2012 May/June

MAY / JUNE 2012 | Volume 18 | Number 3

CHRONIC DISEASE: TRENDING UP? RECOGNIZING ADDICTION THE FEMALE ATHLETE TRIAD WHAT HAS CMA DONE FOR US THIS YEAR?

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2 | THE BULLETIN | MAY / JUNE 2012

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS Billing/Collections CME Tracking

Feature Articles 8 Chronic Disease: Trending Up? 16 Recognizing Addiction

Discounted Insurance

20 FAQS: The Bar on the Corporate Practice of Medicine

Financial Services

26 The Female Athlete Triad

Health Information Technology

30 GoodRx: New Start-up for Drs. and Patients

Resources House of Delegates

34 Book Reviews

Representation

37 Public Health News

Human Resources Services

42 What Has CMA Done for Us This Year?

Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory iAPP for

Departments

the iPhone

6 From the Editor’s Desk

Physicians’ Confidential Line

7 Message From the SCCMA President

Practice Management

22 MICRA Savings

Resources and Education Professional Development Publications Referral Services With

23 NORCAL News 28 Hospital News 38 Medical Times From the Past

Membership Directory/Website

39 In Memoriam

Reimbursement Advocacy/

40 SCCMA Alliance News

Coding Services Verizon Discount

44 Classified Ads MAY / JUNE 2012 | THE BULLETIN | 3

The Santa Clara County Medical Association Officers President William Lewis, MD President-Elect Rives Chalmers, MD Past President Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

Chief Executive Officer

Councilors

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Seham El-Diwany, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

AMA Trustee - SCCMA James G. Hinsdale, MD Tanya W. Spirtos, MD (Alternate)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (Past-President) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2012 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MAY / JUNE 2012

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President James Ramseur, Jr, MD President-Elect John Clark, MD Past President John Jameson, MD Secretary Eliot Light, MD Treasurer Steven Vetter, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

R. Kurt Lofgren, MD

Valerie Barnes, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Kelly O'Keefe, MD

David Holley, MD

Patricia Ruckle, MD

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FROM THE EDITOR’S DESK

Joseph Andresen, MD Editor, The Bulletin

The United States Improves Rank to 25th This Year

By Joseph Andresen, MD Editor, The Bulletin We have work to do! The international nonprofit “Save the Children,” in their annual report,* finds Norway the healthiest place for mothers and their children for the third year in a row; the worst is the West African nation of Niger, 165th. Measures include child mortality, the education of women and girls, as well as the economic empowerment and political involvement of women. The contrast between nations at the top of the list and bottom is striking. For instance, girls on average have 18 years of schooling in Norway vs. four in Niger. Almost every mother in Niger will lose one of her children before the age of five years.

Well, how are we doing here in the United States? There has been improvement from 31st last year to 25th this year, with the U.S. ranked between Belarus and the Czech Republic. But maternal mortality is the worst of any industrialized nation (1/2100 births). Child mortality is 41st overall. Poverty in the United States continues to account for the big gap between health care available to women of higher income vs. very poor women. Despite having some of the best technology in caring for premature infants, we continue to have important work to do here. Share your thoughts in how we might see ourselves among the top 10 nations in the world for mothers and children next year.

I am proud to share some of the highlights in this issue of The Bulletin: Dr. Toton, an orthopedic surgeon and SCMA editorial board member shares his review of Dr. Lee Lipsenthal’s book, “Enjoy Every Sandwich,” sharing his treatise on living life without fearing death. As he so eloquently states, “I no longer have a bucket list, I have love in my life.” Many moments of wisdom we can all learn from.

Do you routinely ask your patients: “How much alcohol do you drink? Would you be willing to cut back?” “Have you had more than four (three for women) drinks at any one time, or more than fourteen 6 | THE BULLETIN | MAY / JUNE 2012

(seven for women) drinks a Joseph Andresen, MD, is the week?” “Have you been sad or editor of The Bulletin. He is board blue, or have you experienced certified in anesthesiology and is loss of interest, for greater currently practicing in the Santa Clara Valley area. than two weeks or more?”

If yes, “Would you like some help?” Dr. David Pating gives us steps to move beyond hesitation in asking our patients whether they may have alcohol or drug abuse, in his “Recognizing Addiction.”

Did you know the “Corporate Practice of Medicine Bar” prohibits lay individuals, organizations, and corporations from hiring or employing physicians, or otherwise interfering with a physician’s practice of medicine? Learn more about the nuances, exceptions, and importance of these regulations and how they may apply to you.

What are the signs and symptoms of the female athlete triad? What do asthma, COPD, hypertension, osteoarthritis, all have in common? Improve your clinical fund of knowledge with articles on each of these important topics.

Finally, I would like to acknowledge Dr. William Lewis and Dr. James Ramseur as outgoing 2011-2012 Presidents of the Santa Clara County Medical Association and Monterey County Medical Society respectively. We applaud their contributions, hard work, and advocacy on our behalf.

As Dr. Lewis so vividly enlightened us to the plight of Syrian physicians treating civilians in his previous column, keeping our personal challenges in perspective and remaining engaged is essential to the future of our medical profession. *http://www.savethechildren.org/atf/ cf/{9def2ebe-10ae-432c-9bd0-df91d2eba74a}/STATEOFTHEWORLDSMOTHERSREPORT2012.PDF

MESSAGE FROM THE SCCMA PRESIDENT

william s. lewis, MD President, Santa Clara County Medical Association

A Letter to the 85%

By William S. Lewis, MD President, Santa Clara County Medical Association As of 2011, the total membership in the American Medical Association was 217, 490, of which about 35% were medical students and residents. With roughly 900,000 practicing physicians in the United States, that means that only about 15% of them are AMA members. I am one of them. I’m afraid that begs this question: am I stupid or are 85% of physicians misguided?

Lately, the AMA has come under fire for supporting the Patient Protection and Affordable Care Act. Ostensibly, AMA support was a political tradeoff for a permanent fix of the Sustainable Growth Rate formula, which calls for draconian cuts to Medicare reimbursement. But the AMA was bamboozled, because the Affordable Care Act passed without the fix. The more cynical observers contend the AMA was beholden to the White House because the AMA relies upon revenues generated from publication of the ICD and CPT codes, an exclusive right granted by the federal government. The more generous call it a regrettable mistake in an ongoing battle, but ultimately the SGR will be replaced, and come that day, the results will be much better with the advocacy of the AMA than without it.

Since 2009, numerous physician groups have emerged, supposedly to speak for a majority of physicians and repeal Obamacare. These groups aspire to be an alternative to the AMA. One of their main arguments is that the AMA only represents a small minority of physicians. Well, have you heard of America’s Medical Society, Doctors for Patient Care, the Doctor Patient Medical Association, the American Academy of Private Physicians, or the Association of Physicians and Surgeons? That alone should tell you something. Available membership information is limited. Two of these organizations indicate membership of less than 5,000, and there is no reason to suppose any of the other groups are doing much better. Generously, this amounts to, at most, 1% of practicing physicians in any one of these organizations. Regardless of their opinion on Obamacare, these organizations cannot credibly claim to speak for physicians at a national level.

Frankly, even if membership in these organizations was much higher, who would listen to them?

When medicine is politically fragmented, it carries little, if any, political clout. It is much too easy to dismiss disagreeable groups as all “special interests.” If physicians covet meaningful influence on broad national issues, physicians need a single organization recognized as representing the entire house of medicine. Only then can doctors transform public respect for the profession of medicine into political power.

Fortunately, physicians have one. So why have they been leaving it in droves for decades? In the 1950s, 75% of physicians belonged to the AMA. Since then, we’ve seen slow and steady attrition. By 2007, long before the Affordable Care Act, just 26% of physicians were AMA members, and 30% of these were medical students and residents. Membership now stands at about 23%. Therefore, while support of the Affordable Care Act certainly prompted an exodus, the AMA’s downward trajectory was already well established for numerous reasons.

One obvious explanation is the money. It’s not cheap. And when added to dues for the county medical association, the state medical association, and specialty organizations, it feels even more expensive.

With downward pressure on physician incomes, the fact that AMA membership is not required may be the only excuse needed for most physicians to quit.

After all, the AMA advocates for physician members and non-members alike.

Another potential reason is the cultural shift over the past few generations. In today’s society, the focus is on the individual. As a result, some say young physicians are less likely to think of their profession as a defining element of their lives. If doctors treat medicine more as a vocation than a calling, they feel less inclined to engage with the broader medical community.

Changing practice patterns constitute another major factor in AMA membership decay. In the past, most physicians were small businessmen (and women) in solo and small groups. They knew their vulnerabilities and the AMA provided the umbrella of protection. Now, most young physicians join large groups with guaranteed salaries and benefits. With layers of management above them, they let others worry about the business of medicine. They feel their professional future is safe and secure, so the AMA

William S. Lewis, MD, is the 2011-2012 President of the Santa Clara County Medical Association. He is a board certified ENT physician and is currently practicing in the Los Gatos area.

seems superfluous.

Another common and understandable excuse is the belief that it’s enough to belong to local and state medical associations. After all, many of the issues facing doctors are dictated by state regulations.

Additionally, there are many opportunities to participate at the county and state level. Doctors can get involved, express opinions, and make a difference.

However, when it comes to the AMA, few doctors know their delegate, let alone serve as one. Fewer still will ever serve in a leadership position or sit on an important AMA committee. Finally, while many physicians may like to change AMA policy, most probably feel it’s impossible to make a difference. The AMA is just too big and complicated with competing agendas.

Here in Santa Clara County, our membership continues to grow within the California Medical Association. And with membership comes influence and power. Our district delegation is the largest in the state. We have more CMA trustees than ever before. One of our very own, Dr. James Hinsdale, recently served as chairman of the Board of Trustees and the president of CMA. We have ears and a voice in most every corner of CMA operations. Our position amongst county medical associations is enviable and valuable.

But there is a catch. AMA membership in our district and in the rest of the state is falling. As a result, California’s AMA delegation is shrinking.

Sadly, our district is directly affected. Beginning this year, we will have just one AMA delegate and alternate, instead of two. So when it comes to advancing CMA policy for national action, we are getting weaker. And just when we need a stronger voice in Washington, we are going mute.

If you are reading this article, you are almost certainly a member of the CMA, and you are to be commended for your commitment to the medical profession above and beyond your specialty or mode of practice. It is almost equally probable that you are not an AMA member. Whatever the reason, you should reconsider. You understand the value of organized medicine. You recognize national health care policy affects you, your patients, and your profession.

You acknowledge the CMA cannot effect change in Washington alone. You see there is, and there can only be, one organization, for better or for worse, recognized by the public and legislators as the voice of physicians. You know, if we all do our share, we can make a difference. And, hopefully, you now agree, I am not stupid.

MAY / JUNE 2012 | THE BULLETIN | 7

8 | THE BULLETIN | MAY / JUNE 2012

Chronic Disease: Trending Up?

By David Reynolds Reprinted with permission from the Southern California Physician Magazine America is aging. The first of the Baby Boom generation is entering retirement age—the first of a very large group about to transition to senior status. Americans are also living longer—long enough to develop chronic problems. And America is also getting heavier—eating more, and moving less. All of this adds up to an increase in many chronic diseases—osteoarthritis, diabetes, hypertension, and on and on. Many millions of Americans are affected by a chronic condition—and quite often, more than one related condition.

This increase in chronic disease burdens the health care system, and it is increasingly showing up in physician practices. Knowing the most effective treatment options and understanding how to encourage patient compliance is key to improving outcomes and keeping health care costs down. Here’s what research shows about five common chronic diseases: asthma, chronic obstructive pulmonary disease, diabetes, hypertension, and osteoarthritis.

Asthma

According to the National Heart, Lung, and Blood Institute, 1 in 13 people in the United States has asthma. And while improperly controlled asthma imposes a cost on patients and families, it also affects the health care system. Acute asthma flare-ups can claim primary care resources, disturb physician practice schedules, and increase emergency room and hospital bed use. Asthma control is within the reach of most individuals, which is good news, since controlling the condition can reduce these burdens.

• In 2005, 8.9% of children in the U.S. had asthma.

• Each year, asthma causes 13 million missed school days and 10 million missed work days.

• Among children under 15, asthma is the third most common cause of hospital admission.

• The average inpatient stay for an asthma admission is 3.2 days.

• There were 42.3 asthma-related emergency room visits per 10,000 people in California. This rate decreases as patients get older. Children under five have a rate of 101.3 visits per 10,000 people.

As America ages, some chronic diseases are becoming more and more prevalent. Here are the most recent statistics for five common chronic diseases.

• In California, the number of emergency room visits for asthma is highest in the winter and lowest in the summer.

• African Americans have the highest rate of emergency room visits as a group —144.5 per 10,000 people in California.

• Nationwide, asthma-related emergency room visits top 200,000 and physician office visits top 10.5 million each year.

What to Look for Since early diagnosis can provide some treatment benefits, consider extra follow-up with patients who: • have a family history of asthma; 40% of children with parents who have asthma will also develop the condition.

• have allergies; 70% of those with asthma also have allergies.

• have airway hyperreactivity.

• have atopy, such as eczema, allergic rhinitis, or allergic conjunctivitis; atopy has been shown to be a major risk factor for the development of asthma.

If You Can Only Get Your Patient to Do One Thing Make an action plan. Work with your patient to create an asthma action plan. This written plan should include information on how patients can assess their own status, what medications to take under what circumstances, and when to call a physician. Self-monitoring techniques are especially important, so that worsening asthma can be recognized— especially for patients who may not be able to easily perceive symptoms, or for those who have had severe acute incidents.

Chronic Obstructive Pulmonary Disease

The World Health Organization estimates that 210 million people have Chronic Obstructive Pulmonary Disease worldwide, and that five percent of all deaths globally in 2005 were related. And these deaths (primarily due to tobacco use or second-hand smoke) are projected to increase by 30% over the next 10 years. And while COPD is not curable, a solid, consistent treatment plan can control symptoms and provide patients with increased quality of life.

The Global initiative for chronic Obstructive Lung Disease, created in collaboration with the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the World Health Organization, MAY / JUNE 2012 | THE BULLETIN | 9

Chronic Disease: Trending Up?, continued from page 9 provides COPD information, and is a worthwhile resource for physicians and patients alike.

• The COPD death rate for women is growing more quickly than for men. From 1980 to 2000, the rate more than doubled (from 20.1 to 56.7 deaths per 100,000), while for men it increased more modestly (from 73.0 to 82.6 deaths per 100,000).

• COPD, when considered as a single cause of death ranks just under coronary heart disease, cerebrovascular disease, and acute respiratory infection, worldwide.

• By 2020, COPD is on track to be the third leading cause of death in the U.S. • In 2000, COPD-related emergency room visits topped 1.5 million.

What to Look for Early diagnosis of COPD is key to preventing damage to lungs and providing the best patient outcomes. Consider extra follow-up with patients who: • have a history of mucus blocking the airways; • have had shortness of breath; • have a chronic cough; • have exposure to risk factors, such as tobacco use or secondhand smoke.

If You Can Only Get Your Patient to Do One Thing Manage the disease with medication. COPD is managed through bronchiodilator medications, either as needed, or on a regular treatment schedule—tailored to the patient’s individual symptoms. While these treatments do not halt the reduction in lung function, they do help patients manage symptoms and can increase quality of life. As COPD progresses, patients often experience COPD flare-ups (usually in conjunction with a bronchial infection or irritation). Managing these exacerbations can range from adjusting a patient’s medications to hospitalization, depending on the severity of the exacerbation.

Diabetes

Diagnosed cases of diabetes affects 17.9 million people in the United States, with an additional estimated 5.7 million undiagnosed cases.

Taken together, this is nearly 8% of the country’s population. At least 57 million have pre-diabetes—indicated by a higher-than-normal blood glucose level (but under that needed for a diabetes diagnosis). And, according to a 2008 report from the Centers for Disease Control, the diabetes rate has nearly doubled in the last 10 years (with a strong tie to rising obesity rates).

This suggests that physicians will work with an increasingly large portion of patients who have the disease, and its myriad complications, including heart disease, hypertension, neuropathy, amputation, kidney disease, and blindness. Effective diabetes management will become more important—for physicians and their patients.

The National Diabetes Education Program (NDEP) is a coalition of the National Institutes of Health, the Centers for Disease Control and Prevention, and hundreds of public and private organizations, with the goal of reducing diabetes-related morbidity and mortality. NDEP has a wide range of publications and resources for physicians and patients.

• California has a higher incidence of diabetes than the U.S. average, but a lower incidence of death.

• Marin, El Dorado, and San Francisco counties have the lowest incidence of diabetes in California; Yuba, Imperial, and Tulare 10 | THE BULLETIN | MAY / JUNE 2012

counties have the highest incidence.

• $1 out of every $10 spent on health care in the U.S. is spent on diabetes (including complications).

• Diabetes is the sixth leading cause of death in the nation.

• Nearly 33% of people with diabetes also have severe gum disease.

• The risk of stroke for people with diabetes is two to four times more than for those without.

• More than 60% of people with diabetes also have hypertension.

• In 2007, diabetes cost the nation $116 billion in direct medical costs and $58 billion in indirect costs (such as missed work, disability, and premature mortality).

What to Look for Identifying patients with undiagnosed diabetes, as well as those with pre-diabetes, can prevent or delay the onset of type 2 diabetes. Consider extra follow-up (including testing plasma glucose) with patients over 45 or overweight adults who: • have a family history of diabetes; • have hypertension; • are African American, Hispanic or Latino, American Indian, Alaska Native, Asian American, or Pacific Islander; • had gestational diabetes; • have vascular disease; • show signs of insulin resistance.

If You Can Only Get Your Patient to Do One Thing Control blood glucose. Working with your patient to create a plan for managing blood glucose usually involves some combination of dietary control, exercise, and insulin (when appropriate). By helping your patients become well educated about how healthy eating and physical activity, combined with monitoring blood glucose and using insulin as indicated, they can make informed decisions and effectively self-manage the disease on a day-to-day basis—and potentially avoid the complications of diabetes.

Hypertension

Hypertension affects a large proportion of the country’s population—and most who have it don’t know it. According to the American Heart Association, one in three adults in the United States has hypertension, and over three-quarters of those who have it are unaware that they do. And the death rate is rising—in the 10 years ending in 2006, the hypertension death rate rose by over 19%, indicating that the disease is on the rise.

The National Heart, Lung, and Blood Institute (NHLBI) provides information to improve prevention and treatment of heart, lung, and blood diseases. The NHLBI is part of the National Institutes of Health and offers a wide range of physician guidelines, research information, and patient education covering asthma, hypertension, obesity, and many other conditions.

• Over 74 million people nationwide have hypertension; over 60 million with hypertension in the nation are over 65.

• In 2006, hypertension was listed as a primary or contributing cause of death for 326,000 people in the U.S. • Hypertension will cost the country an estimated $76.6 billion in health care and lost work days.

• California has the highest number of lost work days per year due to hypertension in the nation.

• Over 140 different hypertension medications are available.

What to Look for According to a National Ambulatory Medical Care Survey, hypertension is the most common primary diagnosis in the United States.

Consider extra follow-up with patients who: • have a family history of hypertension; • are overweight; • are physically inactive; • use tobacco; • drink alcohol excessively; • exhibit high cholesterol, diabetes, kidney disease, or sleep apnea.

If You Can Only Get Your Patient to Do One Thing Modify lifestyle. The first step in controlling high blood pressure is changing lifestyle. This includes weight loss for overweight patients, regular exercise, moderating alcohol consumption, and adopting a calcium- and potassium-rich diet with dietary sodium restriction, such as the Dietary Approaches to Stop Hypertension—or DASH—diet. Consider your patient and work to create a plan that addresses the most prevalent lifestyle issues.

Osteoarthritis

While the term arthritis covers over 100 diseases, the most common type is osteoarthritis. And although osteoarthritis can occur in any joint, it’s most common in weight-bearing joints, including the knee, hip, and spine. Over 20 million Americans are affected by osteoarthritis, with most people over 60 having some degree of the disease. It’s the most prevalent joint condition worldwide. As the population ages, the occurrence of osteoarthritis is projected to rise.

The U.S. Department of Health and Human Services, through the Agency for Healthcare Research and Quality, maintains physician guidelines and patient education resources for osteoarthritis.

• 27 million people in the U.S. have osteoarthritis.

• One of every two people will develop osteoarthritis in their lifetime.

• Each year, over 600,000 osteoarthritis-related joint replacements are performed.

• In 2004, there were over 11 million osteoarthritis-related

patient visits.

• Osteoarthritis accounts for over $128 billion in costs to the nation’s economy each year.

• 39 million physician visits and 500,000 hospitalizations annually are arthritis-related.

• By 2030, the number of people with arthritis is expected to increase 40%.

• Over 60% of arthritis patients are women.

What to Look for If osteoarthritis can be diagnosed early enough, joint damage may be avoided through addressing underlying risk factors and providing preventative drug therapies. Consider follow-up with older patients who: • are female; • are overweight or obese; • have joint injuries or malformed joints or cartilage; • are employed in occupations that place repetitive stress on a particular joint.

If You Can Only Get Your Patient to Do One Thing Address underlying factors. While pain relief is important for maintaining a patient’s quality of life (as well as the ability to follow an exercise plan), it doesn’t do anything to address the disease. If the disease is diagnosed early enough, addressing underlying factors may result in pain relief and restoration of function. Patient education may help in both of these realms. Chronic pain classes offered in many communities, and self-education resources on the Internet are two education options.

Regular contact with your patients may also help. One study reported in American Family Physician showed that monthly physician phone calls had good clinical outcomes.

Exercise and weight loss can both help patients with osteoarthritis. Patients who are worried that exercise will further damage a joint can be assured that low-impact exercise does not appear to advance the disease. Exercise can be used to maintain function, strength, and range of motion, and it also helps patients manage their weight. Obesity increases the chance of developing osteoarthritis and it adds additional stress on compromised joints.

Improving Patient Compliance Five ways to get patients to cooperate With most chronic conditions, patient compliance is paramount. Monitoring and controlling a chronic disease over the course of a lifetime is often challenging, and the best outcomes are tied to how well patients are able to adhere to a treatment plan. Here are some ways to increase patient compliance.

Build trust. Patients who trust and respect their physicians are more likely to follow that physician’s treatment plans. This includes building empathy and expressing concern and hope for patients, as well as including the patient in decisions, where appropriate.

Establish solid communication. This

is a two-way street. Good communication ensures that patient concerns are heard and valued, and that physician instructions are heard and understood. Performing brief exit interviews is one way to ensure that patients understand; tailoring the management plan to a patient’s situation and lifestyle help build communication and may increase compliance.

Ask a few open-ended questions. By giving your patients the opportunity to talk about what matters to them — whether or not it’s directly related to the issue at hand — you provide them with an opportunity to share, and that builds trust.

Increase contact. Scheduling more frequent appointments and making sure patients have contact with other resources can help improve compliance. Scheduling followup appointments before the patient leaves, as well as following up with patients who miss appointments can also help.

Understand cultural concerns. Patient compliance can be greatly affected by cultural concerns. By respecting and understanding these differences — as well as looking for ways that they can be incorporated into management plans — physicians can build trust with patients and families.

MAY / JUNE 2012 | THE BULLETIN | 11

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• Level II Trauma Center • Neurosciences Institute • Orthopedics Institute • Pediatrics • Surgical Services • Weight-Loss Surgery

johnmuirhealth.com MAY / JUNE 2012 | THE BULLETIN | 13

DocBookMD is provided FREE to SCCMA DocBookMD is provided FREE and MCMS members thanks NORCAL. to SCCMA and MCMStomembers thanks to NORCAL.

communicate collaborate coordinate

Mobilize your practice with

DocBookMD FAST • E ASY • S E CURE

• HIPAA-compliant • On-demand messaging • Share images of X-rays, EKGs, wounds • Fast look-up of physicians and pharmacies

14 | THE BULLETIN | MAY / JUNE 2012

Features include...

1 DocBookMD is designed by physicians for physicians and provides an exclusive HIPAA-compliant professional network to communicate collaborate and coordinate with your medical society colleagues

On-Demand Messaging

• HIPAA-compliant • Send instant messages • Set message priority: Get a 5 min, 15 min or normal response time

2 Multi-Media Collaboration Securely send high resolution images, e.g. of X-rays, EKGs or wounds

3 Fast Look-Up A directory of county Medical Society colleagues

4 Quick Pharmacy Search It’s easy to get started:

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Use on Multiple devices

Switch easily and seamlessly between up to two devices: iPhone or Android, and an iPad or iPod touch.

• First download DocBookMD from the iTunes App Store or Google play • Open up the app on your device to begin the registration process. You will need your Medical Society ID number.

If you do not have it, contact your medical society for assistance.

• Start using DocBookMD to communicate collaborate and coordinate!

For more details go to:

communicate collaborate coordinate

DocBookMD.com MAY / JUNE 2012 | THE BULLETIN | 15

An Addiction Primer for the Primary Care Physician

16 | THE BULLETIN | MAY / JUNE 2012

By David Pating, MD Reprinted with permission from San Francisco Medicine Ten years ago, 650 national physicians were asked to diagnose a thirty-eight-year-old married woman who complained of abdominal pain, gastritis on gastroscopy, hypertension, job-related anxiety, and insomnia. Among the responses received were peptic ulcer, gastric reflux, irritable bowel syndrome, and depression. In this survey, only 6% of physicians mentioned possible alcohol abuse. While it's a truism that "common disorders are common," in this survey, less than onethird of primary care physicians said they routinely screened for alcohol abuse; most admitted they were uncomfortable asking about drug or alcohol use, particularly with older patients or those they may have known a long time. The reasons: "I'm too busy", "I don't know how", or "I don't feel comfortable with addicted patients in my practice".

This is a sad state of affairs, particularly when the National Institute on Health (NIH) has identified that one in five patients in primary care drink amounts that put them at risk for health and social consequences; another 6%, in the last month, used an illicit drug–usually marijuana, but increasingly prescription drugs and opiates. The cost for failing to recognize alcohol and drug abuse in our medical practices is enormous. Patients with alcohol or drug problems have one-third more emergency room visits and account for up to 40% of hospitalizations and 50% to 70% of suicide attempts. On an outpatient basis, patients who drink above nationally recognized safe-drinking guidelines were found to have 50% more office visits and greater medication nonadherence.

Recognizing physician reluctance to ask about substance use, the NIH issued, in 2005, simplified guidelines for screening for alcohol and drug use as a new "vital sign".1 The NIH defines safe drinking for men as no more than four standard drinks (measured as a 12-ounce beer, 5-ounce glass of wine or 1.5 ounces of liquor) at one time, or 14 drinks per week (or on average no more than two drinks a day). For women or older adults above age 65, safe drinking is no more than three standard drinks at one time or seven drinks per week. Patients who drink above these amounts are "at-risk" drinkers and should be advised to "cut back" to "moderate" or "safe" use. For patients who used an illicit drug in the last month, they should be advised to quit.

Screening and brief intervention (SBI) for alcohol and drug abuse is this simple: How much alcohol do you drink? Would you be willing to cut back? These standards are now adopted by the National Committee for Quality Assurance (NCQA) and endorsement of similar standards by the Joint Commission is anticipated.

Of course, the diagnosis of alcohol or drug abuse is greatly simplified in the unfortunate circumstance that your patient arrives at your office doorstep intoxicated or in withdrawal. For simple alcohol withdrawal, those who manifest moderate anxiety and tremor with mildly elevated blood pressure and pulse, I encourage you to offer medical detoxification with a benzodiazepine. Alcohol withdrawal can be dangerous and life-threatening due to the rare risks of seizure or delirium tremens. More important, mounting evidence indicates that multiple episodes of untreated alcohol withdrawal contribute to increased seizure risk and dementia. In my substance abuse clinic, we try never to send away a patient in alcohol withdrawal without

adequate benzodiazepines.

Most withdrawal from other illicit drugs is less worrisome. In my personal experience, most acute psychosis from stimulants resolves with sleep. Opiate withdrawal, while uncomfortable, is not usually life-threatening.

My advice for the primary care clinician concerned with the management of opiate withdrawal is to be more prudent in prescribing opiates in the first place. Prescription drugs, including Oxycontin, are the fastest-growing drugs of abuse. While only 10% of patients abuse prescription drugs, including both benzodiazepines and opiates, when they are prescribed by a physician, those with family history or premorbid history of alcohol or drug abuse are at greater risk of abuse. My second advice for clinicians managing patients in opiate withdrawal is to consider obtaining DEA certification to use the new opioid agonist-antagonist buprenorphine in their office practice. Online training for buprenorphine is available at the American Society of Addiction Medicine (www.asam.org) or the American Academy of Addiction Psychiatry (www.aaap.org).

Last, as a reminder, when addressing alcohol or drug use in your patients, it's important to know that one-half of those with substance abuse also have a mental health disorder, most commonly depression.

If you simply remember to ask about depression every time you ask about alcohol use, or ask about alcohol use whenever you ask about depression, you will catapult your practice into "best practice" compliance.

"Have you had more than four (three for women) drinks at any one time, or more than fourteen (seven for women) drinks a week?" or "Have you been sad or blue, or have you experienced loss of interest, for greater than two weeks or more?"

If yes, "Would you like some help?"

Help for alcohol and drug abuse comes in many forms. Help can be a referral to an outpatient or residential substance-abuse treatment program or a referral to a self-help meeting such as Alcoholic's Anonymous, or it can consist of simple advice in your office. For the latter, the NIH website, http://rethinkingdrinking.niaaa.nih.gov, is an excellent resource of online tips, self-help tools, and resources to help patients drink safely. In general, when a physician gives simple advice recommending that an at-risk drinker cut back, one in five patients will reduce their drinking to moderate levels within six months, and another two in five will have considered the feedback and may respond to further encouragement. For other drugs, such as methamphetamines or cocaine, novel programs like the STOP program at San Francisco General Hospital have demonstrated remarkable results; and methadone clinics remain the standard referral for heroin dependence.

In short, in this day of modern, electronically connected medicine, there is no longer a reason to not ask and advise about alcohol or drug abuse. It's the new state of the art in primary care.

1. National Institute of Alcohol Abuse and Addiction.

Helping Patients Who Drink Too Much: A Clinician's Guide. Updated 2005 edition. http://pubs.niaaa.nih.gov/ publications/practitioner/cliniciansguide2005/clinicians_ guide.htm.

MAY / JUNE 2012 | THE BULLETIN | 17

practice management

GROUP Level Term Life Program Looking for cost effective life insurance?

Rates reduced 5%!

Santa Clara County Medical Association and Monterey County Medical Society members may apply for up to $1,000,000 of life insurance on either a 10-year level term or 20year level term basis.

Rates for the first 10 or 20 years of your coverage are locked in, so that you do not have to experience increases in premium solely as the result of getting older*. This results in substantial premium savings during the term of the coverage. After the initial 10- or 20-year term period, you can reapply for coverage at your then-attained age or transfer to the regular term life program if you no longer qualify

through underwriting.

Thanks to positive program loss experience, rates are being reduced by 5% effective July 1, 2012. So apply now!

You may also insure your spouse or domestic partner for up to $1,000,000 and your eligible employees for up to $500,000.

Each plan also includes two special member services: travel assistance services for medical emergencies when you are traveling away from home**; and a funeral planning and concierge service, at no additional cost to you***.

Call Marsh/Seabury & Smith Insurance Program Management for more information at 800/842-3761, e-mail CMACounty.Insurance@marsh.com, or visit www.CountyC-

MAMemberInsurance.com to download a brochure and application. *The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the policy with 60-days advance written notice. Underwritten by ReliaStar Life Insurance Company.

Policy form LP08GP. **ING Travel Assistance Services provided by Europ Assistance USA, Bethesda, MD 20814. ***Funeral Planning and Concierge Services provided by Everest Funeral Package, LLC, Houston, TX 77056.

Employment Practices Liability Insurance (EPLI) Many members think they have coverage for wrongful termination, harassment, and discrimination claims by employees or patients (third party). However, most policies exclude coverage for these types of actions or only provide limited coverage (a contribution to defense costs).

The Santa Clara County Medical Association and Monterey County Medical Society sponsored Employment Practices Liability program includes a unique blend of risk management services and insurance specifically designed to assist physicians in addressing these important issues.

Among the features of the program are: • A helpline staffed by experienced employment defense attorneys. Any manager, officer, or principal of your practice has access to the helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline, and employee terminations.

• If a member seeks helpline advice on an employee termination which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim.

18 | THE BULLETIN | MAY / JUNE 2012

• Free comprehensive criminal background checks for newly hired and promoted managers/supervisors.

• EEO compliance training for managers/supervisors. This internet-based training program is compliant with California law, which requires employers with 50 or more employees to provide supervisors with sexual harassment training.

While this training is only required for larger companies, the California statute sets the “best practices” threshold for all employers regardless of size.

• Defense costs for representing members against allegations of ADA violations.

This valuable member program is available to members through Marsh, our sponsored insurance program administrator, and in conjunction with the Employment Practices Risk Management Association (EPRMA). For more information on these important benefits, and a special First Time Buyers program, please contact Marsh at 800/842-3761 or email CMACounty.Insurance@marsh.com.

Billing Collections Consulting

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As a proud sponsor of the Santa Clara County Medical Association’s Annual Awards Banquet, Legacy Wealth Advisors would like to congratulate the recipients of this year’s awards.

The LWA team includes Michelle Hamilton, MBA as a specialist in financial planning and portfolio administration.

MAY / JUNE 2012 | THE BULLETIN | 19

WHAT IS THE BAR?

The bar on the corporate practice of medicine prohibits lay individuals, organizations and corporations from hiring or employing physicians, or from otherwise interfering with a physician’s practice of medicine. It also prohibits these lay professionals from engaging in the business of providing health care services by contracting with health care professionals to provide those services. The corporate practice ban does not apply to physician partnerships or professional medical corporations because they are controlled by physicians (Business and Professions Codes §2052 and 2400).

Can hospitals employ physicians?

The California Attorney General has concluded that hospitals may not employ physicians to provide professional services. For example, to the extent a pathologist practices medicine (i.e., prescribes, diagnoses, etc.) as a hospital laboratory director, the nonprofessional corporate laboratory that employs the pathologist is unlawfully engaged in the practice of medicine.

To prevent violating the bar, doctors who work in hospitals form physician groups that enter into contracting agreements with hospitals. The medical group is responsible for paying the physicians’ salaries, not the hospital.

Conversely, the medical staff at the hospital is responsible for granting practice privileges and for oversight of that emergency room physician or pathologist.

Physicians can enter into contracts to provide services at a hospital, but the ability for physicians to share revenue with a hospital is also limited. This can only be done as long as a physician’s independent contract with a hospital does not impair the physician’s freedom of action, and the compensation received by the hospital is commensurate with its expenses incurred in connection with furnishing the facilities and services rendered. If the payments to the hospital exceed the actual value of services

20 | THE BULLETIN | MAY / JUNE 2012

FAQs: THE BAR ON THE CORPORATE PRACTICE OF MEDICINE rendered, this would be considered fee splitting and is illegal.

Are there exceptions?

Yes. Under limited circumstances, a hospital may directly employ a physician: • Teaching hospitals: Business & Professions Code §2401 allows a clinic operated primarily for the purpose of medical education by a private or public nonprofit university medical school to charge for professional services for “teaching patients” rendered by physicians who hold academic appointments on the faculty. As long as the facility is used primarily for the purpose of medical education and the services are for “teaching patients,” employment is authorized.

• Hospital districts: The Legislature created an exemption for hospital districts to employ physicians under extremely narrow circumstances.

• County hospitals: The laws prohibiting the corporate practice of medicine do not apply to counties given the broad “police powers” granted to them. Thus, counties may employ physicians.

Are there other ways to legally circumvent the corporate bar?

No. Lay entities have attempted to circumvent the corporate bar by engaging physicians in various types of business arrangements, but these strategies are still illegal. For example, a lay entity/hospital might agree to handle all business decisions and employ a physician to handle all clinical decisions. However, it is difficult, if not impossible, to isolate “purely business” decisions from those affecting the quality of care delivered to patients.

For example, the purchase of a piece of radiological equipment could be looked at as a purely business consideration (cost, gross billing to be generated, space, and employee needs) or a medical decision (type of equipment needed, scope of practice, skill levels required by the operators of the equipment, and medical ethics) or by an amalgam of both.

In addition from prohibiting lay entities from taking outright control over traditional medical decisions, California law presumes that certain business arrangements can result in the lay control of the practice of medicine and automatically prohibits most lay entities from, among other things: 1. Having an economic interest in the net profits of a medical practice, and/or 2. Contracting with physicians on an employment or independent contract basis for the provision of medical services.

If a lay entity has a financial interest in a physician’s “bottom line,” then the entity has a direct interest in and ability to control the medical

side of the business, such as how many hours the physician will work, what medications the physician may purchase, and what type of medical technology should be utilized. This is illegal.

According to the Medical Board of California, the following “business” or “management” decisions and activities resulting in control over the physician’s practice of medicine should be made by a physician licensed in the State of California and not by an unlicensed person or entity: • Ownership of a patient’s medical records, including determining the contents.

• Selection (hiring/firing as it relates to clinical competency or proficiency) of professional, physician extender, and allied health staff.

• Setting contractual arrangements with third-party payors.

• Decisions regarding coding and billing procedures for patient care services.

• Approval of the selection of medical equipment for the medical practice.

Extreme caution should be taken if a hospital is trying to integrate medical practices through a “friendly” physician who has a majority stock in a medical corporation. An affiliated professional corporation can be used by hospitals to circumvent the bar. The courts and attorney general’s office can and do find such arrangements in violation of the bar where it appears that the lay entity is controlling the practice of medicine. For example, an appellate court condemned the formation of “straw man” corporations as an attempt to facilitate compliance with the corporate practice bar. In this case, physician owners “friendly” with a hospital held 58% interest in a medical corporation. Their interest, however, was held in trust for the hospital. The court concluded that the hospital was engaged in the unlawful corporate practice of medicine.

What are the penalties for violating the corporate practice bar?

Individuals who are not licensed as physicians or entities that engage in the corporate practice of medicine can be found guilty of a misdemeanor. Any person found guilty of a misdemeanor can be punished by a fine of $200 to $1,200, or by imprisonment for a term of 60-180 days, or by both fine and imprisonment. If the practice risks great bodily harm, serious illness, or death, the violator is subject to imprisonment for a term not exceeding one year.

Physicians who violate the corporate practice bar by entering into agreements that violate the law can be charged with aiding and abetting an unlicensed person to engage in the practice of medicine. This activity constitutes unprofessional conduct, which can result in loss of licensure.

For more information, see CMA medical-legal document #0280, “Corporate Practice of Medicine Bar.” MAY / JUNE 2012 | THE BULLETIN | 21

68,809 Ways SCCMA-MCMSCMA Are Working for You! MICRA is California’s hard-fought law to provide for injured patients and stable medical liability rates. Organized medicine continues to help preserve MICRA. Physician members can also help by supporting CALPAC. CALPAC supports the candidacy of elected officials who

support organized medicine’s views on MICRA and other health care issues. Encourage nonmember colleagues to join the SCCMA-MCMSCMA and support CALPAC. Membership has never been so valuable!

2012 Santa Clara County Medical Association/Monterey County Medical Society MICRA Premium Savings Chart Specialty Allergy Anesthesiology Cardiology (Invasive) Cardiovascular Surgery Dermatology (Lipo/Cosmetic) Emergency Medicine Family Practice (Non-Surgical) General Surgery Internal Medicine (Non-Invasive) Neurosurgery OB/GYN Ophthalmology (LASIK/Cosmetic) Orthopaedics Otolaryngology (Cosmetic) Pathology Pediatrics (Non-Surgical) Plastic Surgery Proctology Psychiatry (Non-Shock) Radiology (Non-Invasive) Thoracic Surgery Urology Average - All Specialties

Santa Clara Dade County County, FL* $3,019 $7,944 $9,542 $24,098 $21,174 $13,022 $7,218 $22,286 $6,315 $41,521 $29,188 $6,315 $21,174 $21,174 $4,629 $6,315 $21,174 $21,174 $4,395 $6,315 $24,098 $9,542 $15,074

$24,183 $48,367 $95,007 $172,739 $54,413 $95,007 $44,912 $200,377 $50,094 $248,744 $200,377 $50,094 $146,828 $60,459 $44,912 $31,093 $95,007 $69,096 $24,183 $95,007 $172,739 $60,459 $94,732

Long Island Wayne New York* County, MI* $10,826 $37,657 $40,738 $121,665 $36,779 $58,971 $26,817 $121,665 $36,779 $321,713 $196,111 $36,437 $146,084 $108,110 $24,769 $26,817 $108,110 $64,281 $10,826 $61,100 $100,500 $64,281 $80,047

$16,909 $41,697 $66,711 $174,918 $23,797 $87,121 $33,893 $143,445 $34,350 $201,512 $135,935 $37,955 $144,667 $81,556 $19,524 $28,928 $91,565 $53,751 $17,853 $45,293 $154,089 $55,655 $76,869

FL-NY-MI Average* $17,306 $42,574 $67,485 $156,441 $38,330 $80,366 $35,207 $155,162 $40,408 $257,323 $177,474 $41,495 $145,860 $83,375 $29,735 $28,946 $98,227 $62,376 $17,621 $67,133 $142,443 $60,132 $83,883

MICRA Savings $14,287 $34,630 $57,943 $132,343 $17,156 $67,344 $27,989 $132,876 $34,093 $215,802 $148,286 $35,180 $124,686 $62,201 $25,106 $22,631 $77,053 $41,202 $13,226 $60,818 $118,345 $50,590 $68,809

* The rates for counties in Florida, New York, and Michigan, as well as the averages, are 2011 rates provided by the CMA. The NORCAL rates are 2012 rates. NORCAL does not guarantee that the Florida, New York, and Michigan rates are current or accurate, as different insurance carriers may classify medical specialties differently. The tables in this report are for illustrative purposes only.

22 | THE BULLETIN | MAY / JUNE 2012

fiedmember to help with your issue. No automated telephone tango. benefit . We’re on call 24 hours a day, every day of the year. Great

News From NORCAL Mutual Insurance Company

7. Hard-working numbers you can count on.

For most doctors who practice as solos or in small groups of two to four physicians, you may now qualify for a 7% reduction on your NORCAL Mutual premiums.*

utual.Com

RISK MANAGEMENT

al Society and DISCOUNT DETAILS:

NORCAL Mutual’s 5% discount for completing two risk management CME credits is now 7% for policyholders who complete a third CME credit and remain a member of the (SCCMA or MCMS). Risk management CME activities are available to NORCAL policyholders free of charge. CME credits can conveniently be earned online at MyNORCAL, the policyholder log-in area of the NORCAL Mutual website, www.norcalmutual.com. If you don’t currently have a MyNORCAL account, call NORCAL’s Policyholder Services at 877/4437232, Monday through Friday, from 8:00 a.m.

– 5:00 p.m.

This expanded Risk Management Discount for SCCMA or MCMS members is applicable to policies renewing January 1, 2012 or later. Policyholders must have earned the three CME credits and have been active members of SCCMA or MCMS 90 days prior to their policy renewal, in order to receive the 7% discount in 2012.

Remember to keep your SCCMA or MCMS membership current, in order to get the full 7% discount for 2013. Please invite your colleagues to join SCCMA or MCMS and to apply to NORCAL to become eligible for the 7% discount.

AN OVERALL RATE DECREASE FROM NORCAL MUTUAL:

In addition to offering this extra savings to SCCMA and MCMS members, NORCAL Mutual is also reducing California rates an

overall 7.07%. The rate reduction impact per policyholder will vary depending on a number of factors, such as the area of the state where they practice and their medical specialty.

This overall rate reduction will take effect retroactively to January 1, so that the majority of NORCAL’s policyholders, who renew on January 1 or later, will benefit from the rate decrease. NORCAL will re-rate all policies that were either written or renewed in 2012 and apply the new rates. Policyholders can expect to see their rate adjustment reflected in an upcoming, scheduled billing statement, no later than July 1.

Congratulations Our passion protects to the NORCAL your practice Group!

OTHER BENEFITS:

A.M. Best, the insurance rating service, has rated the NORCAL Group an “A” rating for strength and stability for the 29th consecutive year.

NORCAL has also eliminated the age requirement for the retirement tail premium waiver. Policyholders can retire completely and permanently from their practice of medicine at any age, and receive a free tail, as long as they have been a policyholder for the previous five years and remain retired. All other provisions allowing limited work remain unchanged, including, for example, the ability for a physician to work on a limited basis for remuneration, or on a charitable basis, without jeopardizing their free tail.

If you have any questions about the Risk Management Discount or the overall rate decrease, please call NORCAL’s Policyholder Services at 877/443-7232, Monday through Friday, from 8:00 a.m. – 5:00 p.m. *If you are currently part of NORCAL Mutual’s surcharge program, you are not eligible for the Risk Management Discount Program.

MAY / JUNE 2012 | THE BULLETIN | 23

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455 O’Connor Dr., San Jose Premier medical building with modern offices, updated finishes.

Onsite Pharmacy. Directly adjacent to O’Connor Hospital.

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4155 Moorpark Ave, San Jose Great medical location at Saratoga & Moorpark Ave. Convenient freeway access, excellent price!

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125 N. Jackson Ave., San Jose 2 office condos available for lease/sale. Ideal for physicians, dentists or chiropractor.

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HealthMedRealty.com | License #1902032 MAY / JUNE 2012 | THE BULLETIN | 25

TheFemale Athlete Triad

By Neville Golden, MD, and Jennifer Carlson, MD In our effort to raise awareness among physicians and health care professionals about eating disorders, including among athletes, the Eating Disorders Resource Center (EDRC) is honored to submit this article written by our partners Neville Golden, MD, and Jennifer Carlson, MD, with Lucile Packard Children’s Hospital Comprehensive Eating Disorders Program (CEDP). For more information about the LPCH Eating Disorders Program, call 650/4984468 or go to the website eatingdisorders.lpch. org. For local resources, check out EDRC’s www. edrcsv.org.

Since the introduction of the Title IX law, over forty years ago, more young women have become involved in exercise and competitive athletics. While athletics can impart a number of benefits, they can also create challenging issues for the female athlete. One such issue is the Female Athlete Triad.

Definition

The Female Athlete Triad is a syndrome that is composed of three intersecting components: low energy availability, menstrual dys-

function, and reduced bone mineral density (BMD). Low energy availability refers to the negative balance between energy intake and energy output. This imbalance, whether unintentional or intentional, is due to insufficient intake for the degree of physical exercise. When it is an intentional restriction of calories, it may fall anywhere along the spectrum of irregular eating from disordered eating to a diagnosable eating disorder. This disordered eating may be particularly prevalent in sports that emphasize a lean physique or low body weight.

Menstrual dysfunction encompasses a range of menstrual disorders, including luteal phase defects, oligomenorrhea, primary and secondary amenorrhea. Generally, most of the irregularities are thought to be secondary to suppression of the hypothalamic-pituitarygonadal axis, possibly mediated via leptin, resulting in a hypoestrogenic state.

The final component, reduced BMD, reflects BMD lower than would be expected for a patient of that age. Both increased bone resorption and reduced bone formation are responsible for the decrease in BMD, and there is an associated increased fracture risk which may affect an athlete later in her life.

Epidemiology

Few studies have attempted to measure

the prevalence of all components of the Female Athlete Triad simultaneously. Studies of athletes have found a rate of the triad ranging from 1% in high school students to 16% in elite endurance runners. However, rates of the individual components tend to be much higher. In one study of high school students by Hoch et al, 36% met criteria for low energy availability, 54% for amenorrhea/oligomenorrhea, and 13% for low BMD. The triad can affect athletes at all levels of competition, from recreational to the very elite.

Management and Treatment of the Female Athlete Triad

Management and treatment of the Female Athlete Triad is best addressed with a team approach. Important members include a physician, registered dietician, mental health practitioner for those with disordered eating, coach, athletic trainer, exercise physiologist, and parents.

Prevention: Prevention of the triad is key.

Athletes, parents, and coaches should be educated about the caloric requirements for different sporting activities, as well as made aware of the warning signs of the triad and its medical consequences. Emphasis on thinness should be discouraged and low body weight should not

NEDA Thanks American Medical Association for Newly Released Course on Eating Disorders The National Eating Disorders Association (NEDA) proudly announced in April the American Medical Association’s (AMA) latest online course, Screening and Managing Eating Disorders in Primary Practice, which was developed to educate physicians about eating disorders, with the goal of earlier detection and intervention.

The course – the first of its kind – is a part of the AMA’s Educating Physicians on Controversies and Challenges in Health (EPoCH) 26 | THE BULLETIN | MAY / JUNE 2012

program and: provides a basic diagnostic overview of the range of eating disorders; reviews the screening and referral process; and briefly describes the role of the primary care physician in treating patients with eating disorders. The curriculum fills a much needed void, helping more patients receive care and perhaps preventing severe chronic eating disorders.

be linked to peak athletic performance. Coaches and families should also be made aware of potentially harmful weight loss practices and the warning signs that will allow for early intervention.

Assessment: Screening for the triad should be performed at the pre-participation sports examination or at the annual health screening examination. Amenorrhea is not a normal consequence of exercise, and it should be considered a red flag for more extensive screening. If an athlete has been amenorrheic for more than six months or has sustained stress fractures or low impact fractures, a bone density (DXA) scan should be obtained to evaluate for low bone mass. In athletes, the American College of Sports Medicine (ACSM) recommends that a BMD Z-score < -1.0 warrants further investigation.

Treatment: An at-risk athlete should be referred to a registered dietician for dietary assessment and recommendations. The initial goal should be to increase caloric intake, thus increasing energy availability. To optimize calcium utilization and to promote peak bone mass acquisition, calcium and vitamin D supplementation should be recommended. The Institute of Medicine recommends that girls between 9 and 18 years of age receive 1,300 mg of calcium and 600 IU of vitamin D a day. For women between 19 and 30 years, the recommendations are for 1,000 mg of calcium and 600 IU of vitamin D per day.

If an athlete has difficulty increasing her daily calories or if there are concerns about an eating disorder, then an evaluation and treatment by a mental health provider with expertise in eating disorders is appropriate. The mental health treatment may include indi-

vidual psychotherapy, family-based treatment, and group therapy. If an athlete refuses treatment, the International Olympic Committee recommends that she not be allowed to continue her training and competition. Ongoing treatment for such an athlete is critical and clearance to resume participation in athletics should be determined on an individual basis by the treatment team based on her response to intervention.

To follow weight progress, athletes should be monitored at regular intervals on the same scale using a protocol of post-voiding, clothed in a gown. Hormone levels (FSH, LH, estradiol) can be followed every three months to monitor f o r response to treatment.

If the estradiol level continues to be low (< 3 0 pg/

mL), continued hypothalamic amenorrhea is likely. Once the estradiol level is above 30 pg/ mL, 90% of patients will resume their menses within 3-6 months. Once spontaneous menses have resumed, bone mass will often improve; however, it may not revert to a normal level. For those with low bone mass, a DXA scan should be repeated one year after the first scan.

For athletes who do not demonstrate a response to increase in caloric intake, training may need to be modified. It is preferable to continue some exercise, and weight-bearing activities are better for increasing bone mass.

However, if continued amenorrhea persists after an initial decrease in exercise, the athlete may need to be completely withdrawn from training and competing. Because this can be such a difficult recommendation for an athlete, it is important to involve the family and coach in this decision, as well.

There are no pharmacological agents known to improve bone mass to normal levels in female athletes. Oral contraceptives are indicated for contraceptive purposes, but are not efficacious for improving bone mass. Other medications, such as bisphosphonates and selective estrogen receptor modulators, have not been studied in the triad and are not recommended at this time.

Conclusion

The Female Athlete Triad is a syndrome that may affect women as they engage in sports and exercise. The triad may affect athletes of all levels and intensities. Early screening and intervention with a multidisciplinary team is important in prevention of the longer term complications.

MAY / JUNE 2012 | THE BULLETIN | 27

hospital news

Older Adult Mental Health Program Opens at El Camino Hospital Los Gatos El Camino Hospital is pleased to announce the opening of the Older Adults Transitions Services (OATS) program in Los Gatos. OATS has operated successfully at the Mountain View campus of El Camino Hospital since 1993. OATS is an intensive outpatient program specifically designed for older adults who can benefit from psychiatric treatment in a multidisciplinary setting.

Program Description

The OATS program addresses the special needs of older adults who suffer acute psychiatric illnesses and for whom traditional interventions such as office-based medication therapy, counseling, and/or support groups, have proved ineffective. Cognitive behavioral therapy is used as the primary theoretical framework, and treatment is delivered in a non-labeling, supportive environment emphasizing strengths and skill building. The program provides the intensive treatment and consistent support individuals need to recover from psychiatric symptoms and develop the coping skills to get on with their lives. Because caring for these patients can be emotionally challenging for their loved ones, family counseling is also part of the program. In addition to depression, anxiety disorders, bipolar disorders, or panic disorders, patients frequently have chronic medical conditions; treatment is carefully coordinated with each patientâ&#x20AC;&#x2122;s medical doctor.

Staff

Our staff consists of psychiatrist-medical directors, registered nurses, licensed therapists, and occupational therapists. The team is experienced and empathetic, and gets to know each patient individually so as to provide treatment that is both personalized and relevant.

All patients are assigned to a professional staff member for treatment planning, individual counseling, discharge planning, and family intervention and education. The psychiatrist-medical director sees each patient regularly for evaluation and medication monitoring.

The OATS program and physician fees are benefits covered by Medicare, most senior HMOs, and other insurances. An assessment interview is required prior to admission.

Schedule

Referrals

The OATS program is available four days a week on our Los Gatos campus and five days per week on our Mountain View campus, up to five hours per day, and includes both group and individual therapy. This program is not suitable for patients who are not ambulatory or who have been diagnosed with dementia.

A typical stay in the OATS program is 12 weeks. Over time, the patientâ&#x20AC;&#x2122;s schedule usually decreases in both frequency and intensity. Lunch is available during the first four weeks of treatment, until the patient feels well enough to make other arrangements.

28 | THE BULLETIN | MAY / JUNE 2012

Payment

If you would like more program information or to make a referral to the Los Gatos OATS program at 825 Pollard Road, Suite 201, please call Kathleen Condon at 408/866-4028. To refer to the Mountain View OATS program, please call 650/940-7138.

The Black Plague was a major pestilence in the 14th century.

kill

Communication Failures more then 50,000 patients each year in the 21st century. *

eVigils.com eVigils™ is a private, closed-loop, and secure “collaborative texting” service which improves on standard texting, e-mail, and paging to prevent common communications errors.

eVigils™ means never again wasting time trying to reach and hear from team members, never again wading through e-mails looking for what you need.

eVigils™ is compliant with HIPAA and the Joint Commission ruling on texting. * Institute of Medicine. “To err is human: building a safer health system.” Washington, DC: National Academy Press; 2000

© MITEM Corporation, 2012

Artwork copyright © 2012 Dan Harding

GoodRx Launches the First and Only Prescription Drug Price Comparison Tool for Pharmacies Nationwide Helps Insured and Uninsured Consumers Save 20-80% GoodRx recently announced that it has created an innovative prescription drug price comparison technology that provides consumers with accurate drug prices from virtually every U.S. pharmacy. GoodRx, available as both a website (www.goodrx.com) and free iphone app (www.goodrx.com/iphone), allows consumers to compare drug prices, which can differ greatly between competing pharmacies, and find discounts, free coupons, and savings tips.

Consumers simply enter the name of a prescription drug and their zip code. GoodRx immediately displays both a list and a map of prices for both the brand-name and generic versions of the drug from local and mail-order pharmacies. GoodRx’s database contains over one million prices for more than 6,000 brand name and generic drugs.

In addition, consumers can set up refill reminders and price alerts through GoodRx’s My Prescriptions feature, which emails the latest prices in time for a consumer’s next refill.

“The good news is that the price of many important prescription drugs has decreased over the last few years. The bad news is that prices vary wildly and health insurance covers less and less of those costs. We can instantly compare prices for home electronics, airline tickets, and cars –so why not drugs?” asks Doug Hirsch, co-founder and chief executive officer of GoodRx. “GoodRx empowers consumers, doctors, and health care providers to make educated decisions about what drugs to prescribe and where to fill them. This technology not only saves money, but also encourages consumers to fill and refill the prescriptions they need to stay healthy.”

Americans spent more than $300 billion on 4 billion prescription fills in 2010. According to the Kaiser Family Foundation, there were nearly 50 million uninsured Americans between the ages of 18 and 64 in 2010. GoodRx provides price and discount information for both cashpaying and insured consumers, who can often find generic drugs for less than their insurance co-pay. GoodRx can also be a valuable tool for: • Senior citizens without prescription benefits, estimated by the Kaiser Family Foundation to be about 5 million; senior citizens covered by Medicare stuck in the “donut hole.”

• Individuals with untaxed health spending accounts, health insurance plans that have high deductibles, or a co-pay as a percentage of prescription costs.

• Insured individuals whose employers have scaled back health insurance benefits.

30 | THE BULLETIN | MAY / JUNE 2012

“One of the best ways patients can use GoodRx is at their doctor’s office, when they receive a prescription. Too often, prescriptions go unfilled because patients cannot afford them,” said Dr. Sharon Orrange, Associate Professor of Medicine at the University of Southern California and author of GoodRx’s Small Doses Blog (www.goodrx.com/blog).

“With GoodRx, patients can be their own health care advocate and find the lowest price brand name or generic drug while still in their doctor’s office.”

Key Features of GoodRx: • Instant access to current cash and negotiated prices at local pharmacies.

• Access to free discount coupons that can be used at most pharmacies.

• My Prescriptions email refill reminders with the up-to-date prices for their medicine.

• Specific strategies and tips for consumers to increase savings.

• Drug manufacturer coupons which can be worth $1,000 or more per year.

“GoodRx represents the future of health care in the U.S., as consumers look for more transparency in the health and drug industry,” said Dawn Lepore, former CEO of Drugstore.com and advisor to GoodRx. “GoodRx is led by very talented Internet entrepreneurs who helped shape Internet giants Yahoo and Facebook. They are bringing much needed innovation to the process of purchasing prescription medicines and they are poised to have a significant impact on the way Americans think about buying their prescription medicines.”

About GoodRx

GoodRx is the first and only prescription drug price comparison tool created for consumers with prices from pharmacies nationwide.

GoodRx’s founders are seasoned technology executives who were early employees at Facebook, Yahoo, and other successful companies.

GoodRx has received seed funding from Founders Fund, GRP Partners, Highland Capital, SV Angel, Lerer Ventures, Dawn Lepore (former CEO of drugstore.com), Mike Ovitz (Broad Beach Ventures), Ed Wilson (former president of Tribune Broadcasting), and others. For more information, visit www.goodrx.com.

Examples of Cash Price Savings Potential With GoodRx (Los Angeles, CA): Prescription Lisinopril (generic Zestril) 30 5mg tablets Simvastatin (generic Zocor) 30 20mg tablets Levothyroxine sodium (generic Synthroid) 30 125mcg tablets Omeprazole (generic Prilosec) 30 20mg capsules Metformin (generic Glucophage) 60 500mg tablets

Low Local Price $4.00 Ralph’s (Kroger) $6.40 Costco $3.33 (based on 90-day supply) Walmart $10.34 Costco $3.33 (based on 90-day supply) Walmart

Low Mail Order Price $3.50 Health Warehouse. com $3.50 Health Warehouse. com $3.50 Health Warehouse. com

Typical Retail Price $15 - $44

$11.75 Costco Home Delivery $3.50 Health Warehouse. com

$20-$177

$11-$60 $12-$65

$8-45

Comments Hypertension; 77M Rx’s (2nd most dispensed) High cholesterol; 76M Rx’s (3rd most dispensed) Thyroid; 68M Rx’s (5th most dispensed) Gastrointestinal; 45M Rx’s (10th most dispensed) Diabetes; 42M Rx’s (11th most dispensed)

Sources: GoodRx, http://drugtopics.modernmedicine.com/drugtopics/data/articlestandard//drugtopics/252011/727243/article.pdf

MAY / JUNE 2012 | THE BULLETIN | 31

Your Legacy

Designed Representing healthcare providers and their families for over 40 years.

Trust and Estate Planning: • Highly Personalized and • Asset and Inheritance Protection Comprehensive Estate Plans • Incapacity Planning • Wealth Transfer Planning www.hinshawestateplanning.com

Medical Malpractice Defense • Administrative Defense Healthcare Labor Law Hinshaw, Marsh, Still & Hinshaw 12901 Saratoga Avenue | Saratoga, CA 95070 408-861-6500 | www.hinshaw-law.com 32 | THE BULLETIN | MAY / JUNE 2012

Why choose between national resources and local clout?

In California, The Doctors Company protects its members with both.

With 71,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage. Our 20,000 California members also benefit from the significant local clout provided by long-standing relationships with the state’s leading attorneys and expert witnesses, plus litigation training tailored to California’s legal environment.

This uncompromising approach, combined with our Tribute® Plan that has already earmarked over $106 million to California physicians, has made us the leading national insurer of physician and surgeon medical liability.

To learn more, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293, or visit us at www.doctorsagency.com.

We relentlessly defend, protect, and reward the practice of good medicine.

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

3649_CA_Bulletin_SantaClara_Regional_REA.indd 1

When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that.

— Carmen V. Gary Bertuccelli, social worker Pam Nates, chaplain

4/5/12 11:21 AM

When patients and families are coping with serious, life-limiting illness,

they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals.

• The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

4850 Union Avenue, San Jose, CA 95124 408.559.5600 l hospicevalley.org

MAY / JUNE 2012 | THE BULLETIN | 33

current books

The Healer Within Enjoy Every Sandwich, by Lee Lipsenthal, MD

By John Toton, MD Reprinted with permission from Sonoma Medicine Enjoy Every Sandwich, by Lee Lipsenthal, MD, 224 pages, Crown, $22.

In recent years, two popular works — one text and one video — have addressed the finality of one’s life and demonstrated that the adventure can be so constructive that it might be rationally enjoyed rather than feared.

In Tuesdays with Morrie, published in 1997, Mitch Albom, the onetime pupil of Professor Morrie Schwartz, reconnects with his spiritual mentor after many years, finding Morrie dying, ever so slowly, from Lou Gehrig’s disease. In weekly meetings that become ever more difficult for both, the old professor teaches the reclaimed student that many of us have become obsessed with the trivialities of life to the expense of our human relationships.

The professor’s wisdom encourages Mitch to be attentive to what really matters in life.

Ten years later, in September 2007, Randy Pausch, a professor of computer science at Carnegie Mellon University, gave a lecture to his students titled “Really Achieving Your Childhood Dreams.” Pausch, a young man still in his prime with a family and successful career, and an admired teacher in the developing field of human-computer interaction, had been diagnosed with pancreatic cancer a year earlier. Shortly before his lecture, it was found to be incurable and fatal.

Though Randy appeared to be fit, he knew that this would be his last lecture. His goal was to teach his students all he could about family, encouraging them (and us) to have fun and enjoy everything one does in life, living it to the fullest because one never knows when it can be taken away. He says he would rather have cancer than be hit by a bus, because at least with the cancer he has time to prepare family for his death. The lecture, posted in its entirety on YouTube, became so popular that it was transcribed into a book, remaining on the New York Times bestseller list for almost two years.

Clearly, the public is fascinated by the topic of “a good death.” One common thread with Morrie and Randy is that the dying person is a 34 | THE BULLETIN | MAY / JUNE 2012

professor who has dedicated his career to teaching.

Physicians are also teachers, with patients/students who seek their experience and knowledge to guide them through life. When the doctor/teacher faces the same challenge as Morrie or Randy, a physician’s perspective can be quite valuable.

In Enjoy Every Sandwich, Dr. Lee Lipsenthal, a Marin County physician known to many of us as a motivational speaker and associate of Dr. Dean Ornish, faces his terminal diagnosis of cancer. He memorializes his challenge and response beginning July 19, 2009, the day he makes himself a bacon, lettuce, and tomato sandwich, but can’t swallow it. For some unknown reason, it gets stuck in his esophagus. With tongue in cheek, his physician wife reassures him, “It’s just a stricture; forty years of heartburn will do that; you’ve had a hiatal hernia since birth.” A classic medical response, but nonetheless both doctors know intuitively that they need a real diagnosis. With their backdoor access to the medical community, they get a GI consult and endoscopy the next day.

The gastroenterologist specifies an “erosion” as the cause and performs a biopsy.

Lipsenthal waits for the result with a sense of apprehension. “I’m a physician,” he says to his gastroenterologist friend, when told he should come to the office to discuss the biopsy report.

“What is it?”

It’s an adenoma of the distal esophagus.

At that moment, Dr. Lee Lipsenthal, the prominent physician — whose medical practice consists of treating the sickest cardiac and diabetic patients, encouraging them to what health they can achieve, and supporting them when little or nothing can be done — realizes that he is now, at 52 years of age, a patient with a 90% five-year death sentence. He himself has never seen a patient with this diagnosis survive. His will not be an easy or painless death.

Lipsenthal faces the burden of “how to let

one’s wife, let your children, down easily.” His physician wife will want every possible treatment, proven and experimental. His son is just starting college and will likely graduate without his father there. Thankfully, his daughter is still at home.

There are also Lipsenthal’s parents back East, who have lived their lives with (and passed on to their children) a paranoia that, “Bad things can happen to the unwary, so watch out.” Lipsenthal has made every effort to beat back this cultural fear over the years, but he knows that telling his parents about his condition will, predictably, break them.

Giving up his job as medical director of the Preventive Medicine Research Institute in Sausalito adds to Lipsenthal’s burden, but his colleagues support his need to dedicate time to his treatment.

Unlike your everyday practicing doctor, Lipsenthal has an almost infinite number of resources and contacts available: traditional

Continued on page 36

current books

Changing From Within Finding Balance in a Medical Life, by Lee Lipsenthal, MD

By Lori Selleck, MD Reprinted with permission from Marin Medicine Finding Balance in a Medical Life, Lee Lipsenthal, MD, 208 pages, $20.

Our medical community in Marin is fortunate to have several notable physicians engaged in wellness programs, such as Drs. Rachel Naomi Remen, Dean Ornish, and Lee Lipsenthal. They have all written books about their work. One of the best is Lipsenthal’s Finding Balance in a Medical Life, originally published in 2007. The subtitle is, “A guided program to help you reclaim a sense of balance in your busy life in medicine.”

While much has been written on the subject of wellness and life balance, Lipsenthal’s book is a fascinating read from a physician’s perspective. The discussion ranges from the types of personalities that go into medicine to the current stressors of trying to manage a busy practice, as well as a personal life. The same abilities we used to excel and persevere in our training now often get in the way of finding a sustainable balance between the two.

Lipsenthal shares his own journey from being a busy internist with a mainstream practice in Philadelphia, through his experiences with “meditation, spirituality, neurophysiology, shamanism, integrative or holistic medicine, organizational development and psychology.” He describes the process of self-analysis and self-awareness so that his colleagues may learn “not how to be a great doctor, but how to have a great life while using our medical skills and knowledge.”

Finding Balance in a Medical Life is a wellwritten, thought-provoking guide to understanding the dilemma we physicians are in, along with strategies for how to change. The book gives an overview of the subject with many anecdotes from Lipsenthal’s life and the lives of his colleagues. For readers who are interested in real behavior change, however, the book also includes exercises to enable that process. For those who may be skeptical of this potentially “soft” subject, Lipsenthal supports his conclusions with more than 140 scientific references.

One section of the book discusses the personality traits of physicians.

Lipsenthal observes that while physicians are intelligent, caring, and inquisitive, they are also competitive, obsessive, perfectionist, and compulsive — all traits of Type A personalities. While those traits are essential to our medical training, they can get in our way now. “We rise to the occasion of our training,” Lipsenthal writes.

“We work longer hours for little money and see more and more patients.

Because we do this for so long, it becomes our way of being.”

One highlight of the book is the simple question, “Are we happy?”

Multiple surveys have shown that physicians are increasingly dissatisfied with their practices and have trouble finding work-life balance. Some of the reasons for this dissatisfaction were tallied by a 2001 Kaiser Family Foundation survey of 2,608 physicians. Of that group, 74% cited excessive administrative duties, 56% said they did not have enough time for families, hobbies, and friends, and 54% were dissatisfied with a lack of autonomy. In almost all studies of physician satisfaction, roughly one-third of the respondents state that they would not choose medicine as a career again. Lipsenthal, while acknowledging that external factors are partly responsible for our unhappiness, points out that some of our unhappiness comes from our own attitudes, which we have the ability to change.

In addition to discussing happiness, or lack thereof, Lipsenthal presents a lot of information on physician health. Studies from the 1990s, for example, found that “we smoked less, exercised more, and ate healthier than our patients, yet our overall mortality was higher than any other professional group.

Our per capita rates of heart disease, depression, and stroke were higher than any other working group and the lifespan of a physician was shorter than comparable socioeconomic

groups. Most disturbing is that women physicians had a life expectancy 10 years lower than the general population in the same socioeconomic category.”

Lipsenthal does point out that this data reflects women who went to medical school in the 1940s and 1950s and had trouble being accepted into a male-dominated profession. Yet, the problems persist. “Even now,” he writes, “while the majority of medical school enrollees are women, it is not always an easy place for women. In addition, women are still expected to perform most of the housework and parenting roles. Add to this the fact that most women physicians are perfectionists who are trying to do two jobs that are impossible to do perfectly (work and home) and it is still a recipe for disaster.”

After describing “The Road to Burnout,” Lipsenthal moves to “The Road Within.” He devotes the second half of his book to self-evaluation, stress management, and how to shift

Continued on page 36 MAY / JUNE 2012 | THE BULLETIN | 35

The Healer Within, continued from page 34 medicine, cancer specialists, alternative medicine, meditation, spiritual healing, Native American shamanic breathwork, psychology, and neuromedical brain science. Friends knowledgeable in these healing arts help him understand the out-of-body, -time and -space dreams he experiences during his intense meditation and shamanic breathing exercises.

He allows himself to give up control, which he finds liberating. The breathwork, in particular, leads to “wonder and curiosity, decreasing fear of death, as death is not within our control.”

Lipsenthal’s experiences allow him to find his “neuro-imaginal mind,” and in so doing, he finds that we are all living beings sharing an

energetic connection with all life. Our brains are “hard wired to pick up spiritual experiences,” which defines “the God or Spirit spot in all of us.“ Facing his own mortality, Lipsenthal finds his way through depression, exhaustion, and anger by recognizing pain and suffering as just events of the moment, rather than as conditions that define who he is. He will survive the pain and live, or he will die, but pain and suffering will not go on forever. This insight gives him a sense of peace during the times of extreme pain.

Just like Morrie and Randy, Lipsenthal reaffirms the importance of having a true sense of gratitude for life and for living every day with

joy, love, and laughter. He adds for our consideration prayer, meditation, exercise, yoga, art, acceptance, and knowledge.

Lipsenthal does undergo a full course of chemotherapy. He is rescued from the dark abyss by his contact with the shamanic world, a world that strengthens his body and spiritual mind. He experiences a temporary physical and emotional recovery, during which he offers a course titled “The Healer Within” to both the general public and the healing professions. He says in the book’s foreword, “I no longer have a bucket list, I have love in my life.”

Dr. Lee Lipsenthal died on September 20, 2011, at the age of 54.

Changing From Within, continued from page 35 our perspectives, finally putting everything together in a chapter titled “Psychosynthesis.”

The last page, “What Is Balance?” offers several possible answers. Among them: • Balance is being realistic about what you can control and what you can’t.

• Balance is learning to accept and appreciate your own limitations.

• Balance is remembering to love those

36 | THE BULLETIN | MAY / JUNE 2012

people in your life who give you meaning and purpose.

• Balance is learning to understand, love, and embrace the part of your personality with which you struggle.

• Balance is taking care of yourself first, so that you can take care of your family. Then, coming from a stable and loving home, you can serve your patients.

• Balance is taking care of the body you’ve been given.

• Balance is being open to new ways of thinking.

I recommend Lipsenthal’s book to physicians who are finding themselves in need of some type of change. By reading it, they can get a clearer picture of what that change may be, and they can learn the tools to get started.

PUBLIC HEALTH NEWS

Updated Zebra Packet Now Available Online: Clinicians Guide to Biological, Chemical, and Radiological Exposures

By Marty Fenstersheib, MD, MPH Health Officer for Santa Clara County When the Santa Clara County Public Health Department published the first version of the “Zebra Packet: Bioterrorism Information for Clinicians” in October 2000, we had no idea the extent to which our country would change less than one year later. The September 11th attacks and anthrax mailings in 2001 have not only made us much more diligent in recognizing acts of terrorism, but we have become better prepared for emergencies caused by biological, chemical, or radiological weapons. Since the original Zebra Packet was created, much has changed; clinical protocols have been refined, and disease reporting instructions have evolved. What has not changed is that terrorism remains a very serious threat to our community. To remain as ready as possible for such emergencies, the Santa Clara County Public Health Department has created a second edition of the Zebra Packet.

The updated version provides a comprehensive resource for clinicians to become familiar with biological, chemical, and radiological exposure, as well as medical management guidelines for treatment and disease reporting instructions for the Santa Clara County Public Health Department. This second edition carefully summarizes the Medical Management Guidelines (MMGs) published by the Centers for Disease Control and Agency for Toxic Substances and Disease Registry (CDC/ATSDR). Links are provided back to the CDC/ATSDR websites for further information.

The second edition is now available online on the Public Health Department’s website, www.sccphd.org, under “Health Providers,” or can be viewed directly at www.zebrapacket.com.

In addition, the new version of the Zebra Packet reiterates the important information we, as medical professionals, need to have at our fingertips in case we are faced with a biological, chemical, or radiological attack.

The threat from terrorism is serious, but quick and effective health and medical responses could save many lives. It is our hope that clinicians in Santa Clara County will fully utilize the updated Zebra Packet as a helpful tool to find information on biological, chemical, and radiological exposures.

MAY / JUNE 2012 | THE BULLETIN | 37

MEDICAL TIMES FROM THE PAST

A Famous Grizzly Bear Attack in 1854

By Michael A. Shea, MD Leon P. Fox Medical History Committee Charles Henry McKiernan built his ranch in the mountains southwest of Los Gatos, in June of 1851. Mountain Charley, his local name, was more of a hunter than a rancher. He hunted deer and sold the venison to buyers in San Francisco.

He also was known for his grizzly bear hunting.

Grizzly bears abounded in the area. According to one Franciscan padre in Santa Cruz, they were numerous, “prowling about in herds, like hogs on a farm.”

These animals, known for their ferocity, could reach eight feet in height and weigh up to 800 pounds.

On May 11, 1854, Charley and a man named Taylor were deer hunting near his ranch, when they encountered a very large grizzly bear. Taylor fired the first shot and missed. Charley fired and the ball struck the bear in the head, but did not penetrate. The bear, stunned, fell to the ground. Charley struck him on the head with his gun, breaking the barrel. The bear immediately arose, with his huge jaw wide open, made a snap at Charley. He crushed his skull and tore out a piece of bone just above the left eye. After biting the victim on both arms, the bear went crashing through the brush, heading down the mountain.

Dr. T. J. Ingersoll was called to attend to Charley, and the following is his actual account of the incident and the treatment: “My partner, Dr. A. W. Bell, went out and found him the next morning about sunrise, with the front part of his head terribly mangled and some wounds on both arms, but rational. The piece of skull taken out by the animal was sent in with a request that I should have a plate of silver made and come out immediately to assist in dressing the wound. Making all necessary preparations, I hastened to the patient, getting there about 9:00 p.m., when I found that the piece of bone of os frontis sent in was only about half of the bone taken out. On the next morning, returned to San Jose to have another plate made, sufficiently large to cover the brain – getting back to the patient the same day at 8:00 p.m. Dr. Bell and myself proceeded to apply the plate and dress the wounds; got through about 11:00 p.m.

The part of the bone detached was all that portion of the os frontis, above the left eye and nose, and in the orbit about three-fourths of an inch – taking a portion of the zygomatic process, ranging up about four inches parallel with the

38 | THE BULLETIN | MAY / JUNE 2012

coronal suture, from that point, irregularly to the right of the root of the nose, about three-and-three-quarter inches on each of the three sides. The muscles and integument were brought together and secured with sutures – soon closed by first intention, with the exception of two or three points for the matter to flow, and where the parts would not meet. By general bleeding and cold applications to the head, very little disturbance took place.

After the expiration of a week, I found that the plate was irritating the parts so much that it was impossible for them to become sound, and immediately took it out, very much against the wishes of the patient.

I would mention that it was at the urgent solicitation of the patient that the plate was used in the first place, notwithstanding the expostulations of his physicians. The wound healed kindly, with the exception of the two points on each side of the nose, where there were some spicula of bone, which kept up some irritation and discharging of matter.

The left eyeball, in consequence of the muscles above it contracting, not having sufficient support, turned up about eight degrees. General health was good.

Some twelve months after the events related above, the patient, having suffered from an intolerable pain in the head, came into town and consulted Dr. Spencer and myself. It was decided to perform an operation.

Accordingly, we with some others, waited for him at the National Hotel, where after administering chloroform, the operation took place. We cut down and found a deep-seated abscess under the anterior lobe of the brain, at least twoinches deep, above and behind the nasal process, which was discharging through the small sinus above the left eye. The operation had the desired effect – the abscess soon got well, and the patient was relieved of the pain he had been suffering some time before.

His health is good, but as a matter of course, his face is much disfigured.

He does not think that his mind or memory has been affected by the injury he received from the bear, but sometimes complains of a dull sensation in the region of the brain.”

Mountain Charley survived another 38 years, passing away January 16, 1892.

In Memoriam

Clyde Latta Boice, MD December 10, 1914 â&#x20AC;&#x201C; May 3, 2012 Clyde Latta Boice, MD, 97, of Fulton, peacefully passed away Thursday, May 3, 2012, at Fulton Manor Care Center. He was born in Washington, IA, December 10, 1914, the son of Clyde Allison Boice, MD, and Lorena Belle Latta Boice.

Dr. Boice married his long-time love, Frances Elizabeth (Betty) Stephen, also of Washington, IA, August 24, 1937. Together they raised six children: Sarah B. Mays of Point Reyes Station, CA; Stephen Boice (Joan) of La Selva Beach, CA; James Boice (DruAnn) of Sheep Ranch, CA; Margret B. Randolph (Lance), and Allison Boice, both of Fulton, MO. He graduated from the University of Iowa in 1941 with his MD degree. He did his internship at Methodist Hospital, Indianapolis, IN. During WWII, he served as a flight surgeon on the U.S.S. Bennington aircraft carrier in the Pacific and at numerous Naval air stations on the East and West coasts. He left the Navy in 1946 as a Lt. Cmdr. He completed his residency in radiology at the U.S. Naval Hospital in Oakland, CA, and in Palo Alto, CA, where he practiced radiology for 30 years.

He was a Diplomate for the American Board of Radiology, Fellow of the American College of Radiology, member of the American Medical Association, the California Medical Association, the Radiological Society of North America, and the American Roentgen Ray Society. He served as chief of staff for Palo Alto/ Stanford Hospital during 1961 and 1962. He served as president of the Santa Clara County Medical Association in 1961. He was a charter member of the Los Altos Hunt Club and served on the board to incorporate Los Altos Hills, CA. He was also a member of the Corinthian Yacht Club (Tiburon, CA).

After retirement, he and his wife moved to Orcas Island, WA. There, he served as a member of the Orcas Island Yacht Club, served on the board of the Orcas Island Library Association, and was a member of the vestry of Emmanuel Episcopal Church.

In 1993, Clyde and Betty moved from Orcas Island to Fulton, to be nearer their two daughters, Allison Boice and Margret (Peg) Randolph.

He will be sadly missed and lovingly re-

membered by: his wife Betty, five children, five grandchildren, and six great grandchildren. He is preceded in death by: his parents; a brother, William Allison Boice, MD; two sisters, Mary Myrtle Boice Anderson, Sevilla Ruth Boice Hopp; and one daughter, Susan Boice McMenamin.

Clyde has requested cremation and that his ashes be scattered in the Pacific Ocean. A family memorial will be held at a later date. In lieu of flowers, donations may be made to Saint Albanâ&#x20AC;&#x2122;s Episcopal Church, P.O. Box, 6065, Fulton, MO, or charity of choice.

MAY / JUNE 2012 | THE BULLETIN | 39

sccma alliance news

Bocce Ball Event a Great Success for the Medical Family On March 30, Doctor’s Day, 28 members of the medical family converged on Campo di Bocce in Los Gatos for what hopes to be the first annual SCC Medical Family Bocce Ball Tournament. Awards to the winning teams were to the Campen, Hayashi, Adeep, Hernandez, and Lewis families. Dr. Chris Campen won the closest to the “pallino” trophy.

L to R: The Campens, Kathleen Miller and Craig Thomas, Bill Lewis, Duke Khuu, and guest of SCCMA.

L to R: The Hayashis, and the Adeeps.

SCCMA Alliance Receives Awards at CMAA Annual Session

CMAA held its Annual Session in Sacramento on April 27 and 28. Mary Hayashi, Suzanne Jackson, Carolyn Miller, Debbi Ricks, and Donna Spagna were among the county members in attendance.

SCCMAA received a membership award 40 | THE BULLETIN | MAY / JUNE 2012

for a 27% increase in membership as SCCMAA member Donna Spagna was honwell as an award for the highest mone- ored and received the Dedicated County Allitary contributions by a county Alliance ance Member Award from the CMAA for her from CALPAC, the political action ongoing volunteerism in our county Alliance. component to the CMA. Donna was also honored for her commitment The Alliance was also awarded a and dedication to helping cancer survivors CMAA Foundation $1,000 grant for its through the Breast Cancer Center, the Ameriongoing program “Not For a Minute . . can Cancer Society, and the Stanford Cancer . Never” community education project. Clinic.

Two thousand static car stickers will be distributed this year at the Silicon Valley Duck Race at Vasona Park, on Sunday, June 10, 2012. Join your Alliance for this annual community-wide fun and fundraiser.

L to R: Suzanne Jackson, Carolyn Miller, Donna Spagna, On Saturday,

Mary Hayashi, and Debbi Ricks.

Santa Clara County Medical Association Alliance Annual Membership Dues July 2012-June 2013

Membership in the Alliance is very important to our continued efforts to promote quality health in our community.

Your membership or that of your spouse/partner increases the Alliance’s ability to speak with a stronger voice to the health concerns in our community. Alliance membership allows you to be directly involved in our projects, activities, and events. Even if you do not have time to actively participate in our projects, or can only participate occasionally, your dues are very important as they support our ongoing projects and grants.

Membership Categories • • • • •

Regular Member: Physician, spouse, domestic partner, divorced spouse Sustaining Member: Retired physician or spouse, domestic partner, divorced spouse of a part-time, retired or deceased physician Physician-in-Training: Medical student, resident, or spouse, domestic partner of a medical student or resident Checkbook Member: My time is limited. I will support Alliance programs with my dues only.

Friend of Medicine: Neither a physician, medical student, nor spouse, domestic partner of a physician or medical student. Must be sponsored annually by an Alliance Member.

Name:

Spouse/Domestic Partner’s Name:

__________________________________________________________________________________________ ( As you wish it to appear. Please print.)

Address:___________________________________________________________________________________ Street City ST Zip Contact Phone:_________________________________ FAX Number:__________________________________ Email Address:_______________________________________

Regular Membership Dues Sustaining Membership Dues Physician-in-Training Dues Checkbook Member Friend of Medicine

$105.00* $ 80.00* $ 15.00 $105.00* $ 55.00

$_________ $_________ $_________ $_________ $_________

(* Included in the dues amount are the AMA Alliance Dues of $50, which are optional.)

Pay Dues by Mail Send dues to: SCCMAA Membership 700 Empey Way San Jose, CA 95128

Sponsor’s Name______________________________________ $_________ $_________ $_________

____ My check is enclosed payable to SCCMAA ____ I prefer to charge my credit card: ____Visa____MC____AExp Card #_______________________________________ Exp____/____

Pay Dues Through the Medical Association

Pay your Alliance dues directly through the invoice from the Medical Association.

.

Contribution to SCCMAA Health Promotions CALPAC Membership $ 25.00 Total

Join Us!

Signature________________________________________________

Santa Clara County Medical Association Alliance 700 Empey Way, San Jose, CA 95128 408-998-8850 www.sccmaa.org MAY / JUNE 2012 | THE BULLETIN | 41

“What Has CMA Done for Us This Year??”

Paul Phinney, MD, CMA President-Elect Addresses SCCMA at the Town Hall Meeting May 1 Complimenting SCCMA as one of the largest and best-managed component medical societies in the state, Dr. Paul Phinney praised the leadership skills of William Parrish, CEO of the SCCMA, as well as CMA Past-President and AMA delegate Jim Hinsdale, MD, and current officers and councilors.

SCCMA membership numbers currently represent 63% of the practicing physicians and continues the 20-year trend in growth, attracting almost all of the students and residents from local medical schools and training programs.

Summarizing CMA activities for 2011, Dr. Phinney pointed to:

1. Internal CMA reorganization: a. Personnel additions in public relations/press, social media, and government relations. b. Launch of the new website, www.cmanet.org, enabling easier access to resources and services, the medical-legal library, and education seminars/webinars. The new format allows customization of content and delivery depending on your preferences.

2. Improvement in CMA’s financial health by paying down the liability of the frozen defined benefit plan.

3. CMA as the first state medical association to adopt groundbreaking policy recommending legalization and regulation of cannabis.

At the state level, CMA:

4. Fought against drastic cuts to health and human services in the state budget by organizing and working with the Alliance for Patient Care to: a. Protect the Healthy Families program (threatened again). b. Ensure $7.3 million funding for vaccines to low-income/ uninsured children. c. Ensure $4.4 million for the “Every Woman Counts” breast and cervical cancer screening program. d. Prevent diversion of Maddy Fund monies to state coffers. e. Protect funding for the EMS Commission.

5. Fought to shield Medi-Cal from additional cuts by: a. Working to secure an injunction blocking the 10% reduction in 2011 Medi-Cal reimbursement rates. b. Suing the state in CMA et al vs Douglas (Toby Douglas = chief deputy director in charge of Medi-Cal). c. Successfully challenging the DHCS refusal to provide public documents related to proposed Medi-Cal cuts. d. Lobbying the CMS to stop $137 million in Medi-Cal physician payment cuts for services provided to children.

6. Cultivated a positive working relationship with Governor Brown’s administration, communicating with the governor,

42 | THE BULLETIN | MAY / JUNE 2012

attorney general and state controller on issues of health care.

7. Worked successfully with legislators to enact public health oriented bills signed into law: a. Allowing individuals to purchase sterile syringes at pharmacies without a prescription. b. Requiring health insurance policies to provide coverage for maternity services. c. Prohibiting minors from using tanning beds without parental consent d. Allowing minors to obtain the HPV vaccine without parental consent. e. Prohibiting sale, manufacture, or distribution of BPAcontaining products intended for a child less than 3 years old.

At the federal level, CMA through its tireless and vocal advocate Elizabeth McNeil and the executive committee:

8. Continued to advocate for overhauling the broken Medicare payment system and eliminating the flawed SGR formula (ultimately settling for deferment of the 27% Medicare cuts until late 2012).

9. Halted $150 million in Medicare geographic payment cuts to California physicians.

On behalf of CMA physician members, CMA’s Center for Economic Services (CES) recouped more than $2.7 million dollars from payors, while fielding almost 2,400 calls about billing and contracting issues from over 1,200 different physician practices. The CES also filed a formal complaint with the DMHC regarding the Blue Cross Special Investigation Unit’s illegal recoupment practices.

So, what is in store for the rest of this year? According to Dr. Phinney, we are facing a “perfect storm” due to a lame duck Congress, againpostponed 27% Medicare cuts under SGR, ongoing debates about the Affordable Care Act (and the soon-to-be-announced Supreme Court Decision), and severe budgetary constraints/deficits at both the federal and state levels.

Dr. Phinney specifically points to three areas of interest and change in the coming year: 1. The state budget is depending heavily on passage of the Governor’s tax initiative (endorsed by the CMA), which seeks a temporary 1-2% increase in income taxes for individuals making $250,000 or more and a temporary sales tax hike.

Proposed severe budget cuts for the fiscal year, beginning July 1, already presume that these new tax revenues will be approved by the voters. Without passage, we would face even more drastic cuts in 2012 and later years.

2. The Supreme Court Decision about ACA is still unpredictable,

as this issue goes to press. The worst impact would occur if the individual mandate is struck down while leaving the remainder of ACA intact. No matter what, health care reform will move forward, and California is preparing to lead the way.

3. The California Health Benefit Exchange (CHBE) will attempt to define itself and balance benefit adequacy with affordability and access to health care – not an easy task! California is the first state to pass legislation enabling an exchange through an active purchaser model which selectively contracts with plans, furthering the goals of the exchange. Its Executive Director Peter Lee is adamant that he will use the CHBE to aggressively change the business of health insurance in this state. What will be the ripple effect throughout the rest of the insurance market?

Will this be the precursor of a single payor in California? Stay tuned to the CMA website and bulletins for updates.

This incoming president of CMA will be keeping a close watch on the internal changes affecting our organization, on the direction and effect of our advocacy efforts on behalf of patients and physicians, and on health care reform and all its ramifications. In his opinion, more attention must be paid to satisfying the needs of current CMA members, as well as attracting medical students and young physicians. The House of Delegates’ focus on policy and advocacy must be streamlined through electronic means, and this will provide additional venues for involvement and debate among the general membership. The need for timely decisions on medical-economic issues during the digital age calls into question the utility of current House and Board governance, structure, and procedures.

Although he focused on the legal, legislative, regulatory and electoral issues facing the house of medicine, Dr. Phinney ultimately pointed to the physician-patient relationship as the key cornerstone of our very existence and the lifeblood of our future. This is why physicians must be central to the discussion and development of health care reform and practice models focusing on patient-centered, physician-driven, high value and quality, universally accessible and affordable health care in California. Dr. Phinney concluded his remarks with “Failure is not an option” as we create our future as physicians.

California Medical Association Political Action Committee

Fighting for you!

CALPAC needs your help to support candidates and legislators who understand and embrace medicine’s agenda.

Our top priorities are: 1. Protect MICRA 2. Preserve the ban on the corporate practice of medicine 3. Provide solutions to our physician shortage crisis!

Please visit www.calpac.org for more information

With over 25 years of real world design experience, 1027 Design delivers designs that work. It doesn't matter how "neat, cool or beautiful" a design is if it doesn't work for you and your customers.

If you’re looking for a unique solution for your business, contact us now.

www.1027design.com • 530.941.4706 MAY / JUNE 2012 | THE BULLETIN | 43

Classifieds office space for rent/ lease MEDICAL COMPLEX FOR LEASE • MORGAN HILL Available now, 1,200 sq. ft. Well-partitioned, excellent location. Next to lab and family practice offices. New carpet and paint. Flexible term. Call 408/666-4308.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking.

Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/355-1519.

OFFICE FOR LEASE • MORGAN HILL 1,300 sq. ft. office at 16360 Monterey Rd in Morgan Hill (between Tennant and Dunne).

Turn key: two exam rooms with tables, reception desk, physician desk, chairs. $1,400/ month. Available now. Call 408/402-0707.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500– 4,000 sq. ft. Call Rick at 408/228-0454.

NEWLY UPDATED 1,508 SQ. FT. MEDICAL SUITE Available now, in all-medical building next to Regional Medical Center. Four exam rooms, two offices, reception, ADA restroom, galley kitchen, storage, sound speakers in all rooms. Some furniture, exam tables included.

Great space, available now. $3,770 gross.

Call or email Liz Walker at 408/436-8386 or lizwalker@reliablepropertymanagement.net.

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE Available to share with prominent aesthetic dermatologist. This upscale office has seven exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes 44 | THE BULLETIN | MAY / JUNE 2012

available from 1,000 to 2,500+ sq. ft. Timeshare also available. Call Betty at 408/8482525.

ties and janitorial included. Available full-time seven days a week. Please email judy.drjayakar@yahoo.com or call 650/464-5035.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/6449800.

PRIVATE PRACTICE/OFFICE for sale

MEDICAL/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft, ground floor near Santana Row. $2.00 sq. ft.

Available now. Email at sksiddiqui@yahoo. com.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE Excellent location. Westgate area. 1,584 sq. ft. West Valley Professional Center, 5150 Graves Ave. Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/8671815 or 408/221-7821.

SANTA CLARA OFFICE • HOMESTEAD AND JACKSON Plumbed for Dental/Medical, or other use.

1,200 sq. ft. Downtown across from post office and weekly farmers market. Excellent location! Dentist on site, please do not disturb.

Don’t miss! Come see! Call 408/838-8191 or 408/741-1956.

OFFICE FOR SUBLEASE • MOUNTAIN VIEW Fully furnished medical doctor’s office for sublease in prime Mountain View location across from El Camino Hospital. Private doctor’s office and three fully furnished exam rooms, plus shared waiting and reception area. Utili-

METRO MEDICAL BILLING, INC. • • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com

PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO, at 408/228-0454 or e-mail riflovin@allianceoccmed.com for additional information.

INTERNIST WANTED San Jose Medical Group has an immediate opening for a Board Certified, experienced Internist. One of our busy Internists relocated to Southern California recently, creating an opportunity for the right candidate to step into a successful growing practice. Must have excellent communication, clinical, and interpersonal skills. Excellent salary and benefits with bonus opportunities. Please fax CV to 408/278-3181 or email Tania_mcadams@ sanjosemed.com.

EMPLOYMENT OPPORTUNITY Physician/Locum tenens for Family/Internal Medicine. Office based practice only. Coverage mostly needed during vacation. Parttime, must have excellent communication, interpersonal and clinical skills. Please fax CV to 408/356-6676.

EXCELLENT CAREER OPPORTUNITY Samaritan Family Practice, a growing medical group, is looking for an experienced Physician Assistant to join. This is a full time, temporary with possibility of permanent position opportunity, with no call or in patient responsibilities. Family Practice experience needed.

Duties: Treating illnesses or injuries that need attention such as: flu, cold, rash, minor injuries, pain management, cuts, bumps, bruises, work, sports physicals, and annual physicals. The successful candidate will be self-directed, personable, and possess the skills necessary to provide high quality of care. Full support medical staff, as well as clerical support on site.

Malpractice insurance is provided. Competitive salary w/benefits offered. Please contact Lisa Foster at 408/340-5712 or email lisafsfp@yahoo.com for additional information.

Located at 2460 Samaritan Dr., San Jose, CA 95124.

WELLNESS AND HEALTH PROMOTION COORDINATOR Make San Jose State University Your University of Choice Job Title: Wellness and Health Promotion Coordinator Job ID: 22344 Full/Part time: Full-time Regular/Temporary: Regular Department: Student Health Center Compensation Classification: Health Educator Anticipated Hiring Salary: $4,869/month $5,208/month Salary Range: $4,006/month - $6,410/month FLSA status: Exempt

first aid to campus visitors.

The Wellness and Health Promotion department supports the mission of the Student Health Center by providing wellness and preventive health counseling, programs and other services, which take place both within and outside of the SHC. Reporting to the Assistant Director for Campus Wellness and working in collaboration with other SHC/Campus Staff and Faculty, the Wellness and Health Promotion Coordinator (WHP Coordinator) is responsible for developing strong, evidencebased, data-driven programs and services based on relevant, measurable, and practical health and learning outcomes to improve individual and community health behaviors and status. The WHP Coordinator is responsible for individual and group health education/ counseling for SJSU students and is expected to incorporate multicultural diversity and social justice concepts and principles into health promotion services. The WHP Coordinator co-coordinates the peer educator program including paid and volunteer students who provide 1:1 advising, outreach, presentations, and workshops to the SJSU student body. Specialty areas supervised may include: Sexual Health, Chronic Diseases, Stress Management, and Body Image.

First Screening Date May 25, 2012 This position is open until filled; however, applications received after the first screening date will be considered at the discretion of the university.

Required Application Material Resume Letter of Interest Complete SJSU Online Employment Application to apply, please visit our website at: http://apptrkr.com/249795 Please note that failure to completely fill out each section of the online application may result in your application not receiving consideration.

EO/AAE PART TIME PHYSICIAN OPENING Oceanaire is a residential eating disorder treatment program for adult women with anorexia, bulimia, and binge eating disorders.

We offer the following position open at our new facility in Fremont: Primary Care Physician (Part Time Immediate Opening, 5-10 hours weekly). The physician will be responsible for monitoring the medical stability of up Continued on page 46

Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

California State University Employees Union (CSUEU) Benefits Summary About the Position The Student Health Center (SHC) provides a variety of medical services including primary and urgent/acute care, evaluation, treatment, and guidance for individual health problems, family planning services, and Wellness Services (including sexual health; gender and ethnic health issues; nutrition; disordered eating; responding to stress; alcohol, tobacco, and drug abuse; chronic disease; body image; violence prevention; and human flourishing). In addition, the SHC provides limited initial care for work injuries of employees, and if necessary, assists in referring such persons for ongoing care. The SHC may also provide

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 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m MAY / JUNE 2012 | THE BULLETIN | 45

Classifieds, from page 45 to six adult women in treatment for a primary eating disorder. Responsibilities include reviewing medical records for admission, performing initial admissions exams, meeting with each client on a weekly basis, interfacing with our multidisciplinary treatment team, and providing phone support for our staff when periodic medical concerns arise. Experience with eating disorders is a plus, but not required. Please send your resume via email if interested in this position. Email resume to: golee.abrishami@centerfordiscovery. com. Oceanaire and The Center for Discovery are both licensed and JCAHO accredited.

See http://www.oceanaire.ed for more information about our programs.

Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613

FOR SALE SL65 MERCEDES BENZ V12 Twin Bi Turbo 604 HP. Silver metallic, light grey interior at $13,000 original down.

Contact 408/621-4350. $80,000.

LEXUS LS400 SEDAN Classic 1990 with all available options. 87K original miles. Good condition, immaculate interior. $4,995. Contact 408/356-5521.

OPHTHALMOLOGY PRACTICE FOR SALE OR PARTNERSHIP Office is 11 years old. PPO, Medicare, and cash. Take over very low rate payment on office loan plus a small amount of cash. Call 408/871-6800.

PRIVATE PRACTICE FOR SALE Established IM practice for sale. Close to El Camino Hospital. If interested, please contact 650/862-7745.

NEED HELP WITH CLAIMS? TRY SCCMA/MCMS’s SPECIAL MEMBER BENEFIT: REIMBURSEMENT ADVOCACY PROGRAM If you need help in evaluating disputes between insurance companies and patients concerning fees and medical services, and need assistance in resolving disputes directly with the involved parties, contact Sandie Becker, CMC, Coding/ Reimbursement Specialist.

Phone: 408/998-8850 or 831/455-1008 or Email: sandie@sccma.org.

46 | THE BULLETIN | MAY / JUNE 2012

Rental Agent Pajaro Dunes Company 1-800-564-1771

WANTED OFFICE SHARING Recapture the spirit of healing. Overhead sharing in beautiful women’s wellness center in Carmel, CA. Call Dr. Taylor at 831/622-1995 or email DrTaylor@womanswellspring.com.

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

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Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

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.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

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MAY / JUNE 2012 | THE BULLETIN | 47

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