September 2014 by SMCMA

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

September 2014

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 3 Issue 8

Physician PROPOSITION 46

STOP THE TRIAL LAWYERS FROM CHANGING MICRA. VOTE NO ON PROPOSITION 46 ON NOVEMBER 4. ALSO IN THIS ISSUE Treating Patients with Chronic Pain The “3-Use Rules” for Evaluating Mobile Health Solutions New CDC Fall Prevention Toolkit

YOU WORK TO PROTECT YOUR PATIENTS. We work to protect you.

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

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

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

September 2014 / Volume 3, Issue 8 Columns President’s Message: How empathic is your pain management? ....4 Vincent Mason, MD

Executive Report: Talk to your patients about Proposition 46. . .......6 Sue U. Malone

Feature Articles

Editorial/Advertising Inquiries

Treating patients with chronic pain. . .................................................9

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.

Joseph Kwok, DO

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

The “3-use rules” for evaluation mobile health solutions.. .............11 Uli Chettipally, MD, MPH

CDC introduces new fall prevention toolkit....................................13 San Mateo County Fall Prevention Task Force

For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

Of Interest Member Updates, Index of Advertisers......................................... 14

President’s Message by Vincent Mason, MD

How empathic is your pain management?

ain is real. Pain is subjective. Pain has been around since the beginning of time. Pain was managed in many cultures and civilizations by a surgical procedure known as trepanation (boring a small hole in the skull to bring blood back to the brain); this dates back as far as 3000,

BC, and performed as recently as 1913 by French surgeon J. LucasChampionnière. The ancient Greeks believed that pain was caused by Poine, goddess of vengeance, sent to punish mortal fools. It’s nice to live in the 21st century. I remember managing my first chronic pain patient. I was a fourthyear medical student doing my “sub internship” on the solid tumor ward. My patient was a pleasant middle-aged woman suffering from metastatic breast cancer. When I would round in the mornings, she would smile and engage me with conversations and stories about herself and her family, and even wanted to know about my life

and aspirations. By the end of my four-week rotation, she helped me to understand how her “invisible” chronic malignant pain was affecting her. I had listened to her self-report of pain by one of three methods: VRS—verbal rating scale, NRS— numeric rating scale, or VAS—visual analogue scale. I had no place in my own mind for the pain she was experiencing. All I knew is that when her pain was at it’s highest, she was not very talkative nor engaging. When I saw her this way, I would always ask,“Would you like some pain medicine?” Her reply: “It’s not time for my next dose.” She wanted to manage this transition through prayer. However, after discussing how to manage her pain with the supervising oncologist, it was clear that there were better ways to help her get through her day. Her fear: She would be perceived as “weak” and drug-seeking. I went on to see other patients; more ambulatory with pain (acute and chronic), especially patients with sickle cell disease-associated pain. My supervising physician always had discussions about pain management, dependence (chemical vs. psychological), and drug-seeking

“

behavior and how to detect and manage it. The thing I remember most is: always make an effort to manage your patient’s pain so that he or she can regain the ability to do what they like most. Pain is complex beyond the physical: Nociceptive (noxious peripheral stimuli –heat cold intense mechanical for chemical irritant); Inflammatory (Inflammation-macrophage, mast cell and neutrophil granulocyte and tissue damage): Neuropathic and Functional. Pain treatment and management not only require understanding of the four types of pain as above, but also understanding a caretakers’ own perception of pain and its treatment modalities (from the traditional to the alternative) and other factors that may impede how pain is managed including race and ethnicity, cultural background, socio-economic status, language barriers, and so on. Health care providers (physicians, surgeons, allied health professionals, and so on), as well as mental health professionals, are all dealing with pain. There are standards for

The ancient Greeks believed that pain was caused by Poine, goddess of vengeance, sent

“

to punish mortal fools. It’s nice to live in the 21st century.

4 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER 2014

assessing pain: (1) Wong-Baker FACES pain Rating Scale, (2) 0-10 Numeric Pain Rating Scale, (3) visual Analog Scale, (4) Verbal Pain Intensity Scale, (5) Where is Your Pain? and (6) Neuropathy Pain Scale and Descriptor Differential Scale. And there is even new technology: Virtual human technology as a novel way to investigate differences in pain assessment. To complicate it more, there are additional mandates for clinicians: AB 487, which required California physicians to complete 12 CME by December 2006 as well as CURES which will go into effect on November 5 if Proposition 46 passes. The literature about pain management is vast. In this issue we get to read, “Treating Patients with chronic pain,” which defines the types of pain and outlines pain management techniques, from the traditional (from NSAIDs to Opiods to SSRIs), as well as alternative treatments. In the meantime think about how you, as a clinician, deal with pain management in your patient. It can depend on several factors: (1) years of experience, (2) practice specialty (primary care vs. emergency department vs. pain management unit vs. oncology vs. surgery), (3) racial ethnic difference between patient and care provider, (4) your personal attitude about pain (how empathic are we as clinicians?), (5) time constraints, (6) knowing when to refer and when to integrate mental health and OT/PT in the patient’s care, and so on. ■

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SEPTEMBER 2014 | SAN MATEO COUNTY PHYSICIAN 5

Executive Report by Sue U. Malone

Talk to your patients about Proposition 46 to quit their practice or move to places with lower medical malpractice insurance premiums—reducing access to care.

By now, you are probably familiar with Proposition 46, the MICRA lawsuit initiative that will appear on the November 4, 2014, ballot. Since the measure was first introduced, SMCMA and CMA have been working tirelessly to ensure it is defeated at the polls in November.

•

Threatens privacy by requiring a massive expansion of a personal prescription drug database.

•

Requires alcohol and drug testing of doctors, which was only added to this initiative to distract from the main purpose—to change MICRA.

How will Proposition 46 affect health care costs?

Communicating the No on 46 message to patients will be critical to defeating it. As a trusted medical expert, you are in a unique position to share how Proposition 46 would truly affect all health care users and taxpayers. The CMA has assembled the following questions-and-answers to help guide you through your conversations with your patients. What will Proposition 46 do? Proposition 46 does three things: •

Quadruples the limit on medical malpractice awards in California, which will cost consumers and taxpayers hundreds of millions of dollars every year in higher health care costs, and cause many doctors and other medical care professionals

There is no question that more lawsuits against health care providers will increase costs, and someone has to pay. And that someone is consumers and taxpayers. California’s former Legislative Analyst found Proposition 46 would increase health costs for consumers and the state by about $9.9 billion annually. This translates to more than $1,000/year in higher health care costs for a family of four. How does this affect taxpayers? If lawsuits increase and health care costs go up, state and local governments pay these out of the budgets they receive from taxpayers. Increased health costs to state and local governments could force cuts to other vital services like education, public safety and social safety net programs. Or, state and local governments may decide to make up that additional cost by raising revenues, and that will come from taxpayers.

6 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER 2014

What about access to health care? How will that be affected by Proposition 46? If California’s medical liability cap goes up, people could lose the ability to see their trusted doctors. Many community clinics operate on slim margins, particularly community clinics that serve low-income, uninsured and rural patients. Any significant increase in their costs will force them to reduce or eliminate services for patients. Many doctors will be forced to leave California to practice in states where medical liability insurance is more affordable. Respected community clinics, including Planned Parenthood, warn that specialists like OBGYNs will have no choice but to reduce or eliminate vital services, especially for women and families in underserved areas. How does Proposition 46 threaten personal privacy? Proposition 46 forces doctors and pharmacists to use a massive statewide database filled with Californians’ personal medical prescription information. This database has no increased security standards to protect personal prescription information from hacking and theft. What is wrong with the provision mandating use of the CURES database? This sounds simple, but it’s not. While the CURES database is already in existence, Proposition 46 would require an immediate ramp up, and will force the CURES database to respond to tens of

millions of inquiries each year — something the database simply cannot do in its current form or functionality.

What about children, seniors, and low-income Californians and the $250,000 MICRA cap?

A non-functioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients.

Those who will be most hurt by Proposition 46 and the higher health care costs are the very people who are most vulnerable and least able to absorb higher costs: seniors, families and low-income Californians.

Shouldn’t doctors be drug tested?

More lawsuits, like those that will result from Proposition 46, will increase costs for those who can least afford them. And it will reduce patient access to care.

The physician community and all health care providers are always looking for ways to improve patient safety, but the drug testing provision in Proposition 46 was included for political, not policy reasons. The lawyers who wrote and funded getting Proposition 46 on the ballot included this “sweetener” to deceive voters from the real reason behind the initiative, to make lawsuits easier and more lucrative for lawyers. Are the drug testing provisions in prop. 46 The same as what the FAA and Department of Transportation require of pilots and airline personnel? No. Proposition 46 cherry picks portions of the FAA procedure for pilots, but excludes other important provisions that ensure due process and fairness. For example, Proposition 46 imposes a “presumption of negligence” immediately upon a positive test or if a physician is unable to take the test within the mandated 12 hour timeframe. This is not part of the FAA/ Department of Transportation regulatory framework. Anyone (disgruntled patient, co-worker, family member) could make a claim that a physician is impaired. In fact, Proposition 46 grants immunity to anyone who reports any information that “appears” to show that a physician “may” be impaired. Are patients only entitled to $250,000 in the event of a medical liability case? No. MICRA was set up to ensure patients received fair compensation if they were injured. Under MICRA, patients receive: •

UNLIMITED economic damages for any and all past and future medical costs.

•

UNLIMITED economic damages for lost wages and lifetime earning potential.

•

UNLIMITED punitive damages - punishment awarded for malicious or willful misconduct.

•

Up to $250,000 for speculative “non-economic” damages, often called pain and suffering.

The $250,000 cap reduces incentives to file meritless lawsuits, while at the same time ensures that legitimate claims can move forward.

That’s why groups like the American Academy of Pediatrics – California, California Children’s Hospital Association, Children’s Specialty Care Coalition and senior advocates like those at Curry Senior Center oppose this measure. Won’t Proposition 46 help improve quality by holding doctors more accountable? Even one medical error is too many, and that’s why the entire health care community is always looking for ways to improve patient safety. But don’t be fooled by this measure. Increasing lawsuits is not the answer and will do absolutely nothing to improve health care quality. Worse, the resulting higher health care costs will put health care services even more out of reach for people who already suffer from lack of access. ■

HELP SPREAD THE WORD ABOUT PROP 46 SMCMA has a selection of NO ON 46 campaign materials, including brochures, lab coat cards, posters, and lawn signs. Contact us at (650) 312-1663 or smcma@smcma.org to schedule a free delivery to your home or office in San Mateo County.

SEPTEMBER 2014 | SAN MATEO COUNTY PHYSICIAN 7

MICRA IS UNDER ATTACK!

By now, many of you are familiar with Proposition 46, the MICRA lawsuit initiative that will appear on the November 4, 2014, ballot. Proposition 46 will increase MICRA’s cap on non-economic damages (i.e., “pain and suffering”) from $250,000 to $1.1 million, with annual increases going forward. Proposition 46 also requires drug testing of physicians and mandatory use of the CURES prescription drug database. It is being touted by its sponsors as a measure that will protect patient safety, but these safety provisions are merely “sweeteners” designed to appeal to voters and mask the real intent – to change MICRA. Proposition 46 is being opposed a coalition of doctors, community health clinics, Planned Parenthood Affiliates of California, local governments, working men and women, business groups, taxpayer groups, hospitals and educators, all of whom know that it will lead to more lawsuits and higher health care costs. What’s more, it will threaten personal privacy and jeopardize people’s access to their trusted doctors or clinics.

2. Neuropathic pain is referral pain related to nerve injury, such as sciatica or carpal tunnel syndrome. This type of pain is usually described as burning pain and is associated with numbness.

TREATING PATIENTS WITH CHRONIC PAIN by Joseph Kwok, MD Many physicians loathe to treat patients with chronic pain, and for good reason—they can be difficult. Patients with chronic pain can have emotional baggage, some have addiction behaviors, and some have issues with learned helplessness. Training for pain management during medical school and residency is also very limited. As a result, physicians tend to use only certain analgesics (NSAIDs and acetaminophen, as well as opioids) to treat persistent pain.

However, each individual responds to medication differently, and a onesize-fits-all solution will not work with our diverse patient population. In addition, opioid misuse has become a national epidemic. Since 2009, prescription medication overdose has eclipsed motor vehicle accidents as the leading cause of accidental death in the United States. In fact, the U.S. represents just 4% of the world’s population, but uses 99% of the hydrocodone in the world. Obviously, there is increased scrutiny on physicians who prescribe opioids to their patients with chronic pain. I will describe some current approaches to the treatment of chronic pain, as well as some alternatives to opioids that can be used. First, it is important to understand the different types of pain. 1. Nociceptive pain is related to tissue damage, such as in osteoarthritis or postsurgical pain. This type of pain is usually very sharp and very localized.

3. Central pain is related to changes in the central nervous system, such as fibromyalgia and headache related to a traumatic brain injury. It is a more diffuse pain, dull and difficult to localize. Different types of pain respond differently to different types of pain medication. Using the right combinations of medication and treatment, physicians have a better chance of providing relief for patients suffering from chronic daily pain. It is also important to understand that chronic pain syndrome is a chronic disease, similar to diabetes or COPD. The best that medicine can offer is stable control of the disease process—there is no cure for the disease. To date, multiple studies have shown that the best pain management plan tends to reduce chronic pain by up to three points on the visual analog scales. Many doctors and patients are looking for a pain-free state when starting a pain management treatment. This may result in over-prescribing, which can lead to addiction and adverse reactions from the medication. Understanding the limitations on pain management, as well as combining opioid use with adjunctive therapy, can decrease the risk associated with opioid use in the U.S. Nonsteroidal anti-inflammatory medication (NSAIDs) Medications such as ibuprofen, naproxen, and nabumetone are fairly common in pain medicine. They

SEPTEMBER 2014 | SAN MATEO COUNTY PHYSICIAN 9

provide significant relief for patients with pain related to inflammatory processes such as osteoarthritis and acute muscle injury (nociceptive pain). They are not very helpful for neuropathic pain such as myotonic dystrophy neuropathy or sciatica. However, chronic use of NSAIDs may lead to increased risk for gastric bleeding, cardiovascular disease, and renal failure. Beside oral formulations of NSAIDs, there are also topical formulations that may have fewer systemic side effects. Antiepileptic drugs (AED) Antiepileptic drugs are frequently used to treat neuropathic pain. Medications such as gabapentin, pregabalin, carbamazpine and topirmate are commonly use to treat pain related to nerve damage such as sciatica, postherpetic neuralgia, and diabetic neuropathy. Because these medications act on both the central and peripheral nervous systems, they are also useful for treating central pain such as fibromyalgia and headache related to a traumatic brain injury. Common side effects associated with AEDs include peripheral edema and drowsiness. Therefore, care must be taken during medication titration.

Clinical Pearl: It is also important to note that these medications require a period of titration before they become effective for pain management. It usually takes from two weeks to one month of continuous daily use before the medication has any effect relieving pain. Physicians often prescribe these medications to their patients as a “rescue” for breakthrough pain, and then give up before the medications can become effective. Instead, they turn to

long-acting opioids because they are more “effective,” which often leads to problems down the road due to opioid tolerance, addiction, or opioidinduced hyperalgesia. In our pain clinic, the typical rules of thumb before declaring treatment a failure are: (1) trying at least three different AEDs, each for at least one month, before switching to long-acting opioids. Special note about AEDs: Topiramate is useful for patients with a history of PTSD and/or obesity in addition to chronic pain. Lamotrigine is useful for patients with a dual diagnosis of bipolar disorder and chronic pain. Antidepressant medications Antidepressants are a very important class of medication for the treatment of chronic pain. Scientists from the Université de Montréal found that negative and positive emotions have a direct impact on pain. In general, medications that affect both the norepinephrine level as well as the serotonin level (SNRI) tend to be superior to the other SSRIs. Venlafexine and duloxetine are two example of SNRIs that are commonly used for patient with chronic pain. Common side effects associated with the use of SNRIs may include heart palpitation, nausea, and decreased appetite. These may be related to effects of norepinephrine.

10 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER 2014

Caution must be taken when using SNRIs and abortive migraine agents (triptans). The Food and Drug Administration has issued warning concerning the use of SSRI and SNRI in addition to triptans, which may lead to serotonin syndrome. Non-medication interventions In the treatment of chronic pain, non-medication treatments are often ignored, but they can be the most useful modality we have. Behavior interventions, such as cognitive behavior therapy (CBT), should always be considered. Studies have shown that treating chronic pain with a combination of CBT and medication has superior results than wtreatment with medication alone. Various mind-body interventions are available in our community, such as mindfulness-based stress reduction, functional restoration, and biofeedback therapy. Conclusion Of course, there are times when adjunctive therapy is not helpful, and the patient can receive great benefit from the use of opioids, such as older patients with renal failure who cannot take NSAIDs. I do not mean to imply that opioids are evil and should never be prescribed for pain. However, if we are able to expand our understanding of all the options available for treating pain, we can provide our patients superior care and comfort while limiting the potential for opioid addiction and abuse. ■

About the Author Joseph Kwok, DO, practices pain medicine and physical medicine and rehabilitation at Kaiser Permanente Medical Group in South San Francisco. He helps patients with a variety of nerve, muscle, and bone-related injuries take control of their lives via comprehensive treatments that include physical therapy, pain psychology, acupuncture, medication, and education.

Is it USABLE? This pertains to the PRODUCT: Is the quality of the product and workmanship good? Is the technology sound? Is the design and user interface attractive and easy to use? Is the data produced consistent and accurate? Does it work the way it is supposed to? Is it easy to learn? Is it easy to maintain? This is a technology and design question and can be answered easily. Most mobile and digital health companies are at this stage. Is it proven to be USEFUL?

THE “3-USE RULES” FOR EVALUATING MOBILE

HEALTH SOLUTIONS

Every day we are seeing an array of new mobile health products and solutions entering the market. With major technology companies like Apple, Google and Samsung entering the fray, there is a lot of talk about the developments and the future of this space. There is also a lot of hype in the media about how wonderful life will be, with all these devices measuring and monitoring our every heartbeat and every move. It reminds me of that 1980s song “Every Breath You Take” by The Police. I am an optimist and a firm believer in information technology being a

by Uli Chettipally, MD. MPH part of the solution to our current problems in healthcare. I also believe that we will see a major transformation in healthcare business in the next 10 years. So, how does one evaluate, embrace and invest in these mobile health solutions? There are three things I look for in a mobile health solution.To succeed in a market, a solution has to be 1) USABLE, 2) proven to be USEFUL, and 3) should be USED. This sounds simple, right? Let me explain what these rules mean.

About the Author Uli Chettipally, MD, MPH, is an emergency physician, researcher and innovator at Kaiser Permanente Medical Center, South San Francisco. Dr. Chettipally is also the co-founder of the San Francisco Bay Area Chapter of the Society of Physician Entrepreneurs (SoPE), a nonprofit, global biomedical and healthcare innovation and entrepreneurship network. Visit www.sopenet.org to learn more. Are you a physician interested in innovation, entrepreneurship or investing? You are invited to get involved with SoPE—there will be a meeting of the local chapter at the SMCMA office on Tuesday, October 28, from 6:00 p.m. This meeting is open to all SMCMA members, and there is no charge to attend. Contact Dr. Chettipally to learn more and to reserve space: uli.chettipally@gmail.com.

This pertains to the PROBLEM. What is the problem the product is trying to solve? Is there a target disease or condition that the solution can help predict, prevent, cure, maintain or monitor? Is the problem significant? Is there evidence to show that using the solution will solve the problem? This is a clinical question and is harder to answer. Several start-ups are at this stage, trying to prove their solutions’ benefits through clinical studies. Will it be USED? This question pertains to the PROVIDERS and PATIENTS. How will it affect the work of providers? How will it make patients feel? Who will pay for the product or service? Are market conditions favorable? Are there tangible benefits that come from using the solution? Can the outcomes be measured in cost savings, improvement in quality of life or convenience? This is a business question, which is even harder to answer. A solution has to make business sense and have a proven model to provide value to payers, distributors and users, while generating revenue. There are companies that will not be able answer these questions right now. They may be in an exploratory phase and have a long-term outlook, in which case one should be prepared for a long timeframe to derive value from the product or service. ■

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CDC INTRODUCES NEW FALL PREVENTION TOOK KIT: Stopping Elderly Accidents, Deaths & Injuries (STEADI)

Falls are a significant problem for older adults—resulting in medical visits, hospitalizations, sometimes death and very often a loss of independence. One in three older adults, aged 65 years and older, fall each year, In 2012, 1,474 older San Mateo residents were admitted into the hospital, 4,334 were seen in an emergency department and 54 died as a result of falling. In addition, many more visited physician offices and urgent care centers, or called 911 for lift assists because they had fallen—causing a strain on our medical system while contributing to a poor quality of life for our older adults. The Centers for Disease Control and Prevention (CDC) recently released a new tool kit available for health care providers called STEADI—Stopping Elderly Accidents, Deaths & Injuries. The STEADI Tool Kit is based on a simple algorithm (adapted from the American and British Geriatric Societies’ Clinical Practice Guideline). It includes basic information about falls, case studies, conversation starters, and standardized gait and balance assessment tests (with instructional videos). In addition, there are multi-lingual educational handouts about fall prevention specifically designed for patients, families and friends. STEADI Tool Kit materials are free and can be ordered or downloaded from www.cdc.gov/homeandrecreationalsafety/falls/steadi/about.html. One very useful resource from STEADI Took Kit you might want to consider using in your practice is the brochure entitled Stay Independent—Are You at Risk? It includes a simple 12-question fall risk self-assessment that can be taken by your patients while in the waiting room prior to the appointment. You or your staff can review their responses and determine if further discussion and evaluation need to be taken. It also provides you with an opportunity to address fall prevention with all of your patients 65 years or older. Another resource is the San Mateo County Fall Prevention Task Force. The Task Force can assist your patients with written materials and referrals to local fall prevention resources, such as home safety and modification services, exercise programs, and fall prevention workshops. Refer your patients to 1-844-NOFALLS (663-2557) or www.smcfallprevention.org for information. ■

What can you do for your patients who have fallen or are at risk for falling? • Review fall history—patients that fall are at greater risk for falling again. • Review medications—four or more medications increase fall risk. Anti-depressants, anti-psychotic medication, sleeping pills and more increase falls. • Check for orthostatic hypotension. • Discuss need for vision and hearing tests. • Observe gait and balance. Are more tests needed? Should patient be referred to physical therapy or local fall prevention program for further assessment or intervention? • Discuss home safety. Make referral to fall prevention program, occupational therapist, or agency that can help install grab bars and other home safety equipment. • Call 1-844-NoFalls (1-844-663-2557) or visit www.smcfallprevention.org.

SEPTEMBER 2014 | SAN MATEO COUNTY PHYSICIAN 13

NEW SMCMA MEMBERS

Mira Cheung, MD Daly City/PD*

Kimberly Jong, MD Burlingame/IM

Bina Lu, MD Burlingame/IM

Amit Kamboj, MD S San Francisco/GI, HEM

Rene Relos, MD Redwood City/GS

Laura DiPaolo, MD Burlingame/FM

Monica Devoy, MD Burlingame/OBG

Hao Hao Huang, MD Burlingame/FM

* Certified by the American Board of Medical Specialties (ABMS)

Christopher Woods, MD Burlingame/CD

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In Memoriam Roy Cauwet, MD August 19, 2014

Edward Persike, MD July 27, 2014

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ADDRESS SERVICE REQUESTED

PROud tO b e e NdORse d bY the sAN MAteO CO u NtY MediCAL AssOCiAtiON

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

A N o r c A l G r o u p c o m pA N y