the message, june 2012

messageA M O N T H L Y N E W S M A G A Z I N E O FS P O K A N E C O U N T Y M E D I C A L S O C I E T Y – J U N E 2 0 1 2

T HE

Getting Clear about our Patients’ End-of-Life PreferencesBy Terri Oskin, MDSCMS President

Emergency Medical Services Protocol

Hospice Care—Its Evolution and Future

June SCMS The Message Open2

AD SPACE

June SCMS The Message Open3

T A b l E O f C O n T E n T S

Getting Clear about our Patients’ End-of-life Preferences . . . . . . . . . . . . . . . . . . . . . . 1

Emergency Medical Services Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

What is or isn’t being Taught to Residents Regarding End-of-life Choices . . . . . . . . . . . . . 2

Your Practice and End-of-life Issues: POlST and Death with Dignity . . . . . . . . . . . . . . . . 3

Hospice Care—Its Evolution and future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Hospice Services and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Killing the Pain not the Patient: Palliative Care versus Assisted Suicide . . . . . . . . . . . . . . . 6

Compassion & Choices of Washington: Upholding Patient Autonomy at the End of life . . . . . . 10

new Cervical Cancer Screening Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Physician leadership Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Meet Jeanette Radmer of numerica Credit Union . . . . . . . . . . . . . . . . . . . . . . . . . . 14

William I . bender, MD – SCMS Physician Citizen of the Year for 2011 . . . . . . . . . . . . . . . . 15

Membership Recognition for June 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Did you know…? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Meet Windy Rudd of US bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

In The news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Meetings, Conferences and Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Continuing Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

fYI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

In Memoriam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

new Physicians/Physician Assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Real Estate Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Classifieds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

"Let us touch the dying, the poor, the LoneLy and the unwanted according to the graces we have received and Let us not be ashamed or sLow to do the humbLe work."

mother teresa

2012 Officers and Board of Trustees

Terri Oskin, MD President

Anne Oakley, MD President-Elect

bradley Pope, MD Immediate Past President

David bare, MD Vice President

William Keyes, MD Secretary-Treasurer

Trustees:Robert benedetti, MDAudrey brantz, MDMichael Cunningham, MDKarian Dierks, MDRandi Hart, MDlouis Koncz, PA-CShane Mcnevin, MDGary newkirk, MDfredric Shepard, MDCarla Smith, MD

newsletter editor – Anne Oakley, MD

Spokane County Medical Society Message

A monthly newsletter published by the Spokane County Medical Society . The annual subscription rate is $21 .74

(this includes the 8 .7% tax rate) .

Advertising Correspondence Quisenberry Marketing & Design Attn: Jordan Quisenberry518 S . Maple Spokane, WA 99204 509-325-0701 fax 509-325-3889 jordan@quisenberry .net

All rights reserved . This publication, or any part thereof, may not be

reproduced without the express written permission of the Spokane County Medical Society . Authors’

opinions do not necessarily reflect the official policies of SCMS nor the Editor

or publisher . The Editor reserves the right to edit all contributions for clarity and length, as well as

the right not to publish submitted articles and advertisements,

for any reason . Acceptance of advertising for this publication in

no way constitutes Society approval or endorsement of products or

services advertised herein .

June SCMS The Message 1

Getting Clear about our Patients’ End-of-Life Preferences

By Terri Oskin, MD

SCMS President

This month we focus on healthcare directives/living wills and physician orders for life-sustaining treatment (POlST) . How many of you remember the first time you obtained a “code status” from a patient? Maybe it occurred as a medical

student or during your residency . I remember . I remember how uncomfortable I felt too . I can also recall when I first suggested to my family, including my mother, that it was time to complete the POlST form for my dad . luckily we had discussed end-of-life decisions before, and my parents did have an advanced directive . However, that did not make checking the DnR box any easier .

Here’s a sobering fact: Despite the advances in treating heart disease, the outcomes for people experiencing a sudden cardiac arrest (SCA) over the past 20 years really have not changed . The percent surviving to hospital discharge remains low at less than 20 percent .* However, among survivors, long-term outcomes have improved . Poor prognostic indicators for those who do survive an initial SCA include: coma following CPR; development of hypotension, pneumonia or renal failure after CPR; need for mechanical ventilation; advanced heart disease and older age . These poorer outcomes are particularly important to consider as we assist our elderly patients in making end-of-life treatment plans .

So who needs a living will? Everyone! from the teenager who may have the unfortunate life-threatening ski accident to the 80-year-old who is still running bloomsday . We cannot predict our lives’ outcomes and living wills help caregivers and families understand the individual’s wishes regarding life support . When a living will is available and its contents have been discussed with the patient’s healthcare provider and family, critical decision making processes are made with respect for the patient . Over the years I have tried to include this topic with my patients during their annual exam . I have observed that most people have very firm opinions regarding life support, if you only ask .

And what about the POlST form? The WSMA has a great pamphlet for members called “Who will decide if you can’t?” It is meant for the patient and explains the differences between healthcare directives, durable powers of attorney for healthcare and the POlST form . With the emergence of retirement centers and assisted living centers I am seeing more POlST forms coming into my office requesting my signature . What I find alarming about this practice is the lack of counseling . Many times I already have a POlST form on file for the patient that we discussed in detail .

So which form should be honored if the patient becomes unresponsive? I encourage each of you to review these forms as they come over before signing to ensure that they indeed represent your patients’ wishes .

Resources for patients and families

Some great informational tools are available to you, which can be shared with your patients . The WSMA has two patient education pamphlets . The one entitled “Who will decide if you can’t” contains a health care directive form as well as the durable power of attorney for health care form and POlST information for patients and family members . Remember, the former must be notarized to be legal . The Washington State Department of Health also distributes a patient handout regarding the Washington State living Will Registry . These pamphlets are free and available either through the WSMA or the state department of health . As an alternative to the well-known living will, I like the form entitled “five Wishes .” This form is available through Aging with Dignity at www .agingwithdignity .org . There is a charge for this .

In closing:

1 . Encourage all your patients to complete a living will and share their preferences with family . A well-kept secret is just that .

2 . Take the time to review POlST forms with your patients . be sure they understand their choices including possible outcomes .

And finally,

3 . Have you completed your living will yet?

*This statistic is very basic and includes all comers into the study; I’ve not broken it down by age, sex, co-morbidities, type of rhythm etc. It is based on a 24-year retrospective study done in Seattle looking at outcomes of over 12,000 patients treated by Emergency Medical Services (EMS) between 1977 and 2001. This information was obtained from Up to Date, Overview of sudden cardiac arrest.

Spokane County Medical Society members and significant others are invited to enjoy a cruise aboard The Serendipity on the Spokane River. Thursday, July 12 Cruise starting at Templin’s

Marina Boat loading starting at 5:30 p.m. Embarking promptly at 6:00 p.m. Returning at 8:30 p.m.

Limited space available—RSVP to [email protected]

Attention Female Physicians

SAVE THE DATE!March 15-16, 2013A retreat for all female physicians is

being planned.

More details to come.


Emergency Medical Services ProtocolBy Scott C. Edminster, MD, FACEP

Medical Director, City of Spokane Fire Department

If you call 9-1-1 in the Spokane metropolitan area you can expect a timely and perhaps somewhat overwhelming response from uniformed pre-hospital providers who are expert at resuscitation and have the full complement of high tech tools at their disposal . Their involvement significantly improves survival and outcomes from major trauma, heart attack, stroke, respiratory failure, cardiopulmonary arrest and a host of other life and limb threatening events . Thanks in part to paramedics who are capable of interpreting 12 lead EKGs and identifying heart attacks in the field; Spokane has some of the fastest door to angioplasty times in the country . Recently, the incidence of successful resuscitation from cardiac origin cardiopulmonary arrest (CPA) is very close to that of the nation’s leader, Seattle . Our EMS system is very much a part of the state mandated trauma and cardiac-stroke systems that identify those patients needing transport to the designated centers of excellence . Our 9-1-1/EMS system is saving lives and limbs on a daily basis .

The 9-1-1 system is in place to save lives . If it is accessed and activated for a potentially life ending event, when appropriate, the EMS dispatchers will prompt initiation of bystander CPR and will provide over-the-phone hands only CPR instructions to the caller . Responding EMS personnel will continue resuscitation or initiate it if none is in progress at the time of their arrival and will not cease until it is evident that the resuscitation attempt has become futile . If the goal is for a terminally ill person to die in piece at home then it is probably best to advise against calling 9-1-1 . Certainly, “no code” does not mean “no care” and the relief of pain and suffering for those with terminal illness may sometimes be part of the role of EMS .

Paramedics, and more so EMTs, have a limited protocol driven scope of practice . They are usually not privy to the details of medical history and, in the time critical setting of near death, have limited time to spend discerning subtleties . Given these limitations they should not be expected to make sophisticated life and death decisions in the absence of clear cut advanced care directives . Our EMS providers are well trained to honor Do-not-Resuscitate Orders . In fact, our local EMS providers (along with Drs . bill bender and Jim Shaw) played a pioneering role in the development of and subsequent improvements to the Physician Orders for life-Sustaining Treatment form which has spread across the state and beyond . The POlST form is the preferred means by which a patient who does not desire full resuscitation due to a rapidly deteriorating medical circumstance would communicate that wish . Other forms of written documentation may appear from time to time . In either case, EMS personnel are trained to make certain that both the patient (or legally empowered surrogate decision maker) and attending practitioner (MD, DO, ARnP or PA-C) have signed it .

Telephone orders are discouraged unless the EMS provider can identify the patient’s physician on the phone . Consultation with the emergency physician on duty at the potential receiving hospital (on line medical control) is an additional option to provide some guidance .

In the absence of an acceptable advanced directive, or in case of uncertainty, the pre-hospital provider is obligated to undertake full resuscitative measures to the full level of their training . The best way to avoid an unwanted resuscitation attempt is to be certain that care to your patients includes intimate communication regarding their end of life wishes and that those be clearly documented, preferably on the POlST form, and signed by yourself and your patient .

References: Spokane County EMS and Trauma Care Council EMS Manual; County Operating Procedures and Guidelines

G30-32 field Resuscitation Guidelines

G33 EMS-no CPR

What is or isn’t Being Taught to Residents Regarding End-of-Life ChoicesBy Mary Noble MD, FACP

Director, Ambulatory Care Clinic

Clinical Associate Professor of Medicine,

U of Washington School of Medicine

Although I had some initial thoughts about how to answer this question, I first turned to a senior Internal Medicine resident who was in the clinic with me on the morning I received the email asking me to write this article . He shared some valuable insights .

Dr Allen said, “During my residency, I’ve developed a sense that it is almost as fulfilling for me to help someone to die with dignity, as it is to save a life . This is something I experience with the patient as well as with the family . It is professionally very meaningful . I learned this in bits and pieces while dealing with patients in the hospital and with their families, primarily though role modeling . My senior residents or faculty attendings and I would go in to see patients together to have these conversations . Over time, they would ask me if I felt comfortable doing this by myself . now I do the same thing with the junior residents who I work with . I’ve learned that you can’t be afraid to hold their hands .

Continued on page 3


Continued from page 2

The touch is important . In the clinic, I talk about it with elderly patients more than with younger ones, but it depends on the circumstances . I start the conversation by talking about their goals . We make plans based on the goals .”

The residency experience needs to prepare our physicians to deal with the depth and breadth of internal medicine so that they are equipped to move on to work as general internists in the community, hospitalist physicians, or continue their training in subspecialty fellowships . As internists, we care for adults, many of whom have multiple health challenges or are elderly . It is not uncommon for our patients to face the end of their lives and we want our resident physicians to be skilled, supportive and thoughtful as they deal with this . This may come up at an initial patient visit, when a grim diagnosis needs to be discussed, or in the setting of addressing “health maintenance” issues . As noted by the physician quoted above, it is important to help patients talk about their personal goals .

As the patient’s primary care physician, we have a unique relationship which provides us with the big picture of who this person is, and perhaps who this person was . At the end of life, we are best suited to assist families in discussing goals and helping make difficult decisions . When the residents have been taking care of a very ill patient in the hospital, they understand the complexities of the situation, are able to call the primary physician if there is one, and then to engage the family and the patient in this conversation . We strive to teach the residents that this role should not be abdicated to others . In some situations, we may need to request support from the palliative care team, but most of the time, as the physicians caring for the patients, we are in the best position to undertake this important task .

In the clinic, we encourage our Internal Medicine residents to discuss Advance Directives and complete POlST forms with all patients who are agreeable . We note it clearly in the record when

these documents are filed . To help them broaden their experience and expertise in end-of-life issues, the IMRS residents spend one week during their geriatrics rotation doing hospice medicine through Hospice of Spokane including time at the Hospice House . They find this to be very valuable, supplementing their continuity clinic experience with the patients they follow for three years, and the hospital patients for whom they provide care . Sometimes these are very short term interactions; other times they come to know those patients very, very well .

Your Practice and End-of-Life Issues: POLST and Death with DignityBy Dennis “Denny” Maher

WSMA Legal Affairs Director

POLST

POlST (Physician Orders for life Sustaining Treatment) is a standardized, highly visible form which expresses life-sustaining treatments an individual wishes to be administered in an emergency . The form is intended to be used by patients with advanced, life-limiting illness . POlST is the product of discussions between the individual and the attending physician (or PA-C or ARnP), and must be signed by each . The form serves to transfer such orders between care settings .

The POlST form resulted from a brief statutory direction to the Department of Health (DOH) to develop guidelines and treatment protocols for emergency personnel to follow for an individual who has made his/her wishes known regarding resuscitation and related care .

Continued on page 4



The POlST form was introduced as a pilot program in the Spokane area, and is now used throughout Washington . The DOH supervises the POlST form . The POlST taskforce of the Washington End of life Consensus Coalition (WEOlCC) oversees it . The Washington State Medical Association (WSMA) distributes the POlST form, staffs the WEOlCC, and provides resources related to POlST .

POlST is not an advanced directive, nor does it take the place of one . An advance directive must meet certain statutory requirements, and directs withholding or withdrawal of life-sustaining treatment in a terminal or permanent unconscious condition . POlST may either request treatment be withheld or administered . POlST may reflect the wishes in a patient’s advance directive, but an advance directive is not necessary for the POlST form to be valid .

The POlST form was updated in December, 2010 . life-saving treatments were kept on the front page, and orders for antibiotics and nutrition were moved to the back . The form encourages awareness of a patient’s advance directive and the legal status of a healthcare surrogate signing a POlST on behalf of a patient .

Consider the following guidelines when using the POlST form:

1 . Use the current version of the POlST form (http://www .wsma .org/patient_resources/polst .cfm) and

2 . Verify POlST orders are consistent with the patient’s wishes: a . Update POlST whenever the patient’s medical

condition changes (or at least every few years), b . Review advance directives for consistency with

POlST andc . To reduce the risk of fraud, verify the legal status of a

healthcare surrogate signing a POlST on behalf of a patient to the extent possible .

Death with Dignity

The Death with Dignity Act (DWDA) was passed by initiative in Washington in 2008 . The Department of Health (DOH) adopted rules for the DWDA in 2009, develops and maintains forms for the DWDA, collects data and reports statistics annually .

The DWDA allows an attending physician to prescribe medication (after two requests – one in writing and one orally) a qualified patient may ingest to end his/her life . The attending physician must properly complete required documentation . The medication must be self-administered by the patient – another person cannot administer it . There is immunity for acting in good faith under the DWDA .

The patient requesting the medication must be a Washington resident and terminally ill . The patient must request the medications using a standard form witnessed by two persons . One witness shall not: (i) be a relative; (ii) be a person entitled to a share of the patient’s estate; or (iii) own, operate, or be employed at any health care facility where the patient is a resident .

The attending physician must determine the patient has a terminal disease with six months or less to live . The attending physician, or a psychiatrist/psychologist, must attest the patient does not have a mental disorder . The attending physician must verify the patient: (i) is a Washington resident by a driver’s license, voter registration, or proof of property ownership/lease; (ii) is acting voluntarily; and (iii) has made his/her decision after being fully informed of all relevant information (including diagnosis, prognosis, potential risks and probable result of taking the medications, and feasible alternatives) . The attending physician must also document the patient was; (i) informed of the right to rescind his/her request; (ii) advised to inform the next of kin; (iii) counseled about the importance of having another person present when the patient ingests the medications; and (iv) was advised not to take the medications in a public place .

Patients may withdraw their request for medications at any time . Physicians may choose not to participate in the DWDA . A health care facility may prohibit a physician from participating under the DWDA at the facility .

In 2009, 65 patients participated in the DWDA program and 87 in 2010 . In 2011, medication to end a patient’s life was dispensed to 103 individuals . Of those, 70 died after ingesting the medication and 24 died without ingesting the medication . Information is incomplete for the others . The 2011 data is available at: http://www .doh .wa .gov/dwda/forms/DWDA2011 .pdf .

for more information about the DWDA, including a detailed question and answer document, and access to the DWDA forms, visit the WSMA website, http://www .wsma .org/medical_professionalism/clinical-resources .cfm#dwda, or the DOH, http://www .doh .wa .gov/dwda/ .


Hospice Care—Its Evolution and Future

By Robert Bray, MD

Medical Director Hospice of Spokane

The origins of modern hospice care are in the 1960’s with the work of Dr . Cicley Saunders in london . She was a physician with prior experience in both nursing as well as medical social work . Her concept of care for the dying included holistic, patient

centered care, focusing on relief of suffering in all domains (physical, emotional and spiritual), and enhancing quality of life during the remaining time . The delivery model for this was to be a multidisciplinary team approach . Those tenets form the foundation of current hospice care .

The first American hospice was founded in 1974 and Medicare approved the hospice benefit in 1982 . The basics of the Medicare hospice benefit are a prognosis of six or fewer months and would eventually include admission qualifying guidelines as defined by the Medicare intermediaries . The payment method to Medicare certified hospices was defined as a per diem payment for the basket of required services: case managing nurse and social worker, chaplain, medical director and administrative services, as well as coverage for medications directly related to the terminal diagnosis .

Initially, at least 60% of hospice patients had terminal cancer diagnoses and Medicare limited hospice coverage to a total of six months . Over time, it was clear that a lifetime limit on the hospice benefit only encourages later referrals and is contrary to the intent of the hospice benefit . now, the benefit can extend beyond six months if the patient’s condition continues to meet the admission guidelines . As of 2010, cancer diagnoses constitute approximately 35% of hospice admissions nationwide . Of the remaining 65% of non-cancer terminal diagnoses, the most frequent categories are end stage heart disease (14%), dementia (13%), general debility (13%) and lung disease (8%) .

Recent trends in hospice utilization show a steady reduction in length of stay (lOS) — the median lOS is 19 days . lOS of fewer than seven days accounts for 35% of hospice admissions . Hospice care is delivered to the place that the patient calls home (private home or facility) for 95% of admissions, with 5% provided in hospitals or hospice inpatient units .

The trend toward shorter lengths of stay is a concern for hospice programs . Quality goals of hospice programs include rapid control of pain symptoms upon admission, but it requires more time to assist patients and their families with emotional or spiritual pain . Reconciliation and emotional healing are things that will not be measured in 48-hour increments .

The future of hospice care will likely include the following:

» Payment reform: one suggestion is a variable per diem

payment, with higher rates paid in the initial admission

process and during the period prior to death reflecting

the increased work during those times . The rate would

be less during the middle of longer lengths of stay .

» Concurrent care: Washington Medicaid has recently

approved concurrent care for pediatrics, enabling

both hospice services and continued disease directed

therapy (i .e ., chemotherapy) to be given to Medicaid

pediatric beneficiaries . Although the details of the

payment mechanisms are still being worked out, this

reflects the reality of pediatric end of life care with

parents often choosing aggressive care to prolong life

and simultaneous palliative care for symptom control .

Recent studies of this approach in adult oncology

patients have demonstrated that early provision of

palliative care to a randomized group of metastatic

lung cancer patients resulted in improved quality of life

scores, lower incidence of depression and, even though

they received less aggressive care prior to death, they

lived an average of three months longer . Temel, et al,

nEJM 363:8, 733-42 . August 19, 2010 .

no matter what the future holds, some things should not change regarding hospice care:

» Our commitment to help relieve suffering at the end of

life — whether that suffering is physical, emotional or

spiritual .

» Continue to focus on delivering care in a

multidisciplinary team manner .

» Continue our commitment to enhancing the quality of

life for the time each patient has left .

Hospice care is about life .


Hospice Services and Reimbursement By Anne Koepsell, RN, BSN, MHA, CLNC

Executive Director

Washington State Hospice & Palliative Care Organization

Hospice is a concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments .

» Hospice provides choices to patients about services

available and supports the wishes of patients about their

end-of-life care .

» Hospice care neither prolongs life nor hastens death and

deals with the emotional, social and spiritual impact of the

disease on the patient and the patient’s family and friends

» Hospice’s goal is to improve the quality of a patient’s last

days by offering comfort and dignity and by addressing

all symptoms of a disease, with a special emphasis on

offering relief from pain and suffering .

» Hospice provides patients with the support to spend

the remaining days of life in the place of their choice,

surrounded by loved ones . This includes providing

any durable medical equipment, medical supplies and

medications needed to manage the terminal illness .

» Hospice care is provided by a team-oriented group

of specially trained professionals and volunteers who

provide support for the patient and their family .

» Hospice services are provided on an intermittent basis

as needed by the individual, but services are available 24

hours a day, 7 days a week to provide support and care to

patients and family members .

» Hospice is sensitive to the patient’s personal, cultural and

religious values, beliefs and practices .

» Hospice offers a variety of bereavement and counseling

services to families before and after a patient’s death .

To be eligible for Medicare/Medicaid reimbursement of hospice care, a physician must certify that the patient has less than six month to live if the disease runs its normal course . The patient signs an elective statement indicating he or she understands the nature of the illness and of hospice care . Most insurance plans follow the Medicare model of eligibility for the hospice benefit, often with some latitude in prognosis .

Medicare and Medicaid, as well as most insurance companies, reimburse hospice care on a daily per diem from the day of admission to the day of death or discharge . This reimbursement model is a flat rate per day for all patients, irrespective of their costs of care . All elements of care related to the terminal illness are covered under this daily per diem . It is a risk-sharing, managed care model of reimbursement and is what allows larger hospice programs to cover some treatments that smaller programs cannot . The hospice pays for the professional care provided by the interdisciplinary care, all medications, medical supplies, DME and other items necessary for the care of the patient . Additionally, the cost for the 12 months of bereavement services to family members is included in this daily per diem .

In 2010, the median length of stay for WA state Medicare beneficiaries was 23 days, i .e ., 50% of all patients were on service 23 days or less . Additionally, about 25% of all patients are on service seven days or less . The mean, or average, length of stay was 57 days, with only about 5% of patients on service longer than six months . These short lengths of stay result in intense efforts to achieve the care goals of the patient and family members .

Killing the Pain Not the Patient: Palliative Care versus Assisted SuicideBy Richard M. Doerflinger and Carlos F. Gomez, M.D., Ph.D.

Some time ago an ad appeared in a medical journal promoting a new pain-killing drug . To emphasize that this new product could relieve pain without sleepiness or other side-effects, the ad began with a slogan: "Stop the pain . not the patient ."

The outcome of our society's debate on physician-assisted suicide may depend on how well we communicate—and act upon—a similar message . We are living at a time when some doctors and lawmakers think that the best solution for some patients' suffering is to give them lethal drugs for suicide . Catholics committed to the dignity of each human person must insist: "Kill the pain . not the patient ."

It is a compelling message . Some opinion polls show support for assisted suicide when it is presented as the only relief for a dying patient in unbearable pain . but when Americans are offered an alternative, they overwhelmingly say that society should concentrate on ensuring pain control and compassionate care for such patients—not on helping them take their lives . This preference is even stronger among dying patients themselves . When the medical journal The lancet reported on interviews with cancer patients on June 29, 1996, it found that dying patients experiencing significant pain were more opposed to assisted suicide than the general public . "

Continued on page 7



Patients with pain do not seem to view euthanasia or physician-assisted suicide as the appropriate response to poor pain management," wrote Dr . Ezekiel Emanuel, a director of the study . "Indeed, oncology patients in pain may be suspicious that if euthanasia or physician-assisted suicide are legalized, the medical care system may not focus sufficient resources on provision of pain relief and palliative care ."

Realizing that assisted suicide is less popular than improved palliative care, euthanasia advocates have resorted to the claim that there is really not much difference between the two . Their argument goes like this:

"let's be honest . Doctors commonly practice euthanasia now, under the guise of pain control . They give dying patients massive doses of morphine to suppress their breathing, and then call their death a mere 'side-effect .' They justify this hypocrisy by invoking an invention of medieval theologians called 'the principle of double effect .' Sometimes they even sedate these patients into unconsciousness so they can starve them to death . This 'terminal sedation' is really slow euthanasia . It would be far more candid, as well as more humane, to practice euthanasia openly ."

This argument has appeared in newspaper opinion pieces, medical journals, and briefs to the U .S . Supreme Court . In 1996 it was even endorsed to some extent by two federal appeals courts that sought to give constitutional protection to physician-assisted suicide .

Yet the American medical profession, and the Supreme Court, rejected this argument . To understand why they were right to do so, we must explore two realities: the facts about modern pain control, and the meaning of that so-called medieval invention, the principle of double effect .

The Facts about Pain Control

Many doctors hesitate to give dying patients adequate pain relief because they fear that high doses of painkillers such as morphine will suppress the breathing reflex and cause death . Yet we now know that this fear is based on false assumptions, and on inadequate training of physicians in pain management techniques . Even among oncologists, who probably deal with more patients in severe pain, there is too little knowledge of the medically appropriate use of analgesic drugs .

In reality, a very large dose of morphine may well cause death—if given to a healthy person who is not in pain and has not received morphine before . but when administered for pain, such drugs are taken up first by the patient's pain receptors . In fact, patients regularly receiving morphine for pain quickly build up a resistance to side-effects such as respiratory suppression, so they can easily tolerate doses that would cause death in other people . fortunately they build up a tolerance to the side-effects far more quickly than to the drugs' analgesic effects—so doctors need not hesitate to increase dosages when needed to relieve pain . The question, "What is the maximum dose of morphine for a cancer patient in pain?", has one answer: "The dose that will relieve the pain ." As long as a patient is awake and in pain, the risk of hastening death by increasing the dose of narcotics is virtually zero . Unrelieved pain is itself a stimulant, which overwhelms any depressive effects of narcotics . Patients whose unrelieved pain is distorting the very fabric of their lives need adequate pain control the way a diabetic needs insulin to function properly .

Very rarely it may be necessary to induce sleep to relieve pain and other distress in the final stage of dying . Euthanasia advocates call this "terminal sedation," but it is the same kind of sedation that is sometimes needed to calm distressed or restless patients with non-terminal conditions . While some terminally ill patients may die under such sedation, this is generally because they were imminently dying already .

Continued on page 8



In competent medical hands, sedation for imminently dying patients is a humane, appropriate and medically established approach to what is often called "intractable suffering ." It does not kill the patient, but it can make his or her suffering bearable . It may also allow a physician the time to re-assess a patient's pain needs: The terminally ill sedated patient may later be withdrawn from the sedatives and brought back to consciousness, with his or her pain under control .

The factual evidence supports these claims . In 1992 the Journal of the American Medical Association (JAMA) reported on 97 terminally ill patients who died after life support was withheld or withdrawn . Sixty-eight of the patients received painkilling drugs or sedatives to relieve pain and other distress while dying—and they lived longer than the patients who did not receive drugs . The study found that the dosages of these drugs were chosen to ensure relief of suffering, not to hasten death .

Only recently has the medical profession begun to appreciate that unrelieved pain can itself hasten death . It can weaken the patient, suppress his or her immune system, and induce depression and suicidal feelings . It can keep patients from living out their lives with a modicum of dignity, in the fellowship of their families and friends . So adequate pain relief can actually lengthen life . According to a JAMA news item of March 25, 1992, part of modern medicine's task may be that of "killing pain before it kills the patient ." Or as the Catholic Health Association says in its 1993 guide Care of the Dying: A Catholic Perspective: "Unrelieved agony will shorten a life more surely than adequate doses of morphine ."

In short, when dosages of painkilling drugs are adjusted to relieve patients' pain, there is little if any risk that they will hasten death . This fact alone should put to rest the myth that pain control is euthanasia by another name .

The Principle of Double Effect

What of the rare case when providing pain relief or sedation does risk hastening death? Is this really the same thing as deliberately killing a patient?

Centuries of Catholic moral tradition say it is not . Sometimes it is impossible to achieve some good effect without causing a bad effect as well . When an act has both a good and a bad effect, we should ask ourselves whether it meets four criteria .

first, the act itself must be good or at least morally indifferent; giving medication to relieve pain certainly meets this test . Second, the good effect must not be attained by means of the bad effect—we cannot claim, like Jack Kevorkian, that we may deliberately kill suffering people because once they are dead they can't suffer .

Third, the bad effect must not be intended; we cannot give pain medication in order to end pain and cause death . fourth, there must be a serious reason for pursuing the good effect; it would be irresponsible to risk hastening death to relieve an ordinary headache .

Taken together, these criteria have become known in Catholic moral reasoning as the principle of double effect . Euthanasia supporters like to emphasize the principle's Catholic origins so they can dismiss it as an arcane Medieval invention . Dr . Timothy Quill, for example, argues that it should not be used in our pluralistic society because it "originated in the context of a particular religious tradition" (new England Journal of Medicine, Dec . 11, 1997) .

but one might as well rescind laws against robbing banks on the grounds that "Thou shalt not steal" comes from a particular religious tradition . A moment's reflection will show us that the principle of double effect is no Catholic peculiarity, but simply good common sense .

When the ninth Circuit Court of Appeals sought to establish a "right" to assisted suicide in 1996, its opinion rejected the distinction between intended and unintended hastening of death . Judge Kleinfeld's dissenting opinion used a down-to-earth example to show how wrong the court's majority opinion was . "When General Eisenhower ordered American soldiers onto the beaches of normandy," he wrote, "he knew that he was sending many American soldiers to certain death, despite his best efforts to minimize casualties . His purpose, though, was to . . . liberate Europe from the nazis . The majority's theory of ethics would imply that this purpose was legally and ethically indistinguishable from a purpose of killing American soldiers ." Ultimately the U .S . Supreme Court reversed the appeals court's decision and upheld the principle of double effect, citing Judge Kleinfeld's historical example to illustrate its moral and legal validity .

Students of bible history could draw the point out further . When King David was overcome by desire for the wife of Uriah the Hittite, he ordered Uriah to the front lines with the express purpose of making sure he was killed (2 Sm 11:15-17) . That was an act of murder, concealed by wartime . Anyone who cannot tell the difference between King David at his most sinful and General Eisenhower's decision about D-Day should not be entrusted with life-and-death decisions!

The importance of intentions in making moral decisions should be clear to all physicians, who routinely prescribe medicines and treatments that may have unhappy or unforeseen consequences . If, despite everyone's best efforts, a patient stops breathing and dies on the operating table from anesthesia during a delicate operation, is the surgeon a killer? If so, the medical profession is filled with "unintentional murderers ."

Continued on page 9



A more honest appraisal would be to admit that human life is fragile, that actions can have unexpected or unintended consequences, and that human beings—including skilled and ethically responsible physicians—are fallible .

Are there borderline cases where people's intentions are not clear? Are there instances when it is irresponsible to risk hastening death even as a side-effect? Of course . The principle of double effect does not automatically clarify all questions of intent, and it does not mean that causing death is justified whenever it is not directly intended . but the distinction is a useful tool for moral decisions . In modern medicine, quite literally, we couldn't live without it .

Assisted Suicide vs. Pain Control

In important ways, assisted suicide and good palliative care are not only distinct—they are radically opposed to each other . Consider the following:

Control of pain and suffering eliminates the demand for assisted suicide . As Dr . Herbert Hendin notes in his 1997 book Seduced by Death, some terminally ill patients have suicidal thoughts, but "these patients usually respond well to treatment for depressive illness and pain medication and are then grateful to be alive ." Such treatment responds to the underlying reasons why patients ask for death, instead of treating the patient himself as the problem to be eliminated . When pain control and other care improves, assisted suicide becomes largely irrelevant .

Assisted suicide undermines good pain management. During the Supreme Court's January 1997 oral arguments on its assisted suicide cases, Justice Stephen breyer noted a remarkable fact from a report by the british parliament's House of lords: The netherlands, which has allowed assisted suicide and euthanasia for years, had only three hospices nationwide, while Great britain, which bans these practices, had 185 hospices . He had placed his finger on one of the most insidious effects of legalization: Once the "quick and easy" solution of assisted suicide is accepted in a society, doctors lose the incentive to pursue more difficult but life-affirming ways of truly caring for patients close to death .

The converse is also true: prohibiting assisted suicide sets a clear limit to doctors' options so they can commit themselves to the challenges of accompanying patients through their last days . As one physician said after years practicing hospice medicine: "Only because I knew that I could not and would not kill my patients was I able to enter most fully and intimately into caring for them as they lay dying" (quoted in leon Kass, "Why Doctors Must not Kill," Commonweal, Sept . 1992, p . 9) .

The assisted suicide movement is willing to discredit modern pain control to advance its own cause . Euthanasia advocates know that when they equate assisted suicide and modern pain management, they are not just elevating the status of assisted

suicide—among people who oppose direct killing of the innocent, they are undermining good pain control . They do not seem to care that their arguments will make doctors and patients more distrustful of legitimate practices that can truly help people live with dignity in their last days .

but strong voices are being raised to make sure they do not get away with this . In an April 1997 report on constitutional arguments about assisted suicide, the prestigious new York State Task force n life and the law urged people on all sides of the assisted suicide issue to keep important distinctions clear . noting that "many physicians would sooner give up their allegiance to adequate pain control than their opposition to assisted suicide and euthanasia," the Task force warned that "characterizing the provision of pain relief as a form of euthanasia may well lead to an increase in needless suffering at the end of life ."

This warning is even being raised by some who do not oppose physician-assisted suicide in principle . "Clinicians must believe, to some degree, in a form of the principle of double effect in order to provide optimal symptom relief at the end of life," writes Dr . Howard brody in the April 1998 Minnesota law Review . Dr . brody does not oppose assisted suicide in all cases, but he knows that many doctors do—and he knows they will not practice good palliative care if it is seen as tantamount to euthanasia . "A serious assault on the logic of the principle of double effect," he writes, "could do major violence to the (already reluctant and ill-informed) commitment of most physicians to the goals of palliative care and hospice ."

It is startling that a movement ostensibly dedicated to the well-being of dying patients risks undermining their care to advance its political goal . What can the Hemlock Society say in its defense? That any such adverse effects on patients are only an unintended side-effect?

Conclusion

In short, pain control and other elements of palliative care must be clearly distinguished from intentional killing of patients . In trying to blur this distinction, euthanasia advocates only show their own indifference to the goal of promoting better care for dying patients .

In logic and in practice, two very different paths lie before the medical profession and our society: What Pope John Paul II has called the "false mercy" of assisted suicide and euthanasia, and the "the way of love and true mercy" that dedicates us to compassionate care (The Gospel of life, no . 66-67) . It is literally a choice between death and life .

Mr. Doerflinger is Associate Director for Policy Development,

Secretariat for Pro-Life Activities, National Conference of Catholic

Bishops.

Dr. Carlos F. Gomez, who was medical director of the University

of Virginia Health System's Center for Hospice and Palliative Care

from when it opened in 1995 until 2003, died June 12, 2010.


Compassion & Choices of Washington: Upholding Patient Autonomy at the End of Life By Robb Miller, Executive Director

Compassion & Choices of Washington

Since the passage of the Initiative 1000 (the Washington Death With Dignity Act or DWDA) in november 2008 and its enactment in March 2009, mentally competent, terminally ill Washingtonians with six months or less to live now have the legal option of physician aid in dying .

Many physicians – especially specialists working in oncology, neurology, pulmonology and cardiology – have received, or eventually will receive, inquiries from their patients about the DWDA . How a physician responds to requests about aid in dying can have a significant effect on the patient/physician relationship . If a physician abruptly cuts off the conversation, missed opportunities to discuss patients’ concerns or fears about dying and options such as hospice or palliative care may occur .

While many people assume that support for the DWDA came primarily from western Washington, this was not the case . The law won in all but nine counties in Washington . In Spokane County, it passed by 52 percent .

The DWDA is an “opt-in” law . This means that no physician, pharmacist, psychiatrist or psychologist is required to participate . Additionally, the law allows health systems to prohibit its employed providers from participating (so long as they are on their employers’ property) .

for example, most religiously affiliated healthcare providers in Washington have elected not to participate in the law . However, “participation” is defined as performing the duties of a participating physician, pharmacist or psychiatric/psychological evaluation provider and does not include either providing information about the DWDA or referring patients to other physicians or organizations who will . This is when Compassion & Choices can be a valuable resource to physicians and other medical providers .

Compassion & Choices in a nonprofit organization that advocates for excellent, patient-centered end-of-life care and upholds the rights of qualified patients to have the option of Death With Dignity . Compassion & Choices provides counseling, information and emotional support to terminally ill patients and their loved ones . This includes personal presence at the time of death to ensure that the medical protocol is strictly adhered to and to support family and other loved ones who are present . There is never a fee for Compassion & Choices’ services .

While Compassion & Choices upholds patients’ rights to use the law, Compassion & Choices does not promote or encourage physician aid in dying . Compassion & Choices has three medical directors, all MDs, who provide expertise and advice to physicians who seek information about the DWDA or elect to participate in the law as attending (prescribing) or consulting physicians .

Services for physicians include Compassion & Choices’ Physician Guide to the DWDA that provides concise information about the requirements of participating physicians, Department of Health (DOH) reporting forms and instructions about what medications to prescribe . Compassion & Choices’ medical directors can also assist with locating physicians willing to participate in the law, as well as referring to participating pharmacies .

While considerable support for the law exists in Spokane County, the recent DOH report on the 2011 DWDA indicated that only five patients out of 94 patients who died after acquiring (but not necessarily using) life-ending medication under the law lived east of the Cascades . Although Compassion & Choices is aware of a few physicians who are willing to participate in the law, the law requires participating physicians to be qualified to confirm patients’ diagnoses as terminal with six months or less to live . for example, a patient with AlS would need to be evaluated by a neurologist . Consequently some patients from central and eastern Washington have had to make arduous trips to be seen by qualified participating physicians in Seattle .

If you are a physician who would be willing to participate as an attending or consulting physician, please contact Compassion & Choices’ office . All contacts and personal information are kept strictly confidential . no patients are referred to you without your prior authorization via a conversation with a Compassion & Choices medical director .

because most physicians in the Spokane area do not know other physicians willing to participate in the DWDA, referring patients to Compassion & Choices can often be the most helpful response to patients who inquire about the option . Information for patients and medical providers can be found on Compassion & Choices’ website, www . CompassionWA .org, or can be requested by phone or email: (877) 222-2816 toll free or info@CompassionWA .org . brochures are also available upon request .

Information about the DWDA, including the DOH’s 2011 Annual Report on the DWDA and required forms, is available at http://www .doh .wa .gov/dwda/ . The DOH does not counsel patients or provide information about participating physicians .

for physicians whose employers prohibit participation in the DWDA or who elect not to participate for personal or professional reasons, referring to Compassion & Choices allows the physicians to honor patients’ end-of-life choices and provide them with a resource for information and support .


New Cervical Cancer Screening Guidelines -

Should Not Lessen the Importance of the Annual Exam

By Felix Martinez, Jr., M.D.

The experts have weighed in and now have spoken in unison: “less is more .”

In March 2012, four major organizations - preventative, professional and governmental - jointly issued new guidelines for cervical cancer screening .

The authors of the new guidelines reviewed thousands of trials and different types of studies performed all over the world1 . The guidelines come from the United States Preventative Services Task force (USPSTf) and collaboration among the American Cancer Society, American Society of Colposcopy and Cervical Pathology (ASCCP), American Society for Clinical Pathology (ASCP) and the American Congress of Obstetrics and Gynecology (ACOG) . Major changes are listed in Table 1 and are summarized below:

1 . Screening begins at age 212 . for women age 21-29, Pap testing only every three (3) years.

3 . Combined testing (Pap & HPV test) for women over 30, with lengthening of testing interval to every five (5) years

for women who are Pap negative & HPV negative .4 . Cessation of Pap screening in women with no history of

HSIl in the past 10 years at age 65 .

It is evident that these changes in guidelines will not be the last in the march of cervical cancer screening toward minimal testing

over the longest possible interval.

The call for screening cutbacks is based on knowledge accrued over the last decade about the biology and epidemiology of HPV infection, and the precancerous changes initiated by HPV infection .

The organizations issuing these guidelines, for the first time, are now largely in agreement on the strategies for both screening and follow up .

Studies show that the death rate for cervical cancer is not affected by lengthening screening intervals, and the new guidelines aim to reduce the number of false positive tests and procedures which are deemed unnecessary by the experts .

both the USPSTf and the consortium of medical groups led by the ACS continue to emphasize the importance of the Pap test . They recognize that efforts to promote Pap testing help reduce the number of women who develop cervical cancer because they have not had recent screening . The experts, therefore, do not want to de-emphasize or denigrate the Pap test, but aver that the Pap test and the HPV test can be used more effectively .

The new changes do not apply to women with immune compromise, most notably HIV infection . Also, those having organ transplant or other immunosuppressive condition or therapy are excluded .

Co-testing - having both a Pap test and HPV test at the same time - was embraced by the USPSTf for the first time, calling it the “preferred” screening strategy for women 30-65 . The USPSTf thereby acknowledges the principal that co-testing is effective because each test independently screens for slightly different things . In a concession to offering screening only with a Pap, the task force offers women ages 30-65 the option of having a Pap test alone every three years .

The presence of virus in women 30 and older may signal a persistent infection that increases the risk for cervical cancer . The high sensitivity of the HPV test in cervical cancer screening is a valuable part of co-testing .

All sets of new guidelines discourage use of HPV tests in women under the age of 30 because many in this age group will clear the infections on their own, without the need for medical intervention .

Previous guidelines for women under the age of 30 had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21 . now, recommendations are that Pap testing begin at age 21 with Pap tests alone every 3 years for women age 21-29 .

There were 11,270 cases of cervical cancer and 4,070 deaths from cervical cancer in 2011, and 1-2 cases per 100,000 girls ages 15-19 occurred over the past 10 years .5 The low incidence in teenagers has convinced the experts that it is safe to wait until age 21 to screen .

Since cervical cancer is so rare under the age of 21, the experts have concluded that multiple sexual partners and/or early initiation of sexual activity doesn’t affect the incidence of cancer, and these former risk factors have been deemed irrelevant as long as screening begins at age 21 .

The consortium also believes that it is safe to test women less often because cervical cancer grows slowly and the screening “window” allows 10-20 years to catch precancerous changes .

Continued on page 12



for women who have total hysterectomy for a noncancerous condition, testing can be eliminated if a woman has not had CIn 2-3+ on previous Pap testing .

Co-testing for women 30 and older is not a new recommendation and was part of the ASCCP Guidelines issued in 2009 . One area of confusion in co-testing occurs when women are cytology

negative but HPV positive. Under the guidelines, there are two options in this setting:

Option #1) Repeat co-testing in one (1) year . Women who re-test HPV-positive (or who have lSIl or HSIl) should undergo colposcopy . Women with normal or ASCUS cytology and who are HPVnegative should return to routine screening .

Option #2) Immediate testing for HPV 16 and 18 . Women who test positive for either of these viral types should undergo colposcopy . Women who test negative for both of these viral types should be co-tested in 12 months with management of results as outlined in Option #1 .

Pap test or no Pap test, every woman needs a yearly medical exam for reasons vital to her health . Every set of new guidelines brings fear that women will visit their provider less often if they hear or read the phrase “in 3-5 years .” Therefore, practitioners now emphasize the requisite need for an annual exam for “non-Pap” essentials such as cardiovascular screening, breast exam, cholesterol screening, colorectal screening, blood sugar irregularities, osteoporosis, thyroid disease and even depression .

for women under 21, blood pressure, height, weight, counseling on contraception and even counseling on domestic violence are important reasons for an annual visit .

Let’s not let any sort of guidelines lessen the importance of seeing a doctor once a year!

See Screening for Cervical Cancer Chart on page 13

Physician Leadership ResourcesBook

A link for any of the resources listed can be found at the SCMS website (www.spcms.org) Leadership Resources tab.

The Best Care Possible: A physician's quest to transform care through the end of life by Ira byock, MD . A doctor on the front lines of hospital care illuminates one of the most important and controversial ethical issues of our time . Dr . Ira byock, one of the foremost palliative-care physicians in the country, argues that how we die is among the biggest national crises facing us today .

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FIGURE 1

References:

1 Annals of Internal Medicine, March 2012 on annals .org

2 The lancet Oncology, Volume 13, Issue 1, Pages 78 - 88, January 2012

3 CA: A Cancer Journal for Clinicians, Volume 62, Issue 2, pages 129–142, March/April 2012

4 new Guidelines Discourage Annual Pap Tests, The lA Times, March 14, 2012

5 U .S . Cancer StatisticsU .S . Cancer Statistics Working Group . United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report . Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and national Cancer Institute; 2010 . Available at: http://www .cdc .gov/uscs .


Meet Jeanette Radmer of Numerica Credit Union- An SCMS Community of Professionals Partner

Self-introduction

My name is Jeanette Radmer . I am the business Development Relationship Officer for numerica Credit Union, established in Spokane since 1937 . I am charged with taking care of those in the medical and dental community . I’ve been in the financial services industry for 18 years and obtained my Washington State Insurance license in 2003 .

How long have you

been in Spokane?

I have lived in Spokane my entire life . I graduated from Eastern Washington University with a degree in business Administration and Hospitality Management .

What service do you provide professionals?

Similar to healthcare professionals, I provide a personalized, consultative and comprehensive approach to you, and to those staffed at your facility . It is my job to ensure that you are receiving the highest quality financial services from checking accounts and auto loans, to mortgages and investments - quickly and conveniently .

numerica Credit Union takes care of me, so I can take care of you . I value your time, money and dreams, but more importantly, I value the relationship that I have with each and every one of you . I’m committed to making your life easier .

What makes your organization stand out as a “good”

partner?

numerica Credit Union’s mission is simple: Enhance lives . fulfill dreams . build Community .

It’s easy to see the commonality between our mission and that of the medical community in Spokane . The outreach programs, enhanced educational opportunities and medical programs for the underserved are exactly the type of programs that numerica supports .

As a long-established credit union, the first credit union in this area, we provide not only financial solutions, but also community support for the medical and dental community throughout central and eastern Washington . What is important to you is important to us .

What is your thinking about the Spokane area medical

community?

Our diverse and experienced medical community provides many routes to promote a healthy and sustainable Spokane, allowing us to work, thrive and serve, right here . We are fortunate to have a community of quality healthcare professionals serving the greater Spokane area today . And, through the expansion of medical education in Spokane, they are ensuring that the future will provide the same quality of healthcare for generations to come .

It is numerica Credit Union’s responsibility and commitment to contribute to the medical community’s overall financial wellbeing, and return that high-quality service to you . After all, you improve the quality of our lives; we should return the favor .


William I. Bender, MD – SCMS Physician Citizen of the Year for 2011Dr . William I . “bill” bender of Columbia neurology was named Physician Citizen of the Year for 2011 by the Spokane County Medical Society on May 4, 2012 . Dr . David bare, Vice President of the Medical Society, presented a plaque to Dr . bender for his outstanding contributions to the medical profession and the community .

Dr . bender received his medical degree from The Chicago Medical School in 1978 . He completed his residency in neurology at the USC Medical Center, los Angeles and is board certified in neurology .

In his nomination of bender, Dr . John McCarthy wrote, “He is the epitome of a physician who is non-judgmental, professional and ethical .”

As a community advocate for healthy living in Spokane, bender is the founder of Spokefest and co-chair of Summer Parkways . bender believes in celebrating health, fitness and the great outdoors .

McCarthy closed his nomination of bender with the following: “In summary, bill is a leader in this community who embodies what we as physicians and PAs should strive towards . He is a solid physician, community member and leader . His presence in this community has made it better on a number of levels and we can look forward to this continuing and the community benefitting .”

The Spokane County Medical Society is proud to award the honor of 2011 Physician Citizen of the Year to Dr . William bender .

Dr. David Bare (left) with Dr. William Bender (center), recipient

of the 2011 Physician Citizen of the Year Award and Dr. Berdine

Bender, wife of Dr. William Bender

Did you know…?Eric Johnson, MD, President of the Spokane Scholars board was the Master of Ceremonies at the banquet where Terri Oskin, MD presented the Science Awards to scholars .

The Spokane County Medical Society “Docs for the Cure” team participated in the Susan G . Komen Race for the Cure with shirts donated by the Community of Professionals partners .

George novan, MD and brian Pitcher, PhD, Chancellor of WSU Spokane, spoke with the Community of Professionals partners at the WSU Spokane campus .

Physician and family members met and stored their items at the bank of America building before and after the bloomsday race (sponsored by Community of Professionals partners) .

Over 300 members have responded to the Medical Informatics Committee Survey regarding Health Information Exchange .

Scott Armstrong, CEO/President of Group Health Cooperative, spoke at the Dean’s breakfast forum at Gonzaga University School of business on Healthcare Reform in Spokane .

Membership Recognition for June 2012Thank you to the members listed below . Their contribution of time and talent has helped to make the Spokane County Medical Society the strong organization it is today .

20 Years

William E. Bronson, MD 6/17/1992

Gary L. Craig, MD 6/17/1992

Peter W. Graves, MD 6/17/1992

Steven M. Kernerman, DO 6/17/1992

Paul H. Lin, MD 6/17/1992

Kirk L. Rowbotham, MD 6/17/1992

10 Years

Daniela C. Alexianu, MD 6/26/2002

Amy M. Backer, MD 6/26/2002

Heather M. Brennan, MD 6/26/2002

William J. Dubiel, MD 6/26/2002

Sherry A. Franks, PA-C 6/26/2002


Meet Windy Rudd of US BankAn SCMS Community of Professionals Partner

Self-introduction

My name is Windy Rudd . I am a Relationship Manager and Assistant Vice President of US bank’s Private banking Department . I have been serving clients at U .S . bank for more than 20 years .

How long have you be

in Spokane?

Originally from Coeur d’Alene, ID, I moved to Spokane, WA 25 years ago .

What service do you provide for professionals?

I serve as a trusted advisor and advocate, working with other experts within U .S . bank to deliver the best solutions and advice to benefit my clients .

U .S . bank is committed to partnering with professionals throughout various stages of their lives, as their needs change and become more complex . Whether one is beginning to accumulate wealth, enjoying the heights of success in their career or planning to preserve wealth for future generations, U .S . bank has the expertise and resources for these unique circumstances .

What makes your organization stand out as a “good”

partner?

local decision-making, personal leadership and community involvement are at the heart of everything we do at U .S . bank .

Through these economic times, our historical prudent approach to banking helped position U .S . bank as an industry leader of strength and stability . This consistent approach to banking during the past and into the present, has positioned us strongly to help in our nation’s recovery as we move forward .

What is your thinking about the Spokane area medical

community?

The Spokane community maintains a very dynamic group of medical professionals with the highest skill levels to provide comprehensive healthcare solutions .

With the recent announcement in the academic world bringing a 4-year medical school to Spokane, the community will now have a tool to not only train students in the medical field, but also have the opportunity to retain them . Integrating students in the Spokane community during their studies will help sell them on a place to begin their professional lives . This bodes well for Spokane from a skill perspective . Keeping these individuals in Spokane is where U .S . bank can help . Our Private banking department is designed to provide financial solutions to meet the complex and unique needs of these students and medical professionals .

In The News

Family Health Center of Spokane Recognized

Congratulations to Family Health Center of Spokane, a Physicians Insurance Group member, named as one of the better-performing practices by the national Medical Group Management Association in its 2011 report.

Family Health Center of Spokane met the following selection criteria:

• Greater than the median for total medical revenue after

operating costs per fTE physician

• less than the median for operating cost (not including nPP

costs) per medical procedure (inside the practice)

Greater Spokane Incorporated: Look Who Went to

Washington

Another year, another advocacy trip to Washington D.C. is in the books. The regional delegation met with government officials, elected officials, Air Force officials, presented a Key to the City to retiring Representative Norm Dicks, talked about tankers, transportation, graduate medical education and a lot more.

Here’s what Dr. Brad Pope advocated for, among other issues important to medicine, while on the trip:

Medical education: Our elected officials are greatly supportive of the Biomedical and Health Sciences Building at the Riverpoint Campus, as well as the upcoming expansion, with the second year of studies at WSU Spokane soon to be a reality (fall of 2013!).




What the federal government can influence is Graduate Medical Education (GME), mostly known as residency slots. Our region is in need of more residency slots, especially in rural areas. Representative Cathy McMorris Rodgers has a bill that would create a pilot program for rural primary care residency slots. We’ll keep an eye out for the bill.

George Novan, MD Chosen as Graduation Speaker

George Novan, MD was the graduation speaker for the University of Washington School of Medicine Class of 2012 for their ceremony on Saturday, June 2!

Dr. Novan was selected from the medical students’ nominations. This graduating class, which entered in 2008, included the students In WWAMI Spokane’s first cohort of first-year students. Dr. Novan is the director of their Introduction to Clinical Medicine 1 course, the associate director of the WWAMI program at WSU Spokane and for many years was the director of the third year clinical clerkship in Internal Medicine in Spokane. Thus many UWSoM students had the opportunity to experience Dr. Novan’s passion for medicine, empathy for patients, enthusiasm for teaching, great humor and precise clinical skills creating expansive differential diagnoses.

Dr. Novan is the first non-Seattle graduation speaker for at least ten years.

George, congratulations on this great honor and thank you for representing the Spokane medical community to the WWAMI region!

If you are interested in becoming a preceptor or mentor for medical students, residents or PA students, please call or email: Deb Harper 358-7796 or [email protected].

University of Washington School of Medicine Announces

Faculty Appointments

Drs. Joseph Cvancara, Paul Dunn, Irfan Jawed and Joel Sears have received clinical faculty appointments with the University of Washington School of Medicine:

They are all fine physicians and truly exemplify the best of our profession in their dedication to teaching medical students and residents. Please congratulate them on this fine accomplishment.

George R. Lindholm, M.D. Retired after 27 Years at

InCyte Pathology

George R. Lindholm, M.D. retired at the end of May after a career in pathology that spanned 32 years. He was with InCyte Pathology since 1985.

Dr. Lindholm received his medical degree from the University of Washington School of Medicine and is board certified in anatomic, clinical and forensic pathology. He completed his pathology residency at the University of Washington and with the King County Medical Examiner as well as a fellowship in clinical pathology research with the American Cancer Society in Seattle.

Meetings, Conferences and EventsInstitutional Review Board (IRB) – Meets the second Thursday of every month at noon at the Heart Institute, classroom b . Should you have any questions regarding this process, please contact the IRb office at 509 .358 .7631 .

Caduceus Al Anon Family Group – Meets every Thursday evening from 6:15 pm until 7:15 pm at 626 n . Mullan Road, Spokane, WA . non-smoking meeting for spouses and significant others of Healthcare Providers who are in recovery or who may need help seeking recovery . facilitated 12 Step Al Anon format . no dues or fees . Contact 509 .928 .4102 for more information .

Physician Family Support Group — Physicians, physician spouses or significant others, and their adult family members share their experience, strength, and hope concerning difficult physician family issues which may include medical illness, mental illness, addictions, work-related stress, life transitions, and relationship difficulties . The meetings are on Tuesdays from 6:30 pm – 8 pm at Sacred Heart . format: 12 Step principles for everyone, confidential and anonymous personal sharing; no dues or fees . Contact bob or Carol at 509 .624 .7320 for more information .

Foot and Ankle Pain: Appropriate Imaging and Interesting Cases. Speakers: Dr. Shirzad from NW Orthopeadic Specialists and Dr. Sanders from Inland Imaging Wednesday, June 6 Inland Imaging Business Center 801 S Stevens St. 5:30 – 6 P.M. Dinner 6-8 P.M.- Presentation and Interesting Cases RSVP to: [email protected] or 363.7799

No Pay/Slow Pay: Health Care Collections Workshop (WSMA Practice Management Seminar) Tuesday, June 12 Spokane Valley Hospital 12:30–4:30 p .m . In challenging economic times, more and more physicians’ practices experience delays in payment or get no payment at all from some patients . As your patients struggle to make ends meet, it’s increasingly important that you engage with them, and in a timely manner . find workable financial strategies to keep “good” patients coming to your practice, and learn how to manage those relationships appropriately . Seminar registrants will receive with their registration confirmation an assessment tool for submitting questions to the presenter in advance of the seminar . WSMA and WSMGMA members $149 per person (may sponsor staff in the same practice for the member rate) . Three or more members or sponsored staff from the same practice may register for a group discount of $129 per person . non-members: Please call for pricing . Space is limited, so register early! Register online at www .wsma .org .


Continuing Medical EducationPromoting Healthy Families (Practice Management Alerts from the American Medical Association ) is designed to help physicians successfully talk about healthy behaviors with their adult patients in a way that may spark—and help sustain—positive changes for the whole family . The continuing medical education activity includes a video module, a detailed monograph and patient handout . These activities have been certified for AMA PRA Category 1 CreditTM .

for more information www .ama-assn .org .

FYIDr. Otis Brawley: 'The System Really Is Not Failing ...

Failure Is The System'

Anyone going to hear a speech by Dr . Otis brawley might think he or she could easily predict what brawley will say . Since he's the chief medical officer and executive vice president of the American Cancer Society, you might expect him to urge doctors to aggressively screen all their patients for cancer, and to aggressively treat them as well .

You'd be wrong .

At a recent Association of Health Care Journalists meeting in Atlanta (where Dr . brawley also serves as a professor at Emory University), he slammed everyone in the health care system for overuse of under-proven treatments . These themes are also in his new book, How We Do Harm: A Doctor breaks Ranks About being Sick In America .

Read the complete article at http://tinyurl .com/6ozgl5c .

WSMA Supports Washington End of Life Consensus

Coalition (WEOLCC) for Sojourns Award

Relationships between providers of medical care and health plans isn’t always colored by contracting, coding and administrative issues . In an example of congruence of interests in a quality of care – and life – issue, the WSMA is supporting the application of the End of life Consensus Coalition for recognition by the Regence foundation . for the past five years the foundation has worked with a wide range of stakeholders to enhance quality and improve access to palliative

and end-of-life care for individuals and their families in Idaho, Oregon, Utah and Washington . The foundation’s Sojourns Award recognizes inspirational leaders in the field of palliative and end-of-life care . The Collation is a worthy candidate for such recognition .

We created the WEOlCC in 1997 with an agreement among participating parties to set aside their opinions on the issue of physician-assisted suicide, and instead develop a consensus on how to improve care for patients at the end of their lives . The Coalition includes over 450 individuals and organizations .

The goals: To empower patients, physicians and other care-givers to make knowledgeable choices regarding end-of-life care based on thoughtful conversations about living and dying well . The Coalition consists of palliative care specialists, hospice medical directors, state representatives, leaders of professional health care organizations, psychologists, social workers, elder law attorneys, bereavement specialists, funeral home directors, patient advocates, and lay persons . We supply a small budget and staff person to coordinate their efforts .

Central to these efforts are the Coalition’s plans to build upon patients’ use and understanding of advance directives and, in particular, the Physician Orders for life-Sustaining Treatment (POlST) form .


In Memoriam

Rupert Otto Brockmann, MD, JD

Rupert brockmann passed away on April 10, 2012, in his home in bellingham, WA . It was his late wife Marguerite’s birthday .

Rupert, known as brock to many of his family and friends, was born April 19, 1936 in bradshaw, nE . He was the fifth son of John and Selma

brockmann, a fraternal twin with his brother Hubert, and one of eight children . He attended the University of Wyoming majoring in pre-

med . He went on to complete medical school at the University of Colorado . He did his residency and specialty training in Portland, OR,

served his country as a Captain at fairchild Air force base and started an Otolaryngology practice in Spokane, WA . After many years as

a successful EnT physician, he graduated from Gonzaga University with his degree in law, became an attorney and obtained a Masters in

Health law from DePaul University . He was a lifelong student and enjoyed using his knowledge to help others every step of the way .

brock met his wife Marg on a trip to Washington, D .C . in 1955, both of them representing their respective states at a national 4-H

conference . She was “the love of his life .” brock and Marg were married June 7, 1959 and enjoyed 52 years together .

brock and Marg lived in Denver, CO and Portland, OR in the early years of their marriage, then made their home and raised their three

children in Spokane, WA . Marg and brock moved to bellingham in 2010 to be closer to family .

brock was preceded in death by his wife of 52 years, Marguerite brockmann and his brother francis . He is survived by his three children

bruce brockmann (Allison) of Calgary, Alberta; Kathryn Wade (Steve) of Chehalis, WA; laurie brockmann of bellingham, WA and eight

grandchildren . He is also survived by his brothers Erwin (Jo), Dale (Wilma), Paul (nancy), Hubert (Joyce), his sisters Jeannie Carpenter (bob),

Mary lou bath (Jim), sister-in-law (Hilda), Marg’s three sisters and their spouses, sister- in-law (Mary) and many loving nieces and nephews .


The following physicians and physician assistants have applied for membership and notice of application is presented. Any member who has information of a derogatory nature concerning an applicant’s moral or ethical conduct, medical qualifications or such requisites shall convey this to our Credentials Committee in writing 104 S Freya St., Orange Flag Bldg #114, Spokane, Washington, 99202.

PHYSICIANS

Basnett, Saneer, MDPsychiatryMed School: Government Medical College, India (2005)Internship: Internal Medicine Residency Spokane (2009)Residency: U of Washington (2012)Practicing with Providence Sacred Heart Psychiatric Center 7/2012

Boyum, Jon D., MDSurgery/Thoracic SurgeryMed School: U of Washington (2000)Internship: Eisenhower Army Medical Center (2001)Residencies: U of Vermont (2006), Oregon Health Science U (2012)Practicing with Surgical Specialists of Spokane 8/2012

Consiglieri, Giac D., MDNeurological SurgeryMed School: U of Southern California, Keck (2005)Internship: Good Samaritan Regional Medical Center (2006)Residency: St. Joseph Hospital (2012)Practicing with Inland Neurosurgery and Spine Associates, PS 9/2012

Daly, Jennifer C., MDDiagnostic RadiologyMed School: U of Vermont (2005)Internship: Newton-Wellesley Hospital (2006)Residency: U of California, Irvine (2010)Fellowship: U of Southern California, Los Angeles (2011)Practicing with Radia Inc., PS 8/2011

Dong, Mei, MD, PhDMedical Oncology/HematologyMed School; Harbin Medical U, China (1997)Internship/Residency: Norwalk Hospital (2009)Fellowship: U of Texas, Houston (2012)Practicing with Cancer Care Northwest 8/2012

Germain, Rasha S., MDNeurological SurgeryMed School: U of Southern California, Keck (2005)Internship: Good Samaritan Regional Medical Center (2006)Residency: St. Joseph Hospital (2012)Practicing with Inland Neurosurgery and Spine Associates, PS 9/2012

Hay, Arlene P., MDPediatricsMed School: U of Santos Tomas, Philippine’s (1989)Internship/Residency: Greenville Hospital System (1997)Practicing with Rockwood North Clinic 7/2012

Hayes Balmardrid, Melissa A., MDDiagnostic RadiologyMed School: Tulane U (2006)Internship/Residency: Tulane U (2011)Fellowship: Duke U (2012)Practicing with Radia Inc., PS 7/2012

Kelly, Megan S., MDObstetrics and GynecologyMed School: U of Michigan (1993)Internship/Residency: Ohio State U (1997)Practicing with Obstetrix Medical Group of Washington Inc., PS 7/2012

Kadri, Abdulmajeed, MDInternal MedicineMed School: U of Texas, San Antonio (1999)Internship/Residency: Oregon Health & Sciences U (2002)Practicing with Apogee Physicians 7/2012

Kamae, Kondon, MDOphthalmologyMed School: U of Hawaii (2006)Internship: U of Utah (2008)Residency: John A. Moran Eye Center (2011)Fellowships: John A. Moran Eye Center (2007), (2012)Practicing with Spokane Eye Clinic 9/2012

Kicska, Gregory A., MD, PhDDiagnostic RadiologyMed School: Albert Einstein College of Medicine (2003)Internship: Memorial Sloan-Kettering Cancer Center (2004)Residency: U of Pennsylvania (2008)Fellowship: U of Pennsylvania (2009)Practicing with Radia Inc., PS 5/2012

Lewis, Katrina, MDAnesthesiology/Pain MedicineMed School: U of Cape Town, South Africa (1987)Internship: Kettering Medical Center (2004)Residencies: U of South Florida (2006), U of Miami (2008)Fellowship: Tufts U (2009)Practicing with Spine Team Spokane 5/2012

McEvoy, Jennifer R., MDDiagnostic RadiologyMed School: U of Colorado (2006)Internship: Exempla St. Joseph Hospital (2007)Residency: U of Wisconsin Hospital & Clinics (2011)Fellowship: U of Wisconsin Hospital & Clinics (2012)Practicing with Radia, Inc., PS 7/2012

O’Riordan, Moira A., MDDiagnostic RadiologyMed School: U of Chicago-Pritzker (2006)Internship: U of Chicago Hospitals (2007)Residency: U of California, San Francisco (2011)Fellowships: U of California, San Francisco (2010), (2011), (2012)Practicing with Radia Inc., PS 7/2012




Palmer, Jr., Robert H., MDObstetrics and GynecologyMed School: U Autonomous of Guadalajara, Mexico (1983)Internship: U of California, Irvine (1984)Residency: Emory U (1988)Practicing with Obstetrix Medical Group of Washington, Inc., PS 7/2012

Webb, Alden R., DOPathology/DermatopathologyMed School: Midwestern U (2007)Internship/Residency: Indiana U (2011)Fellowship: Indiana U (2012)Practicing with InCyte Pathology 8/2012

PHYSICIANS PRESENTED A SECOND TIME

Chilcott, Margaret E., DOFamily MedicineMed School: Lake Erie College of Osteo Med (2005)Practicing with Rockwood Family Medicine 5/2012

Coco, Dominique P., MDAnatomic & Clinical PathologyMed School: Louisiana State U (2001)Practicing with Pathology Services (Deaconess) 4/2012

Holbert, Daniel V., MDDiagnostic RadiologyMed School: Albany Medical College (2006)Practicing with Radia Inc., PS 7/2012

King, Scott N., MDDiagnostic RadiologyMed School: U of Nevada (2006)Practicing with Inland Imaging Associates (2012)

King, Sarah R., MDInternal MedicineMed School: U of Nevada (2006)Practicing with Rockwood Clinic, PS 8/2012

Kneller, James R. W., MDInternal Medicine/Cardiovascular Disease/Clinical Cardiac ElectrophysiologyMed School: McGill U (2004)Practicing with Inland Cardiology Associates 8/2012

Nguyen, Khanh L., MDNeurologyMed School: U of Oklahoma (2002)Practicing with Providence Neuroscience Center (5/2012)

Reddy, Gautham P., MDDiagnostic RadiologyMed School: George Washington U (1991)Practicing with Radia, Inc., PS 5/2012

Steiger, David, MDInternal Medicine/Critical Care MedicineMed School: Wayne State U (2007)Practicing with Spokane Critical Care dba Spokane Respiratory Consultants 7/2012

Tickman, Ronald J., MDAnatomic and Clinical Pathology/CytopathologyMed School: Emory U (1984)Practicing with Pathology Services (Deaconess) 4/2012

Wade Newell, Heather J., MDPediatricsMed School: U of Iowa (2006)Practicing with Rockwood Clinic, PS 8/2012

PHYSICIAN ASSISTANT

Phillips, Joshua J., PA-CPhysician AssistantSchool: U of Washington, Medex Northwest (2010)Practicing with Providence Medical Group – Orthopedic Specialties 5/2012

PHYSICIAN ASSISTANT PRESENTED A SECOND TIME

Biondo, Natale “Nat” J., PA-CPhysician AssistantSchool: U of Washington, Medex Northwest (2001)Practicing with Deaconess Hospital 4/2012

REAl ESTATE

Luxury Condos for Rent/Purchase near Hospitals. 2 bedroom luxury Condos at the City View Terrace Condominiums are available for rent or purchase . These beautiful condos are literally within walking distance to the Spokane Hospitals (1/4 mile from Sacred Heart, 1 mile from Deaconess) . Security gate, covered carports, very secure and quiet . newly Remodeled . full appliances, including full-sized washer and dryer . Wired for cable and phone . for Rent $ 850/month . for Sale: Seller financing Available . Rent-to-Own Option Available: $400 of your monthly rent will credit towards your purchase price . Please Contact Dr . Taff (888) 930-3686 or dmist@inreach .com .

For Sale: 17718 E linke Rd, Greenacres WA $649,900 Elegance redefined featuring a custom-built rancher and horse property situated on 5 breathtaking acres . for you over 3,800 sq feet, opulent master bedroom, formal dining, open floor plan & a gourmet kitchen . for your horses a 56’ x 48’ metal show barn, heated tack room, 12x12 wash area, 11 matted stalls, mechanical horse walker . Everything to accommodate you & your equestrian needs . Offered by John l Scott Real Estate – John Creighton at (509) 979-2535 . for a virtual tour www .tourfactory .com/709316 .

Spokane County Medical Society members and significant others are invited to enjoy a cruise aboard The Serendipity on the Spokane River. Thursday, July 12 Cruise starting at Templin’s

Marina Boat loading starting at 5:30 p.m. Embarking promptly at 6:00 p.m. Returning at 8:30 p.m.

Limited space available—RSVP to [email protected]

Attention Female Physicians

SAVE THE DATE!March 15-16, 2013A retreat for all female physicians is

being planned.

More details to come.


POSITIOnS AVAIlAblE

PHYSICIAN OPPORTUNITIES AT COMMUNITY HEALTH ASSOCIATION OF SPOKANE (CHAS) Enjoy a quality life/work balance and excellent benefits including competitive pay, generous personal time off, no hospital call, CME reimbursement, 401(k), full medical and dental, nHSC loan repayment and more . To learn more about physician employment opportunities, contact Toni Weatherwax at (509)444-8888 or hr@chas .org .

QTC MEDICAL GROUP is one of the nation’s largest private providers of medical disability evaluations . We are contracted through the Department of Veterans Affairs to manage their compensation and pension programs . We are currently expanding our network of family Practice, Internal Medicine and General Medicine providers for our Washington Clinics . We offer excellent hours and we work with your availability . We pay on a per exam basis and you can be covered on our malpractice insurance policy . The exams require nO treatment, adjudication, prescriptions to write, on-call shifts, overhead and case file administration . Please contact Gia Melkus at 1-800-260-1515 x5366 or email gmelkus@qtcm .com or visit our website www .qtcm .com to learn more about our company .

PRIMARY CARE INTERNIST WANTED (Pullman) - Immediate opportunity for bE/bC primary care internist to join a privately owned, multi-specialty, physician practice . Palouse Medical offers a competitive employment package, guaranteed first year salary, comprehensive benefits and partnership potential . Dedicated to delivering quality care, we are proud to offer an extensive array of patient services and on-site laboratory and imaging departments . We can’t wait to introduce you to the communities that we love and serve . Call Theresa Kwate at (509) 332-2517 ext . 20 or email tkwate@palousemedical .com . Contact us today and discuss your future at Palouse Medical!

FAMILY MEDICINE SPOKANE Immediate opening with family Medicine Spokane (fMS) for a full time bC/bE fP physician who has a passion for teaching . fMS is affiliated with the University of Washington School of Medicine . We have seven residents per year in our traditional program, one per year in our Rural Training Track and also administer Ob and Sports Medicine fellowships . This diversity benefits our educational mission and prepares our residents for urban & rural underserved practices . We offer a competitive salary, benefit package and gratifying lifestyle . Please contact Diane borgwardt, Administrative Director at 509-459-0688 or e-mail at borgwaD@fammedspokane .org .

SPRINGDALE COMMUNITY HEALTH CENTER ARnP or PA-C n .E . Washington Health Programs (nEWHP) has an immediate opportunity for an excellent Physician Assistant (certified) or nurse Practitioner with family Practice experience to join our Springdale Community Health Center located in rural Springdale, WA . This position is for family Practice outpatient care; urgent care experience is a plus but not required . nEWHP offers competitive compensation, comprehensive benefits . . nHSC eligible site . EOE and provider . Application Deadline: Until filled . Send resume to: n .E . Washington Health Programs Attn: Human Resources PO box 808 Chewelah, WA . 99109 or electronically to desirees@newhp .org .

CONTRACT BACK-UP PHYSICIAN 4 + HOURS/MONTH - Octapharma Plasma is hiring a Contract back-Up Physician in our Spokane, WA Donor Center! This position requires just 4 hours per month . GEnERAl DESCRIPTIOn Provide independent medical judgment for issues relating to donor safety, health and suitability for plasmapheresis and immunization . Provide federal and international mandated training and supervision of donor center medical staff to assure compliance with applicable laws . We provide on-the-job training . WHO IS OCTAPHARMA PlASMA? Octapharma Plasma, Inc . is dedicated to improving the health and lives of people worldwide . OPI owns and operates plasma collection centers critical to the development of life-saving patient therapies utilized by thousands of patients globally .

learn more at www .OctapharmaPlasma .com! APPlY TODAY! Apply today by sending your resume/CV to Careers@OctapharmaPlasma .com!

PROVIDENCE HEALTH & SERVICES is building its Urgent Care presence in Spokane . We are recruiting for bE/bC Urgent/Immediate Care physicians and advanced practice providers (nurse practitioners and physician assistants welcome to apply) . This is a great opportunity to join a growing employed medical group in beautiful eastern Washington . The exceptional Providence care team is implementing a system-wide standardized EHR and providers benefit from shared best practices and robust clinical and business support . Providence already operates hospitals, residency programs and numerous primary care and specialty clinics in Spokane . Competitive compensation and excellent benefits package, including relocation . learn more: Mark Rearrick, Providence physician recruiter, (509) 474-6605, mark .rearrick@providence .org, www .providence .org/physicianopportunitiesexperience is a plus but not required . nEWHP offers competitive com

PREMIER CLINICAL RESEARCH, an independent dedicated research facility here in Spokane with 20 years of research experience is looking for a Pediatrician to be a part of our physician network for future studies . for more information please contact: April Gleason, Director of business Development, (509) 390-6768, premierclincalresearch@gmail .com .

PHYSICIANS NEEDED FOR WORKERS COMPENSATION EXAMS let us help you get started in earning additional professional income! We are an established I .M .E . practice currently looking for Active Practice and board Certified Orthopedic and neurological Doctors, to perform Workers Compensation Exams . located just minutes away from Rockwood Clinic in north Spokane, we offer a flexible schedule in a helpful, working environment . Previous experience performing Workers Compensation Exams is not required . Please contact lorraine Stephens for further information at (509) 484-0380 .


MEDICAl OffICES/bUIlDInGS

Good location and spacious suite available next to Valley Hospital on Vercler . 2,429 sq ft in building and less than 10 years old . Includes parking and maintenance of building . Please call Carolyn at Spokane Cardiology (509) 455-8820 .

Sublease: Furnished Medical Office Space ~ need immediate space for one or more north Spokane care providers? This shared suite is ready for occupancy; all furniture and exam room equipment included . Two exam rooms, one provider office, one nurse’s station and shared surgery suite, medical records storage area, reception and waiting area . 963 sq ft total, original lease $23/sq ft; will negotiate lower rate . Excellent location in a full-service medical building with lab and full radiology services . for more information, call (509) 981-9298 .

South Hill – on 29th Avenue near Southeast Boulevard - Two offices now available in a beautifully landscaped setting . building designed by nationally recognized architects . both offices are corner suites with windows down six feet from the ceiling . Generous parking . Ten minutes from Sacred Heart or Deaconess Hospitals . Phone (509) 535-1455 or (509) 768-5860 .

Clinical Space for Lease - built in January 2011 . 1128 sq ft, four exams rooms, two administrative offices, one office with a counter (electronic bar for laptops, etc .), restroom, reception area and waiting room . Rates are negotiable . Interested parties contact Sharon Stephens at bates Drug Stores, Inc . 3704 n . nevada, (509) 489-4500 Ext . 213 or Sam@batesrx .com .

Office space located at 1315 North Division. This location is two miles north of downtown Spokane and just west of Gonzaga and the university district . It consists of 902 sq . ft . and rents for $1015 per month plus 20% of the building Avista and City of Spokane bills . The rest of the building is occupied by a physiatry and pain management medical practice . The space would be ideal for an ancillary medical, chiropractic or therapeutic clinic . Parking is ample and convenient . The space has a nice waiting area and receptionist-enclosed area, with several office, storage or exam rooms . Call (509) 321-2276 for more information or for a showing of your ideal location .

Seattle, WA (206) 343-7300 or 1-800-962-1399

Spokane, WA (509) 456-5868 or 1-800-962-1398

Endorsed by the Washington State Medical Association

www.phyins.com

*Dividend information is total of all past dividends. Future dividends are not guaranteed.

Physician-owned and -directed

Specialty-specific risk management support

More than $60 million in dividends*


1 800 523-2464 | CDACA SI N O.COM | /CDACA SI N O R E S O RT25 miles south of Coeur d’Alene at the junction of US-95 and Hwy-58

SPOKANE COUNTY MEDICAL SOCIETY - ORANGE FLAG BUILDING104 S FREYA ST STE 114SPOKANE, WA 99202

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