January 2012

official publication of the san diego county medical society January 2012

Reaching

8,500 Physicians

Every Month

Our Obesity Epidemic “Physicians United For A Healthy San Diego”

“A” (ExcEllEnt) RAting

renewal rate

in a row of a.M. Best

of last

95

28

years

totAl DiviDEnDs DEclARED

$425M

or very satisfied

total years deClared dividend

Customers satisfied

32 34

93%

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strenghten your Practice at norcalMutual.coM Proud to support the San Diego County Medical Society.

B

S A N D I E G O P HY S I CI A N .or g O c tob e r 2011

Our passion protects your practice

Octo ber 2011 SAN DIEGO P HY SIC I A N. o rg

1

this month Volume 99, Number 1

Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Roderick C. Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Art Director Lisa Williams Copy Editor Adam Elder

SDCMS Board of Directors Officers President Robert E. Wailes, MD (CMA Trustee) President-elect Sherry L. Franklin, MD (CMA Trustee) Treasurer Robert E. Peters, PhD, MD Secretary J. Steven Poceta, MD Immediate Past President Susan Kaweski, MD

features

geographic and geographic alternate Directors East County William T-C Tseng, MD, Heywood “Woody” Zeidman,

MD, Kimberly M. Lovett, MD (A:Venu Prabaker, MD) Hillcrest Theodore S. Thomas, MD, Steven A. Ornish, MD, Jason P. Lujan, MD (A:Gregory M. Balourdas, MD) Kearny Mesa John G. Lane, MD (A:Marvalyn E. DeCambre, MD, Sergio R. Flores, MD) La Jolla Gregory I. Ostrow, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Douglas Fenton, MD, Niren Angle, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD)

OUR OBESITY EPIDEMIC 8 A Call to Action

by Robert E. Wailes, MD

10 Facts and Figures: Defining Overweight and Obesity

by Centers for Disease Control and Prevention

16 A Community of One: An Ecological Approach to Reducing Obesity

Ways Physicians Can Get Started

At-large and At-large alternate Directors Jeffrey O. Leach, MD, Bing S. Pao, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD, Peter O. Raudaskoski, MD, Mihir Y. Parikh, MD, Suman Sinha, MD (A: Carol L. Young, MD, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD)

26 Obesity and Postoperative Surgical Risk

Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker)

by Nick Macchione, MS, MPH, FACHE, and Wilma Wooten, MD, MPH

22 Childhood Obesity Initiative:

by Christopher Searles, MD, and Cheryl L. Moder

other voting members

by Howard Marcus, MD, FACP

Young Physician Director Van L. Cheng, MD Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Medical Student Director Beth P. Griffiths

OTHER NONVOTING MEMBERS

departments

Young Physician Alternate Director Renjit A. Sundharadas, MD Resident Physician Alternate Director Christina Pagano, MD Retired Physician Alternate Director Mitsuo Tomita, MD CMA President-elect James T. Hay, MD CMA Past Presidents Robert E. Hertzka, MD (Legislative Committee Chair), Ralph R. Ocampo, MD CMA Trustee Albert Ray, MD CMA Trustee (OTHER) Catherine D. Moore, MD CMA SSGPF Delegates James W. Ochi, MD, Ritvik Prakash Mehta, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu MD, Ashish K. Wadhwa, MD

4 Briefly Noted

SDCMS and CMA Seminars, Webinars, and Events, and More …

6 Your Monthly Benefits Check-up Our 2012 Seminar and Webinar Schedule and More …

34 Physician Marketplace

Classifieds

36 Vanilla CheezeCake Cups With Raspberry Sauce: It’s Healthy!

by Carmen Beaubeaux

36

Note Explaining the Two Directory Pages Bagged With This Issue: SDCMS’ 2012 San Diego County Physician Directory, mailed with the December 2011 issue of San Diego Physician, contained two pages with printer errors. Please include the reprinted pages bagged with this issue with your 2012 directory.

Thank you, and please accept our sincerest apologies for the errors!

2 SAN DIEGO PHYSICIAN .org jan uary 2012

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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bySAN DIEGO PHYSICIAN the policyholders we protect. jan Owned uary 2012 .org 3

brieflynoted featured member

calendar SDCMS SEMINARS & WEBINARS

COMMUNITY HEALTHCARE CALENDAR

Prescription Opioid Misuse Academy: The Dark Side of Prescription Opioids MAR 15 • Catamaran Resort Hotel, San Diego • www.acmt.net

9th Annual Natural Supplements: An Evidence-based Update JAN 19–22 • Hilton San Diego Bayfront

Topics and Advances in Pulmonary and Critical Care Medicine MAR 17–18 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed

SDCMS.org/event

Workplace Harmony JAN 18 • 11:30am–1:00pm Legislative Advocacy Training (workshop) JAN 21 • 8:00am–12:00pm EHR and Documentation Risk Issues (webinar only) JAN 25 • 6:30pm–7:30pm EHR and Documentation Risk Issues (webinar only) JAN 26 • 11:30am–12:30pm Certified Medical Coder Course JAN 27, FEB 3, 10, 17, 24 • 8:00am–4:00pm HIPAA 5010 (webinar only) FEB 9 • 11:30am–1:00pm Tax Time FEB 16 • 11:30am–1:00pm Collection Strategies MAR 1 • 11:30am–1:00pm 50 Tips for Avoiding Employment Lawsuits MAR 15 • 11:30am–1:00pm Media Training (workshop) MAR 24 • 8:00am–12:00pm ICD-10 Training MAR 29 • 11:30am–1:00pm Solo Practice Strategies for Docs MAR 31 • 8:30am–11:00am

Brain Tumors: 2nd Annual Collaborative Care Conference JAN 21 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ braintumors Bridging the Hearts and Minds of Youth: Mindfulness in Clinical Practice, Education, and Research FEB 4–5 • Catamaran Hotel, San Diego • cme.ucsd.edu/bridging 18th Annual Network of Oncology Clinicians and Researchers Meeting FEB 9–11 • Caesars Palace, Las Vegas • www.nocrannualmeeting. com/2012/index.asp Cell Society: 2nd Annual Clinical Meeting FEB 17–18 • Coronado Island Marriott Resort • xmedicacme. com/cell_society Timmy Global Health Mission Trip to Ecuador MAR 10–17 • Clinics seeing approximately 40 patients per provider per day. • www. timmyglobalhealth.org Topics and Advances in Internal Medicine MAR 12–16 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed

California Orthopaedic Association Annual Meeting APR 19–22 • Park Hyatt Resort in Carlsbad • www.coa.org/coaannual-meeting.html Sharon’s Ride Run Walk for Epilepsy 2012!

APR 25 • De Anza Cove, Mission Bay Park • $25 Individuals/$50 Family/Phil’s BBQ Lunch included • 7:30am-1:00pm • sharonsride2012.kintera.org 15th Annual California Health Care Leadership Academy APR 27–29 • Disneyland Hotel, Anaheim • Models of healthcare financing and delivery will change as implementation of federal health reform kicks into high gear.

What are the best options for successful medical practice in the new environment? Hear from the experts and leaders of change, and attend a comprehensive slate of practice management seminars and workshops to position your practice for success. Details coming in January — stay tuned!

13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort

Stay on top of the issues critical to managing your practice …

Sign up to receive SDCMS’ e-newsletter “News You Can Use” by emailing Gehring@SDCMS.org.

4 SAN DIEGO PHYSICIAN.org jan uary 2012

Become an SDCMS

Featured Member!

SDCMS would like to feature some of our member physicians for you co heruld app e ne ear their noteworthy acxt! complishments in these pages and on SDCMS. org! If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org.

Thank you, and thank you for your membership in SDCMS and CMA!

legislator birthdays One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday!

BIRTHDAY: JAN. 28 U.S. Representative Brian Bilbray (District 50) E: (via website) bilbray.house.gov Washington, DC, Office: T: (202) 225-0508 • F: (202) 225-2558 Solana Beach Office: 380 Stevens Ave., Ste. 212, Solana Beach, CA 92075 T: (858) 350-1150 • F: (858) 350-0750

BIRTHDAY: FEB. 11 State Senator Joel Anderson (District 36) E: (via website) cssrc.us/web/36 E: senator.anderson@sen.ca.gov Sacramento Office: State Capitol, Rm. 2054, Sacramento, CA 95814 T: (916) 651-4036 • F: (916) 447-9008 El Cajon Office: 500 Fesler St., #201, El Cajon, CA 92020 T: (619) 596-3136 • F: (619) 596-3140

you take care of the san diego communit y ’s health. we take care of san diego’s

healthcare communit y.

get in touch

3 income Tax Planning 3 Wealth Management

Your SDCMS and SDCMSF Support Teams Are Here to Help!

3 employee Benefit Plans

SDCMS Contact Information

5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DIRECTOR OF BUSINESS DEVELOPMENT Sylvia Lange at (858) 300-2782 or Sylvia.Lange@SDCMS.org DATABASE ADMINISTRATOR Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org MEMBERSHIP ADMINISTRATIVE ASSISTANT Serena Sauerheber at (858) 300-2779 or Serena.

Sauerheber@SDCMS.org OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure 3 succession Planning 3 Practice Valuations 3 internal Control Review and Risk Assessment

akt A KT LLP, CPAs and Business Consu LTAnTs CARL SBAD

ESCONDIDO

760-431-8440

S A N DIEGO

W W W.AKTCPA.COM ron mitchell, cpa director of health services

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SDCMSF Contact Information

5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Tanya Rovira at (858) 565-8161 or Tanya.Rovira@SDCMS.org RESOURCE DEVELOPMENT DIRECTOR Lauren Banfe at (858) 565-7930 or Lauren.Banfe@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org

Give Us 5 Minutes and We’ll Give You a Benefits Check-up!

Call SDCMS at (858) 565-8888 to schedule a time Today!

jan uary 2012 SAN DIEGO PHYSICIAN .org 5

Your Monthly Benefits

check-up Put Your SDCMS-CMA Membership to Work!

This Month:

✓✓ Last Year’s Seminars and Webinars: A Huge Success! ✓✓ Our 2012 Seminar / Webinar Schedule ✓✓ Deadlines and Reminders

6 SAN DIEGO PHYSICIAN.org jan uary 2012

Last Year’s Seminars and Webinars in a Nutshell: A Huge Success!

SDCMS would like to thank those 1,779 member physicians, office managers, and staff who attended our 36-plus seminars and webinars in 2011! Our most popular seminars covered topics including Medicare, collections procedures, OSHA, HIPAA, and how to treat patients right. Don’t forget that all seminars and webinars are available for viewing by SDCMS member physicians and office managers at SDCMS.org/webinars. For assistance with logging in, contact Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org.

Thank you again for your membership with SDCMS-CMA and for allowing us to help you and your staff with your training needs throughout the year by offering a robust seminar schedule. We look forward to seeing you again in 2012!

PRACTICE MANAGEMENT AND MEMBERSHIP DEADLINES & REMINDERS • ONGOING: TDC-insured SDCMS member physicians MUST satisfy their participation requirement ONCE EVERY TWO YEARS in order to continue receiving their TDC medical professional liability insurance premium credit. Contact Janet Lockett at SDCMS at (858) 300-2778 or at Janet.

Lockett@SDCMS.org.

• JAN 1: SDCMS-CMA Membership Dues Deadline • FEB 29: Last day for eligible professionals to register and attest to receive incentive payment for calendar year 2011 (eHR).

Our 2012 Seminar and Webinar Schedule: Mark Your Calendar!

Your

Monthl y Benefit check-u s p

SDCMS member physicians and their staff are invited to attend, free of charge, our seminars and webinars held throughout the year. Courses, such as the Certified Medical Coder course that begins on Jan. 27, are offered to members and staff at a discount. Details may change — please visit SDCMS.org/event for the latest information or contact SDCMS to confirm.

Most SDCMS seminars are held in our large meeting room at 5575 Ruffin Road, Suite 250, San Diego 92123. Webinars are made available for those who can’t step away from the office. Advanced registration is required for both seminars and webinars. For further information, watch your faxes, visit SDCMS. org/event, or contact Serena Sauerheber at (858) 300-2779 or at Serena.Sauerheber@SDCMS.org.

JAN 18 (11:30am–1:00pm): Workplace Harmony JAN 21 (8:00am–12:00pm): Advocacy Training (workshop) JAN 25 (6:30pm–7:30pm): Electronic Health Records: Best Practices (webinar only) JAN 26 (11:30am–12:30pm): Electronic Health Records: Best Practices (webinar only) JAN 27, FEB 3, 10, 17, 24 (8:00am–4:00pm): Certified Medical Coder Certification Course FEB 9 (11:30am–1:00pm): HIPAA 5010 (webinar only) FEB 16 (11:30am–1:00pm): Tax Time: Changes in Tax Law MARCH 1 (11:30am–1:00pm): Collection Strategies MARCH 15 (11:30am–1:00pm): 50 Tips for Avoiding Employment Lawsuits MARCH 24 (8:00am–12:00pm): Media Training (workshop) MARCH 29 (11:30am–1:00pm): ICD-10 Training MARCH 31 (8:30am–11:00am): Solo Practice Strategies for Docs APRIL 10, 11 (11:00am–2:00pm): SDCMS Vendor Fair (tentative) APRIL 18 (6:30pm–7:30pm): Managing Challenging Patients APRIL 19 (11:30am–12:30pm): Managing Challenging Patients APRIL 20, 21 (9:00am–4:00pm, 9:00am–1:00pm): The Leader’s Toolbox (workshop) APRIL 26 (11:30am–1:00pm): Subpoena Seminar APRIL 28 (8:00am–4:00pm): Preparing to Practice (workshop) MAY 10 (11:30am–1:00pm): Follow-up ICD10: Where Are We Now? MAY 16 (11:30am–1:00pm): Retirement Seminar MAY 24 (11:30am–2:00pm): Cal-OSHA Certification Training MAY 30 (11:30am–1:00pm): NPs and PAs: Organizational, Hiring, and Management Basics JUNE 7 (11:30am–1:00pm): Social Media in Healthcare JUNE 14 (11:30am–1:00pm): Are Your Contracts Healthy?

JUNE 20 (11:30am–1:00pm): Business Law 101 for New Physicians JUNE 21 (6:00pm–7:30pm): Business Law 101 for New Physicians JUNE 23 (8:30am–11:30am): Financial and Legal Life Skills (workshop) JULY 7 (8:30am–11:30am): Microsoft Outlook for Crazy Busy Docs (workshop) JULY 11 (6:30pm–7:30pm): Communicating Adverse Outcomes (webinar only) JULY 12 (11:30am–12:30pm): Communicating Adverse Outcomes (webinar only) AUG 9 (11:30am–1:00pm): EHR Incentives AUG 23 (11:30am–1:00pm): Buying, Selling, and Leasing Office Space SEPT 6 (11:30am–1:00pm): Practice Valuation SEPT 15 (8:00am–12:00pm): Media Training (workshop) SEPT 20 (11:30am–1:00pm): How To’s of Appeals SEPT 27 (11:30am–2:00pm): Strategies for Medical Office Managers OCT 4 (11:30am–1:00pm): Worker’s Compensation Billing OCT 18 (11:30am–1:00pm): EHR Meaningful Use NOV 1 (11:30am–1:00pm): Identity Theft NOV 2, 3 (9:00am–4:00pm, 9:00am–1:00pm): The Leader’s Toolbox (workshop) NOV 14 (6:30pm–7:30pm): Top 10 Patient Safety Issues for Office Practice (webinar only) NOV 15 (11:30am–12:30pm): Top 10 Patient Safety Issues for Office Practice (webinar only)

jan uary 2012 SAN DIEGO PHYSICIAN.org 7

Our Obesity Epidemic A Call to Action ❱❱

The vision of the San Diego County Medical Society (SDCMS) is “Physicians United for a Healthy San Diego.” In pursuit of this vision, I want to address the obesity epidemic that has such a huge impact on public health in San Diego. As president I want to kick off a multiyear project to coordinate our community’s efforts to reduce this unhealthy condition.

Obesity has reached epidemic proportions nationwide. Recent data reveals that every state in our nation now has at least 20 percent of the population classified as obese. The health effects are severe to the individual and costly to our healthcare system. Nearly all organ systems within the body suffer from the effects of obesity, so this affects all medical specialties.

I write this column today as a call to action. I will convene a gathering of experts

8 SAN DIEGO PHYSICIAN.org jan uary 2012

by Robert E. Wailes, MD

in February to see how SDCMS can engage all of San Diego County’s physicians and other community leaders in the fight. We want to encourage and support the many organizations already providing significant help and treatment in this area. I know that we currently have many local experts and many existing programs already working on this problem. I want to help coordinate the efforts to create more efficiency and impact in treating our diverse population within San Diego County.

I would like to approach this problem on many different fronts. To achieve any level of success, we will need to have a multipronged attack. Some of these approaches may include increased education at the primary school level, increased awareness of the importance of exercise within the educational system, and, for

adults, greater training in regard to nutrition and dietary habits, greater efforts at revealing accurate calorie counts for the foods that we consume in general and in restaurants, better counseling regarding the severe health impacts of obesity in an effort to change behaviors, and more education regarding treatment alternatives to combat obesity among many other treatment opportunities.

If you or your organization wishes to engage holistically in the communitywide fight to address obesity, please contact me at President@SDCMS.org by Jan. 20, 2012.

If you or your organization wishes to engage holistically in the communitywide fight to address obesity, please contact me at President@SDCMS.org

by Jan. 20, 2012.

On Feb. 27, 2012, we will meet to create a countywide action plan for San Diego County’s physician community.

If we are successful with some new or expanded programs, I would hope to leverage that success by exporting this program to other communities in an effort to have a greater impact nationally. I look forward to collaborating together toward achieving success in this public health effort.

Best wishes for a healthy, happy, and prosperous future.

Dr. Wailes, SDCMS-CMA member since 1993, is president of the San Diego County Medical Society.

Our Obesity Epidemic

facts and figures

Defining Overweight and Obesity ❱❱

by the CDC

Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered healthy for a given height. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.

Definitions for Adults: For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the “body mass index” (BMI). BMI is used because, for most people, it correlates with their amount of body fat.

10 SAN DIEGO PHYSICIAN.org jan uary 2012

• An adult who has a BMI between 25 and 29.9 is considered overweight.

• An adult who has a BMI of 30 or higher is considered obese.

See the following table for an example.

HEIGHT WEIGHT RANGE 5’9”

BMI

CONSIDERED

124 pounds or less

below 18.5

Underweight

125–168 pounds

18.5–24.9

healthy weight

169–202 pounds

25.0–29.9

overweight

203 pounds or more

30 or higher

obese

It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight even though they do not have excess body fat. For more information about BMI, visit www.cdc.gov/healthyweight/assessing/bmi/index.html.

Other methods of estimating body fat and body fat distribution include measurements of skinfold thickness and waist circumference, calculation of waist-to-hip circumference ratios, and techniques such as ultrasound, computed tomography, and magnetic resonance imaging (MRI).

Definitions for Children and Teens: For children and teens, BMI ranges above a normal weight have different labels (overweight and obese). Additionally, BMI ranges for children and teens are defined so that they take into account normal differences

in body fat between boys and girls and differences in body fat at various ages. For more information about BMI for children and teens (also called BMI-for-age), visit BMI for Children and Teens (apps.nccd.cdc.gov/ dnpabmi/Calculator.aspx).

For more, see www.cdc.gov/obesity/childhood/basics.html.

Assessing Health Risks Associated with Overweight and Obesity: BMI is just one indicator of potential health risks associated with being overweight or obese. For assessing someone’s likelihood of developing overweight- or obesity-related diseases, the National Heart, Lung, and Blood Institute guidelines recommend looking at two other predictors: • The individual’s waist circumference (because abdominal fat is a predictor of risk for obesity-related diseases).

• Other risk factors the individual has for diseases and conditions associated with obesity (for example, high blood pressure or physical inactivity).

For more information about the assessment of health risk for developing overweight- and obesity-related diseases, visit the following webpages from the National Heart, Lung, and Blood Institute: • Assessing Your Risk (www.nhlbi.nih. gov/health/public/heart/obesity/ lose_wt/risk.htm) • Body Mass Index Table (www.nhlbi. nih.gov/guidelines/obesity/bmi_tbl. htm) • Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm)

jan uary 2012 SAN DIEGO PHYSICIAN.org 11

Our Obesity Epidemic Prevalence of Obesity Among Adults 2009 by the OECD

Prevalence of obesity among adults, 2009 (or nearest year) Measured data

Self-reported data

33.8 30.0

26.5 25.1 24.6 24.2 23.0 23.0 22.1 20.2 20.1 20.1 19.5 18.1 18.1 18.0 17.0 16.9 16.9 16.4 16.0 15.4 15.2 14.7 13.9 13.8 13.8 13.4 12.5 12.4 11.8 11.2 11.2 10.3 10.0

40 30 % of adult population

20

United States Mexico New Zealand Chile Australia Canada United Kingdom Ireland Luxembourg Finland Iceland Russian Federation Hungary Greece South Africa Estonia Czech Republic Slovak Republic OECD Slovenia Spain Portugal Turkey Prevalence ofGermany obesity among adults, 2009 (or nearest year) Brazil Measured data Self-reported data Belgium Israel Denmark Poland Austria Netherlands France Sweden Italy Norway Switzerland 3.9 Japan Korea 3.8 2.9 China 2.4 Indonesia India 2.1 33.8

30.0

8.1

10

0

Source: OECD Health Data2011; national sources for non-OECD countries.

40 30 % of adult population

26.5 25.1 24.6 24.2 23.0 23.0 22.1

20.2 20.1 20.1 19.5 18.1 18.1 18.0 17.0 16.9 16.9 16.4 16.0 15.4 15.2 14.7 13.9 13.8 13.8 13.4 12.5 12.4 11.8 11.2 11.2 10.3 10.0

8.1 3.9 3.8 2.9 2.4 2.1

20

10

Source: OECD Health Data2011; national sources for non-OECD countries.

12 SAN DIEGO PHYSICIAN.org jan uary 2012

0

United Stat Mexico New Zealan Chile Australia Canada United King Ireland Luxembour Finland Iceland Russian Fed Hungary Greece South Afric Estonia Czech Repu Slovak Rep OECD Slovenia Spain Portugal Turkey Germany Brazil Belgium Israel Denmark Poland Austria Netherlands France Sweden Italy Norway Switzerland Japan Korea China Indonesia India

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8.4375x11_SMF Physicians AD.indd 1

11/17/11 11:59 AM

Our Obesity Epidemic

Adult Obesity: Did You Know?

Source: CDC

Obesity Is Common, Serious, and Costly: • About one-third of U.S. adults (33.8%) are obese.

Prevalence of Obesity in California by Race/ Ethnicity (Percentage of Adult Population)

• No state has met the nation’s Healthy People 2010 goal to lower obesity prevalence to 15%. The number of states with an obesity prevalence of 30% or more has increased to 12 states in 2010. In 2009, nine states had obesity rates of 30% or more. In 2000, no state had an obesity prevalence of 30% or more.

• Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, some of the leading causes of death.

• In 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs paid by third-party payors for people who are obese were $1,429 higher than those of normal weight.

Source: CDC

Obesity Prevalence Varies Across States and Regions: NON-HISPANIC WHITE

21.8%

• The South has the highest obesity prevalence (29.4%) followed by the Midwest (28.7%), Northeast (24.9%) and the West (24.1%).

• Obesity affects some groups more than others.

NON-HISPANIC BLACK

35.8% HISPANIC

• By state, obesity prevalence, on the basis of self-report, ranged from 21% in Colorado to 34% in Mississippi in 2010. Twelve states had a prevalence of 30% or more.

30.6

%

NON-HISPANIC ASIAN

8.4% NON-HISPANIC HAWAIIAN / PACIFIC ISLANDER

21.7% NON-HISPANIC MULTIRACIAL

23.7% 14 SAN DIEGO PHYSICIAN.org jan uary 2012

• Non-Hispanic blacks have the highest rates of obesity (44.1%) compared with Mexican Americans (39.3%), all Hispanics (37.9%) and non-Hispanic whites (32.6%).

Obesity and Socioeconomic Status: • Among non-Hispanic black and Mexican-American men, those with higher incomes are more likely to be obese than those with low income.

• Higher income women are less likely to be obese than low-income women.

• There is no significant relationship between obesity and education among men.

Among women, however, there is a trend: Those with college degrees are less likely to be obese compared with less-educated women.

• Between 1988–1994 and 2007–2008 the prevalence of obesity increased in adults at all income and education levels.

jan uary 2012 SAN DIEGO PHYSICIAN.org 15

Our Obesity Epidemic

A

Community of One An Ecological Approach to Reducing Obesity ❱❱

by Nick Macchione, MS, MPH, FACHE, and Wilma Wooten, MD, MPH

16 SAN DIEGO PHYSICIAN.org jan uary 2012

The Problem

Obesity is the paramount public health concern in 2012, as rates have tripled in the past 30 years. Obesity among U.S. children ages 6 to 11 increased from 6.5 percent in 1980 to 19.6 percent in 2008. Among adolescents ages 12 to 19, obesity has increased from 5.0 percent to 18.1 percent.

Nationwide, three in five adults are overweight or obese (1). The medical, quality of life, and economic consequences are staggering. Risks for the leading causes of death (cardiovascular disease, cancer, and diabetes) increase with obesity (2). A 2009

The medical, quality of life, and economic consequences are staggering. study found the estimated annual direct and indirect costs of being overweight or obese and physically inactive in California was $41.2 billion, while in San Diego it was more than $3 billion (3).

Strategies

2001 marked the beginning of a concerted effort across San Diego County to curb the tide on obesity. Committed public leadership from County Supervisors Ron Roberts and Pam Slater-Price and the rest of the Board of Supervisors championed many of the early regionwide interventions.

Guided by data; evidence-informed and best-practice models; and dedicated physicians, nurses, clinicians, teachers, parents, business and faith leaders, foundations and nonprofit agencies, effective solutions to obesity have begun to take hold that are transforming San Diego County and creating better health for all.

jan uary 2012 SAN DIEGO PHYSICIAN.org 17

Our Obesity Epidemic Milestone

Key Dates

Major Focus and/or Accomplishments

Reduce or Eliminate Health Disparities With Information (REHDI)

2001–Present

Launch of a public/private partnership led

by HHSA, Public Health Services to address health disparities. REHDI continues with a “place-based” framework.

Coalition on Children and Weight San Diego

2001

Addressed the rise of overweight children in San Diego County. It became part of the COI in 2008.

Childhood Obesity Master Plan

2004

Board of Supervisors unanimously approved creation and funding for this plan.

The Call to Action: San Diego County Childhood Obesity Action Plan (COAP)

2006 (revised 2010)

Outlined policy and environmental changes necessary to reduce and prevent childhood obesity.

The Childhood Obesity Initiative (COI)

2006–Present

Creation of a multisector initiative charged with implementation of the COAP.

The Chronic Disease Agenda

2008

HHSA launches 19 evidence-based activities through environmental, policy, and systems change strategies. Transitioned to CPPW in 2010.

Nutrition Security Plan

2009–Present

Coordinated effort to increase the number of people eligible for California SNAP (CalFresh).

Communities Putting Prevention to Work (CPPW)/Healthy Works Grant

2010–Present

HHSA receives a two-year, $16.1 million obesity prevention grant to reduce chronic disease. Ends March 18, 2012.

Building Better Health (BBH)

2010

Board of Supervisors approves the BBH component of the Live Well, San Diego! initiative, Sept. 13, 2010.

Live Well, San Diego!

Initiative

2010–Present

The County of San Diego’s 10-year transformational plan to improve health, safety, and economic stability of families.

Community Transformation Grant (CTG)

2011

HHSA receives a five-year, $15 million chronic disease prevention grant. Ends in September 2016.

This transformation is built upon the success from several prior health improvement initiatives, such as the Coalition on Children and Weight and the Childhood Obesity Initiative (COI). The transformation has broadened its scope to go beyond just obesity and includes other chronic conditions. Today, we are guided by Live Well, San Diego!, an innovative strategic initiative that cuts across sectors, agencies, disciplines, and programs, and is framed within the spectrum of ecology. Place does matter, and data-driven strategies that address root causes and multifactor determinants of health are now driving how we do business. The following table outlines the most influential milestones in this countywide effort:

Lessons Learned

18 SAN DIEGO PHYSICIAN.org jan uary 2012

Live Well, San Diego! is taking a fragmented system and moving an entire county toward a unified approach to health — “A Community of One” — by addressing the leading causes and conditions of death and disability illustrated in the 3-4-50 principle. However, this can only be achieved with the buy-in and commitment of all public and private organizational stakeholders, as well as the personal responsibility of all San Diegans.

Through collaborative partnership, Live Well, San Diego! has implemented multiple community forums across the region involving local stakeholders and national experts. The COI has grown and expanded since its inception and continues to work collaboratively across hundreds of agencies and partners locally, statewide, and nationally on multiple ecological levels to increase capacity and engage the community. Key to COI’s continued success and impact is the engagement and leadership of champions across seven core domain areas: government, healthcare, schools and after-school, early childhood, community, media, and business. These efforts are moving San Diego County toward becoming a healthier Community of One.

3

behaviors

Tobacco use poor diet no exercise



4

diseases

heart disease type 2 diabetes lung disease cancer



50

percent

of deaths

Broadening the Scope of Partners to Increase the Span of Influence

To effect change through nontraditional health sectors, it has been necessary to engage in key partnerships with city planners and managers, as well as with officials across all county municipalities and jurisdictions. CPPW efforts focused on integrating public health language and concepts into the SANDAG Regional Transportation Plan, as well as within numerous municipalities’ general plans, illustrate this principle. Public Health’s level of influence

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Our Obesity Epidemic has expanded into traffic engineering best practices through advocating Complete Streets policies, promoting (and funding) Safe Routes to Schools programs, and providing support and technical assistance for various stakeholder groups in the healthy design of buildings and facilities. By expanding the scope of partners, the span of influence is increased to achieve bolder accomplishments.

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To effect change through nontraditional health sectors, it has been necessary to engage in key partnerships with city planners and managers, as well as with officials across all county municipalities and jurisdictions.

Local Accomplishments

Through the groundbreaking work of COI and CPPW, the vision of Live Well, San Diego! is beginning to materialize through fundamentally strategic policy, systems, and environmental changes. A sampling of the results of these changes include: • Institutionalized obesity prevention strategies in routine clinical practice.

• Increased healthy and local foods in school meal programs.

• Enabling more than 7,000 Cal Fresh, WIC, and SSI recipients to use EBT cards to purchase fresh produce and providing matching funds to increase their monthly produce purchases.

• Removal of costly permitting requirements and zoning restrictions for establishing community gardens.

• Adoption of lactation accommoda-

tion policies by the California School Boards Association, the San Diego Unified School District, and SPAWAR, earning the latter a 2011 California State Mother-Baby Friendly Workplace Award.

• Expanding the use of the San Diego Immunization Registry to monitor body mass index (BMI).

Ultimate Outcome and I mpact

The data emerging indicates that these collective efforts are paying off, resulting in a “healthy bottom line.” The number of overweight and obese 5th, 7th, and 9th graders in San Diego County declined by 3.7 percent from 2005 to 2010. Statewide, the drop was 1.1 percent, although 31 of California’s 58 counties had increasing percentages (4).

Future I mplications

Live Well, San Diego! requires a collective commitment and shared responsibility across all County/government agencies and external partners, programs, and services to be fully realized. A unified vision that cuts across sectors, agencies, disciplines, and programs has occurred by framing health within the spectrum of a person’s ecology.

We are becoming A Community of One. Over the next 10 years, Live Well, San Diego! will result in healthier communities and smarter, more effective systems of care built upon four foundational strategies: building better service delivery systems, supporting healthy choices, pursuing policy changes for healthy environments, and changing the culture from within to promote employee wellness.

Get Involved

Achieving reductions in obesity-related morbidity and mortality is not easy, but it is within our grasp. Ensuring access to fresh and healthful produce, walkable and safe neighborhoods, and opportunities for recreation and social connections

are goals that are achievable. Healthcare practitioners and administrators are encouraged to support San Diego’s vision for better health and wellness. Here are a few suggested concrete and actionable steps that are recommended to help reduce the burden of obesity and chronic disease in our community, and to achieve better health for all: • Become a Healthy Food in Healthcare facility or provider by taking the Healthy Food in Healthcare Pledge (www.noharm.org/us_canada/issues/ food/pledge.php).

• Download and use the Physician Advocacy à la Carte Menu of Options (ourcommunityourkids.org/media/4373/Menu%20FINALpub.pdf).

• Access and utilize the provider toolkits for obesity prevention and healthy communities (ourcommunityourkids.org/domains--committees/

healthcare.aspx#resources).

• Get involved with prevention coalitions and HHSA regional community forums.

• Effect workplace wellness programs and policies to support tobacco-free living, healthy eating (including lactation policy), and active living, and to improve clinical preventive services regarding high blood pressure and high blood cholesterol.

To learn more about obesity and chronic disease prevention efforts in San Diego County, please visit the COI website at www.ourcommunityourkids.org and the CPPW/Healthy Works website at www. healthyworks.org.

Mr. Macchione is director of Health and Human Services Agency, County of San Diego. Dr. Wooten is the public health officer of Health and Human Services Agency, County of San Diego.

References:

1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295, (13): 1549-1555.

2. Office of the Surgeon General (2010). The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville, MD, U.S. Department of Health and Human Services.

3. California Center for Health Advocacy (2009).

The Economic Costs of Overweight, Obesity, and Physical Activity Among California Adults — 2006. Accessed 12/8/11 at www.publichealthadvocacy.org/costofobesity.html.

4. Babey, S. H., Wolstein, J., Diamant, A. L., Bloom, A., & Goldstein, H. (2011). A patchwork of progress: Changes in overweight and obesity among California 5th-, 7th-, and 9th-graders, 2005–2010. UCLA Center for Health Policy Research and California Center for Public Health Advocacy. Accessed 12/8/11 at www. healthpolicy.ucla.edu/pubs/files/PatchworkStudy.pdf.

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Our Obesity Epidemic

Childhood Obesity Initiative Ways Physicians Can Get Started ❱❱

22 SAN DIEGO PHYSICIAN.org jan uary 2012

by Christopher Searles, MD, and Cheryl L. Moder

San Diego County has received some very welcome news about its regionwide fight against childhood obesity. A recent study by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy shows that between 2005 and 2010, the number of overweight and obese students in San Diego County dropped 3.7 percent. Statewide, the drop was 1.1 percent, while 31 of California’s 58 counties actually saw an increase during the same time period.

The news of declining obesity rates in San Diego County is certainly welcome, but we still have a lot of work ahead of us to turn the tide of both adult and childhood obesity in our county. Just as the etiology of the obesity epidemic is multifactorial, our response must bring together partners from multiple sectors and communities to address the issue head on.

For the past six years, the San Diego County Childhood Obesity Initiative (COI) has provided key support to partners throughout our region, and a place for these partners to converge and work together to find real solutions to the obesity challenges in our communities. Facilitated by the nonprofit Community Health Improvement Partners (CHIP), the COI is a public/ private partnership that engages community partners from multiple sectors to work together in an effort to impact childhood obesity through environmental, systems, and policy change throughout San Diego County.

The Initiative was formed to assure effective implementation of the strategies outlined in the San Diego County Childhood Obesity Action Plan, a groundbreaking, comprehensive plan that identifies strategies in seven domains with the most influence on developing healthy community environments (government; healthcare; schools; early childhood; community; media; and business). With centralized coordination and leadership of COI, leaders from hundreds of public and private agencies and organizations have voluntarily stepped forward to champion the cause, guide work in and across sectors, and engage their peers and colleagues

jan uary 2012 SAN DIEGO PHYSICIAN.org 23

Our Obesity Epidemic We know intuitively that it may not be the 15 minutes we spend in the doctor’s office that can make the greatest impact on health, but rather the other 23 hours and 45 minutes of the day in the places where we live, work, learn, and play that have the greatest impact on health.

to work together to create communities that support health by improving access to healthful foods and opportunities for physical activity in local neighborhoods.

With much work in progress, this tremendous effort has resulted in policy change, advancement, and implementation of childhood obesity prevention strategies and development of best practice models that have been replicated throughout San Diego County and elsewhere.

Some examples include: • Numerous food/physical activity policies have been passed by the San Diego County Board of Supervisors.

• Partnerships created between public health and land use/transportation planning professionals have led to integration of public health into community design and transportation strategies.

• With technical assistance, numerous municipalities have incorporated health elements into city general plans and implemented “healthy” redevelopment projects.

• Regular forums educate elected officials and have gained support for healthy food/physical activity policies.

• A free, centralized resource and referral network for community-based nutrition and physical activity programs via telephone or website was created through 211 San Diego.

• Youth Engagement and Action for Health (YEAH!), a training program for youth leaders to encourage neighborhood assessments and advocacy for policy and environmental change, has helped to create a new generation of public health advocates.

As the COI has shown, a robust response that brings together partners from across our communities offers the best chance at improving health in our region. While physicians are certainly at the forefront of this battle, significant progress will only be made if we turn the walls of our clinics inside out to make strong connections with the communities in which our patients live. Making sure that our patients can see

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us in the office is only part of the solution to finding better health.

We know intuitively that it may not be the 15 minutes we spend in the doctor’s office that can make the greatest impact on health, but rather the other 23 hours and 45 minutes of the day in the places where we live, work, learn, and play that have the greatest impact on health. The simplest recommendations — things like improved nutrition and increasing exercise — can often fall flat when the communities where our patients return to are struggling to support these recommendations. For example, a suggestion to increase consumption of fruits and vegetables might be especially challenging for patients who have no supermarkets in their neighborhoods, inadequate access to transportation, and limited income.

By increasing our own “community competence,” better understanding the barriers our patients face as they translate

F

our recommendations into positive action, and advocating for communities that support health, we can increase the power of the clinical moment and improve the health of our patients.

Where to start? Luckily, with its Physician Advocacy Menu, the San Diego County Childhood Obesity Initiative has made it easier than ever to give physicians the options that work best for them. This menu of ideas offers ways physicians can engage communities and create the kind of strong community collaborations that support the hard work that physicians do in their offices. Employing these ideas can make a huge difference in our efforts to improve the health of our patients who depend on us. The menu offers a wide range of ideas about ways physicians can get started, even those with a busy schedule. From engaging your local schools to providing healthy tips to patients or simply learning more about the communi-

or the Unique. The savvy. The refined. For the Connoisseur of Life.

ties we serve, this “menu” is designed to help physicians find the advocacy tool that works best for them.

For more information about the San Diego County Childhood Obesity Initiative or to download a copy of the Physician Advocacy menu, please visit the COI website at www.OurCommunityOurKids. org or call (858) 609-7964.

Dr. Searles, SDCMS-CMA member since 2007, is board certified in family medicine and psychiatry and is co-chair of the SD COI. Ms. Moder is director of the San Diego County Childhood Obesity Initiative, a public/private partnership focused on reducing and preventing obesity through education, advocacy, policy development, and environmental change. The Initiative is facilitated by Community Health Improvement Partners, a San Diego non-profit that assesses and addresses the most significant health needs of San Diego County residents.

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Our Obesity Epidemic

Obesity and Postoperative Surgical Risk ❱❱

by Howard Marcus, MD, FACP

26 SAN DIEGO PHYSICIAN.org jan uary 2012

Note: To read this article with references, please visit SDCMS.org.

Obesity rates in the United States continue to rise. According to the National Institutes of Health (NIH), one method of determining obesity is through the use of body mass index (BMI), where a BMI over 30 is considered obese.

During an analysis of cross-specialty claims, The Doctors Company noticed an increase in the number of claims filed by patients who are overweight or obese. As a result, The Doctors Company believes it is especially important for member physicians to be aware of the risks of treating obese patients, beginning with examining surgical morbidity and mortality related to obesity.

Claims reviews revealed a pattern of severe postoperative respiratory depression in obese patients who had either a known or suspected diagnosis of obstructive sleep apnea (OSA). The following case reports illustrate the importance of a focused preoperative evaluation to identify patients who are at risk for OSA and to appropriately manage and monitor postoperative pain control without compromising respiratory status.

• This 33-year-old patient was 5'6" and weighed 312 pounds (BMI 50.4).

She underwent bladder suspension and inguinal hernia repair without a preoperative history or evaluation for OSA. Postoperatively, Dilaudid 2mg and Phenergan 100mg IV were administered while in the postanesthesia care unit (PACU), and the patient was transferred to the floor at 10 a.m. Over the next eight hours, she received a total dose of 12mg of

jan uary 2012 SAN DIEGO PHYSICIAN.org 27

Our Obesity Epidemic IV Dilaudid. That evening the nurse recorded that patient was “sleeping quietly,” and at 8:45 the patient was “sleeping, snoring.” At 9:15 the nurse found the patient pulseless and in respiratory arrest. The patient was declared brain dead and died two days later. Subsequently, the husband reported her prior history of nocturnal symptoms consistent with OSA.

Claims reviews revealed a pattern of severe postoperative respiratory depression in obese patients who had either a known or suspected diagnosis of obstructive sleep apnea (OSA).

• A 51-year-old male with height of 5'6" and 210 pounds (BMI of 33.9) underwent a partial colectomy. The patient received a total of fentanyl 100mcg and morphine sulfate 5mg over one hour in the PACU. The patient initially experienced oxygen desaturation, which improved during the next few hours. The patient was then transferred to the floor with an order to maintain the O2 saturations above 90.

However, the patient was not continuously monitored while on morphine sulfate patient-controlled analgesia (PCA) pump. The nurse recorded an SaO2 of 89 percent and received orders from the surgeon to increase inspired oxygen to 6 liters/minute. Subsequently, the patient was found nonresponsive and pulseless with a pCO2 of 130.

The patient died a week later. The autopsy noted the cause of death as global anoxic brain injury.

• A 42-year-old patient who was 5'5",

28 SAN DIEGO PHYSICIAN.org jan uary 2012

220 pounds (BMI 36.6), with a known history of OSA was admitted overnight following a hysterectomy. She was medicated with morphine sulfate, monitored on pulse oximetry, and received continuous positive airway pressure (CPAP). The patient was discharged with oral narcotics for pain control but without orders to continue CPAP. She expired at home 24 hours after discharge.

The Clinical Picture?

Obstructive sleep apnea has been defined as “an apnea-hypopnea index (AHI — the total number of episodes of apnea and hypopnea per hour of sleep) of five or higher in association with symptoms of excessive daytime somnolence.” Symptomatic sleep apnea is common and occurs in 4 percent of men and 2 percent of women ages 30 to 60. Furthermore, 24 percent of men and 9 percent of women have an AHI of at least five, although they may not complain of daytime somnolence. It has been estimated that more than 80 percent of men and 90 percent of women with OSA do not have a documented diagnosis.

Risk factors include obesity, increased neck circumference, craniofacial abnormalities, and hypothyroidism. Patients with upper-body/abdominal obesity are at highest risk for OSA. Additional risk factors include African-American race, current cigarette smokers, and upper airway softtissue abnormalities.

The pathophysiology of OSA involves a balance between neural respiratory stimulation and mechanical airway patency.

Brainstem nuclei coordinate the ventilatory actions of upper airway muscles, chest wall muscles, and the diaphragm. Upperairway patency is maintained by the bony, cartilaginous, and skeletal muscle structures of the naso and oropharynx.

Patients with OSA have a reduced upperairway size due to excess soft tissue or a highly compliant airway. Upper-airway obstruction occurs when the negative pressure generated by the inspiratory muscles exceeds the capacity of the upper-airway dilator muscles to maintain airway patency. A reduced airway size, combined with

diminished neural output to upper-airway muscles during sleep, can result in partial or complete upper-airway collapse.

Opioids and OSA

Opioids, both oral and parenteral, may profoundly impair respiration in the postoperative period in patients with OSA leading to obstructive apneas, drastic oxygen desaturation, and elevated end-tidal CO2.

The effect of opioids on respiratory depression occurs both as a direct depressant action on neural activity of respirations as well as a reduction in pharyngeal muscle tone. This may result in decompensated respiratory depression, which may not be recognized by the caregiver. Patients with OSA receiving sustained-release oral opiates for chronic pain have longer apnea duration, more severe hypoxia, irregular respiratory pauses and gasping, and long periods of obstructive hypoventilation.

Making the Correct Diagnosis

The key to making the diagnosis of OSA starts with a careful history regarding symptoms of irregular and abnormal respiratory patterns during sleep; daytime symptoms due to disrupted sleep, such as drowsiness, fatigue, and poor concentration; and signs of disturbed sleep, such as snoring, restlessness, and resuscitative snorts. Measuring the neck circumference in centimeters and adjusting for other conditions may be used to predict OSA.

Patient Safety Tips

Based on the numerous case reports of adverse postoperative outcomes, such as respiratory arrest in the light of opioid use and obesity, there are a number of strategies that can be used: • The preoperative evaluation should include a focused history and calculation of BMI and neck circumference: Consider a sleep apnea study when appropriate prior to scheduled surgery.

• Patients thought to be at substantial risk for OSA or with a proven history of OSA should be identified and placed on continuous monitoring — ideally with apnea monitors, oximeters, and capnometers.

• Opiates must be prescribed only with the greatest care. Consider the use of nonopioid medications (such as NSAIDs) instead of or in combination with judicious and careful opioid dosing, and use regional analgesic techniques rather than systemic opioids whenever possible.

• Anecdotal evidence shows that CPAP can alleviate postoperative airway obstruction and may decrease major postoperative complications.

• Do not assume that an obese surgical patient requires higher doses of medication to control pain — he or she may need less than the patient with a normal BMI. • Be aware that oral opiates may cause respiratory depression in OSA patients.

• Patients who use CPAP devices at home should use them while in the hospital, especially if they are receivProject4:Layout 1

9/22/08

ing narcotics.

• Ensure that everyone involved in the patient’s treatment plan is aware of the diagnosis or suspected diagnosis of OSA, particularly in obese patients.

• Healthcare professionals providing postoperative monitoring should be trained in recognizing potential signs of sleep apnea.

For discussion of other obesity-related issues in the surgical setting, such as those patients at increased risk for pulmonary emboli and specific anesthesia-related concerns, visit www.thedoctors.com.

It has been estimated that more than 80 percent of men and 90 percent of women with OSA do not have a documented diagnosis.

Dr. Marcus is a general internist in Austin, Texas, and chairman of The Doctors Company Physician Advisory Board in Texas. Dr. Marcus also chairs the Texas Alliance for Patient Access (TAPA), a consortium of healthcare institutions and stakeholders that includes The Doctors Company as a founding member.

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When calling an advertiser, mention you saw their advertisement in San Diego Physician magazine.

jan uary 2012 SAN DIEGO PHYSICIAN.org 31

Looking for a way to give back to the community?

The San Diego County Medical Society Foundation’s (SDCMSF) mission is to address the unmet San Diego healthcare needs of all patients and physicians through innovation, education, and service. SDCMSF is proud to partner with volunteer specialty physicians and nearly 100 community clinics in the county who provide primary care services for the medically uninsured and underserved. These clinics have little to no access to specialty care for their patients and need your help!

Opportunities for Physicians 1

Volunteer for Project Access San Diego:

If you are a specialist in private practice in San Diego, please consider joining more than 180 specialists in the county by seeing a limited number of uninsured adult community clinic patients in your office for free. Project Access coordinates all aspects of care so your volunteerism is hassle-free for you and your office staff.

2

Volunteer for eConsultSD:

eConsultSD allows primary care physicians from the community clinics in San Diego to articulate a clinical question to a specialist and receive a timely response in a HIPAA-compliant, web-based portal. eConsultSD is an easy way for busy specialist physicians to give back to the community who are not able to provide direct patient care.

3

Obtain a Volunteer or Paid Position at a Local Community Clinic: SDCMSF is happy to connect specialist physicians with a community clinic that needs your services on site. This opportunity involves traveling to a clinic within San Diego County as your schedule permits.

4

Make a Contribution:

SDCMSF needs your support to care for the medically underserved in our community. Please consider making a contribution of any size to support the Foundation’s efforts.

Contributions can be made online at SDCMSF.org or sent to the San Diego County Medical Society Foundation at 5575 Ruffin Road, Suite 250, San Diego, CA 92123.

Thank you for your support!

Thank you for your dedication to the medically underserved. If you are interested in any of the opportunities above, please contact Lauren Banfe, resource development director, at (858) 565-7930 or at Lauren.Banfe@SDCMS.org.

The San Diego County Medical Society Foundation is a 501(c)3 organization (Tax ID # 95-2568714).

Please visit SDCMSF.org for more information. Telephone: (858) 300-2777 or Fax: (858) 569-1334

SDCMSF was formed as a separate 501(c)3 in 2004 by the San Diego County Medical Society.

32 S AN D I E G O P HY S I CI A N. or A ugus t 2011 32 SAN DIEGO PHYSICIAN.org janguary 2012

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Your Contact Info Here jan uary 2012 SAN DIEGO PHYSICIAN.org 33

classifieds PHYSICIAN POSITIONS AVAILABLE PART- OR FULL-TIME PHYSICIAN OR PHYSICIAN ASSISTANT: Immediate opening for a part- or full-time physician or physician assistant in a busy internal medicine practice with two offices in La Mesa and El Cajon.

This office uses EHR with speech recognition. The candidate should be willing to see patients at hospitals and SNF as well. Efficient, hardworking team-player with compassion towards patient care is expected. Compensation is competitive and commensurate with experience. Interested candidates can email CV to vprabaker@ yahoo.com, attention to Venu Prabaker, MD. [999] XIMED HOSPITALISTS, INC., LA JOLLA, CA: Prestigious, 350-physician multi-specialty group seeks experienced full-time hospitalists to be part of an established hospitalists program at Scripps Memorial Hospital, La Jolla. Board-certified internal medicine physicians with superior clinical skills and willing to work in a team environment. Excellent communication skills a must. Outstanding salary, bonus, and benefits. Please email CV to Yvonne Montelius, XiMED Hospitalists, at ymontelius@ ximedinc.com or fax to (858) 587-1642. [997] NEUROLOGIST: This practice is seeking a qualified neurologist to join our practice here in beautiful La Jolla. We are a well-established neurology practice with four physicians. We are located on and provide on call for Scripps Memorial Hospital, La Jolla campus. We have a large referral base with two HMOs and contract with numerous insurance companies. There is outstanding earning potential, and the opportunity to expand into other areas is certainly a possibility. On-call ratio is 1:4. One of our physicians is the stroke director at Scripps Memorial Hospital. Our practice treats neurodegenerative diseases with emphasis on dementias. We treat a large number of movement disorder, stroke, and Botox treatment, as well as Parkinson’s disease. If you know anyone who would be interested in this excellent opportunity, please contact our office at or forward resumes to mrsbinx@ hotmail.com. [995] INTERNAL MEDICINE, PRIVATE PRACTICE PART TIME: LIFE/WORK BALANCE! Unusual and exceptionally attractive private practice IM opportunity in beautiful North San Diego County. Stable, long-term, part-time position available with flexible scheduling. Collegial, single-specialty group, exceptional office staff, and above all very high-quality patient care set this far apart from many other situations. Outpatient only, paperless office, easy access from anywhere in the county. Multiple scheduling options available, making this very attractive for any physician wanting part-time only work or wanting to combine with other job opportunities. Outstanding way to experience private practice. Email CV to portofino3@aol.com or call (619) 248-2324. [993] GENERAL CARDIOLOGIST: Recruiting for a general cardiologist for busy cardiology practice. Must perform diagnostic cath. Board eligible/certified. California license required. Must possess excellent education and training in the United States. Please send resume to SDCardioJobs@gmail.com. [989] INTERVENTIONAL CARDIOLOGIST: Recruiting for well-rounded interventional cardiologist interested in both an office-based practice and hospital procedures.

The individual should be well trained in all aspects of cardiology for diagnostic and therapeutic interventions, including cardiac, peripheral vascular disease, and renal vascular disease. Please send resume to SDCardioJobs@gmail.com. [990] BOARD-CERTIFIED FAMILY PRACTICE PHYSICIAN NEEDED: To cover hours at busy urgent care/family practice office in Carlsbad. Nights and weekend coverage needed, some day coverage available. Please fax CV to (760) 603-7719 or email CV to gcwakeman@sbcglobal.net. [985] BC FAMILY PRACTIONER MD/DO WANTED TO JOIN OUR PRACTICE IN BEAUTIFUL CORONADO: Seeking

FT family physician to join our practice before July 2012.

There would be a salary assistance guarantee through a leading local IPA for first year and also a buy-in opportunity as well. The ideal candidate would be willing to share practice with one FT FP and PT FP in practice together and share call and expenses. There would be additional earning opportunities for PT inpatient hospitalist at local hospital as well. Hospital work is optional however. We provide a full range of pediatric and adult family medicine (but no OB). Our practice is well known and has a reputation of personal excellence and service to a wonderful community in an ideal location. Also there is very good earning potential as well. If seriously interested in this unique opportunity, please send your CV and references to donalddill@sbcglobal.net, Attn: Gloria Rivera, or call (619) 435-3155 or fax (619) 435-3158. [968]

Euclid Avenue near the Talmadge gates. Two entrances: one from the street and another from the parking lot.

Handicapped entrance off the parking lot. Commercial tenants may use the parking lot Monday–Fridays 8am– 6pm. Contact patwoodard@aol.com for more information or to view. [998] CLAIREMONT OFFICE SPACE TO SHARE: Currently occupied by two general internists. Great central location in Clairemont, halfway between Sharp Memorial and Scripps La Jolla hospitals. Office just recently remodeled. Free parking. Looking to share with specialty physician. Fully furnished. Terms negotiable. Please contact Gary at (858) 430-1651 for more details. [996] OFFICE SPACE TO SHARE: Currently occupied by orthopedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or full-time physician. Fully furnished, fully equipped with fluoro machine and four exam rooms, and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950.

[804]

PHYSICIANS: North County Health Services is a Joint Commission-accredited FQHC, celebrating 40 years of service and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for BC/BE physicians for both full-time and per-diem positions. Spanish communication skills are helpful but not required. Compensation includes attractive salary, great benefit and retirement programs, malpractice, reimbursement for CME and licensure.

This is an opportunity to make a difference in the lives of patients who are under or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available. Email cynthia.bekdache@nchs-health. org or (fax) 760-736-8740. [966]

FULL-AND PART-TIME OFFICE SPACE: IN UTC with 8th floor view in suite with established psychologists and psychiatrists in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking.

Contact Christine Saroian, MD, at (619) 682-6912. [862]

PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic. org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912]

OFFICE SPACE TO SHARE: Office space to share in National City with a well-respected physician who has been in private practice for 30 years. Office is about 900 square feet with two exam rooms and an additional office/multi-purpose space. Office is currently being used part-time, Monday through Wednesday, but hours are flexible to accommodate another part-time practice. If interested, please contact me at bpmedina@msn.com.

[991a]

SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care.

Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night.

Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778]

OFFICE SPACE IN ENCINITAS — 477 N. EL CAMINO REAL: 1,600 sq. ft. beautiful office occupied by a dermatologist. One or two rooms available. May have the space to yourself for a full day and some half days. Prime location in a multi-specialty four building complex with an outpatient surgery center. Close to Scripps Encinitas Hospital. Available immediately and staff available if needed. Great for solo physician or a small group seeking a presence in North County. Please contact Dana at (760) 436-8700. [987]

OFFICE SPACE SAN DIEGO NORTH COUNTY OFFICE SPACE TO SHAR: Share reception, waiting area, and exam/consultation rooms in Class A medical building. Office is close to TCMC and all ancillary services. Flexible, P/T availability. Great opportunity for a North County satellite office.

For more information, contact Anne at abilleter@ncim. net or at (760) 726-2180. [003]

PLEASE CONTACT IF YOU HAVE OFFICE SPACE AVAILABLE TO SUBLET: Will consider any area in greater San Diego but would specifically be interested in Poway, Escondido, Vista, North County, as well as East County/La Mesa. Prefer situation where we can use existing office staff. Contact sundhmail@yahoo.com. [983] SCRIPPS ENCINITAS CONSULTATION ROOM/EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703]

FOR SALE OR LEASE OR LEASE-OPTION: Coronado condo/office. California Plaza. 1001 B Ave., Ste. 100. Corner first floor, 900 sq. ft. Perfect doctor’s office. $375K. Owner will carry. Call (619) 997-3112. [002]

3998 VISTA WAY, IN OCEANSIDE: Two medical office spaces approximately 2,000 sq. ft. available for lease.

Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $1.75 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@ coveycommercial.com. [965]

TALMADGE OFFICE SPACE $995/$850: Easy access partially furnished office with parking. Previously a doctor’s office with 1,245 sq.ft. of space. Two 1/2 baths, reception area, lab, and six other rooms. We also have a 1,185 sq.ft. space behind this one. Could be medical, dental, or professional office. Located on the north end of

SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

34 SAN DIEGO PHYSICIAN.org jan uary 2012

interest to La Mesa OB/GYN at (619) 463-4181. [648] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable.

Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building.

Medicare certified ambulatory surgery center next door.

Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867]

experience preferred. Send resume to mrsbinx@hotmail. com. [001] PART- OR FULL-TIME PHYSICIAN OR PHYSICIAN ASSISTANT: (see #999 under “PHYSICIAN POSITIONS AVAILABLE”) NURSE PRACTITIONER/PHYSICIAN ASSISTANT/ NURSE MIDWIFE: North County Health Services is a Joint Commission-accredited FQHC, celebrating 40 years of service and serving more than 60,000 patients in multiple locations in North San Diego County.

We have opportunities for certified family nurse practitioners and physician assistants and nurse midwives for both full-time and per-diem positions. Spanish communication skills are helpful but not required.

Compensation includes attractive salary, great benefit and retirement programs, malpractice, reimbursement for CME and licensure. This is an opportunity to make a difference in the lives of patients who are under or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available.

Email cynthia.bekdache@nchs-health.org or fax (760) 736-8740. [984] MEDICAL EQUIPMENT USED X-RAY PROCESSOR FOR SALE: Kodak RP XOMAT, model #M6B, 90 second processor. Works great.

Contact Lisa Sullivan at lisas@sdsm.net or by phone at (619) 229-3934. [992]

Residental Real estate

BANK OWNED - LA JOLLA ESTATE Offered at $1,849,000 This sprawling Ranch-style home, with gorgeous pool & spa, commands almost a HALF ACRE of lushly landscaped grounds.

Hidden at the end of this quiet West Muirlands cul-de-sac, you’ll find a magnificent family compound or entertainer’s dream!

A privately gated, tree lined drive leads to the stately entry courtyard. Bright, spacious kitchen with newer stainless steel appliances.

5 bedrooms and 6 baths to accommodate a large family and guests. 4,656 square feet.

Contact: Suzanne M. Giannella Broker Associate, Realtor®, CNE CA DRE #01770605 Pacific Sotheby’s International Realty 858.248.6398 suzanne.giannella@sothebysrealty.com www.sothebysrealty.com Each office is Independently Owned and Operated.

TIME SHARES FOR SALE: 1 week / year at the Pono Kai in Kauai, Hawaii. Price $18,000. (2 bed / 2 bath). 2 weeks / year at the Summer Bay in Las Vegas. Price $14,000 (2 bed / 2 bath). Try before you buy. Both can be used at this time, 1 week for 2 $1,500. If interested, please contact me at bpmedina@msn. [991b] NONPHYSICIAN POSITIONS AVAILABLE Registered Polysomnography Technician; Medical Office Assistant/Front Desk: AKANE Institute of Allergy, Asthma, and Sleep Medicine is a medical practice with our main office and sleep lab located in Scripps Ranch on Scripps Poway Pkwy off I-15. We provide specialty care for allergy, asthma, and sleep disorders. We are currently looking to recruit for the following positions: Registered Polysomnography Technician (RPSGT); Medical Office Assistant/Front Desk. We are looking for individuals who are technology savvy as we have a paperless office. We believe in providing state-ofthe-art medical care and exceeding patient expectations.

We are seeking applicants with previous experience, proven clinical skills, and friendly personality. Both parttime and full-time options are available with health benefits for full-time employees. If interested in joining our team, please contact us at akaneinstitute@gmail.com or at (858) 412-7362. [004]

Increase Your Referral Business San Diego Physician is the only publication that is distributed to all 8,500 practicing physicians in San Diego County.

Advertising is a cost-effective and profitable way to increase your referral business.

Contact Dari Pebdani at 858-231-1231 or at DPebdani@sdcms.org

FT MEDICAL INSURANCE BILLER WANTED: Collections, A/R, with knowledge of full cycle billing. Verification of insurance benefits, and be familiar with electronic and paper billing insurance claim follow-up. Previous

jan uary 2012 SAN DIEGO PHYSICIAN.org 35

healthier Desserts

Vanilla CheezeCake Cups With Raspberry Sauce It’s Healthy!

By Carmen Beaubeaux

All this talk about diet and health makes me think about dessert.

Maybe that’s because the final course is usually a concoction of fresh, whole foods like fruit and nuts … and cream must be involved. The best sweets should be an emotional experience — a sight for sore eyes; a reward for bearing through a difficult day; a distraction from the mundane; a minicelebration of the best the planet has to offer.

There’s nothing naughty about it.

By combining high-value, raw ingredients with a bit of portion control you can indulge without guilt. Restore your confidence in the power of dessert with these Vanilla CheezeCake Cups with Raspberry Sauce. They’re lactose free, gluten free, high protein and low glycemic — in fact, these little beauties just might be the most nutritious meal of the day. Here’s the recipe to prove it.

Vanilla CheezeCake Cups with Raspberry Sauce Ingredients

2 cups of raw almonds 1 cup of medjool dates 3 cups of raw cashews 3/4 cup of freshly squeezed lime or lemon juice 3/4 cup of raw honey or raw blue agave 3/4 cup of coconut oil 1/2 cup of water 1 teaspoon of vanilla 1/2 teaspoon of salt 1 12 oz. package of frozen raspberries 1/4 cup of raw blue agave directions

»» One hour before you begin, put your cashews in a bowl and cover to the top with water to soak — to make them soft and smooth for processing.

»» Line 8–10 dessert cups with plastic wrap.

36 SAN DIEGO PHYSICIAN.org jan uary 2012

»» Combine the 3/4 cup of liquefied coconut oil, cashews, juice, honey, water, vanilla, and salt into the food processor and process until silky smooth. »» Fill the prepared dessert cups with the filling, tapping lightly on the counter to eliminate bubbles. »» Freeze for at least two hours. »» Blend the frozen raspberries with the honey. »» Remove the cups from the freezer.

Lift them out by the plastic and unwrap carefully. Place on dishes, and spoon a generous portion of raspberry sauce over the tops. »» Serve immediately, and try to restrain yourself from shouting, “It’s healthy!” Trust me, they will never know.

Carmen lives in Coronado with her husband, James Beaubeaux, COO and CFO of SDCMS. She likes to write, kayak, swim, cook, and dine with Jim.

photo by Denise Jones

»» Put the coconut oil in a glass dish, and place the dish in a larger dish of hot water or on top of a warm stove until the oil liquefies.

»» Meanwhile, combine the almonds and pitted dates in a food processor until they are finely chopped so that you can make a sticky ball.

Divide the crust into the cups, and press firmly and evenly onto the sides.

We Celebrate Excellence – Theodore M. Mazer, MD CAP member and tireless champion for access to quality health care, for those in need

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Diego otolaryngologist Theodore Mazer, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

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

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

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

Superior Physicians. Superior Protection.

37

may 2011 2012 SAN DIEGO P HY SICIA N. o rg 37 jan uary SAN DIEGO PHYSICIAN.org

$5.95 | www.SANDIEGOPHYSICIAN.org San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

Why choose between national resources and local clout?

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With 71,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage.

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

The San Diego County Medical Society has exclusively endorsed our medical professional liability program since 2005. To learn more about our benefits for SDCMS members, call us at (800) 852-8872 or visit www.thedoctors.com.

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Any Tribute Plan projections shown here are not intended to be a forecast of future events or a guarantee of future balance amounts. For a more complete description of the Tribute Plan, see our Frequently Asked Questions at www.thedoctors.com/tributefaq.

38 SAN DIEGO PHYSICIAN.org jan uary 2012