gynecologic surgeon trained to functionally reverse female genital cutting (FGM), having trained with Dr. Pierre Foldes in Paris, France in 2007 and 2009. Dr. Bowers is also transgender herself. Named Mark at birth, she made the transition from man to woman in her mid-thirties. While this gives Dr. Bowers a special empathy for her patients’ plight of feeling trapped in the wrong body, she states, “I don’t talk about my past because, in public, I really do not need to do so—I live as a woman. I see myself that way—as does most of the world.”

6 San Mateo county physician | November/December 2014

My thoughts took me back to political correctness. I recall, shortly after successfully landing here in the Bay Area in 2010, a colleague at the hospital kindly introducing me to another doc as “our transgender surgeon.” At first, I thought the intention was to indicate to the other physician that I perform transgender surgery, but, as the conversation went on, it became clear that the intent of his introduction was rather to indicate that I am transgender! As though this fascinating fact trumped any professional or technical accomplishment such as changing penises into vulvas/vaginas. I have, for many years, lived my life as a woman Ob/Gyn, partner and parent, with transgender only a statistical and highly personal fact.

Struck by my apparent charade as a tall, agin, but tantalizingly attractive woman, my true past was apparently

In March 2014, Dr. Bowers traveled to Burkino Faso on a mission to help restore clitoral function in African FGM victims. Dr. Bowers and her surgical team were able to compete 29 surgeries in 4 days. She and her colleagues were also able to teach a local Gyn doctor the delicate procedure of clitoral restoration.

something far more interesting than any contemporary technical proficiency. As this realization dawned upon me, I began to wonder how this thinking might be logically extended to other minority statuses. I thought forward to our next medical staff meeting, where we could introduce one another by stating our qualifications based upon religion—“I’d like you to meet our Jewish gastroenterologist” or, better yet, our “Presbyterian proctologist” or “Catholic cardiologist.” Elsewhere, it might be “our gay pediatrician” or “our felonious family physician.” The possibilities are endless. When it comes to our transgender population, the issue of pronoun use is a struggle for some of our staff, even for those with the purest of intentions. Somehow, the notion of a woman with a penis or a man with a vagina makes it antithetical for some to use gender appropriate pronouns. Yet, when you think of it, when is the last time you passed a colleague in the hallway and knew, with absolute certainty, the status of that colleague’s respective genitalia? Based strictly upon gender expression (how we wear our hair, makeup, clothing, gait), we make an almost instantaneous assumption about that person’s gender identity, without even a hint of consideration of the status of that person’s genitalia, and we virtually never get the pronouns wrong! Having grown up in the 1960s, my notion of gender roles and ideals for gender-based behavior were long scarred by episodes of “Leave it to Beaver.” It was very clear to me that women were nurturing, wore dresses, and baked cookies, while men were stern, worked outside the home, and read

the newspaper when they came home. I grew up liking to read the paper but also wanting to wear dresses and bake cookies. It’s hard-wired. It’s who I am. I had a perfect Dad who golfed and taught me how to hit a curveball, swear, and shank a 3-iron. I tried and did a pretty good job of being male. But female is my gender---it has always been who I was and who I am. That society did such an impressive job of cementing these notions of gender is a tribute to how rigid notions of gender fueled our mid-20th century military readiness—by keeping men, men and women, women— but was never a true reflection of the human spirit. This unnatural separateness of the sexes has done so much, to both sexes, to hold us all back from the honest expressions of our souls. This narrow definition of gender role behavior especially shackles men and boys with an often-impossible climb to achieve ultimate maleness, whatever that is. The result is frustration, and frustration is at least one of the underpinnings of violence. The true essence of humanity is to express gender, not at extremes on an impossible binary, but along a continuum, dotted by randomness and inconsistency, as troubling as that might sound. But it is in this spirit that gender incongruence (expressions of gender not native to our birth-assigned genders), oddly, holds hope for the future in that someday, surgical intervention in the name of the gender binary might be less popular. And so, the notion of the woman with a penis might not be so daunting. This might prompt the question we might logically ask upon recognition of this fact: “What pronouns do you prefer?” ■

November/December 2014 | SAN MATEO COUNTY PHYSICIAN 7

Treatment options for Obstructive Sleep Apnea Obstructive Sleep Apnea (OSA) is a chronic condition and its treatment requires skills and patience needed to treat a chronic illness. The goals of treatment are to improve symptoms and eliminate the sleep apnea events that may contribute to cardiovascular morbidities. Current treatments include weight loss if indicated, behavioral changes including sleeping in non-supine position, elevation of the head of the bed, and avoiding alcohol and sedatives at bedtime, and the following:

DENTAL APPLIANCE THERAPY

WINX THERAPY

The goal of therapy is to protrude the mandible forward by around 60% of the maximal protrusion. This in turn moves the base of the tongue anteriorly to improve the oropharyngeal airway patency. Oral appliances are better tolerated than CPAP, but with lower efficacy. There are many designs available.

Winx is a new invention by a Silicon Valley start-up company, ApniCure, Inc. The Winx system delivers a negative pressure inside the mouth that in turn moves the soft palate anteriorly and stabilizes the tongue.

Indications: Mild to moderate sleep apnea. Patients with severe sleep apnea may try a dental appliance only if CPAP and BiPAP have failed or are not tolerated. It is not indicated for central sleep apnea.

Indications: Mild to severe obstructive sleep apnea. It is not indicated for central sleep apnea.

Considerations. Cost, inability to determine efficacy prior to using it, and adverse effects.

The success rate is 40% and the tolerance is around 70-80%.

Considerations: Lack of insurance coverage. Adverse effects: Oral soreness, bruises on the soft palate due to the vacuum.

Adverse effects: TMJ pain or disorders, malocclusion, dental pain, teeth movement.

4 PROVENT THERAPY Provent has a one-way valve that opens with inspiration and partially closes in expiration. The elevated air pressure during expiration acts as an expiratory positive pressure device that may keep the airway open. The tolerance is 50% and half of the users respond to therapy. Indications: Mild to severe obstructive sleep apnea. Considerations: Low tolerance, lack of insurance coverage. Adverse effects: Nosebleed, sleep disturbance.

8 San Mateo county physician | November/December 2014

by Mehran Farid-MOAYER, MD

POSITIVE AIRWAY PRESSURE (PAP)

Positive Airway Pressure (PAP) therapy has remained the most effective treatment since its introduction in 1980. The pressure algorithms have improved, and the CPAP masks are now lighter and more comfortable. CPAP tolerance is around 60 to 70%, and the success rate is more than 90%. Indications: Obstructive and Central Sleep apnea. Mild to severe. Considerations: Poor tolerance and acceptance. Although with counseling may improve. Adverse effects: Aerophagia, skin rash on the face due to the mask, nasal irritation due to dry air or the nasal pillows, sleep disturbance due to noise or discomfort.

PILLAR PROCEDURE

Involves implantation of 3-5 small rods in the soft palate. It is an office based procedure by an ENT surgeon. The implants add structural support to stiffen the soft palate and reduce the tissue vibration that can cause snoring. It also reduces the tissue collapse that can obstruct the upper airway and cause sleep apnea. Indications: Snoring and mild sleep apnea. Considerations: Low success rate, lack of insurance coverage. Adverse effects: Irritation and infection of the surgical site.

SOMNOPLASTY

Somnoplasty uses TemperatureControlled Radio Frequency ( TCRF). to shrink the tissues that are causing the problem. Indications: Sleep apnea, as adjunct to other therapies, or as a treatment for snoring. Considerations: Low success rate. Adverse effects: Infection, soreness.

SOFT PALATE SURGERIES

Palate surgery, such as uvulopalatopharyngoplasty (UPPP or UP3), palatopharyngoplasty, uvulopalatal flap, or Trans Oral Robotic Surgery ( TORS), are performed under general anesthesia in the operating room. The procedure involves a combination of tissue removal and tissue repositioning that aims to increase the size of the airway without affecting normal functions such as breathing, speaking, and swallowing.Better patient selection using sleep endoscopy may improve the outcome.

Improvement of nasal airway patency by nasal procedures

This may not improve sleep apnea, but can help improve nocturnal breathing and may increase CPAP tolerance. Indications: Nasal obstruction/ congestion Considerations: Surgical considerations. Adverse effects: Related to surgery and anesthesia in addition to local complications.

10 Maxillomandibular advancement

Maxillomandibular advancement is a comprehensive surgery that includes bringing the mandible and maxilla forward. This procedure serves as the most effective surgical treatment for obstructive sleep apnea. It is also performed in patients with significant jaw deformity that contributes to obstructive sleep apnea. It has a very good success rate (greater than 90%). Indications: OSA with CPAP failure or intolerance.

Finish each day before you begin the next, and interpose a solid wall of sleep between the two. ~ Ralph Waldo Emerson

Considerations: Surgical considerations. Adverse effects: Related to surgery and anesthesia in addition to local complications.

Hypoglossal nerve stimulator

Recently approved by FDA, this therapy is currently offered by 25 medical centers in the U.S. A pacemaker is implanted with two wires: one wire senses the respiratory efforts close to the diaphragm level, and the other electrodes stimulates the hypoglossal nerve at the beginning of each breath. In turn, the tongue is moved forward to keep the upper airway open. The success rate is 66%. The pacemakerâ&#x20AC;&#x2122;s cost is around $20,000-$25,000. Other costs include the typical costs of implanting and follow up of a pacemaker. Indications: Moderate to severe obstructive sleep apnea. Consideration: Cost, lack of insurance coverage, brand new treatment with unknown long term efficacy and adverse effects. Also, the pacemaker is the first generation pacemaker. Adverse effects: Complications of surgery, transient tongue weakness, and tongue soreness.

ABOUT THE AUTHOR Mehran FaridMoayer, MD, is a pulmonary disease critical care, and, sleep specialist. His research interests include restless leg syndrome, sleep disordered breathing, and sleep pharmacology.

Treatment options for Obstructive Sleep Apnea November/December 2014 | SAN MATEO COUNTY PHYSICIAN 9

An ICD-10 Christmas Tale ‘Twas the night before Christmas, when all through the house Not a creature was stirring, not even a mouse: W53.01XA Bitten by mouse, initial encounter W53.01XD Bitten by mouse, subsequent encounter W53.09XA Other contact with mouse, initial encounter W53.09XD Other contact with mouse, subsequent encounter The stockings were hung by the chimney with care, In hopes that St. Nicholas soon would be there: X06.2XXA Exposure to ignition of other clothing and apparel, initial encounter X06.2XXD Exposure to ignition of other clothing and apparel, subsequent encounter X06.3XXA Exposure to melting of other clothing and apparel, initial encounter X06.3XXD Exposure to melting of other clothing and apparel, subsequent encounter The moon on the breast of the new-fallen snow Gave the lustre of mid-day to objects below: X37.2XXA Blizzard (snow)(ice), initial encounter X37.2XXD Blizzard (snow)(ice), subsequent encounter When, what to my wondering eyes should appear, But a miniature sleigh, and eight tiny reindeer: Z01.01 Encounter for examination of eyes and vision with abnormal findings R44.1 Visual hallucinations With a little old driver, so lively and quick, I knew in a moment it must be St. Nick. R54 Age-related physical debility F22 Delusional disorders More rapid than eagles his coursers they came, And he whistled, and shouted, and called them by name: R49.8 Other voice and resonance disorders R49.9 Unspecified voice and resonance disorder “Now, Dasher! Now, Dancer! Now, Prancer and Vixen! On, Comet! On, Cupid! On, Donner and Blitzen! W55.39XA Other contact with other hoof stock, initial encounter W55.39XD Other contact with other hoof stock, subsequent encounter To the top of the porch! To the top of the wall! Now dash away! Dash away! Dash away all!” V97.0 Occupant of aircraft injured in other specified air transport accidents W13.0XXA Fall from, out of or through balcony, initial encounter W13.0XXD Fall from, out of or through balcony, subsequent encounter W22.01XA Walked into wall, initial encounter W22.01XD Walked into wall, subsequent encounter

10 San Mateo county physician | November/December 2014

As dry leaves that before the wild hurricane fly, When they meet with an obstacle, mount to the sky, X37.0XXA Hurricane, initial encounter X37.0XXD Hurricane, subsequent encounter So up to the house-top the coursers they flew, With the sleigh full of toys, and St. Nicholas too. Y93.29 Activity, other involving ice and snow V96.8XXA Other nonpowered-aircraft accidents injuring occupant, initial encounter V96.8XXD Other nonpowered-aircraft accidents injuring occupant, subsequent encounter And then, in a twinkling, I heard on the roof The prancing and pawing of each little hoof. W13.2XXA Fall from, out of or through roof, initial encounter W13.2XXD Fall from, out of or through roof, subsequent encounter W55.32XA Struck by other hoof stock, initial encounter W55.32XD Struck by other hoof stock, subsequent encounter As I drew in my head, and was turning around, Down the chimney St. Nicholas came with a bound. X02.0XXA Exposure to flames in controlled fire in building or structure (fireplace), initial encounter X02.0XXD Exposure to flames in controlled fire in building or structure (fireplace), subsequent encounter He was dressed all in fur, from his head to his foot, And his clothes were all tarnished with ashes and soot; Y93.E9 Activity, other interior property and clothing maintenance A bundle of toys he had hung on his back, And he looked like a peddler just opening his pack. Z59.0 Homelessness Z59.1 Inadequate housing His eyes â&#x20AC;&#x201D; how they twinkled! His dimples how merry! His cheeks were like roses, his nose like a cherry! L71.8 Other rosacea L71.9 Rosacea, unspecified And the beard of his chin was as white as the snow; His droll little mouth was drawn up like a bow, L67.1 Variations in hair color L67.8 Other hair color and hair shaft abnormalities L67.9 Hair color and hair shaft abnormality, unspecified The stump of a pipe he held tight in his teeth, And the smoke it encircled his head like a wreath; Z72.0 Tobacco use Z57.31 Occupational exposure to environmental tobacco smoke F17.290 Nicotine dependence, other tobacco product, uncomplicated F17.291 Nicotine dependence, other tobacco product, in remission F17.293 Nicotine dependence, other tobacco product, with withdrawal F17.298 Nicotine dependence, other tobacco product, with other nicotine-induced disorders

November/December 2014 | SAN MATEO COUNTY PHYSICIAN 11

He had a broad face and a little round belly, That shook, when he laughed like a bowlful of jelly. E66.3 Overweight Z72.3 Lack of physical exercise He was chubby and plump, a right jolly old elf, And I laughed when I saw him, in spite of myself; R29.890 Loss of height E66.09 Other obesity due to excess calories A wink of his eye and a twist of his head, Soon gave me to know I had nothing to dread; H02.043 Spastic entropion of right eye, unspecified eyelid H02.046 Spastic entropion of left eye, unspecified eyelid H02.049 Spastic entropion of unspecified eye, unspecified eyelid He spoke not a word, but went straight to his work, And filled all the stockings; then turned with a jerk, R49.1 Aphonia (Loss of Speech) Z56.5 Uncongenial work environment Z56.3 Stressful work schedule Z56.6 Other physical and mental strain related to work G47.26 Circadian rhythm sleep disorder, shift work type And laying his finger aside of his nose, And giving a nod, up the chimney he rose; He sprang to his sleigh, to his team gave a whistle, V00.221A Fall from sled, initial encounter V00.221D Fall from sled, subsequent encounter V00.228 Other sled accident And away they all flew like the down of a thistle. But I heard him exclaim, ‘ere he drove out of sight, W94.23XA Exposure to sudden change in air pressure in aircraft during ascent, initial encounter W94.23XD Exposure to sudden change in air pressure in aircraft during ascent, subsequent encounter

“Happy Christmas to all, and to all a good-night.”

Adapted from an essay by Gerry Wieder, RN, a self-described “RN with an MBA and a funny bone.” Visit gerrywieder.com/an-icd-10-christmas-tale. Published in the November/December issue of Sierra-Sacramento Valley Medicine.

12 San Mateo county physician | November/December 2014

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NEW SMCMA MEMBERS

Medical office space available in Daly City Shared waiting room with 3 dedicated (non-shared) exam rooms, 1 treatment/procedure room and 1 physician office/ consultation room. In-suite audiology services, allergy services, hearing aid dispensing, medical record storage/ disposal, red bag waste disposal, instrument sterilization. All utilities included except telephone. Abundant free parking, free BART shuttle to medical campus. Space and time sharing options possible.

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Kenji Butterfield, MD AN -San Mateo

Daniel Parry, MD IM* - Foster City Sridhar Prathikanti, MD PSY - Hillsborough Milan Radojicic, MD FM - Burlingame

Vanita Jindal, MD PD - Burlingame

Jennifer Jones, MD IM - S. San Francisco

The following SMCMA members have recently retired from practice:

Sonia DeClercq, MD Brian Henderson, MD Laurie Rubenstein, MD

In Memoriam

Kim Stafford, DO FM - S. San Francisco

Clara Sue, MD IM - Daly City

Edward Barthold, MD March 18, 2014

Garrett D. Kine, MD November 2, 2014

Lorne Eltherington, MD October 13, 2014

Henry Meffert, MD January 1, 2014

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Janusz Madej, MD IM - Portola Valley

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Alicea Wu, MD FM - Burlingame

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Our heart beats in California â&#x20AC;Ś and has for almost 4 decades. Since 1975 NORCAL Mutual has served healthcare professionals throughout the Golden State. Strength, stability and innovative products are just a few reasons why physicians continue to look to us for their medical professional liability insurance. We provide you: Industry-leading claims and risk solutions support 24/7 Full access to our interactive risk management library Flexible coverage options tailored to your needs California is important to us. So is your peace of mind. See how homegrown strength can help protect your practice.

Visit heart.norcalmutual.com or call your agent/broker today.

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