S a n M at e o C o u n t y
May 2013 | Volume 2, Issue 5
A publication of the San Mateo County Medical Association
Managing Difficult Patients Helping Them Understand and Change Their Behaviors
What Illnesses Did You Have in 2012? Getting Past the Ancient Stigmas Against Mental Illness
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Editorial Committee Russ Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor
Contributing Authors Melvin Brown, MD; Shannon Goecke; Russ Granich, MD; Irving Katz, MD; Gregory Lukaszewicz, MD; Sue U. Malone; Richard Shanteau, MD
SMCMA Leadership Gregory C. Lukaszewicz, MD, President Amita Saxena, MD, President-Elect Vincent Mason, MD, Secretary-Treasurer John D. Hoff, MD, Immediate Past President Raymond Gaeta, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Michael Norris, MD; Michael O’Holleran, MD; Irwin Shelub, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate
Editorial and Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and letters to the editor. 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. Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. 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 managing editor Shannon Goecke at (650) 312-1663 or email@example.com. Visit our website at www.smcma.org, like us at www.facebook.com/smcma, and follow us at www.twitter.com/SMCMedAssoc. © 2013 San Mateo County Medical Association
S a n M at e o C o u n t y
M ay 2 0 1 3
Introduction | Russ Granich, MD May is Mental Health Month, an annual observance designed to increase awareness about mental health and mental illness. This year’s theme, “Mental Health Matters: In Your Life,” reminds Americans that caring for their mental health is as important as taking care of their physical health because mental health impacts all areas of life. In this issue of San Mateo County Physician, Melvin Brown, MD, psychiatrist and pain management specialist, discusses the importance of recognizing and treating mental health with the same urgency as physical health. But sometimes, patient behavior can get in the way of effective treatment. Richard Shanteau, MD, a psychiatrist at Kaiser Permanente, discusses some of the differences between healthy and unhealthy patient behavior, touches briefly on personality disorders in general, and provides some tips for dealing with behaviorally-challenging patients. Lead Exposure and Mental Health.................................................. 5 Gregory Lukaszewicz, MD 47% of Patients Say They Would Rather Take Out the Trash Than Take Their Meds....................................... 7 Sue U. Malone What Illnesses Did You Have in 2012?. . ........................................... 9 Melvin Brown, MD Managing Difficult Patients: Helping Them Understand and Change Their Behaviors..................................... 10 Richard Shanteu, MD In Memoriam: Barry Obertstein, MD............................................. 13 Irving Katz, MD Classified Ads, Index of Advertisers. . ............................................ 18
President’s Message | Gregory Lukaszewicz, MD
Lead Exposure and Mental Health The subject of mental health has been receiving more attention lately as politicians and pundits look for answers to such public tragedies as the shootings in Newtown, Connecticut and Aurora, Colorado. Though the task is daunting, there are dedicated individuals and groups working hard to understand the root causes of mental illness and to ensure that patients suffering from such illness receive the services they need. Scientists and researchers in the fields of genetics, brain imaging and basic neuroscience are making inroads into understanding both normal brain function and mental illness. While it seems our political leaders contribute little more than rhetoric, there are psychiatrists, psychologists, social workers, addiction specialists, job training programs, hospitals, halfway houses, and housing and food networks that are doing the difficult, daily work of bringing much needed services to people living with mental illness. One major public health issue has been linked to mental health, individual success and achievement, and even crime rates, but it has largely been ignored over many years: environmental lead exposure and the effect upon children. Lead Wars: The Politics of Science and the Fate of America’s Children, by Gerald Markowitz and David Rosner, chronicles the failure of our government, industry, academia, the media, and the public at large to address what is a major public health issue with clear-cut—though expensive—solutions.
Removing lead from the environment is expensive, but ignoring the problem comes at a much higher cost, not only to the individuals with elevated lead levels, but to society as a whole. Early in the 20th century it became obvious that lead was highly toxic in even relatively small quantities. First seen in workers exposed to lead additives in the paint and gasoline industries and in the bathtub enameling industry, severe
lead poisoning (roughly sixty micrograms per deciliter) caused vomiting, seizures, severe muscle pain, weakness, hallucinations, insanity and death. In addition, cases of lead poisoning also began to appear in the early 1900s in children who ingested lead paint (which has a sweet taste). Even very minor lead levels (one to two micrograms per deciliter) in young children can lead to severely decreased intelligence, impulsiveness, aggression and even violent behavior throughout their entire lives. These observations led a number of European countries to ban the use of lead in paint (which makes paint brighter) in the 1920s and 1930s, and the League of Nations even proposed a global ban on lead-based paint in 1922. However, the United States, the largest producer of lead paint in the world, did not institute a ban until 1978, despite the overwhelming scientific evidence of the dangers of lead exposure. The paint industry was extremely effective in running a very concerted and public campaign to block efforts to ban lead additives in paint, including attempting to discredit scientific studies about the dangers of lead and using advertising to undermine articles about the dangers of lead in popular magazines such as Ladies’ Home Journal. Rather than calling for the removal of lead from paint, government health programs advised parents to control their children from ingesting paint chips, which became known as “pica” and was thought to be a behavioral problem of the poor. Unfortunately, lead does not only have to be ingested as paint chips to build up in toxic levels in children. Lead dust persists for years in old housing where lead paint was used (and is a particular problem with old window casings, which release lead-based dust every time the window is opened or closed) and in the air from burning leaded gasoline. Thus, children in urban environments are at particular risk of developing elevated lead levels. In a 1976-1980 National Health Survey, it was estimated that four percent of children under age six had dangerously high lead levels (thirty micrograms per deciliter). Though things have improved, it is estimated continued on next page
May 2013 | SAN MATEO COUNTY PHYSICIAN 5
President’s Message | Gregory Lukaszewicz, MD
Lead Exposure and Mental Health continued that some 500,000 children between the ages of one and five currently have lead levels above 5 micrograms per deciliter, which the Centers for Disease Control and Prevention cites as a cause for concern. There is even growing evidence that the peak in crime rates in the 1960s and their decline in the 1990s can be tied directly to lead additives in gasoline and their subsequent removal. Why has environmental lead exposure not gotten the attention that other environmental and health issues have? Why did it take so many years to remove lead from paint despite the fact that the dangers were well known? Essentially, there was no strong grassroots social movement that brought the issue to the forefront of the public’s consciousness. The Black Panthers and Young Lords (a Puerto Rican activist group) attempted to run screening and educational programs, but these groups existed on the margins of mainstream society and were largely ignored. The U.S. Department of Health and Human Services in 1990 planned to spend $33 billion to remove lead from homes and
6 San Mateo county physician | May 2013
to promote screening programs, but so far have only spent $2 billion. While $2 billion is by no means a paltry sum, it is not nearly enough to eliminate lead in private homes. The HHS plan was opposed by the lead industry, realtors, landlords, insurance companies, and even some pediatricians who were concerned about the burden of screening children for lead exposure. Removing lead from the environment is expensive, but ignoring the problem comes at a much higher cost, not only to the individuals with elevated lead levels, but to society as a whole. Finally, I would like to mention Barry Oberstein, MD, who passed away on April 15. Barry was very invested in organized medicine, the San Mateo County Medical Association and our delegation to the CMA House of Delegates. Barry’s wit, wisdom, and friendship will be very much missed by all of us who knew and worked with him. Our condolences go out to his family, friends, and patients. ■
Executive Report | Sue U. Malone
47% of Patients Say They would Rather Take Out the Trash Than Take Their Meds The results of the survey by HealthPrize that led to this column’s headline may be overstated, but there is no question that poor medication adherence plagues medical care. According to a study published last year in the Journal of the American Geriatrics Society, 40 percent of older adults in the U.S. do not comply with their doctors’ recommendations for taking medications. This nonadherence costs the U. S. healthcare system up to $290 billion a year and is associated with poor clinical outcomes, more hospitalizations, and higher mortality. Physicians can readily address some of the factors associated with nonadherence, such as cost concerns, discomfort from medication side effects, perceptions of poor medication efficacy, and questions related to medication dosing, frequency, and timing. However, the American Geriatrics report discussed physicians’ responsibility for medication adherence and whether they should take a greater role in ensuring patient compliance. While physicians uniformly agreed that it was their responsibility to discuss medication adherence with patients, the report found that physicians screen for nonadherence by asking patients general questions about taking their medications. How one asks the patient is very important. For example, if you ask your patient if he or she is taking her medication, the response will typically be “yes.” However, asking more pointed questions such as “What medications are you taking?” and “What is your dosing schedule?” will reveal more meaningful answers. In this way the physician can determine if the patient is correctly taking a medication twice a day, once a day, or whatever. Such direct
questions will help providers systematically assess the reason(s) behind a patient’s nonadherence to target solutions. Only a minority of physicians asked patients detailed questions about mediation adherence, although providers uniformly felt it was their responsibility to assess and address medication adherence. On the other hand, providers do not like to be seen as overbearing or intruding into patients’ “territory” to detect nonadherence. They also expressed concern about not having enough time or resources to address nonadherence. The study suggests that physicians could be trained to recognize that simple medication reconciliation does not capture all forms of medication nonadherence and that direct questions need to be asked about patient difficulties with taking medication. Ultimately, doctors feel that the final responsibility for taking the medication falls to the patient. As one doctor noted, “I just feel that, at some point, my responsibility for educating a person and giving them the proper treatment ends, and the patient’s personal responsibility begins.” In time, conversations with patients may change as providers obtain access to automated pharmacy information that will provide information about whether patients are appropriately filling their medications. ■
NEW SMCMA MEMBERS
W elcome ! Anna Petrova, MD FM*/Redwood City
Radhika Varma, MD FM*/Burlingame
May 2013 | SAN MATEO COUNTY PHYSICIAN 7
Breathe Again !!
SMCMA Nominating Committee Report The 2013 Nominating Committee has proposed the following candidates to officers, board, and delegation positions. Nominations may also be made by members of the Association. These nominations are to be in writing, signed by 10 active members, and delivered in person to Association headquarters or registered mail no later than June 21, 2013.
CALIFORNIA SINUS CENTERS & Institute We CARE for: Bacterial Infections / Sinusitis Culture directed treatment Functional Endoscopic Sinus Surgery Orbital Decompression / Graves’ Disease Image Guided Surgical Navigation Revision - complex cases Frontal Sinusitis Advanced Endoscopic Techniques Sinuplasty Sinus Surgery WITHOUT packing Nasal Obstruction / Septoplasty Allergic Fungal Sinusitis Sinonasal Tumors / Polyps Smell / Taste problems CSF leak repairs Mucoceles / Abscesses In-Office CT Scanner Urgent appointments Joint care: ENT - Allergy Pulmonary
Officers President: Amita Saxena, MD President-Elect: Vincent R. Mason, MD Secreary-Treasurer: Michael S. Norris, MD Immediate Past-President: Gregory C. Lukaszewicz, MD
Board of Directors Russ Granich, MD Edward Y. Koo, MD Susan Nguyen, MD Kristen Willison, MD
Atherton (Stanford area)
Board members continuing terms: C.J. Kunnappilly, MD; Michael O’Holleran, MD Irwin Shelub, MD Chris Threatt, MD
Walnut Creek (East Bay) San Francisco (Union Square) Karen Fong, MD
delegation Dirk Baumann, MD John D. Hoff, MD Steve Kmucha, MD Betty Lee, MD Robert Reisfeld, MD
Kathleen Low, NP
Winston Vaughan, MD
Sherry Derakhshandeh, MD
SMCMA 2013 M embership D irec tory Featuring contact information, specialties by geographic location and board certifications, the SMCMA Directory is the most comprehensive compilation of the physician population in San Mateo County.
Delegates continuing terms: Leslie H. Kim, MD Gregory C. Lukaszewicz, MD Vincent R. Mason, MD Amita Saxena, MD William Tatomer, MD
All SMCMA members receive one complimentary copy of this valuable resource. Need additional copies for your staff or second office? The member price is just $55. To order, call (650) 312-1663 or mail your payment to: SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404.
Edward Lipton, MD
Alternatve Delegates continuing terms: Gordon A. Brody, MD Marc Levsky, MD Julie O’Callahan, MD
8 San Mateo county physician | May 2013
1/15/13 11:49 AM
What Illnesses Did You Have in 2012?
Melvin Brown, MD As you read that title, what did you think of ? The flu? A bout of gastroenteritis? Anginal pain? Did you consider those weeks of the “blues” last spring? Or that episode of anxiety, even dread, when you got up in the morning? Or that arrhythmia that led you to your friendly neighborhood cardiologist for scans, EKG’s, a stroll on the treadmill, before he—and reluctantly, you— decided it was “only stress”? These are classic symptoms of the mental illnesses of everyday life, the ones that you and I might well get from time to time, not Schizophrenia or Bipolar Disorder. But the medical profession does not acknowledge these
Medical schools need to get past the ancient stigmas and teach recognition and treatment of the spectrum of mental illness, just as they teach recognition and treatment of the range of physical illnesses.
“mental” illnesses on a par with “real” sicknesses and so does not treat the suffering they cause. This is one of the major failings of our profession in this, the 21st century. We do hear a lot of surface talk about Schizophrenia, lethal depressions, and some manic states in the aftermath of some violent tragedy. But not expending professional energies and medical dollars on mental illnesses covering the true spectrum of syndromes is equivalent to limiting medical coverage to just cancer, heart failure, and some
strokes, and ignoring the broader array of illnesses that afflict our usual patients who seek relief from us. In not recognizing and accepting the range of everyday illness, we miss the opportunity to recognize the crossing point to lethality. Medical schools need to get past the ancient stigmas against mental illness and teach about the spectrum of mental illness, just as they teach recognition and treatment of the range of physical illnesses from the common cold to malignant melanoma. They must destroy out-dated dualisms such as the “mind-body” and truly define and teach that humans are a single entity where emotional and cognitive processes cause and influence physiological processes, where changes in anatomy and physiology create cognitive and emotional alterations. We are but one. Physicians should be free to discuss the mental illnesses they detect without being any more tentative than they would be in their usual discussions with patients. What we now call “Mental Illness” must become talkable. Then the public may reasonably look to doctors and especially to primary physicians who are most likely to see first the potentially lethal patient in time, and who, with clear knowledge and sureness, intervene before disaster hits. We can do our part in preventing future Newtowns and Columbines. About the Author Retired SMCMA member Melvin Brown, MD, was originally an internist before becoming a psychiatrist. He operated a chronic pain management clinic in San Mateo for approximately 25 years. The clinic focused on return to function and quality of life, rather than simply symptom relief. May 2013 | SAN MATEO COUNTY PHYSICIAN 9
Managing Difficult Patients Helping them understand and change their behaviors
Richard Shanteau, MD All physicians have experienced a wide range of behaviors in their patients over the years, and can usually recall vividly a few of those patients whose behaviors made delivering health care to them nightmarish and unsatisfactory. This short essay will list some of the differences between healthy patient behaviors and unhealthy patient behaviors, discuss the large topic of personality disorders briefly, and end with some clinical pearls for clinicians in dealing with their most behaviorally challenging patients. Attributes of “Good” Patients Our patients fall on a spectrum of behaviors, from the most mature and helpful, to the most immature and combative. Understanding what makes a “good” patient can help us better understand the difficult ones. • They have adequate self care habits. They pay attention to their health and strive to exercise, eat right, avoid excesses of alcohol, and stop smoking on their own. • They seek professional attention for significant issues in a timely manner, in the right amount. They keep appointments and do not request too much attention or have crises of anxiousness very often. • They accept professional advice and follow directions reasonably well • They ask for clarification when needed, and are appropriately assertive. They may do research on
10 San Mateo county physician | May 2013
their problems and ask for specific approaches, but they are able to defer to their physicians, recommendations and insights. • They are able to maintain respectful relationships with their caregivers. Of course, few patients meet all these standards all the time. During times of real crisis, even the most mature patients may become more difficult to manage behaviorally. Attributes of “Difficult” Patients • They are often angry, arrogant, and demanding of special attention. They may make a scene in your waiting room, or expect to be able to drop in any time. • They practice help-rejecting complaining—they say “yes, but” often to any and all suggestions, yet keep coming back to confront the physician with their failure to improve.
• They exhibit illness conviction when no illness is present—they can become somatically delusional, yet function normally at work and home. • They are non-compliant, never purchase meds ordered, and fail to keep appointments. • They can be drug-seeking and manipulative. • They are anxious and call too often. • They consume more care than needed. • They practice poor self care in general—obesity, smoking, and so on. • They inflict self-injury or demonstrate suicidality. We are not talking about patients with psychotic illnesses, mental retardation, inadequate social support or lack of financial resources for health care, though of course these issues also make patient care more challenging. Personality Disorders: What is “Personality”?
Narcissistic PD: • Impaired self functioning: exaggerated selfappraisal, high or low (I’m the best/worst person in the world); goals are too high (must be exceptional) or too low (entitled). • Impaired interpersonal functioning: lack of empathy, superficiality, relationships based on need for personal gain. Domains and Traits of NPD: Domain= Antagonism Traits: 1. Grandiosity: feelings of entitlement; selfcenteredness; believe oneself to be better than others; condescending 2. Attention seeking: excessive attempts to attract and be the focus of attention; admiration seeking 3. Manipulativeness: Manipulates others to achieve desired results
Personality is “something you are”—a consistent pattern of behavior, stable over time, of responses to various situations. It involves a sense of self and the capacity for interpersonal relationships.
4. Deceitfulness: Lies in order to achieve desired results
A personality disorder is a dimensional concept—too much or too little of something. At the minimum, it is a mildly distorted sense of self with mildly troubled interpersonal relationships.
6. Hostility: Feels selfsatisfied through dominating, intimidating and humiliating others
Borderline and Narcissistic Personality Disorders These are two fairly common disorders that afflict people who are considered “difficult” in the health care setting. The outline below will give the reader a flavor of the latest definitions of personality disorders, published this spring in the APA Diagnostic and Statistical Manual, Fifth Edition (DSMV) Borderline PD: • Impaired self functioning: poor self image, unstable moods, much self-criticism, empty feelings, lack of goals/career plans/values • Impaired interpersonal functioning: interpersonal hypersensitivity, difficulty recognizing feelings and needs of others, focus on negative attributes or vulnerabilities of others. Domains and Traits of BPD:
5. Callousness: Gross insensitivity to the feelings of others
Medication Management of Borderline PD Most of the difficult patients seen in primary care will not have an official diagnosis of personality disorder on their problem list, so the medications listed below are those a psychiatrist would typically initiate. • Anticonvulsants are best choice: lamotrigine, topiramate, valproate. These help antagonism, disinhibition, and negative affectivity. • Atypical antipsychotics are the second choice: aripiprazole, olanzapine, risperidone can help reduce antagonism, but have major side effects. • Omega-3 fatty acid supplementation treats antagonism and negative affectivity. • SSRI’s are not very helpful, but may be tried. • Benzodiazepines are discouraged—they are disinhibiting, and can increase suicidal behaviors. • Clonidine can help PTSD symptoms.
1. Negative Affectivity: emotional lability, anxiousness, separation insecurity, depressivity. 2. D isinhibition: impulsivity, risk taking. 3. A ntagonism: hostility.
continued on next page
May 2013 | SAN MATEO COUNTY PHYSICIAN 11
Managing Difficult Patients continued • The primary care physician will typically try SSRIs or SNRIs. If mood instability seems to be a prominent issue, using 25 to 50 mg of quetiapine or 0.5 mg of risperidone at bedtime may be quite helpful for sleep and daytime agitation. Management Tips, Clinical Pearls • Understand that these patients are vulnerable, needy—being sick may be the only way some patients get any nurturing. Many of them come from abusive families. • Remember that most personality-disordered or otherwise difficult patients can be coached, taught, and do improve over time. • Avoid anger in the face of provocation. • Allow the anxious patient to call, but establish that they must follow your advice if they do call. • Give the patient what they need, not what they want. Especially be wary of abusable substances, like benzodiazepines and opiods. • It is okay for the patient to reject your treatment plan—you are not refusing care, they are discharging themselves. • It is best to engage all the key players in the patient’s environment: family, employer, lawyers. • Reinforce incremental changes: “Good job, you reduced your pain meds by 10%,. • The major treatment goal is to help them change behaviors in their self-care and in how they relate to you and health care in general. • Set limits, be clear about expectations, and be specific about better behaviors you would like to see. Communication Tips • Address feelings expressed by patient in a respectful tone, using some of their words. • Use statements that show appreciation for their feelings: “I believe you are feeling______,” “I understand you are anxious/mad/scared,” “I apologize if we/I did not respond in the manner you expected.”
12 San Mateo county physician | May 2013
• Check the relationship often” “How are we doing?” “Can I do a better job for you in any way?” Resources • Psychiatry referral or e-consult: The patients will be evaluated and offered med treatment, and individual or group treatments, especially Dialectical Behavior Therapy groups. This approach was created to help borderline PD, but also can help other types of problems. • Outside therapists Conclusion We all have developed our own habitual reactions to our patients, those we like and enjoy seeing, and those who are less likeable and enjoyable. We can, with some study and practice, become more sophisticated in dealing with conflicts and resistances within our patients, thereby promoting their health and happiness over time. ■
About the Author Richard Shanteau, MD, is a psychiatrist with the Kaiser Permanente Medical Group in South San Francisco. He earned his BA in zoology from the University of Kansas (Lawrence) and his MD from the University of Kansas (Kansas City), and completed his residency at the University of Utah School of Medicine. He is boardcertified in Psychiatry by the American Board of Psychiatry and Neurology.
Barry J. Oberstein, MD Barry J. Oberstein, MD, passed away on April 15, 2013 after a more than two-year battle with pancreatic cancer. He was very involved in the San Mateo County Medical Association and was a founding physician of the Mills Peninsula Division of the Palo Alto Medical Foundation. He will be missed by many. Irving Katz, MD, Dr. Oberstein’s close friend for forty years, was kind enough to share his thoughts with us. Recently, I was approached by a woman I did not know. She introduced herself and explained that, as a patient of Dr. Oberstein, she had attended his funeral. She recognized me as having been a pallbearer. With tears in her eyes, she commented on how much she loved and appreciated Dr. Oberstein, then asked if I could recommend a doctor as wonderful and caring as he was. Without hesitation, I responded that there is no such person. This, in essence, casts a true light on Barry. He was concerned with every aspect of his patients’ lives— from their spouses, children and extended families to their moments of joy and sadness. His wonderful diagnostic skills were coupled with the art of communication, extending to follow-up calls he often made at night or on weekends. He personally called patients with lab results.
He was very devoted, also, to mentoring medical students and guiding new doctors in his office as they began their careers. His involvement with setting medical ethics standards through the San Mateo County Medical Association spoke to the highest principles of our profession, his contributions thoughtful and meaningful. Barry’s interests were diverse. He was an excellent and competitive athlete in numerous sports including squash, tennis, golf, and cycling. On a very personal note, during our forty-year friendship, we shared so many experiences. I always appreciated and admired his depth of knowledge in medicine and other topics, his love of learning and his ever-present kind gestures (which he also extended to many others). Following my cardiac surgery some years back, Barry came to our home every night, without fail, to help me wherever necessary. When we bicycled twice weekly, he followed closely behind me to make sure I was all right. During his illness, Barry never complained, He remained positive, trying to make his situation as easy as possible for loved ones and friends. His passing has left a huge void in my life—one that I feel each and every day. ■ —Irving Katz, MD
Barry Oberstein, MD (second from right) and family at grandson Evan’s bar mitzvah.
May 2013 | SAN MATEO COUNTY PHYSICIAN 13
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San Mateo County Medical Association
- Educational seminar -
V aluing , S elling , B uying & T ransitioning
Considering retirement? Selling or wanting to buy a practice? Making this transition requires planning and sufficient time to accomplish this effectively for your patients, staff and family. California has a high cost of living, which makes it more difficult for physicians to sell, transition, start, or purchase a practice. Learn creative strategies to help you accomplish your goals. This seminar will discuss the options, including: bringing in an associate, recruiting, or selling the practice. Included is the latest information on valuation methodology for selling, divorce or estate planning. Topics covered will include: • Goodwill or Intangible Asset Value—Is there still value? • Why it is important to sell the practice before discontinuing surgery or slowing down • Methods to appraise and value the practice • Equipment valuation techniques • Valuing accounts receivable, equipment, leasehold improvement and supplies
Wednesday, June 12, 2013 Buffet and Registration: 6:15 p . m . Program: 6:30-7:45 p . m .
WHERE: San Mateo County Medical Association 777 Mariners Island Blvd., #100, San Mateo
• When to use a practice broker? • Why buy a practice versus start one from scratch?
$99 SMCMA Members/$249 Non-members
• Structuring the relationship between junior and senior partner • Hospital support—salary and overhead guarantees • Medical records retention/ownership—what your attorney/broker may not realize • How to prepare for a new physician taking over the practice
This seminar will be taught by Debra Phairas, an experienced practice management consultant who has appraised more than 350 medical practices of all specialties and assists physicians in valuing, buying, selling, merging, evaluating position opportunities and transitioning from training to practice. Learn more Ms. Phairas at www.practiceconsultants.net.
Please fax your completed registration form to (650) 312-1664, email to firstname.lastname@example.org or mail to SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404. Physician Name: Name and Address of Medical Practice:
Payment Method: Check Enclosed Charge my Visa/Mastercard/Discover (circle your card type) Card Number:
3-Digit Security Code:
May 2013 | SAN MATEO COUNTY PHYSICIAN 15
CALLING ALL DOCS! Stay Fit and Be Involved in Your Community! The San Mateo County Medical Association is hosting Walk with a Doc! Walk with a Doc is a free program of the San Mateo County Medical Association Community Service Foundation that encourages healthy physical activity for county residents of all ages. Walkers enjoy one-hour walks with physician volunteers and can ask questions about general health topics along the way. We are looking for physicians to “lead by example” and walk with participants at designated public parks in San Mateo County on one or more Saturdays. Walks commence with a free blood pressure check for those walkers who desire it, followed by a 3-minute talk by the physician on the importance of regular physical activity. We also need your help to recruit members of the public to join Walk with a Doc. SMCMA will provide you with posters that can be placed in your office/ hospital to announce upcoming walks to your patients and colleagues.
Sign up online at www.smcma.org, or contact Karen Stone at (650) 312-1663 or email@example.com.
Saturday, June 8, 2013 • 10-11:30 a.m.
Saturday, June 22, 2013 • 10-11:30 a.m.
Orange Memorial Park 781 Tennis Drive, South San Francisco
Central Park 50 E. 5th Avenue, San Mateo
Saturday, July 6, 2013 • 10-11:30 a.m.
Saturday, July 20, 2013 • 10-11:30 a.m.
Red Morton Community Park 1120 Roosevelt Avenue, Redwood City
Orange Memorial Park 781 Tennis Drive, South San Francisco
Saturday, August 3, 2013 • 10-11:30 a.m.
Saturday, August 17, 2013 • 10-11:30 a.m.
Leo J. Ryan Memorial Park E. Hillsdale Blvd. @ Shell Blvd., Foster City
Red Morton Community Park 1120 Roosevelt Avenue, Redwood City
Saturday, September 7, 2013 • 10-11:30 a.m.
Saturday, September 21, 2013 • 10-11:30 a.m.
Central Park 50 E. 5th Avenue, San Mateo
Leo J. Ryan Memorial Park E. Hillsdale Blvd. @ Shell Blvd., Foster City
walk with a doc is sponsored in part by the magnolia of millbrae. thank you! 16 San Mateo county physician | May 2013
2013 Annual Meeting of Members Thursday, June 27, 2013 Hosted Reception: 6:30 p . m . Dinner & Program: 7:30 p . m .
Peninsula Golf & Country Club 701 Madera Drive San Mateo, California
SMCMA Members & Their Guests: $50 per person Non-members & Their Guests: $80 per person ✤ Tables of 10: $500 Purchase tickets online at www.smcma.org/annualmeeting2013 or call (650) 312-1663.
Abraham Verghese, MD, MACP Dr. Verghese is Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine, Senior Associate Chair of the Department of Internal Medicine, and author of three bestselling books. His first book, My Own Country (1995) chronicled his experience treating AIDS patients in rural Tennessee in the 1980s. It was later made into a movie starring Naveen Andrews and Marissa Tomei. He followed up with The Tennis Partner (1998) a powerful meditation on his friendship with a charming but troubled medical intern. His third book, Cutting for Stone (2009), an epic novel about twin brothers born of the tragic union between a beautiful Indian nun and a brash British surgeon, stayed on The New York Times bestseller list for more than two years. The San Francisco Chronicle raved: “A masterpiece...The writing is graceful, the characters compassionate and the story full of nuggets of wisdom.” Academy Award-winning director Susanne Beir (best foreign language film in 2011) has signed on to direct a film adaptation of the novel. You won’t want to miss this opportunity to hear from a true Renaissance man!
Distinguished Service Award Recipient
Marc Jaffe, MD Dr. Jaffe, an endocrinologist with Kaiser Permanente Medical Group in South San Francisco, is being honored for his work in implementing an innovative cardiovascular disease (CVD) riskreduction clinical practice for Kaiser patients, and ultimately translated this strategy into a national model for CVD prevention.
May 2013 | SAN MATEO COUNTY PHYSICIAN 17
Lynn C. Sydor, MD has joined a new practice:
Peninsula Dermatology Medical Group, Inc. 1750 El Camino Real, Suite 206 Burlingame, California 94010 650-692-0182 peninsuladermatology.com firstname.lastname@example.org
Tracy Zweig Associates INC.
Nurse Practitioners Physician Assistants
PULMONARY ASSOCIATES IS PLEASED TO ANNOUNCE THAT
Charles K. Everett, MD HAS JOINED THE PRACTICE 1720 El Camino Real, Suite 150 • Burlingame, CA 94010 (650) 697-7079
Index of Advertisers Bayside Realty Partners...........................................................14 BrightStar Care of San Mateo.................................................6
Locum Tenens Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9141 FAX : 8 0 5 - 6 4 1 - 9 1 4 3 email@example.com w w w. t r a c y z w e i g . c o m
Palo Alto Medical Office Space for Lease 3 exam rooms, 2 offices, large nurses’ station and workspace, fully furnished, onsite parking. Available 3 days a week.
Please call (650) 696-8315
California Sinus Centers & Institute....................................8 Dementia Therapeutics........................Inside Back Cover The Doctors Company............................................................14 The Magnolia of Millbrae..........................................................4 Marsh.............................................................Inside Front Cover
PHYSICIAN VOLUNTEERS NEEDED IN HALF MOON BAY: RotaCare Bay Area operates free clinics throughout the Bay Area, providing quality healthcare for the uninsured. The Coastside Clinic in Half Moon Bay needs volunteer physicians on Wednesdays from 6:00 - 8:00 p.m. Call (650) 573-3774 or email firstname.lastname@example.org to sign up.
NORCAL..................................................... Outside Back Cover
San Mateo Co. Medical Association
PHYSICIAN VOLUNTEERS NEEDED IN REDWOOD CITY: 06-18-09 Since 1974, Samaritan House has been providing low-income people in San Mateo County with food, clothing, shelter, health care, worker resources, and counseling services. The clinic in Redwood City has a need for volunteer physicians. Volunteers can serve as little as one four-hour shift per month. To find out more, visit samaritanhousesanmateo.org.
Pulmonary Associates..............................................................18 Tracy Zweig Associates...........................................................18 For information about advertising in San Mateo County Physician, please contact Shannon Goecke at (650) 312-1663 or email@example.com.
18 San Mateo county physician | May 2013
SMCMA MEMBERSHIP DIRECTORY UPDATE: Please note that Melissa Kong, MD, is board certified in Internal Medicine (IM), Cardiovascular Disease (CD) and Cardiac Electrophysiology (CE) in the cities of East Palo Alto and Redwood City.
Introducing Dementia Therapeutics:
The First In-Home, Non-Pharmacological Solution for Alzheimer’s and Dementia. • Dementia Therapeutics interventions are designed by experts. The program consists of over 300 research-based interventions targeting various cognitive as well as non-cognitive domains. Interventions were developed by a fully qualified research team led by Dr. Samuel T. Gontkovsky, Psy.D. • Dementia Therapeutics intervention is performed one-on-one at home. Each client works with an interventionist who tailors the intervention plan to accommodate their individual needs. Providing personalized, one-on-one care within the home facilitates a sense of familiarity with the environment, helping clients remain at higher levels of independence for longer periods of time. • Dementia Therapeutics focuses on more than just memory. The program targets the five primary cognitive domains: executive functioning, attention, language, visual-spacial perception in addition to memory. Interventionists also teach and promote lifestyle changes to positively influence the aging process and overall health. • Dementia Therapeutics provides consistent care. Consistent participation in the program over time is key. Since our program is designed and led by experts, we are able to provide consistent, continuous care that meets the evolving needs of the client.
Call now for a free brochure:
777 Mariners Island Boulevard, Suite 100 San Mateo, California 94404
ADDRESS SERVICE REQUESTED
22,689 To improve patient safety, you need to stay on top of best practices. Thatâ€™s why, as shown by the 2011 numbers above, we provide you the risk management advice you need, when and how you want it. Itâ€™s why we provide industry-leading CME online and through Claims Rx, our monthly publication based on closed claims. And why we tailor solutions to help with your specific risk issues. The results include 98% policyholder retention, the highest-level CME accreditation and reduced risk for you.
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