Vital Signs August 2013

August 2013 • Vol. 35 No. 8Official Magazine of

FRESNO COUNTYFresno-Madera Medical Society

KERN COUNTYKern County Medical Society

KINGS COUNTYKings County Medical Society

MADERA COUNTYFresno-Madera Medical Society

TULARE COUNTYTulare County Medical Society

August 2013 • Vool. 35 No. 8

Vital Signs

See Inside:See Inside:

Covered California Covered CaliforniaUnveils QualifiedUnveils Qualified

Health PlansHealth Plans

PediatricPediatricCrisis ChecklistsCrisis Checklists

Rare ConditionsRare ConditionsManifesting asManifesting asSinus DiseaseSinus Disease

See Inside:See Inside:

Covered California Covered CaliforniaUnveils QualifiedUnveils Qualified

Health PlansHealth Plans

PediatricPediatricCrisis ChecklistsCrisis Checklists

Rare ConditionsRare ConditionsManifesting asManifesting asSinus DiseaseSinus Disease

2 AUGUST 2013 / V ITAL S IGNS

S A N D I E G O

O R A N G E

L O S A N G E L E S

P A L O A L T O

S A C R A M E N T O

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CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

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VITAL S IGNS / AUGUST 2013 3

Official Publication of

Fresno-Madera Medical Society

Kings County Medical Society

Kern County Medical Society

Tulare County Medical Society

August 2013Vol. 35 – Number 8

Editor,Bonna Rogers-Neufeld, MD, FACR

Managing EditorCarol Rau Yrulegui

Fresno-Madera Medical SocietyEditorial CommitteeVirgil M. Airola, MDJohn T. Bonner, MDHemant Dhingra, MDDavid N. Hadden, MDRoydon Steinke, MD

Kings RepresentativeTBD

Kern RepresentativeJohn L. Digges, MD

Tulare RepresentativeThelma Yeary

Vital Signs SubscriptionsSubscriptions to Vital Signs are$24 per year. Payment is due inadvance. Make checks payable tothe Fresno-Madera Medical Society.To subscribe, mail your check andsubscription request to: Vital Signs,Fresno-Madera Medi cal Society,PO Box 28337, Fresno, CA 93729-8337.

Advertising Contact:Display:

Annette Paxton,[email protected]

Classified:Carol Rau Yrulegui

559-224-4224, ext. [email protected]

ContentsVitalSigns

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion piecesaccepted for publication do not necessarily reflect the opinion of the Medical Society. All medicalsocieties require authors to disclose any significant conflicts of interest in the text and/or footnotes ofsubmitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118.

Cover photography: Kīlauea Lighthouse on Kīlauea Point, Kilauea Point National Wildlife Refuge,Kauai, Hawaiiby Bonna Rogers-Neufeld, MD, FACREquipment used: Nikon on auto settings.

Calling all photographers:Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

CMA NEWS ................................................................................................................................5

NEWS

Webinars At-A-Glance ..............................................................................................................8

HEALTHCARE REFORM: Covered California unveils Qualified Health Plans, Expected Premiums ....9

SAVE THE DATE: 33rd Annual Central Valley Cardiology Symposium..........................................10

PEDIATRICS: Crisis Checklists ...............................................................................................11

BLOOD CENTER: Golf Tournament: September 9.....................................................................17

CLASSIFIEDS ...........................................................................................................................18

FRESNO-MADERA MEDICAL SOCIETY .......................................................................................12

• President’s Message

• Walk With A Doc Recap and Upcoming Dates

• FMMS Community Service Award Nomination Forms

KERN COUNTY MEDICAL SOCIETY ............................................................................................15

• President’s Message

TULARE COUNTY MEDICAL SOCIETY.........................................................................................16

• Two Rare Conditions Manifesting as Sinus Disease

• 2014 Coding Book News

• Upcoming Dates to Remember


How Successful IsYour Practice?

Let physician membersknow your practice

is availablefor referrals

Use Vital Signs to advertiseyour practice at special ratesoffered to member physicians.

contact:Annette PaxtonVital Signs

Advertising Representative(559) 454-9331

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You said what to the Medical Board’s investigator?Physicians often come to us after they have been interviewed by a Medical Board investigator or after they have already provided a written description of their care.

Did you know that a Medical Board investigator is a sworn peace officer, with a gun, and a badge, and the power to arrest you?

When the Medical Board demands an explanation, seek help immediately. The attorneys at Baker, Manock & Jensen have helped many physicians through the maze that is a Medical Board investigation. We would be honored to help you.

George L. Strasser5260 North Palm Avenue

Fresno, CA 93704559 432-5400

[email protected]


CMA NEWSphysician voice are their most trusted advisor on medical issues, butwe need to make sure your voice is heard!

Physicians will be victorious in this fight, but in order to do so,we need your help.

JOIN: If you are not already a member of CMA, please considerjoining today. By joining CMA, you will help to ensure that thevoice of California physicians is heard loud and clear in the Capitoland beyond. Together, our unified voice can move mountains.JOIN TODAY on the CMA website, or call the member help lineat 800-786-4262.

DONATE: A fight of this magnitude will be extremely costly.CMA is urging all physicians to consider a donation to CMA’spolitical action committee (CALPAC), which for the last 38 yearshas served as the first line of defense for California’s historicphysician protections. DONATE TODAY

SPEAK OUT: Sign up to be a CMA Key Contact. As a KeyContact, we will provide you with all the tools you need to quicklyand effectively deliver your message to legislators, from talkingpoints to sample letters. CMA has some of the best lobbyists,lawyers and other advocates in the Capitol, but the most powerfulweapon in advancing the cause of physicians and their patients isyou. Hearing from a physician with experience from the frontlinesof medicine can make all the difference for a legislator facing acomplicated health care issue such as MICRA. SIGN UP TODAY.

For more information on MICRA, and what you can do to helpin the fight, visit www.cmanet.org/micra.

TRIAL LAWYERS SEND CADAVER TOE TAGSTO REGISTERED VOTERS IN CALIFORNIAAS THE MICRA BATTLE BEGINS IN EARNESTTrial lawyers and their frontgroup “Consumer Watchdog”recently sent registered voters acadaver toe tag with themessage that “toe tags areneeded (in California) be causeof preventable medical errors.”

With the start of this directmail campaign, it is clear thetrial lawyers are looking toscore a victory this year andencourage legislators to modi fyor overturn Califor nia’sMedical Injury CompensationReform Act (MICRA) with their over the top tactics.

The California Medical Association (CMA) and its MICRAcoalition members at Californians Allied for Patient Protection(CAPP) are fully engaged. With increased legislative visits and thepreparation of our own direct mail campaign and updated materials,we are telling the full story of MICRA and its important role inmaintaining access for all.

CMA has completed polling to update our public messaging andto help guide our strong, coordinated defense of MICRA. Thevoters of California support MICRA and its provisions. You as the Please see CMA News on page 7


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CMA NEWS

CALIFORNIA SUPREME COURT RULESIN PEER REVIEW CASEThe California Supreme Court recently issued a long awaited rulingin a case involving peer review and medical staff self-governance,El-Attar v. Hollywood Presbyterian Medical Center (no. S196830).

In this case, the hospital board at Hollywood PresbyterianMedical Center ignored and overrode the medical staff executivecommittee's (MEC) recommendation to reappoint a physician onstaff. The physician then invoked his right to a joint reviewcommittee hearing to challenge the hospital’s termination of hisprivileges.

Frustrated that the hospital overrode its decision that thephysician should remain on staff, the MEC decided that since it wasthe hospital that wanted to terminate him, then it should be thehospital to prosecute the peer review action. Subsequently thehospital's lay governing board appointed the hearing officer andmembers of the review committee, which ultimately terminatedthe physician's privileges.

Under the medical staff bylaws, however, only the MEC hasauthority to determine the joint review process, including theappointment of the hearing officer and joint review committeemembers. At issue in this case was whether state law allows theMEC to delegate this responsibility, or if by doing so the physician'srights were violated.

On June 6, the California Supreme Court ruled that the merefact that the hospital appointed the joint review committee andhearing officer did not violate fair procedure.

CMA had filed a joint amicus brief with the American MedicalAssociation (AMA) to explain the carefully balanced statutoryrelationship between a hospital governing body and its medicalstaff. A broad coalition of two dozen current or former chiefs of staffthroughout California also had filed a separate amicus brief focusingon the practical aspects of maintaining self-governance andworking with hospital administration. Together, the amicus briefsargue that the hospital in El-Attar failed to respect the medical staffself-governance rights when it unilaterally appointed the reviewpanel and hearing officer in a peer review action.

Notwithstanding the fact that the court ruled against theindividual physician in this case, CMA believes the court’s El-Attardecision can be cited to affirm some important principlesconcerning peer review. To be sure, the specific result in this case islimited to a unique set of facts that makes it less likely to applybroadly, namely, that the MEC delegated its powers to the hospitaland thereby facilitated, if not was complicit in, the violation of themedical staff bylaws. The court acknowledged:

“The situation would be different if the Governing Board hadexercised this power [to appoint the JRC panel and hearing officer] inthe face of active resistance by the MEC. If the Board had appointedthe hearing participants despite the medical staff's own efforts to do so,the Board would have violated the provisions of the peer review statuteproviding that it is the peer review body or its designees that determinethe manner in which a judicial review hearing is held. Although weneed not decide the issue, such a usurpation of the medical staff'spower of appointment may provide grounds to presume that thehearing participants were biased, for in such a case there would begreater reason to think that the Board sought to stack the review panel

with participants who would rule in its favor.”Furthermore, despite finding that the physician was not

deprived of fair procedure under the specific circumstances, theEl-Attar opinion makes some keen observations about the peerreview system and potential for abuse by hospitals:

“There is certainly the potential for a hospital's governing body toabuse the power of appointment in a way that would deprive aphysician of a fair hearing. A hospital's governing body couldundoubtedly seek to select hearing officers and panel members biasedagainst the physician. It might even do so because it wishes to removea physician from a hospital staff for reasons having no bearing onquality of care. But where, as here, the medical staff has left to thehospital 's governing body the task of selecting the participants in thejudicial review hearing, we are not persuaded that we must presumeany hearing officer or panel member appointed by the governing bodyis likely to be biased.”

Finally, the court added a “cautionary note” about misreadingits decision. It explained:

“Although we hold that the assumed violation of Hospital's bylawsin this case was not material, we do not suggest that such bylaws aremeaningless or that a violation of a bylaws provision that implementsprocedural protections above and beyond those specifically mandatedby the Legislature could never be found material. Moreover, weemphasize that even when a violation of the bylaws is immaterial, thatdoes not mean it is irrelevant. The violating entity's decision to departfrom procedures delineated in the bylaws may constitute evidence ofthat entity's bad intent, and it may bolster a claim that the entity hastaken other action that deprived a physician of his or her right to a fairproceeding. (Opn. at 22.)”

These statements reflect the court’s understanding that inreality hospitals can abuse the peer review process. AlthoughCMA is disappointed that the court ruled against the physician,in the long term we believe that this opinion can be used in apositive way to further bolster the importance of fair hearingrights.

More Information: For more information, see CMA On-Calldocuments #5206, “Peer Review – Fair Hearing Requirements," and#7007, "Retaliation by Managed Care Plans

MEANINGFUL USE PAYMENT ADJUSTMENTSARE COMING SOONBeginning January 1, 2015, Medicare physicians who have notsuccessfully attested to meaningful use of an electronic healthrecord (EHR) system may incur payment penalties, as mandated bythe HITECH Act. These payment adjustments are one-to-twopercent of total Medicare charges in 2015, to two percent in 2016and three-to-five percent in 2017 and beyond. Medicaid rates willnot be adjusted for failure to achieve meaningful use.

Physicians who began participation in the Medicare EHRIncentive Program in 2011 or 2012 must demonstrate meaningfuluse for a full year in 2013 to avoid payment adjustments in 2015.

Physicians who begin in 2013 must demonstrate meaningful usefor a 90-day reporting period in 2013 to avoid payment adjustmentsin 2015. Those who begin in 2014 must demonstrate for a 90-dayperiod in the first nine months of calendar year 2014 (by October1, 2014) in order to avoid the payment adjustments in 2015.

Please see CMA News on page 8

Continued from page 5


Education Series

Aug. 21: HIPAA Compliance: The Final HITECH Rule –David Ginsberg • 12:15-1:15pmThe HITECH Act created the extensive funding incentives and standards foradopting electronic health records; it also created new HIPAA rules ormodified existing ones. This webinar will provide an overview of the changesto HIPAA and key steps medical practices can take to comply with thesechanges.

Aug. 28: Medicare: Proposed Changes for 2014 –Michele Kelly • 12:15-1:15pmThis webinar will focus on proposed policy changes to the physician feeschedule for the year 2014 (excluding any discussion on the SGR, or revisedpayment methodology). This discus sion will provide an opportunity forphysicians to hear how new or revised policies may impact their practice, andallow them to provide input to CMA during the Notice and Comment period.

Sept. 4: Appropriate Prescribing and Dispensing: New Measures •12:15-1:15pmThis webinars has been postponed indefinitely. We will inform you if andwhen it is rescheduled. We apologize for any inconvenience.

Sept. 11: California’s Health Benefit Exchange: The Positives andPerils of Contracting – Brett Johnson • 12:15-1:15pmBeginning in 2014, California’s private health insurance market will neverlook the same – individuals and small employers will be able to purchasehealth insurance coverage through the state’s health insurance exchange,named Covered California. It is estimated that by the end of 2016, over onein five Californians will get their health insurance through the Exchange. InOctober of 2013, Californians will be able to access the Covered Californiawebsite and begin enrolling in plans for the 2014 benefit year. Depending onhealth plans’ distribution of enrollees, a surge of physician contractingefforts may occur as these plans attempt to ensure adequate networks arein place prior to January 1, 2014. In this presentation, you will learn moreabout California’s exchange and what it will mean for physicians. You will alsogain an understanding of some of the risks and benefits of being contractedto provide services to exchange enrollees.

Sept. 12: ICD-10 Documentation for Physicians: Part 1AAPC • 12:15-1:15pmContinued on Sept. 19 and 26.

Sept. 18: Recipe for Financial Success: Key Steps to IncreasingYour Net Income – Debra Phairas • 12:15-1:15pmPhysicians and office managers need business management skills,particularly in the financial area. This workshop will teach critical skills inanalyzing the practice profit/loss statement, accounts receivable ratios andstaffing patterns and how to access specialty comparison norms. At leastone source of comparison data specific to your medical specialty will begiven to each participant.

Sept. 19:ICD-10 Documentation for Physicians: Part 2AAPC • 12:15-1:15pmContinued from Sept. 12 and ends Sept. 26.This three-part series covers the key information necessary to understandkey documentation elements to help you not only prepare for ICD-10, but forall the regulations surrounding your practice today.

Sept. 26: ICD-10 Documentation for Physicians: Part 3AAPC • 12:15-1:15pmContinued from Sept. 12 and 19. This three-part series covers the keyinformation necessary to understand key documentation elements to helpyou not only prepare for ICD-10, but for all the regulations surrounding yourpractice today.

CMA Center for Economic Services

Webinars At-A-GlanceMost webinars are FREE for CMA members, $99 for non-members.

CMA members are eligible for special discountson ICD-10-CM Training from AAPC

Questions? CMA Member Help Center: 800-786-4262Please note: this calendar is subject to change.Visit www.cmanet.org/events for updates.

Once physicians demonstrate meaningful use, they mustcontinue to do so every year to avoid the payment penalties.

Only physicians that are eligible for the Medicare EHRIncentive Program are subject to payment adjustments.

For more information, view CMS’s Payment Adjustments andHardship Exceptions Tipsheet and How Payment AdjustmentsAffect Providers Tipsheet.

Contact: Michele Kelly, 213-226-0338 or [email protected].

FEATURED MEMBER BENEFIT:Rental Cars: CMA members receive up to 15 percent off daily,weekend, weekly, and monthly rates from Avis. With Hertz,members can save up to 15 percent off daily rates and 10 percent offstandard daily, weekly, and weekend rates on all car classes forbusiness and leisure rentals. Special international discounts are alsoavailable. Upgrades and other special coupon offers are available.

Members-only codes are needed to take advantage of thesediscounts. Click here or call the member service center at 800-786-4262 (4CMA) to get your codes.

CMA HEALTH LAW LIBRARY UPDATED FOR 2013CMA On-Call, the California Medical Association’s (CMA)online health law library, is fully updated for 2013. One of CMA’smost valuable member benefits, On-Call contains over 4,500 pagesof up-to-date legal information on a variety of subjects of everydayimportance to practicing physicians. The searchable online librarycontains all the information available in the California Physician’sLegal Handbook, an annual publication from CMA’s Center forLegal Affairs.

New documents for 2013 include: E-prescribing (#3207),Compounding Drugs (#3208), Physician Alignment Models(#0312),Value Based Purchasing (#7103), the California HealthBenefit Exchange (#7450), Electronic Health Records: MeaningfulUse Stage 2 (#4305) and Physician Use of Mobile Devices andCloud Computing (#3301).

In addition, physicians can find answers to common physicianpractice questions in the most frequently referenced On-Calldocuments: Prescribing (#3201), Retention of Medical Records(#4005), Medical Records: Allowable Copying Charges (#4002),Termination of the Physician-Patient Relationship (#3503), andAllied Health Professional Relationships: Liability Issues (#3001).

CMA members can access On-Call documents in CMA’s onlineresource center for free at www.cmanet.org/cma-on-call. Non-members can purchase On-Call documents for $2 per page.

The complete health law library (CPLH) is also available forpurchase in an 8-volume print set or annual online subscriptionservice. To order your copy, visit the CMA resource library or call800-882-1262.

CMA members can also contact the CMA legal informationline at 800-786-4262 or [email protected].

CMA NEWSContinued from page 7


Health Plans Selected to Offer Products on the ExchangeIssuer (Product Type) Regions Served Network

Kaiser Permanente (HMO) All of California except Monterey, San Benito and Santa Cruz 14k physicians | 35 hospitals

Anthem Blue Cross (PPO, EPO, HMO) All of California 30k physicians | 300 hospitals

Blue Shield of California (PPO, EPO) All of California 114k physicians | 838 hospitals

Health Net (PPO, HMO) Alameda, Contra Costa, Kern, Los Angeles, Marin, Mariposa, Merced, 44k physicians | 204 hospitalsMonterey, Napa, Orange, Riverside, San Benito, San Bernardino, San Diego,San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano,Sonoma, Stanislaus and Tulare

Western Health Advantage (HMO) El Dorado, Marin, Napa, Sacramento, Solano, Sonoma, Placer and Yolo 3k physicians | 15 hospitals

Molina Healthcare (PPO) El Dorado, Los Angeles, Placer, Riverside, Sacramento, San Bernardino, 4,568 physicians | 29 hospitalsSan Diego and Yolo

L.A. Care Health Plan (HMO) Los Angeles 1,005 physicians | 35 hospitals

Sharp Health Plan (HMO) San Diego 2,600 physicians | 7 hospitals

Alameda Alliance for Health (HMO) Alameda 3,100 physicians | 12 hospitals

Valley Health Plan (HMO) Santa Clara 993 physicians | 4 hospitals

Ventura County Health Care Plan (HMO) San Luis Obispo, Santa Barbara and Ventura 176 physicians | 6 hospitals

Contra Costa Health Services (HMO) Contra Costa 5k physicians | 10 hospitals

Chinese Community Health Plan (HMO) San Francisco and San Mateo 315 physicians | 9 hospitals

Covered California Unveils Qualified Health Plans, Expected Premiums

HEALTHCARE REFORM

CMA VOICES CONCERNSCovered California, the state agency implementing California’sexchange pursuant to the Affordable Care Act (ACA), hasannounced participating health insurers and proposed premiumsfor the state’s health benefits exchange, which is expected to offerhealth insurance coverage to roughly five million Californiansfollowing its launch in January 2014.

In all, 13 commercial health plans were selected to offerproducts on the exchange, including California’s three largestinsurance providers, Kaiser Permanente, Anthem Blue Cross andBlue Shield of California (see chart below).

Throughout the process of drafting a model contract andselecting qualified health plans, the California MedicalAssociation (CMA) has voiced several concerns, many of whichhave yet to be adequately addressed.

One major concern for contracting physicians is a loophole inthe ACA that could see physicians left to foot the bill for servicesprovided to patients who haven’t paid their insurance premiums.The law allows for a three month “grace period” for non-paymentof premiums, but only requires insurers to pay the claims throughthe first month of non-payment. The final version of theexchange model contract included a provision that requires 15days advance notice to physicians when a patient has entered thesecond month of the grace period, but still leaves the burden of60 days worth of unpaid claims on the physician and the patient.

A second issue that has yet to be adequately addressed is thatof network adequacy in the selected qualified health plans.

While Covered California staff has stated that exchangeenrollees will have access to an adequate network of health careproviders, CMA has repeatedly asked that the exchange takeextra steps to ensure that provider directories submitted by planscontain up-to-date and accurate networks. Despite these requests,Covered California continues to favor the status quo method ofmonitoring network adequacy, relying on the Department of

Health Care Services and Department of Insurance, which havebeen lax at best when it comes to ensuring adequate networks.

A history of poorly monitored network adequacy inCalifornia, along with the fact that many physicians are likely tobe hesitant to contract with exchange plans, casts doubt overCovered California’s claim that it will provide enrollees access to“80 percent of practicing physicians” in the state.

The exchange’s expected premiums could also pose achallenge for success of the new marketplace.

Under the premium rates announced earlier this month, thetotal monthly premium for a “silver” level (basic) plan in theSacramento region for a 40-year-old single individual wouldrange from $332 to $476. A 21-year-old enrollee could expect topay more than $130 per month for the most affordablecatastrophic plan

Statewide Average Unsubsidized Premium RatesLowest 2nd Lowest 3rd Lowest Average ofSilver Plan Silver Plan Silver Plan 3 Lowest$304 $325 $335 $321

Statewide Average Bronze/Silver Plansfor a 21 Year-Old After Subsidies(Bronze / Silver) 150 % FPL 200% FPL 250% FPL 300% FPL+Most Affordable $0 / $44 $64 / $108 $137 / $181 $172 / $2162nd Most $5 / $58 $69 / $122 $142 / $195 $177 / $2303rd Most $14 / $63 $78 / $127 $151 / $200 $185 / $234

Federal subsidies will be offered on a sliding scale forindividuals with incomes up to $45,960. Individuals eligible forthe highest subsidy, $276 per month, would still face out-of-pocket expenses of $56 for monthly premiums. These subsidizedpremiums generally far exceed earlier focus groups’ notions ofaffordable (i.e., no more than $25-50 per month for individuals,$100-150 for families).

Given that the annual penalty for not having healthPlease see Healthcare Reform on pag 10


insurance during the exchange’s first yearwill be $95 or one percent of income, itremains to be seen whether healthy peoplewill be willing to pay the high cost ofparticipating in the exchange. Higherpremiums could also have patientdelinquency implications, which mayresult in more physicians being on thehook for two months of claims submittedduring the “grace period” for premiumnon-payment.

CMA encourages physicians to care -fully review any contract solicitation,including those for exchange products,and to call CMA’s reimbursement helplineat 888-401-5911 with any questions.Additional contracting resources areavailable on the CMA website atwww.cmanet.org/ces. For further resourcesabout Covered Ca l i fo rn ia , v i s i twww.cmanet.org/exchange.

Healthcare Reform


“SAVE THE DATE”33rd ANNUAL

CENTRAL VALLEY CARDIOLOGYSYMPOSIUMNovember 9, 2013

Madera Municipal Golf Center8:00am - 3:30 pm

Featured Speakers:

Hossein Almassi, MDProfessor, Cardiothoracic Surgery,

Med. Col of Wisconsin

Norman M. Kaplan, MDProfessor, Dept. of Internal Medicine

Univ. of Texas

Jordan M. Prutkin, MDAssistant Professor, Cardiology

Univ. of Washington

Six (6) hours, Category 1 CMECredit

No charge for Fresno-MaderaMedical Society members

Information: 559-224-4224 x 118:[email protected] orvisit www.fmms.org


PEDIATRICS

Pediatric Crisis ChecklistsVirgil M. Airola, MD

At the Surgery Department meeting a couple ofmonths ago, Children’s Hospital orthopedist JoeGerardi, proposed that our ORs have a set of “how-to” checklists similar to those described by Arriagaet al in “Simulation-Based Trial of Surgical-CrisisChecklists” from January’s New England Journal ofMedicine. The idea was quickly adopted bothbecause the Arriaga article proved more keylifesaving steps were performed with checklist useand because Dr. Joe Gerardi astutely pointed outthey could probably get the anesthesiologists to dothe work since these checklists involved anesthesia“stuff!” Dr. Gerardi and I ended up as project co-chairs.

Reading taught me “checklists are tools that can improvestandardization, teamwork, and overall performance in crisis situations.Checklists for routine perioperative use have been shown in multiplestudies to substantially reduce death and complications and are rapidlybecoming established as the standard of care. Checklists are standard inmanagement of emergencies in aviation and other high reliability fields,but they have not achieved widespread consideration for use in operatingroom crises.”1

The NEJM article revealed several key points.2 Simulations showed asignificant reduction in missed critical steps when checklists were used ina crisis (six percent compared to 23 percent). In a more complex crisis,more keys steps are omitted in both groups. Performance delays were alsofound without checklist use – chest compressions were initiated after only17 seconds in simulated asystole with a checklist compared a delay longerthan 1.5 minutes without a checklist during simulated V Fib. Studyparticipants ranked using checklists at 4.7 (out of 5) when imagining thatthey might be the patient. Clearly, Joe’s idea had merit!

Studies have shown, however, that “crisis checklists will not be usedif the potential users are unaware of them and untrained… Awarenessalone is also not enough – practice is critical.”3 Clearly, development ofthese checklists is important, but engaging in simulated crises while usingthe checklists is key to meaningful use during a real crisis. Practice makesperfect!

The Ziewacz et al and the Arriaga et al articles had 12 checklists. Dr.Nadine Van Wyk found 24 checklists for kids developed by the Societyfor Pediatric Anesthesia. Using these as templates, we were halfwaydone!

But even using published crisis checklists as our templates, the projectseemed huge. So we organized ourselves into teams of physicians, nurses,and others to review background materials and tailor our checklists to ourpatients. This reduced our heavy lifting, and our volunteers made theproject their own – improving our chances for successfully addingchecklists to our toolbox in a crisis!

Our original goal was to make Children’s a safer place even during aninfrequent medical crisis. This project promises to be a major stepforward! Later this year surgeons, anesthesiologists, nurses, andtechnicians will practice using these checklists in simulated crises duringour regular daytime OR schedule because practiced use is the final keystep to improving our performance during a real crisis.

Appended is one of our checklists, “Cardiac Arrest: Asystole/PEA”,followed by our cover page:

Virgil M. Airola, MD

1 Ziewacz JE, Arriaga AF, et al. Operating Room Crisis Checklists. J Am Coll Surg 2011; 213 (2): 213.2 Arriaga AF, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013; 368: 246-53.3 Mulroy MF. Emergency Manuals: The Time Has Come. Anesthesia Patient Safety Foundation Newsletter 2013; Spring-Summer: 10.


Please see FMMS President on page 18

President’s Message

RANJIT RAJPAL, MD

ADDRESSING SOCIAL DETERMINANTS OF HEALTH IN THE CENTRAL VALLEYIn the time of your life, live – so that in that good time there shall be no ugliness or death for yourself

or for any life your life touches. Seek goodness everywhere, and when it is found,bring it out of its hiding-place and let it be free and unashamed. – William Saroyan

When I came to the Valley over three decades ago, I was immediately drawn to its wondrouslandscapes and the indefatigable spirit of the people of the Sierra – I knew instantly that I was home.This Valley of ours is a special place; rich with a diversity of people from all walks of life, who aredriven by a unique passion and dynamism to make positive impacts in their communities. We nowstand at a transitional moment in the history of our Valley, as our voices and stories begin to movefrom the periphery of “the other California” to the core, to reflect the emergent realities of themodern Californian polity.

Though it is true that we have made extraordinary progress and advancements, the fact alsoremains that the health of our Valley is not reflective of what it can and should be. The air quality ofour cities is consistently rated among the most polluted in the nation, too many of our children areafflicted with obesity, we are faced with an impending fresh water crisis, poverty and unemploymentrates are mounting, gaps in access to healthcare, quality education and housing stability persist; thechallenges we face as a community are varied, complex and multi-faceted.

It is, therefore, of paramount importance that we, as a society broaden our scope and understandingof what it means to have a healthy community. All too often we focus solely on generic markersassociated with good health in the popular parlance of the medical community. But the measure of anindividual or a community’s overall health cannot be determined only by traditional and standardizedhealth diagnostics, and it is not solely a function or a reflection of the efficacy of the medicalcommunity. Rather, our health is determined at the confluence of medicine and various fields such aslaw, education, business, agriculture, engineering and urban design. Reputable health advocacyorganizations, including the World Health Organization have placed special emphasis andconsideration on the social determinants of health – the underlying conditions in our social, physical,political, cultural and economic environments and relationships which directly impact our overallhealth, quality of life and epidemiological integrity.

I strongly believe, that as advocates for public health, our Medical Society must forge greatercollaborations within the community and seek to implement and inculcate the theory and praxis of asocial determinants of health approach when addressing healthcare problems in our Central Valley.We need bold and innovative solutions and we must activate our individual and collective agenciesto engage our policy-makers to cohere around public policy geared towards fostering a healthful andsustainable Central Valley. We need to adopt a holistic public health vision which recognizes thatsecuring essential human security needs and fostering relationships of equality and respect are centralaims which will help our communities close these gaps in health. We have the necessary tools andresources to create this positive change and the members of our medical community and the peopleof this great Valley have the courage and determination to fight for our health. This is our home, andI am inspired by the power and possibilities of our collective participation and engagement in meetingthe challenges and opportunities which stand before us.

Fresno-Madera

Post Office Box 28337Fresno, CA 93729-8337

1040 E. Herndon Ave #101Fresno, CA 93720

559-224-4224Fax 559-224-0276

website: www.fmms.org

FMMS OfficersRanjit Rajpal, MD

President

Prahalad Jajodia, MDPresident Elect

A.M. Aminian, MDVice President

Hemant Dhingra, MDSecretary/Treasurer

Sergio Ilic, MDPast President

Board of GovernorsS.P. Dhillon, MD

Ujagger-Singh Dhillon, MDWilliam Ebbeling, MDBabak Eghbalieh, MDAhmad Emami, MD

Anna Marie Gonzalez, MDDavid Hadden, MDS. Nam Kim, MD

Constantine Michas, MDTrilok Puniani, MD

Khalid Rauf, MDMohammad Sheikh, MD

CMA DelegatesFMMS President

A.M. Aminian, MDJohn Bonner, MDMichael Gen, MDBrent Kane, MDKevin Luu, MD

Andre Minuth, MDShazia Maghal, MD

Roydon Steinke, MDToussaint Streat, MD

CMA Alternate DelegatesFMMS President-electPraveen Buddiga, MD

Surinder P. Dhillon, MDDon H. Gaede, MDPeter T. Nassar, MDTrilok Puniani, MDOscar Sablan, MD

Dalpinder Sandu, MDMickey Sachdeva, MD

CMA YPS DelegatePaul J. Grewall, MD

CMA YPS AlternateYuk-Yuen Leung, MD

CMA Trustee District VIVirgil Airola, MD

Staff:Sandi Palumbo

Executive Director


Fresno-Madera

'Walk with a Doc’ strives to encouragehealthy physical activity in people of allages and reverse the consequences ofa sedentary lifestyle in order to improvetheir health and well-being.

GRAB A FRIEND AND HEADTO THE PARK

2013 SATURDAY DATES:August 24 • September 28

7:30-8:30am Registration begins at 7:15am at Woodward Regional Park

Sunset View Shelter

WHO CAN ATTEND:Participation is open to anyone

interested in taking steps to improvetheir health.

ENCOURAGE YOUR PATIENTSTO PARTICIPATE!

In addition to the health benefits ofwalking, you will receive:

• Healthy Snacks• Healthy Lifestyle Tips/Resources• Chance to Talk with a Doc

FURTHER INFORMATION:Contact the Fresno-Madera MedicalSociety at 224-4224, ext. 110 or at

[email protected].

Find us on Facebook:Fresno-Madera Medical Society

http://www.facebook.com/pages/Fresno-Madera-Medical-Society/107731015917068

Fresno-Madera Medical SocietyHosts Free Community Health Walks

WALK WITH A DOCCOMMUNITY OUTREACH PROGRAM

June Walk With A Doc Program

Thank you for the supportof the July

Walk With a Doc

Photos courtesy ofAlan Birnbaum, MD


FRESNO-MADERA MEDICAL SOCIETY2013 PHYSICIAN COMMUNITY SERVICE AWARD

LIFETIME ACHIEVEMENTDear FMMS member: Recognize a Deserving Colleague!

The Medical Society will bestow an award recognizing a physi-cian who has gone beyond the call of duty in providing for thehealth and welfare of our community's residents during his or herlifetime. All nominees must be FMMS members. Criteria for thisaward includes:

•Extraordinary service and dedication to patients, the commu-nity or to the profession•Uncompensated services performed•High quality of care provided to patientsPrevious award recipients: Drs. James Caffee, Roger Larson,

Gilbert Roth, Robert West, Ronald Smith, Dwight Trowbridge, LaurenGrayson, Harold Hanson, John Murray, Max Millar, Ed Defoe, ThomasEliason, Fred Cooley, Robert Peters, Jack Schiff, Burton James,Donald Knapp, Sathaporn Vathayanon, Jack Thorburn, Kenneth Jue,Joseph Woo, Steven Parks, John Conrad, Bjorn Nelson, TheodoreSteinberg, Malcolm Masten and John Bonner.

Nominations from the past three years will be considered. Therecipient is selected by the FMMS Historical Committee andapproved by the FMMS Board of Governors. The award will be pre-sented at the Medical Society's November 6, 2013 dinner meeting.

Please complete and return this form by September 1, 2013. “We make a living by what we get,

but we make a life by what we give.”– Winston Churchill

2013 PHYSICIAN “LIFETIME ACHIEVEMENT” AWARD

I nominate ________________________________________, MD

Please give specific and detailed examples for your nomination:

Submitted by____________________________ Phone_________ Return by September 1, 2013

Mail to: Fresno-Madera Medical Society, Historical CommitteeP. O. Box 28337, Fresno CA 93729-8337

or Fax to: 559-224-0276

FRESNO-MADERA MEDICAL SOCIETY2013 PHYSICIAN COMMUNITY SERVICE AWARD

SPECIAL PROJECT OR SERVICEDear FMMS member: Recognize a Deserving Colleague!

The Medical Society will bestow an award recognizing a physi-cian who has gone beyond the call of duty to devote his or her timeto a one-time or on-going special project or service either locally,statewide, nationally or internationally, that served(s) to promotethe welfare and healthcare of the community or the medical pro-fession. All nominees must be FMMS members.

Previous award recipients are: Drs. Marc Lasher, RichardWhitten, Jr., Walter Byerly, Chun. C. Chan, David Pepper, Chun-WaiChan, Lee Snyder, Women’s Imaging Specialists in Healthcare,Mohammad Arain, John Telles and Joan Voris.

Nominations from the past three years will be considered. Therecipient is selected by the FMMS Historical Committee andapproved by the FMMS Board of Governors. The award will be pre-sented at the Medical Society's November 6, 2013 dinner meet-ing.

Please complete and return this form by September 1, 2013.“It is well to give when asked, but it is betterto give unasked, through understanding.”

– Kahlil Gibran

2013 “SPECIAL PROJECT OR SERVICE” AWARD

I nominate ________________________________________, MD

Please give specific and detailed examples of your nominee’sproject or service:

Submitted by____________________________ Phone_________ Return by September 1, 2013

Mail to: Fresno-Madera Medical Society, Historical CommitteeP. O. Box 28337, Fresno CA 93729-8337

or Fax to: 559-224-0276

Fresno-Madera


2229 Q StreetBakersfield, CA 93301-2900

661-325-9025Fax 661-328-9372

website: www.kms.org

KCMS Officers

Wilbur Suesberry, MDPresident

Alpha J. Anders, MD President-elect

Eric J. Boren, MDSecretary

Ronald L. Morton, MDTreasurer

Joel R. Cohen, MDImmediate Past President

Board of DirectorsBradford A. Anderson, MDLawrence N. Cosner, MD

John L. Digges, MDJ. Michael Hewitt, MD

Susan S. Hyun, MDMark L. Nystrom, MD

Sameer Gupta, MDEdward W. Taylor, MD

CMA Delegates:Jennifer Abraham, MD

John Digges, MDRonald Morton, MD

CMA Alternate Delegates:Lawrence Cosner, Jr., MD

Staff:Sandi Palumbo,

Executive Director

Kathy L. HughesAdministrative Assistant

Kern

CELEBRATION OF LIFEDR. HANS EINSTEIN (1923-2012)

There will be a celebration of life for Dr. Hans Einstein on Saturday, August 10, 2013, 10:00am to1:00pm at the Kern County Museum, Pioneer Village, 3801 Chester Ave. Bakersfield, CA 93301. Allare welcome to pay respects to Dr. Einstein.

A KCMS member stated that Dr. Einstein was a “Great physician – yet a very humble humanbeing.” He was instrumental in the continuing effort toward the development of a vaccine forcoccidioidomycosis (Valley Fever).

Music will start at 10:30am with the Masterworks Choral singing several selections from a medleyof Dr. Einstein’s favorite songs and several classical pieces. The Bakersfield Jazz Singers will singseveral of his favorite swing tunes.

Spoken tributes to Dr. Einstein will start at 11:00am. This is a time to share your stories, or cometo listen. Bring your lunch. Music, refreshments and licorice will be served.

The Celebration of Life will follow the People and Pets Walk for Valley Fever, hosted by the ValleyFever Americas Foundation. Go to valleyfever.com.

President’s Message

WILBUR SUESBERRY, MD


Tulare

3333 S. FairwayVisalia, CA 93277

559-627-2262Fax 559-734-0431

website: www.tcmsonline.org

TCMS OfficersSteve Cantrell, MD

President

Thomas Gray, MDPresident-elect

Monica Manga, MDSecretary/Treasurer

Gaurang Pandya, MDImmediate Past President

Board of DirectorsVirinder Bhardwaj, MDCarlos Dominguez, MDPradeep Kamboj, MD

Christopher Rodarte, MDAntonio Sanchez, MD

Raman Verma, MD

CMA Delegates:Thomas Daglish, MD

Roger Haley, MDJohn Hipskind, MD

CMA Alternate Delegates:Robert Allen, MD

Ralph Kingsford, MD Mark Tetz, MD

Sixth District CMA TrusteeJames Foxe, MD

Staff:Steve M. BeargeonExecutive Director

Francine HipskindProvider Relations

Thelma YearyExecutive Assistant

Dana RamosAdministrative Assistant

Two Rare Conditions Manifestingas Sinus Disease

Kulraj S Dhah, MS IIMedical Student, A.T. Still University School of Osteopathic Medicine in Arizona

and Bruce Hall, MD FACPInternal Medicine, Visalia Medical Clinic, Lindsay, CA

A 46-year-old male presented to the office with 1 week history of daily headaches. Focus of pain wasover left frontal sinus. Initial differential included sinus infection. Further history taking revealedunilateral supraorbital pain with lacrimation of left eye, nasal congestion and drainage, occurringaround the same time every day for the past seven days. Episodes lasted between one to four hours.No previous history of allergies reported. Patient had failed on OTC antihistamines and painmedications. Physical exam was unremarkable. Based on the classic presentation, a diagnosis of clusterheadache was made.

Cluster headache is classically characterized by attacks of severe unilateral orbital, supraorbital, ortemporal pain, accompanied by autonomic phenomena. Unilateral autonomic symptoms mustinclude at least one of the following: ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea,and nasal congestion and are always ipsilateral to the pain. According to the International HeadacheSociety, most headache episodes last 15 to 180 minutes. In the episodic form, attacks can occur daily,usually 1 to 8 times a day for some weeks, followed by a period of remission. The chronic form ofcluster headache lacks sustained remissions1. It has been termed “suicide headache” as some sufferershave been driven to suicide due to the pain or anticipation of the pain4.

The prevalence of cluster headache is less than 1 percent and mostly affects men1. In a meta-analysis of 16 population-based epidemiologic studies, the following observations were reported2:

• The overall male to female ratio was 4.3:1• The lifetime prevalence of cluster headache for adults of all ages was 124 per 100,000

(95% CI 101-154), or 0.124%• The one year prevalence of cluster headache was 53 per 100,000 (95% CI 26-95)First-line treatments for acute cluster headache attack are subcutaneous sumatriptan and oxygen

inhalation3. Verapamil is the agent of choice for the preventive therapy of cluster headache. Otheragents that may be effective include glucocorticoids, lithium, topiramate, and methysergide1.

A 51-year-old patient presented to the office with 10 day history of nose pain. The unilateral,periodic, sharp pains initiated in the left nostril and interfered with sleep. After two days of painunrelieved with home remedies, patient sought treatment at an Urgent Care facility and wasprescribed Augmentin (amoxicillin/clavulanic acid) for suspected bacterial sinus infection. After twomore days without relief, the patient developed sharp pains in the left mandible and scheduled anemergency visit with a dentist. The dental exam, including x-rays, was negative. The dentistattributed the pain to a sinus infection and advised the use of pain medication adjuvant to theantibiotic. Pain pattern and frequency was not relieved by the prescribed regimen. Patient presentedto the PCP ten days after initial pain. On physical exam, patient appeared in moderate to severedistress holding pressure against her left nose in an effort to occlude the left nares. No abnormalitiesof the ear, nose and throat were seen. Based on the classic presentation of pain involving the second

1 May, A., Cluster headache: Epidemiology, clinical features, and diagnosis., UpToDate, Last updated 5/9/2013 2 Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of

population-based studies. Cephalalgia 2008; 28:614.3 Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology

2010; 75:463.4 Kumar, R., Blanda, M., Cluster Headache. Medscape. Last updated 10/18/2012

http://emedicine.medscape.com/article/1142459-overview5 MacDonald BK, Cockerell OC, Sander JW, Shorvon SD. The incidence and lifetime prevalence of neurological disorders in

a prospective community-based study in the UK. Brain 2000; 123 ( Pt 4):665.6 Bajwa, Z., Ho, C., Khan, Sajid., Trigeminal Neuralgia. UpToDate, Last updated 1/5/2012.7 Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia

(an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and theEuropean Federation of Neurological Societies. Neurology 2008; 71:1183.

Please see Sinus on page 17


PO Box 1029Hanford, CA 93230

559-582-0310Fax 559-582-3581

KCMS Officers

Jeffrey W. Csiszar, MDPresident

VacantPresident-elect

Mario Deguchi, MDSecretary Treasurer

Theresa P. Poindexter, MDPast President

Board of DirectorsBradley Beard, MDJames E. Dean, MD

Thomas S. Enloe, Jr., MDYing-Chien Lee, MDUriel Limjoco, MD

Michael MacLein, MDKenny Mai, MD

CMA Delegates:Ying-Chien Lee, MD

StaffMarilyn Rush

Executive Secretary

Tulare Kings

and third divisions of the fifth cranial nerve, the patient was diagnosed with Trigeminal Neuralgia. The annual incidence of Trigeminal Neuralgia (TN) is 4 to 13 per 100,000 people5. Approximately

15,000 new cases occur in the United States each year6. TN is one of the most frequently seenneuralgias in the elderly. The incidence increases gradually with age; most idiopathic cases begin afterage 50, although onset may occur in the second and third decades or, rarely, in children6.

The male to female ratio of TN is about 1:1.5. It is hypothesized that this slight femalepredominance may be related to the longer average lifespan of women compared with men6.

A systematic review and practice parameter published in 2008 from the American Academy ofNeurology (AAN) and the European Federation of Neurological Societies (EFNS) concluded thatcarbamazepine is most effective medication for controlling pain in patients with classic TN,oxcarbazepine is probably effective, and baclofen, lamotrigine, and pimozide are possibly effective7.

Conclusion: The common occurrence of sinus ailments, including allergies and infections, in theCentral Valley can influence our clinical judgment to the potential detriment of our patients. The twocases above illustrate diagnoses that could easily be mistaken for sinus conditions. A thorough historyand physical exam are essential to arriving at the correct diagnosis and beginning proper treatment.

2014 Coding Book NewsIt is that time again to start purchasing coding books. Order your 2014 editions of CPT, ICD-9, ICD-10, and HCPCS thru us. We are offering extraordinarily discounted rates and free shipping directly toyour office.

Please contact Dana Ramos, Provider Relations to order or obtain more information; 559-734-0393 or [email protected].

UPCOMING DATES TO REMEMBER• August 26, 2013: Part A of Noridian Medical MAC Implementation• September 16, 2013: Part B of Noridian Medical MAC Implementation• September 18, 2013: TCMS – ICD-10 Workshop/Training• September 19, 2013: TCMS – ICD-10 Workshop/Training• September 22, 2013: TCMS – Family Day• December 11, 2013: TCMS – Annual Holiday Event

Sinus



MEDICAL OFFICES

Gar McIndoe (661) 631-3808David Williams (661) 631-3816Jason Alexander (661) 631-3818

FOR LEASECrown Pointe Phase II – 2,000-9,277 rsf.

3115 Latte Lane – 5,637 rsf.3115 Latte Lane – 2,660-2,925 rsf.

Meridian Professional Center – 1,740-2,265 rsf.9300 Stockdale Hwy. – 3,743 - 5,378 rsf.9330 Stockdale Hwy. – 1,500-7,700 rsf.

2323 16th St. – 1,194 rsf.2323 16th St. – 1,712 rsf.

2323 16th St. – 2,568 rsf.4939 Calloway Dr. – 1,795 sf.

3941 San Dimas St. – 9,000 rsf. SUB-LEASE

1902 B Street. – 1,698 sf.4100 Truxtun Ave. – Can Be Split

Medical Records & OfficesSprinklered – 4,764 rsf.

Adm. & Billing – 6,613 rsf.FOR SALE

1911 17th Street – 2,376 sf.2019 21st Street – 2,856 sf.2204 Q Street – 4,600 sf.

Crown Pointe Phase II – 2,000-9,277 rsf.Meridian Professional Center – 1,740-2,265 rsf.

9900 Stockdale Hwy. – SOLD OUT!3941 San Dimas St. – 9,000 rsf.

MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words.NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Thirdmonth/3 lines* $30. *Three lines are approximately 40 to 45 characters per line.Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.

Dr. Ahmad Emami announces his Man ofthe Year campaign benefiting the Leukemia& Lymphoma Society. Tax-deductible dona-tions to his campaign can be made at:www.mwoy.org/pages/cca/[email protected] Psychiatry Clinic: A slidingfee scale clinic operated by the UCSFFresno Dept. of Psychiatry at CRMC M-F8am-5 pm. Call 559-320-0580.

LQMG Medical Group is seeking BoardCertified, Internal Medicine physicians tojoin its group. Call 559-450-5703.

Complete suite of office furn. 1 desksw/return & file draws; 2 guest chairs; 10exam rm. chairs; 9 rolling stools for examrms; 6 footstools; 8 desk chairs; 4 examrm tables. Call 559-432-7700.

ANNOUNCEMENT

PHYSICIAN WANTED

FOR SALE

CLASSIFIEDS

FRESNO/MADERA

TULARE

Medical office space; 1476 W. Shaw Ave.between Fruit & West. 1200sf, great loca-tion. Call Shannon Mar, Guarantee RealEstate, 999-6165, [email protected] office; 1046 E. Shields, 1,331 sf,close to Fwy 41 & Manchester Mall. CallShannon Mar, Guarantee Real Estate, 999-6165, [email protected] new (model) home near Willow Intl.campus. 2,760 sf, numerous upgrades, 5bdrms/3bths. Available early to midAugust. Call: 559-273-5336.

Nanny available for your children. Dr.Stanic’s wife, Katarina, knows a right per-son for your home. Contact: Call SequoiaDental Office; 559-635-7186, ask forKatrina or [email protected] (indicateNANNY) under subject)

AVAILABLE

FOR LEASE OR RENT


TransfusionMedicine


VITAL SIGNSPost Office Box 28337Fresno, California 93729-8337

HAVE YOU MOVED?Please notify your medical society ofyour new address and phone number.

PRSRT STDU.S. Postage PAIDFresno, CAPermit No. 30

NORCAL Mutual is owned and directed by its physician-

policyholders, therefore we promise to treat your individual

needs as our own. You can expect caring and personal

service, as you are our first priority. Contact your broker or

call 877-453-4486 today. Visit norcalmutual.com/start

for a premium estimate.

A N O R C A L G R O U P C O M PA N Y

N O R C A L M U T U A L .C O M

P R O U D T O B E E N D O R S E D B Y T H E F R E S N O - M A D E R A M E D I C A L S O C I E T Y A N D T H E K E R N , K I N G S A N D T U L A R E C O U N T Y M E D I C A L S O C I E T I E ST H E K E R N ,A N D

T O B E E N D O R S E D B Y P R O U D

A N D K I N G S T H E K E R N ,

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O U N T Y M E D I C A L CU L A R E TA N D

T H E F R E S N O - M A D E R A M E D I C A L

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C O ML .AL M U T UAN O R C

Vital Signs August 2013

Documents

fresnomadera medi cal

md cap member

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superior protection

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