June 2015 by SMCMA

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

June 2015

Physician

in s id e

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

Volume 4 Issue 6

End-of-Life Options SMCMA supports concept of end-of-life options

Physician Orders for Life Sustaining Treatment (POLST)

At last: I want the last word as to how my story ends

When death comes early: Pediatric end-of-life care

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

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

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

June 2015 - Volume 4, Issue 6 Columns President’s Message: Life: Beginning to end.............................................. 4 Vincent R. Mason, MD

Feature Articles SMCMA supports concept of end-of-life options.................................... 6 Austin Walsh

POLST: Physician orders for life-sustaining treatment........................... 9 Russ Granich, MD

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

At last: I want the last word as to how my story ends . . ......................... 10 Jennifer Glass

When death comes early: Pediatric end-of-life care............................. 11 Nancy Iverson, MD

Of Interest Membership updates, classified ads, index of advertisers. . ................14

On the cover: Paseo de los plátanos by Santiago Rusiñol [Public domain], via Wikimedia Commons.

President’s Message by Vincent Mason, MD

Life: Beginning to end This is my final column as president of the San Mateo County Medical Association. While I won’t miss the anxiety associated with having to write these monthly letters, I will miss the interactions with my physician colleagues.

terminally ill adult California residents the opportunity to seek medical aid-indying medication when specified criteria are met. After passing the Senate in early June, it is currently scheduled to be heard by the Assembly Health Committee on July 7. I look forward to continuing to work with SMCMA.

I want more doctors to know everything the California Medical Association and county medical associations do on behalf of physicians statewide. I know that not all of us can volunteer our time to our county medical association, but we can also show our support with our active membership.

One of the great things about our organization is that you get to have a voice in the community. We get to act on your behalf. I always feel it’s important to have a physician “in the room” whenever the conversation relates to medicine.

Thank you to the SMCMA staff, who helped make my year easier and more fun, particularly executive director Sue Malone. I also owe a special thanks to the SMCMA Board and Executive Committee. and to Philip Goldberg, JD. ■

The passing of the torch... I am grateful to everyone who helped me through my term as president. Last fall, we were part of a robust and diverse coalition that defeated Proposition 46, the anti-MICRA initiative that would have resulted in more lawsuits, higher health care costs, and reduced access to services. Another legislative milestone happened this spring with the passage of HR 2, the Medicare Access and CHIP Reauthorization Act of 2015, which finally repealed the flawed Sustainable Growth Rate (SGR) formula for Medicare reimbursement after a dozen years of “patches.” As I write this, Governor Brown is about to sign Senate Bill 277 (Pan/Allen), which eliminates the personal belief exemption from school vaccination requirements, barring parents from skipping their children’s schoolrequired immunizations unless they have a medical exemption from a physician. Still up in the air is Senate Bill 128 (Wolk/Monning), the Endof-Life Options Bill, which would give

Incoming SMCMA President Mike Norris, MD, left, receives the ceremonial gavel from outgoing President Vincent Mason, MD, at the SMCMA annual meeting on June 18. See the July/August issue of San Mateo County Physician for more event photos, as well as profiles of Dr. Norris and our Distinguished Service Award recipient, James Missett, MD. Photo by Ginger Tree Photography

4 San Mateo county physician | June 2015

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SMCMA supports concept of end-of-life options Local medical professionals recently joined a growing support base for granting the right of terminally ill patients who wish to accept physician aid in dying. As the End of Life Options Act gains momentum through the state Senate, the San Mateo County Medical Association issued a statement on May 20, advocating for the concept of doctors providing aid in dying to those suffering from a terminal illness. by Austin Walsh

State senators Bill Monning, D-Carmel, and Lois Wolk, D-Davis, co-authored Senate Bill 128, which intends to allow mentally competent patients who have six months or less to live to accept a prescription of lethal drugs from doctors. SB 128 would require two doctors to concur that a mentally competent patient with six months or less to live can be prescribed deadly drugs. The patient would also have to discuss other treatment options, and make multiple written and oral requests for the right to die.

The bill is molded in the image of the Death with Dignity Law in Oregon, passed in 1994, and recently used by Brittany Maynard (left), a California woman suffering from terminal brain cancer, who moved last year to legally end her life with aid of a physician. Though the San Mateo County Medical Association has not officially expressed support for the Senate bill, because it is still being amended, the advocacy group does support the concept of physician aid-in dying. Sue Malone, the association’s executive director, said the publicity garnered by Maynard’s quest to gain access to be prescribed life-ending drugs was a catalyst to bring the issue back to the state Legislature. 6 San Mateo county physician | June 2015

“This is not the first time similar legislation has been attempted in California before,” she said. “But it’s further than it has ever gotten.” California first sought to legalize physician-aided death in 1992, and has made multiple unsuccessful attempts since. “Personally, I’m hopeful this will get to the governor’s desk,” Malone said The local group’s support of what has been referred to as physician assisted suicide comes as the California Medical Association dropped its long-standing opposition to the concept Wednesday, May 20. Malone said the county association maintains support for the necessity of palliative medicine and hospice care and consider those avenues crucial as a patient approaches the end of their life. But momentum is mounting both in California at large, as well as the medical profession, for legislation of this nature, said Malone. “The thinking of not only the general public but medicine in general has been swayed that maybe it is an appropriate time to consider this option, under very stringent regulations,” said Malone. But support for a physician aid-in-dying option is not unanimous, according to Tim Rosales, spokesman for Californians Against Assisted Suicide. “This becomes the cheapest option for medical care,” he said. “The fact that some physicians are coming out in support of this is frightening for those individuals without access to quality health care or insurance or don’t have the economic means to pay for such.”

Californians Against Assisted Suicide is an advocacy group comprised of medical professionals, civil rights groups and faithbased organizations that opposes end-of-life legislation, and intends to fight it on the Senate floor. “We are going to mount a strong opposition against it, and hopefully we can defeat it in the Legislature,” he said. But Malone noted that there is a wave of momentum for the concept of allowing terminally-ill people to determine their own fate. “I believe that society at large has been moving and shifting to the belief that a patient has a right to make this decision, in consultation with their physician,” she said. ■

About the Author Austin Walsh is a reporter for the San Mateo Daily Journal. This article originally appeared in the SMDJ on May 25, 2015.

Senate Bill 128 End of Life Options Act Principal Authors: Lois Wolk (D-Davis) William Monning (D-Carmel) January 21, 2015: SB 128 Introduced in California Senate March 17, 2015: Endorsed by Senator Dianne Feinstein March 25, 2015:

Passes Senate Health Committee (6-2)

April 7, 2015:

Passes Senate Judiciary Committee (4-2)

May 20, 2105:

California Medical Association drops its opposition to SB 128, changes its position to neutral

May 20, 2015:

San Mateo Medical Association supports the concept of SB 128.

June 23, 2015:

Scheduled to be heard in Senate Health Committee. Postponed by author to garner more support for the measure.

July 7, 2015:

Scheduled to be heard in Senate Health Committee.

SAN MATEO COUNTY MEDICAL ASSOCIATION END OF LIFE OPTIONS ACT The San Mateo County Medical Association has adopted a position in support of the concept of physician aid-in-dying. As the End of Life Options Act introduced in the California Senate (SB 128) is continuing to be amended, we do not at this time take a position on this specific measure. Physicians are called upon to care for patients at the end of life and we recognize the need for appropriate end-of-life care. We are aware of the physician aid-in-dying laws in Oregon, Washington, and Vermont (as well as court-supported right to physician aid-in-dying in Montana and New Mexico), which has been closely monitored over the years since adopted. The public record shows appropriate use, benefit and absence of abuse problems. Evidence indicates that a plurality and likely a majority of polled physicians along with a majority of the pubic supports a legal option, such as described in SB 128, when decided by the patient and his or her physician. We understand that this is a very complex and emotional topic but it supports continued improvements in end-of-life care. We also feel it honors and protects patients’ right of self-determination. SMCMA would not advocate for anything that could harm patients or medical practice, or violate medical ethics. However, we feel strongly that the evidence with respect to medical opinion on the subject of physician aid in dying is an adjunct to hospice and palliative medicine and leads us to support the concept of legalizing and regulating physician aid-in-dying.

June 2015 | SAN MATEO COUNTY PHYSICIAN 7

P hysician O rders for L ife -S ustaining T reatment

by Russ Granich, MD

The Physician Orders for Life Sustaining Treatment (POLST) form gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures, and CPR. It originated in Oregon in 1991 and was first approved for use in California in 2008. Many other states have adapted a similar form. The Coalition for Compassionate Care in California (http://capolst.org/) is the main group responsible for this form in our state. It has been updated every two years POLST is specifically targeted at patients in the last year or so of life. It is not necessary to use POLST if a person wants full treatment and resuscitation, since that is the default without a form. POLST is not the same as an Advance Directive (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. An AD usually also includes some vague writing about treatment goals and occasionally includes fairly specific desires. It is not an order and would not be followed by an Emergency Medical Services (EMS) responder, as they would a POLST or the older Out-of-Hospital DNR forms. In general, POLST forms should be signed by the patient, unless they lack capacity. It is a legally binding physician order that is supposed to be honored by all healthcare providers, whether the physician has privileges at the facility or not. However, it only goes into effect when a patient is unable to decide. If a patient gets admitted to the hospital, the admitting MD should

write orders consistent with the POLST. A family member cannot reverse the decision and directions on a POLST if the patient signed it. The family member would need to present a compelling reason why the form does not reflect the patient’s wishes. This conflict is best avoided by having the agent or surrogate decision maker present during the discussion. Have them verbally acknowledge the wishes and agree to honor them. There are four sections on the POLST. The first, part “A,” is about resuscitation. The patient can choose between resuscitation or to Allow a Natural Death (i.e. DNR). Section B has to do with overall goals of care. This is the part that has changed since the last iteration. Although basically the same concepts, the text has been updated and reorganized. Section C is about artificial nutrition and section D is for signatures. Let’s go through each section and what it really means and tips on how a palliative care doctor might explain it.

Section A: Cardiopulmonary Resuscitation (CPR) This applies only if the patient is in cardiopulmonary arrest; it does not apply to patients who are declining and breathing or have a pulse. A patient may elect intubation in that circumstance, but still not want CPR. Tip: When a person’s heart stops beating and they stop breathing, this is how we define that they have died. CPR is an attempt to bring someone who has died back to life. It is rarely successful unless in the right circumstances and the right patient. It also will not fix anything else that was going on before. When the time comes and you pass away, would you like to go peaceably, have your family kiss you and say goodbye? Or, would you like us to attempt CPR?” If

the patient opts for CPR, make sure they understand what is actually involved and that the results are not typically as good as what we often see on TV.

Section B: Medical Interventions Full Treatment: The patient would want everything done to prolong their life, including intubation. They may elect to be DNR but would still want other measures taken. This situation can be difficult to interpret, and many EMRs don’t really have this category. I generally define it as any treatment that does not employ chest compressions or intubation. If a patient elects CPR, this section must also be selected. Selective Treatment: This generally includes all treatments except aggressive ICU interventions, such as intubation. It can also represent relatively minor interventions, such as labs, x-rays and antibiotics. Any limitations should be explained. There is a sub section that allows all home based treatments but indicates not to transfer the patients to the hospital except if comfort needs cannot be met at home. This is applicable for patients who would basically would prefer comfort as the primary goal but would also like interventions for easily treated conditions. Comfort-Focused Treatment: This truly means comfort care only, focusing entirely on the person and how their disease affects them, not on the disease itself. Cough is treated with cough suppressants, fever with acetaminophen, and so on. Some providers put empiric antibiotics in this category, which might mean starting antibiotics for symptoms of a UTI or pneumonia.

Continued on page 12

June 2015 | SAN MATEO COUNTY PHYSICIAN 9

At Last: I Want the Last Word as to How My Story Ends

I met my husband Harlan on Match.com and our first date made a lasting impression. I liked this man. I hoped that this would be my last first date.

Last time means last chance. Last chance to say, “I’m sorry,” or, “I love you,” or, “Thank you. I am different because of you.”

It was. We got married in 2012 and, together with Harlan’s two kids, my stepchildren, we became a family. I hoped that our happiness would last forever. Just four months into our marriage, however, we learned that I have advanced lung cancer.

I try to take life one day at a time, but sometimes the days gang up on me. I’m not always comfortable using the future tense. The present is tense enough, and I long for my past perfect.

Since I got cancer, I have a new appreciation for firsts and lasts. I remember the first time I ran a race and came in first, panting as my strong, young lungs filled with air. I think about the last time I went for a hike with Harlan, and we had to make frequent stops so I could catch my breath. I’ll never forget the first time a doctor said, “malignant,” referring to the tumors growing inside me, or the last time an IV dripped chemo into my veins. Was the last time I had chemo the last time I will ever have chemo? Probably not the last. For years I was the first to arrive at any party, and often the last to leave. Now, I fear that I will be the first of my friends to go. Each time I see my parents, or laugh with my sisters, or dance with my husband, I wonder, “Is this the last time?”

In the past, when I had a headache, I took an aspirin. Now, when I have a headache that lasts for more than a day, I get a brain scan. Each week, it seems, there are things that I can suddenly no longer do. I know that everyone has aches and pains at midlife, but odds are not good that this is the middle of my life. For more than two years, I’ve been living with dying. I’m at peace with the idea that my life will end, but how it might end, if cancer runs its course, that terrifies me. There would be great comfort in knowing that I had another option. This is why I support the End-of-Life Option Act for California (SB 128), currently under review in the state Senate. This bill would allow terminally ill, mentally competent adults to legally request and receive a prescription for aid-

by jennifer glass

in-dying medication. Under this law, if it becomes clear that my disease is going to kill me, I would have the option to end my life peacefully, surrounded by family, in the home I love in California. I’ve made my life in California because living here offers me so many options -- professionally, socially, recreationally, gastronomically. Living here, each of us can craft the life best suited to our individual preferences, skills and beliefs. It’s is one of the primary reasons we have such extraordinary quality of life. But quality of life has to include end of life. Too many Californians with terminal illness endure unnecessary suffering at end of life. Polls show that an overwhelming majority of Californians supports aid-in-dying legislation. But the law won’t change unless lawmakers know that this end-of-life option is something their constituents want now. First and foremost, I want to live. I’m doing everything I can to extend my life. No one should have the right to prolong my death. Endings matter, and I want the last word as to how my story ends. I want this for myself and for the people I love. Every Californian should have this option. At last. ■

Jennifer Glass is a writer, speaker and advocate for end-of-life options. This article originally appeared in her Huffington Post column about living with cancer, At the Top of My Lungs. Ms. Glass spoke to the California Senate in support of Senate Bill 128 on January 21, 2015 (pictured above). The SMCMA Board of Directors was fortunate to have her speak at its May 2015 meeting. Sadly, in June, Ms. Glass learned that her cancer had spread to both lungs, her liver and abdomen, cervix and pelvis. She also has a one-inch tumor in her brain. She is back on chemotherapy but continuing to advocate for SB128. She was scheduled to testify before the Assembly Health Committee on June 23, but the hearing was postponed by the bill’s authors until July 7 in order to garner more support. Learn more at jenglass.com. 10 San Mateo county physician | June 2015

WHEN DEATH COMES EARLY: PEDIATRIC END-OF-LIFE CARE “That must be so horrible” is the reaction I encounter most often when relating that I worked with Comfort for Kids, an inhome pediatric hospice and palliative care service. Substitute the word “hard” for “horrible” to get another common response. Occasionally confusion and disbelief are almost palpable: “Hospice—for children? As in children dying?” by Nancy Iverson, MD Yes, children do die. Approximately 55,000 in the United States each year. From causes as diverse as congenital malformations and degenerative diseases to cancer and trauma. But, no, I don’t label the realm of pediatric palliative care as “horrible.” Challenging— yes. Heartrending—often. Complicated— absolutely. But not horrible. What is horrible to consider is how much more unbearable this catastrophic experience is for children and families when they must flounder through the myriad of blows that accompany a child’s life-limiting diagnosis without the aid of support and services that a palliative care philosophy and team can provide. And how especially devastating this trajectory is when, along with grappling with adjustments to a “new normal” such as navigating through tertiary care institutions, painful and/ or toxic interventions, relapses, physical limitations, and enormous stresses on family dynamics, an abrupt jump off the “curative therapy” track is demanded with the threat or reality of imminent death, and the fear of abandonment adds to the anguish. A father may perceive the doctor who recommends discontinuing invasive interventions as “writing off ” his child, a mother may see herself as relinquishing all hope by participating in a discussion about DNR, parents may feel like they are disloyal to the hospital team by accepting a hospice referral. And a powerful sense of failure and shame may emerge for us as doctors—that in failing to save the life of our young patient we have betrayed

not only the child and family but also our profession. Denise Taylor, whose son Joe died at nineteen months of age, writes, “They say a child’s death is the worst thing that can happen to a parent, but I sometimes think it’s the worst thing that can happen to a professional. They are trained to sort things out, to make things better, to get you through—and there’s no sorting this out or making it better, or getting through it.” (http:// www.theguardian.com/ lifeandstyle/2014/jul/05/can-parentgetover-death-of-a-child) Deeply embedded in the medical model is the injunction to fix and to cure, to fight death and disease. How disheartening when these exemplary goals fall short for many diagnoses and real-life situations, especially in the practice of pediatrics, which, of all the medical specialties, most wholeheartedly celebrates the start of a new life and champions every milestone of growth and development. The context of palliative care philosophy invites us to expand our concept of care, to reframe the question, “How can we cure this?” to “How can we best help to ease suffering?” When we accompany a child and family throughout all chapters of illness and end of life, we deepen our capacity to be of service even when a life won’t be saved. We become a resource to help a family more skillfully give voice to otherwise unspeakable fears, hopes, and despair and to partner with them in making choices for a child’s care. Discussions about

end-of-life decisions generally run the spectrum from extremely hard, at best, to excruciating—for all involved. When postponed, usually with the intention of sparing anxiety for families, these conversations are often relegated to crisis points, in which choices feel limited to an “either-or” option, and the distress and turmoil are enormous as the medical team and parents wrestle for control in a situation that is beyond control. When, instead, we adhere to the WHO guideline for palliative care for children, which states that “it begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease,” we may integrate compassionate explorations about the “what if ’s” early on in the course of an illness. We can invite what Atul Gawande, in Being Mortal, describes as “a series of conversations to sort out when they need to switch from fighting for time to fighting for the other things that people value—being with family or traveling or enjoying chocolate ice cream.” Even when we are not able to prevent a death, we may help alleviate suffering as we learn what is most important to children and parents during illness and at the end of a life, and we can continue relentlessly to access every resource possible to provide care and support. Gawande says, “Endings matter, not just for the person but, perhaps even more, for the ones left behind.” In medicine,

Continued on next Page 9

Originally published in the April 2015 of San Francisco Medicine. Artwork: The Sick Child by Edvard Munch (1907), Public Domain. June 2015 | SAN MATEO COUNTY PHYSICIAN 11

Pediatric End-of Life Care (Continued from Previous Page) no matter what skills, technology, or financial resources are available, we will encounter unfixable situations and endings, even in pediatrics. When we, as pediatricians, can grapple with the implications of accepting the limitations of a curative medical model and allow for the possibility that even—especially—in end-of-life care of a child we can and must continue to encourage age and promote health— physical, emotional, mental, and spiritual— for each child and his or her family, we expand the dimensions of our care beyond the constricting confines of cures and failures. Rather than subscribing to the idea that there is nothing we can do, we can explore every possible avenue to help families sojourn this horrific terrain. Even as we bear

witness to unfathomable pain and loss, we also have the opportunity to be in the company of heroes as children, parents, and their families live their stories and the endings with indescribable courage, grace, and love. ■

About the Author

Bay Area Resources for Pediatric Palliative Care and Hospice Children’s Hospice and Palliative Care Coalition: www.chpcc.org/about-us George Mark Children’s House: www.georgemark.org

Nancy Iverson, MD, has practiced pediatrics for more than twenty years in the Bay Area and has been on staff at CPMC, Kaiser, and UCSF. She worked early on with the development of the pediatric palliative care programs, especially the educational components, at UCSF and served as a pediatric consultant for Comfort for Kids, an in-home pediatric palliative hospice and palliative care service.

Hospice by the Bay and By the Bay Kids: www.hospicebythebay.org/ index.php/patients-families/ped

and often just a sip of fluid or a bite of food is all they want. Starvation would only happen if the patient wanted food and it was denied to them. Studies have not shown increased survival with longterm feeding tubes, except for ALS and when there is a mechanical obstruction to swallowing. Some patients will live longer, but some will die of complications. It does not prevent aspiration.

In the event the desires change, simply strike out the old POLST and write void. The new POLST will take effect. If you would like more detailed tips, have questions or want to discuss a particular situation, please contact me through the medical association for guidance. ■

UCSF Benioff Children’s Hospital Compass: www.ucsfbenioffchildrens. org/services/compass_care Lucille Packard Children’s Hospital, Stanford: www.stanfordchildrens.org/ en/service/palliative-care

POLST (Continued from Page 9) Tip: Most patients who don’t die suddenly die of complications of their disease, which often is infection. For some patients, it may be a blessing to die from an infection, rather than to treat it and prolong their suffering. Make sure the patient or their representative understands what comfort care truly is. I also ask and address the symptoms they may be concerned with, such as feeling like they are suffocating because of their COPD or CHF. Then I will explain how we can alleviate those symptoms and keep them comfortable.

Section C: Artificially Administered Nutrition This pertains primarily to feeding tubes. You will notice that nowhere is the term “food” used except to offer food by mouth. There are three options for artificially administered nutrition: long term, trial period, none. This is often an area of concern for patients and family, because they feel they would be letting someone starve to death. Tip: It is natural for patients to start eating less and eventually stop eating, even if they are completely aware. It part of the body shutting down. They don’t feel hunger

Section D: Information and Signatures It is always best to have the patient sign this form. I usually will include the surrogate’s name and contact info, even if not named in an advance directive. Be sure to sign and date the form. Currently only a physician may sign the form, but there is legislation in the works (AB 637-Campos) that would allow NPs to also sign. Reverse side: The back of the form is optional if the physician completes the form. If not, the person who completed it for the physician (usually they have had the discussion with the patient) should have their name listed.

12 San Mateo county physician | June 2015

About the Author Russ Granich, MD, is Chief of the Home Care Department at Kaiser Permanente Medical Group in South San Francisco. He is also medical director of Hospice and Home Health. Board-certified in internal medicine and hospice & palliative care, he completed his education at Boston University School of Medicine at his residency at CPMC. He is also a secretary-treasurer of the SMCMA and chair of the SMCMA Editorial Committee.

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Physician volunteers still needed for Walk with a Doc Walk with a Doc is a free program of the SMCMA Community Service Foundation that encourages physical activity in people of all ages and fitness levels. Community members walk side-by-side with physician volunteers who can answer their general health-related questions along the way. Now in its fourth year, Walk with a Doc has grown to include thirty walks at 15 locations throughout San Mateo County, from March 7 through October 24, 2015. The program’s success relies heavily on the participation of our enthusiastic physicians. Walks take place at 10am on Saturday mornings (excluding Labor Day weekend): July 18: Burgess Park, Menlo Park July 25: Windy Hill Open Space Preserve, Portola Valley August 1: Red Morton Park, Redwood City August 8: Pulgas Ridge Open Space Preserve, Redwood City August 15: Sandpiper Park, Redwood Shores/RWC August 22: Twin Pines Park, Belmont ■ August 29: Beresford Park, San Mateo September 12: Leo J. Ryan Park, Foster City ■ September 19: Ryder Park, San Mateo September 26: Washington Park, Burlingame ■ October 3: Spur Trail, Millbrae October 10: Junipero Serra County Park, San Bruno October 17: Orange Park SSF ■ October 24: Gellert Park, Daly City

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Private, independent, medical practice in Redwood City seeks md A qualified, energetic MD is needed to help a large established and still growing general practice with a broad range of medical services. This is an opportunity for a family practitioner,internist or general physician to join a group of five other MD’s in a busy urban environment in comfortable old world office space. Negotiable contractor agreement. Opportunity for partnership.

Email CV to serena1asma@gmail.com

SAN Jose medical office for rent Medical office for rent located at 5595 Winfield Blvd, (across from Oakridge Mall). The space is 1400sq feet and has 4 exam rooms, physician office and lobby. Furnished with exam tables, lights, phone system, computers, exam equipment, etc. Located in nice medical office building. Great for a satellite office or new practice.

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In Memoriam George C. Beattie, MD May 16, 2015 Index of Advertisers Cooperative of American Physicians.......................Inside Back Cover First Republic Bank..............................................................................................5 The Magnolia of Millbrae................................................................................8 The Doctors Company................................................................................... 13 Mercer................................................................................... Inside Front Cover NORCAL............................................................................. Outside Back Cover Tracy Zweig Associates.................................................................................. 14

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