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official publication of the san diego county medical society October 2012

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• Who Is GERM? • Antimicrobial Resistance • Adult Immunization • Infection Prevention / Legislation / Regulation • Antimicrobial Stewardship • Hantavirus Pulmonary Syndrome

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


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

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this month Volume 99, Number 10

Managing Editor: Kyle Lewis Editorial Board: Van L. Cheng, 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: Sherry L. Franklin, MD (CMA TRUSTEE) President-elect: Robert E. Peters, PhD, MD Treasurer: J. Steven Poceta, MD Secretary: William T-C Tseng, MD, MPH Immediate Past President: Robert E. Wailes, MD (CMA TRUSTEE) geographic and geographic alternate Directors East County: Alexandra E. Page, MD, Venu Prabaker, MD Hillcrest: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD)

features INFECTIOUS DISEASE 14 Who Is GERM (Group to Eradicate Resistant Microorganisms)? BY GONZALO R. BALLON-LANDA, MD

16 Antimicrobial Resistance in San Diego County: An Update BY GONZALO R. BALLON-LANDA, MD, DANIEL KEAYS, MS, and CYNTHIA MACINTOSH, CLS

20 Adult Immunization: We Can Do Better! BY MARK H. SAWYER, MD, FAAP 22 Infection Prevention and Legislation/ Regulation 2011–12: It’s Not Just Hospitals Anymore! BY FRANK MEYERS AND KIM M. DELAHANTY,

RN, BSN, PHN, MBA, CIC

12

departments 4 Briefly Noted

26 The Infectious Disease Pharmacist’s Role in Antimicrobial Stewardship BY MAGGIE BROWNELL, PHARMD 28 Hantavirus Pulmonary Syndrome: A Rare but Deadly Disease BY ROBERT E. PETERS, PHD, MD, FAAFP

Calendar • Join Our Editorial Board • Honor Your Mentor • Nominate Your Office Manager • And More …

Kearny Mesa: John G. Lane, MD, Jason P. Lujan, MD (A: Sergio R. Flores, MD) La Jolla: Geva E. Mannor, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County: Niren Angle, MD, Douglas Fenton, MD, James H. Schultz, MD (A: Anthony H. Sacks, MD) South Bay: Vimal I. Nanavati, MD, Michael H. Verdolin, MD (A: Andres Smith, MD)

At-large Directors Karrar H. Ali, MD, David E.J. Bazzo, MD, Jeffrey O. Leach, MD (DELEGATION CHAIR), Mihir Y. Parikh, MD (EXECUTIVE COMMITTEE BOARD REP), Peter O. Raudaskoski, MD, Kosala Samarasinghe, MD, Suman Sinha, MD, Mark W. Sornson, MD (EXECUTIVE COMMITTEE BOARD REP) At-large ALTERNATE Directors James E. Bush, MD, Theresa L. Currier, MD, Thomas V. McAfee, MD, Carl A. Powell, DO, Elaine J. Watkins, DO, Samuel H. Wood, MD, Holly Beke Yang, MD, Carol L. Young, MD other voting members Communications Chair: Theodore M. Mazer, MD (CMA VICE SPEAKER) Young Physician Director: Van L. Cheng, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Suraj Kedarisetty

OTHER NONVOTING MEMBERS Young Physician Alternate Director: Renjit A. Sundharadas, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Stuart A. Cohen, MD, MPH CMA President: James T. Hay, MD (AMA DELEGATE) CMA Past Presidents: Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA Trustee: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA Trustee (OTHER): Catherine D. Moore, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF Alternate Delegates: Dan I. Giurgiu MD, Ritvik Prakash

Mehta, MD

8 A Tragic Lesson in Drug Safety

by DAVID B. TROXEL, MD, MEDICAL DIRECTOR, THE DOCTORS COMPANY

12 Work-Life Balance: There’s No Place Like Home

by HELANE FRONEK, MD, FACP, FACPH

34 Physician Marketplace Classifieds

36 UC San Diego Health Sciences White Coat Ceremony 2012

by SHERRY L. FRANKLIN, MD

2 Oc tober 2012

36

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.]


SAN DIEGO PHYSICIAN.org 3


brieflynoted calendar SDCMS Seminars, Webinars & Events SDCMS.org/event

For further information or to register for any of the following SDCMS seminars, webinars, and events, visit SDCMS.org/event or contact Rhonda Weckback at (858) 300-2779 or at Rhonda. Weckback@SDCMS.org. Medicare E/M Services: Understanding the Principles and Guidelines (seminar) OCT 26 • 12:00pm–3:30pm

Essentials for ICD-10-CM: Part 1 OCT 18 • 7:45am–8:45am or 12:15pm–1:15pm Essentials for ICD-10-CM: Part 2 OCT 25 • 7:45am–8:45am or 12:15pm–1:15pm Essentials for ICD-10-CM: Part 3 NOV 1 • 7:45am–8:45am or 12:15pm–1:15pm Understanding ARC and CARC Revenue Codes NOV 7 • 12:15pm–1:15pm State Disability Insurance Online for Your Patients and You NOV 14 • 12:15pm–1:15pm

Identity Theft (seminar/webinar) NOV 1 • 11:30am–1:00pm

Essentials for ICD-10-CM: Part 1 NOV 29 • 7:45am–8:45am or 12:15pm–1:15pm

2012: A Critical Year for Changes in Tax Law (seminar/ webinar) NOV 8 • 11:30am–1:00pm

Impact of ICD-10 DEC 5 • 7:30am–9:00am or 12:15pm–1:45pm

The (Physician) Leader’s Toolbox (workshop) NOV 10 (8:00am–4:00pm) and NOV 11 (8:00am–12:00pm) Top 10 Patient Safety Issues for Office Practice (seminar/webinar) NOV 15 • 11:30am–12:30pm

Essentials for ICD-10-CM: Part 2 DEC 6 • 7:45am–8:45am or 12:15pm–1:15pm Essentials for ICD-10-CM: Part 3 DEC 13 • 7:45am–8:45am or 12:15pm–1:15pm

Community Healthcare Calendar

Cma Webinars

CMAnet.org/events

Impact of ICD-10 OCT 10 • 7:30am–9:00am or 12:15pm–1:45pm Establishing Expectations for High Performance From Medical Staff OCT 17 • 12:15pm–1:15pm

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. Events should be physician-focused and should take place in or near San Diego County.

5K Run/Walk for Colon Cancer Awareness OCT 13 • NTC Liberty Station • Registration Opens at 7:45am, Run at 9:00am, Walk at 9:05am • www.getyourrearingear.com CMA / CMA Foundation Gala — Save the Date! OCT 14 • California Museum, Sacramento • Contact Enid at egallegos@cmanet.org for sponsorship and advertising or Shelley at stirsbeck@ thecmafoundation.org for individual or group ticket sales. Ideal Medical Practices (IMP) Camp in San Diego OCT 26–28 • Best Western Island Palms Hotel • When resident physicians click on the registration page, they’ll find that their fee is $175 instead of $400 for practicing physicians. The $175 is basically to cover meals and a few other built-in expenses. • www.impcenter.org. Sharp Grossmont Hospital Heart and Vascular Conference 2012 OCT 27–28 • Rancho Bernardo Inn • $175 • (Google Conference Title) 13th Annual Science and Clinical Application of Integrative Holistic Medicine OCT 28 – NOV 1 • Hilton San Diego Resort • (Google Conference Title) Aces for Health Golf Tournament FEB 28 • Del Mar Country Club • Benefitting the SDCMS Foundation’s Project Access • (858) 565-7930 RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13, 2013 • Call RCMA at (800) 472-6204

Hyperglycemia Management Using Insulin Therapy OCT 10 • Ruth’s Chris Steak House, Del Mar • 6:00pm • scripps. org/conferenceservices

SAVE $50 When You Renew Your SDCMS-CMA Membership by October 31, 2012 — See Page 30 for Details —

4 Oc tober 2012

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: OCTOBER 27 State Senator Mark Wyland (District 38) E: (via website) cssrc.us/web/38 E: senator.wyland@sen.ca.gov Sacramento Office: State Capitol, Rm. 4048, Sacramento, CA 95814 T: (916) 651-4038 • F: (916) 446-7382 Carlsbad Office: 1910 Palomar Point Way, #105, Carlsbad, CA 92008 T: (760) 931-2455 • F: (760) 931-2477 BIRTHDAY: NOVEMBER 1 U.S. Representative Darrell Issa (District 49) E: (via website) issa.house.gov Washington, DC, Office: T: (202) 225-3906 • F: (202) 225-3303 Vista Office: 1800 Thibodo Rd., Ste. #310, Vista, CA 92081 T: (760) 599-5000 • F: (760) 599-1178 BIRTHDAY: NOVEMBER 11 U.S. Senator Barbara Boxer E: (via website) boxer.senate.gov Washington, DC, Office: T: (202) 224-3553 • F: (202) 228-3863 San Diego Office: 600 B St., Ste. 2240, San Diego, CA 92101 T: (619) 239-3884 BIRTHDAY: NOVEMBER 24 State Assemblyman Kevin Jeffries (District 66) E: (via website) arc.asm.ca.gov/member/66 E: assemblymember.jeffries@assembly.ca.gov Sacramento Office: State Assembly, Sacramento, CA 95814 T: (916) 319-2066 • F: (916) 319-2166 Murrieta Office: 41391 Kalmia St., Ste. 220, Murrieta, CA 92562 T: (951) 894-1232 • F: (951) 894-5053


office managers

Nominate Your Office Manager for SDCMS’ 4th Annual “Outstanding Medical Office Manager” Contest Today! SDCMS member physicians can nominate their office manager by explaining in writing (up to 600 words) why their office manager is the best in San Diego County. Send nominations (and questions) to Kyle Lewis at SDCMS at KLewis@SDCMS.org. Nominations deadline is Oct. 31, 2012. The winner will be announced in the December issue.

honor your mentor

Honor a Mentor in the December Issue of San Diego Physician magazine! SDCMS will be paying homage to those individuals who, either recently or in decades past, have inspired San Diego County’s physicians in ways professional or personal to strive to achieve something beyond themselves. SDCMS members who would like to share their stories about their mentors are encouraged to submit those stories to Editor@SDCMS.org (anywhere from a paragraph to several hundred words) by Nov. 1, 2012.

San Diego Physician Editorial Board

SDCMS Member Physicians: If you are interested in learning more about possibly joining the San Diego Physician editorial board, please email Editor@SDCMS.org.

get in touch Your SDCMS and SDCMSF Support Teams Are Here to Help!

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 ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF BUSINESS DEVELOPMENT Brian R. Gerwe at (858) 300-2782 or at Brian.Gerwe@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS Brandon Ethridge at (858) 300-2778 or at Brandon.Ethridge@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org MEMBERSHIP ADMINISTRATIVE ASSISTANT Rhonda Weckback at (858) 300-2779 or Rhonda.Weckback@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

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 Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@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 IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

SAN DIEGO PHYSICIAN.org 5


brieflynoted Physicians of excellence

Six SDCMS Physicians Selected 10 Years in a Row as Top Doctors! Congratulations to the following SDCMS member physicians for having been selected as Top Doctors in each of the past 10 years:

Featured Member

Lawrence F. Eichenfield, MD

Daniel Einhorn, MD

Anthony Edmund Magit, MD

Charles William Nager, MD

Robert Alan Weisman, MD

O. Douglas Wilson, MD

Steven A. Green, MD Dr. Steve Green, SDCMS-CMA member since 1999, was one of five members of the La Jolla Cove Swim Club who endeavored to swim the English Channel in August, which extends approximately 21 miles from the white cliffs of Dover in England to Cap Gris-Nez in France. Four of the five swimmers, including Dr. Green, successfully swam the Channel, with the normal success rate being 50%. Dr. Green crossed in 19 hours and 25 minutes, landing at Cap Blanc-Nez after swimming 45 miles due to strong currents. Congratulations and kudos, Dr. Green! 6 Oc tober 2012

And congratulations to the following SDCMS member physicians for having been selected as Top Doctors in two and three separate specialties this year: Reid Allen Abrams, MD (2) Suraj Arthur Achar, MD (2) Kaveh Bagheri, MD (3) David E.J. Bazzo, MD (2) Lynne M. Bird, MD (2)

John S. Bradley, MD (2) Marc K. Effron, MD (2) Andrew P. Hampshire, MD (2) Lisa Ellen Heikoff, MD (2) Steven D. Kavy, MD (2)

Lars R. Newsome, MD (3) J. Steven Poceta, MD (2) Brent Eugene Rathbun, MD (2) Kenneth Samuel Taylor, MD (2)


Upcoming SDCMS Seminars:

Register Today! All Free to Members & Staff

MEDICARE E/M SERVICES: PRINCIPLES & GUIDELINES Seminar • Fri, Oct 26 • 12:00pm–3:30pm

Topics Covered: • General Documentation Principles • E/M Services 1995 and 1997 Guidelines LUNCH • Counseling / Coordination of Care Guidelines PROVIDE D and Documentation Requirements • Split / Shared Services • Common E/M Documentation / Coding Errors • Tips for Preventing E/M Documentation / Coding Errors • Examples • Resources

Register for Seminar q

2012: A CRITICAL YEAR FOR CHANGES IN TAX LAW

Seminar/Webinar • Thu, Nov 1 • 11:30am–1:00pm Topics Covered: • What Is Identity Theft? • What Information Is Stolen? • What Types of Identity Theft Are There? • What Are Some Common Scams? • How Can I Protect Myself? • What Should I Do If I Am a Victim?

LUNCH PROVIDE D

Register for Seminar q Register for Webinar at www.tiny.cc/sdcms

THE (PHYSICIAN) LEADER’S TOOLBOX Workshop • Sat–Sun, Nov 10–11

Seminar/Webinar • Thu, Nov 8 • 11:30am–1:00pm Topics Covered: • Personal Tax Strategies • Business Tax Strategies • The Affordable Care Act

IDENTITY THEFT

LUNCH PROVIDE D

Topics Covered: • Strategy • Leading Your Team • Building Your Team ��� Managing Your Time • Managing Your Meetings • Managing Your Organization’s Money • Managing Your Message

meal PROVIDEs D

Register for Seminar q Register for Webinar at www.tiny.cc/sdcms

Register for Workshop q

TOP 10 PATIENT SAFETY ISSUES FOR THE OFFICE PRACTICE

ADVOCACY TRAINING: HOW TO BE A BETTER LOBBYIST

At the conclusion of this seminar, participants will be able to: • Identify four risks unique to the office practice setting; • Recall two strategies for follow-up that will decrease your malpractice risks; LUNCH • Name three practical strategies for improving PROVIDE D patient safety in your practice.

An exceptional learning opportunity that involves role-playing the processes associated with advocacy. Better to practice your advocacy skills among friends than on some “hot seat.” BREA

Seminar/Webinar • Thu, Nov 15 • 11:30am–12:30pm

SATISFIES TDC PARTICIPATION REQUIREMENT

Workshop • Sat, Dec 1 • 8:00am–12:00pm

KFAS PROVIDE T D

Register for Seminar q

Register for Webinar at www.tiny.cc/sdcms

Register for Workshop q

FAX to SDCMS AT (858) 569-1334 • QUESTIONS? CALL (858) 565-8888 Physician Full Name Attendee Name / Title (if different) Telephone Email SAN DIEGO PHYSICIAN.org 7


Risk Management

A Tragic Lesson in Drug Safety by David B. Troxel, MD, Medical Director, Board of Governors, The Doctors Company

A four-year-old female with a history of asthma presented with her mother to our insured pediatrician for treatment of a barky cough (croup). The pediatrician prescribed Tussionex, one-half teaspoon once a day. The following day at 6:30 p.m., the office nurse telephoned the residence and spoke with the mother, who reported the child was much better and was running around. The next day, the mother found the child unresponsive and summoned the emergency squad. They administered CPR and transported the child to the hospital, where she was pronounced dead. An autopsy revealed the child had toxic blood levels of hydrocodone and chlorpheniramine (components of Tussionex) and diphenhydramine (an active ingredient of Benadryl). It was alleged the insured pediatrician failed to heed the warnings and recommendations of the manufacturer of Tussionex, including explicit warnings 8 Oc tober 2012

against its administration to children under the age of six; that he failed to heed the warnings of the FDA and the American Academy of Pediatrics against prescribing Tussionex to children under the age of six; and that he prescribed an excessive dose of Tussionex based on the child’s age and weight.

Defense Experts A pediatrician expert stated he had no issue with the insured prescribing Tussionex to a child this age. He said the FDA Alert regarding Tussionex was released just a week before this event occurred, and he felt it was understandable that the insured was not aware of it. He also did not believe the standard of care required the insured to be aware of the FDA press release on Tussionex (released three months before this event) or the notice posted on the FDA website. However, he believed the insured was responsible for knowing the contents

of the FDA “Dear Provider” letter that had been sent within a week of this prescribing event. He also questioned whether a physician is responsible for reviewing each medication he prescribes when a new edition of the Physicians’ Desk Reference (PDR) is released. A toxicology expert stated that both the Benadryl and the antihistamine in the hydrocodone are inhibitors of metabolism of hydrocodone. The toxicologist concluded the amount of hydrocodone found in the blood meant that the child had 3.4 doses in her body at the time of death, which is more than would be expected based on the dosage prescribed. He made similar calculations with regard to chlorpheniramine and concluded there were approximately 4.8 doses at death. Chlorpheniramine has a longer half-life than hydrocodone, which could account for the difference. A pediatric neonatologist felt it was a breach of the standard of care to prescribe


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Risk Management We encourage our members to join the Health Care Notification Network (PDR Drug Alert Network) to receive their FDA Drug Alerts via email. Physicians who participate are less likely to overlook an important FDA Alert, and they can earn CME credits for reading the Alert and taking a short online test on its content. Tussionex to this child. He said slow-release narcotics can accumulate in the system and lead to respiratory depression, which is aggravated by the child’s age, by other drugs in the mixture, and by Benadryl. There is no safe amount to prescribe. The specific drug for croup (when it is very bad) is a corticosteroid; otherwise a vaporizer and observation are the standard of care. The pharmacy that filled the prescription was a co-defendant. Its pharmacist received

an electronic Drug Utilization Review (DUR) Alert requiring him to contact the physician regarding the safety of the prescription. He entered “prescriber contacted, prescribe as is” to override the Alert and filled the prescription without calling the insured.

Plaintiff’s Experts

A forensic pathologist and a toxicologist from the coroner’s office believed there were toxic-to-lethal blood levels of the components of Tussionex, which caused the child’s death. A pediatrician opined that the insured should never have prescribed Tussionex to this child, adding that this drug should never be considered for any child under six years of age. He could not say if the proper dose was one-quarter teaspoon rather than one-half teaspoon, but he opined that the

insured prescribed twice as much as he should have based on the child’s weight. He added that it was not appropriate to recommend using Benadryl as a sleeping aid in a child. (Our insured did not remember ever making this recommendation, while the parents alleged that he did.)

Should This Case Be Tried? The death of a four-year-old child is tragic and would be viewed as such by a jury. While there was one expert to support the insured’s lack of knowledge of the multiple warnings against using Tussionex in children, the plaintiff’s counsel had multiple experts to state the contrary. Furthermore, the PDR in the insured’s office contained the warning, and a jury would likely expect a physician to be fully knowledgeable about medications being prescribed and the dangers contained therein. The insured would be susceptible to the question, “Doctor, who is responsible for knowing about a medication that is prescribed to a patient?” Clearly,

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the correct answer is the physician who is prescribing it. With the insured’s consent, the case was settled.

Discussion Each year, almost 25% of drugs have clinically relevant changes made to their FDAapproved labels. FDA-approved labeling is often the standard to which physicians are held in claims involving medication errors. An analysis of all claims closed at The Doctors Company in 2010 revealed that 6.1% contained medication errors. The most prevalent claims in this category included giving the wrong medication (18%), failing

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Each year, almost 25% of drugs have clinically relevant changes made to their FDA-approved labels. to follow guidelines or protocols (16%), giving the wrong dosage (13%), errors in drug administration (12%), and ordering errors (5%). It is likely that some of these errors could have been prevented by keeping current on FDA-approved drug labeling. We encourage our members to join the Health Care Notification Network (PDR Drug Alert Network) to receive their FDA Drug Alerts via email. Physicians who participate are less likely to overlook an important FDA Alert, and they can earn CME credits for reading the Alert and taking a short online test on its content. PDR Network hosts the CME programs, and The Doctors Company provides the CME credits to all U.S. physicians at no charge. These CME courses are available for physicians who are registered PDR.net users. For more information on this free service, visit www.PDR.net.

Implications for E-prescribing Liability The pharmacist overrode the DUR Alert and filled the prescription without calling the insured. This may be a harbinger of electronic health record e-prescribing liability risk because there is a danger that doctors may suffer “alert fatigue” — and ignore, override, or disable alerts, warnings, reminders, and clinical decision support guidelines. If following an alert or guideline would have prevented an adverse patient event, the physician may be found liable for ignoring it.

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SAN DIEGO PHYSICIAN.org 11


physician well-being

Work-Life Balance

There’s No Place Like Home by Helane Fronek, MD, FACP, FACPh

During a presentation to a group of physician leaders on “work-life balance,” the first question I was asked was, “Does it exist?” If you Google this topic, you’ll find 20,600,000 entries, some enticing us with titles like “The Five Tips to Work-Life Balance.” Clearly, the authors believe that it exists and is as simple as five easy tips. As most of us who have struggled to achieve balance in our lives know, it is definitely not that easy. But what really is balance, and how does it feel? When we stand on one leg and attempt to balance — go ahead, try it! — we find that it is not a rigid state. We lean one way or another, continuously rebalancing ourselves. Similarly, work-life balance requires constant shifting as the conditions of our lives change — the amount of time we need to spend working, with family, engaging in learning new information or in recreational 12 Oc tob er 2012

activities will vary depending on what stage of our life we’re in or what’s occurring at the time. When we’re standing on one leg, we also find that we’re able to balance more effectively if we contract our core muscles. In the same way, when we live from our core — making decisions through the lens of our core values — balance is easier to achieve and maintain. Our core values are those principles or approaches to life that make our life fulfilling — that make it our life and not someone else’s. When we allow our circumstances to prevent us from living according to our values, we feel unhappy and estranged from our own life. A person with a strong value

of family might be frustrated working 80 hours a week, while a person who values achievement above all else might feel completely satisfied. Some of our values are easy to spot, since we naturally focus more time on them, such as family, spirituality, being fit, service, and learning. Other values might be those things that we long for. Another method for determining our values is to recall an experience that made us feel great — what was going on? What values were being honored? Below is a partial chart of values. Take a minute and circle your top 10. How well are you living your values — at home, at work, and in your life? Decide on one thing that you will do this week to bring your values into those parts of your life where they are not as present as you would like. With just a bit of discipline and commitment, we can each make small, incremental adjustments that may be all we need to give ourselves greater balance in our life. Just like Dorothy in “The Wizard of Oz,” we have more ability to find our way than we thought, and the power to do so resides within us. Dr. Fronek, SDCMS-CMA member since 2010, is a certified physician development coach, certified professional co-active coach, and assistant clinical professor of medicine at the UC San Diego School of Medicine. You can read her blog at helanefronekmd.wordpress.com.

Humor

Family

Integrity

Achievement

Excellence

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PETERSON’S DONUT CORNER Get your French crullers, fritters, butterlogs, and cream puffs at this donut haunt that’s open until the wee hours (think 3 a.m. cravings). 903 South Escondido Boulevard, Escondido, petersonsdonutcorner.menutoeat.com

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POWAY MIDLAND RAILROAD & ANTIQUE TRAINS In Old Poway Park, kids both big and small want to choo-choo on a 1907 Baldwin 0-4-0 Steam Locomotive and Tender or 1894 Los Angeles Yellow Line Trolley Car. All aboard! 14134 Midland Road, powaymidlandrr.org May2012SanDiegoMagazine.com91

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Cafe Chloe

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THE BAR AT RANCHO BERNARDO INN Esteban Interiors transformed the once forgettable room, giving it a European brasserie feel where we now love to nosh on executive chef Nicolas Bour’s short rib chili and sloppy joe sliders, and sip the Broken Heart cocktail with blood orange, passion fruit, and pomegranate purees mixed with Herradura Reposado and Cointreau. 17550 Bernardo Oaks Drive, ranchobernardoinn.com

Rob Machado at Black’s Beach in La Jolla. He is a style master. From 1- to 20-foot waves, he makes the difficult seem easy, and his approaches to the waves are seamless. This day he paddled out for the first time on a single fin shaped by Michelle Junod and caught this wave straight off the bat. The light bounces off the cliffs, creating reflections on the water and wave unlike any other lighting scenario I have seen in the water.

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URBN COAL-FIRED PIZZA Their New Haven-style pizza, including original pies like mashed potato and bacon, are so popular they opened a second location in North Park. Hey Vista, way to show the hipsters how it’s done. 203 Main Street, Vista, urbnpizza.com

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SAN DIEGO PHYSICIAN.org 13


Infectious Disease

During the influenza epidemic of 1997 and 1998,

Who Is GERM?

The Group to Eradicate Resistant Microorganisms By Gonzalo R. Ballon-Landa, MD

most hospitals were running perilously low on antibiotics and available beds. The epidemic — one of the worst to have hit San Diego County in the last 30 years — sent thousands of people to the hospitals, emergency rooms, and doctors’ offices. Hospital admissions soared, and the crisis was on. During that epidemic, Ramon E. Moncada, MD, currently retired SDCMSCMA member who was serving at the time on the SDCMS Council, saw the need for a think tank that would connect and unify all of the different health systems in our county to help solve common problems, particularly during epidemics and times of natural health disasters. It was thus that GERM was born, and since that time volunteer physicians, epidemiologists, infectious diseases pharmacists, and hospital council leaders from all of the health systems have collaborated in the anticipation of and planning for natural disasters, such as the bioterrorism threats, SARS, and the novel influenza pandemic of 2009. The lofty goal to which its initials refer — Group to Eradicate Resistant Microorganisms — is unachievable, however the practical results it has yielded have helped San Diego County be one of the best prepared for epidemics and prevention of resistance in the entire country. Many physicians will remember that within one week of the announcement of the first anthrax case, all of the San Diego physicians and most of the clinics received a primer on bioterrorism, prepared by this

body, that helped with what to look for in their offices and clinics, how to respond, and who to contact. In fact, we were the first county in the United States to have a countywide antibiogram. This very edition of San Diego Physician is the third in as many years to publish on infectious diseases’ emerging problems, solutions, and upcoming issues to which the SDCMS membership needs or will need to attend. This year we are continuing with our emphasis on prevention of diseases through vaccines, the control of antibiotic use through identification of complications that arise from the overuse of antibiotics, such as the difficult problem of recurrent C. difficile, and the emerging field of infectious diseases pharmacy. Less lustrous items being euphemistically referred to as refaunation in this issue will become commonplace. When it comes to antibiotics, less is more, as their enormous dangers are being increasingly recognized and new disciplines are emerging such as the infectious diseases pharmacists to help hospitals and communities deal with it. So, dear lector, read on, and remember to save and conserve the symbiont inside our bodies, which is almost as important as any of our other organ systems. Dr. Ballon-Landa, SDCMS-CMA member since 1983, is board-certified in internal medicine and infectious disease and is the chair of the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission.

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Infectious Disease When antibiotics were first used in the general population in the late 1940s, just two or three human generations ago, virtually all strains of Staphylococcus aureus were susceptible to penicillin G. Today, less than 10% of Staph. strains are susceptible. Upon its introduction in the mid-1950s, nearly every infection caused by E. coli was treatable with ampicillin. Today, more than half of clinical isolates of E. coli are ampicillin-resistant. Given enough time and selective pressure, microbes are extremely adaptable. The GERM (Group to Eradicate Resistant Microorganisms) Commission of the San Diego County Medical Society is tasked with monitoring the level of antimicrobial resistance in San Diego, and to periodically report its findings as a possible guide to the medical community. The following is a summary of some of the GERM Commission’s findings. The data presented here is taken from several large healthcare providers in San Diego. As much as possible, hospital and other healthcare-related bacterial isolates are separated from true community-acquired strains.

Fluoroquinolones

Antimicrobial Resistance in San Diego County An Update By Gonzalo R. Ballon-Landa, MD, Daniel Keays, MS, and Cynthia MacIntosh, CLS

16 Oc tober 2012

Following their approval by the Food and Drug Administration in 1987, fluoroquinolones, including ciprofloxacin and levofloxacin, quickly became some of the most widely-used antimicrobics. Since they don’t exist in nature, there was widespread enthusiasm that the development of resistance would be rare, if at all. Unfortunately, that hasn’t been the case, and the last decade has seen a steady increase in the number of fluoroquinoloneresistant strains of Gram-negative bacteria. Table 1 gives a summary of ciprofloxacin resistance in clinical isolates of E. coli in hospitalized patients since 2002. Table 2 shows similar information for outpatients. The trend of increasing fluoroquinolone resistance in E. coli isolates is clear. With the recent discovery that bacteria can transfer genetic material that specifically confers fluoroquinolone resistance, there is little reason to believe this pattern won’t continue (1).


In other Gram-negative organisms, Proteus shows a level of resistance similar to E. coli. Klebsiella and Enterobacter show somewhat less resistance, with an overall susceptibility in 2011 of about 85% of strains. Among the Gram-positives for which fluoroquinolone therapy (excluding ciprofloxacin) is warranted, over 90% of strains of Streptococcus pneumoniae remain susceptible.

Extended Spectrum Beta-lactams Like the fluoroquinolones, the thirdgeneration cephalosporins were introduced with considerable fanfare in the late 1980s. They similarly displayed almost universal effectiveness against members of the Enterobacteriaceae, as well as some other Gram-negative organisms. However, microbes have acquired a broad array of complex enzymes to combat the entire class of beta-lactam antibiotics. Collectively known as extended spectrum beta-lactamases, or ESBLs, the bacterial enzymes that were formerly hydrolytic for early generation beta-lactams have through mutation rendered organisms resistant to the newer drugs. Because the drugs are used mainly in hospitals, most resistant strains are seen in the healthcare setting. Table 3 shows the steady emergence of ESBL-producing E. coli in the San Diego area over the last decade. The antibiotic tabulated was cefotaxime, but the results apply to all third-generation cephalosporins. Other Enterobacteriaceae such as Klebsiella, Enterobacter, and Proteus show a similar pattern. Because beta-lactamase enzymes are inducible, and not produced by the microbe until an antibiotic is encountered, the detection of ESBLs by laboratories is not 100% reliable. Some strains of bacteria are slower to induce beta-lactamase enzymes than other strains. It’s possible the numbers presented here are understated. ESBL-producing strains are sometimes seen in the community setting, particularly in patients who have been recently hospitalized. Their emergence is worldwide, and it is not unusual for a traveler to acquire them as well. ESBL strains are usually resistant to multiple antibiotics, oftentimes to all available oral drugs. Their emergence

Table 1. Percentage of E. coli strains from hospitalized patients in San Diego that were susceptible to ciprofloxacin.

Year

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Number Strains Tested

1322

1586

1261

1295

1370

1434

1308

1372

1675

1760

Percent Strains Susceptible

78%

79%

75%

74%

70%

66%

65%

65%

59%

58%

Table 2. Percentage of E. coli strains from outpatients in San Diego that were susceptible to ciprofloxacin.

Year

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Number Strains Tested

2183

2602

2816

2808

3214

3651

3117

3065 3933

4109

Percent Strains Susceptible

90%

89%

85%

83%

83%

78%

78%

76%

74%

71%

Table 3. Percentage of E. coli strains from hospitalized patients in San Diego that were susceptible to cefotaxime.

Year

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Number Strains Tested

1322

1586

1261

1295

1370

1434

1308

1372

1675

1760

Percent Strains Susceptible

98%

98%

97%

95%

93%

91%

89%

89%

85%

85%

Table 4. Percentage of Enterococcus strains from hospitalized patients in San Diego that were susceptible to vancomycin.

Year

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Number Strains Tested

1194

1355

1041

1166

976

942

1015

899

916

804

Percent Strains Susceptible

96%

94%

92%

87%

82%

84%

82%

81%

78%

76%

in the community would be especially problematic.

Vancomycin-resistant Enterococcus (VRE) Because of the heavy use of vancomycin to combat methicillin-resistant Staphylococcus aureus and treat Clostridium difficile, there has been a significant rise in the number of vancomycin-resistant Enterococcus, especially Enterococcus faecium. Table 4 illustrates the trend of VRE occurrence in hospitalized patients over the last 10 years. Fortunately, vancomycin-resistant Staphylococcus aureus has not been found

in San Diego County, although a number of strains with a minimum inhibitory concentration (MIC) of 2.0 mcg/ml have been isolated. (An MIC of less than or equal to 0.5 mcg/ml is the norm.) Strains of S. aureus with elevated vancomycin MICs are listed as susceptible, but often are more difficult to treat with standard vancomycin dosing.

MRSA In the last few years we have seen a significant decrease in the relative number of methicillin-resistant Staphylococcus aureus isolates in both the inpatient and outpa-

SAN DIEGO PHYSICIAN.org 17


Infectious Disease

When antibiotics were first used in the general population in the late 1940s, just two or three human generations ago, virtually all strains of Staphylococcus aureus were susceptible to penicillin G. Today, less than 10% of Staph. strains are susceptible.

tient setting. Considerable effort has been placed on prevention measures, especially hand hygiene, and it would appear these efforts are paying off. Table 5 summarizes the number of MRSA isolates in the past decade in both the inpatient and outpatient setting. From the laboratory perspective, it is impossible to ascertain if the drop-off in numbers of community-associated MRSA isolates is due to a true lower incidence, or simply lower culture rates resulting from a now somewhat easily recognized infection. Indeed, because risk factors and clinical manifestations of MRSA are so well recognized, many outpatient clinicians empirically treat for MRSA without first culturing the wound or abscess. We have discovered that the state-mandated burden that physicians personally notify patients who are found to have MRSA-positive cultures is heavy on already stretched resources. This significantly discourages doctors from ordering cultures. The consequent lower culture rate likely skews the data in Table 5 toward a falsely lower incidence, particularly as it relates to outpatients.

Macrolides The antibiotic azithromycin (Zithromax, or Z-pack) has become widely used for treating respiratory infections. While the use of azithromycin is often empirical, it is worth noting that in 2011 only 68% of 125 isolates

Table 5. Percentage of Staphylococcus aureus isolates in San Diego that were methicillin-resistant.

Year

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

# Isolates S. aureus, Inpatients

1118

1299

1169

1255

1223

1184

1217

1150

1371

1140

% Strains Methicillin-resistant, Inpatients

43%

47%

48%

53%

54%

54%

51%

47%

42%

47%

# Isolates S. aureus, Outpatients

834

1181

1550

1701

1736

1800

1642

1513

1558

1508

% Strains Methicillin-resistant, Outpatients

27%

41%

51%

53%

53%

52%

49%

46%

43%

42%

18 Oc tober 2012

of Streptococcus pneumoniae in San Diego were azithromycin-susceptible. Clinical laboratories don’t routinely perform susceptibility studies on Group A Streptococcus due to the organism’s universal susceptibility to penicillin, so full susceptibility profiles on the organism are often lacking. But in 2010 workers at Scripps Health in San Diego examined 140 consecutive strains of Group A Streptococcus from the community and found that 20% of them were resistant to macrolides and clindamycin. Over 30% of Group B Streptococci were resistant to macrolides as well. Also, less than 10% of MRSA isolates from the community are macrolide susceptible.

Conclusion To no one’s real surprise, microbes continue to slowly but effectively develop resistance to antimicrobics. Between 1940 and 1962, over 20 new classes of antibiotics became available. Since then, only two have been introduced. There are a handful of new antibiotics in the pipeline, but how many will eventually be FDA-approved and effective is questionable (2). We’ve already seen with Staphylococcus aureus and penicillin and E. coli with ampicillin the possible result of extensive antibiotic use. Proper antibiotic stewardship is reaching a critical stage, and San Diego is no exception. References: 1. Hernandez, A., Sanchez, M., and Martinez, J. “Quinolone Resistance: Much More Than Predicted.” Frontiers in Microbiology 2:22, 2011 (online publication). 2. Butler, M.S., and Cooper, M.A. “Antibiotics in the Clinical Pipeline in 2011.” J. Antibiot. (Tokyo). Jun; 64(6): 413-25, 2011. Dr. Ballon-Landa, SDCMS-CMA member since 1983, is board-certified in internal medicine and infectious disease and is the chairman of the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission. Mr. Keays is a recently retired clinical microbiologist at Scripps Health. He currently lectures in the laboratory training program at UCSD Medical Center. Ms. MacIntosh is a microbiologist in the infectious disease laboratory at Scripps Health. Mr. Keays and Ms. MacIntosh both sit on the SDCMS GERM Commission.


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Infectious Disease

Nobody likes shots, including adults. In fact, there

Adult Immunization We Can Do Better! By Mark H. Sawyer, MD, FAAP

20 Oc tober 2012

are some adults who dislike shots more than some kids I have seen. However, I don’t think this is the reason we are doing so poorly at immunizing our adult population. Most adults will accept their doctor’s advice that they should receive an immunization. In many cases they never get that advice or it is delivered in a halfhearted way. You don’t have to take my word for it. The latest National Flu Survey released in March 2012 indicates that only 70.8% of seniors received an influenza vaccine last year. Even worse, only 50.1% of adults at high risk from influenza because of underlying condition (e.g., heart and lung disease, diabetes, immunosuppression) received one. What about pneumococcal vaccine? Based on the latest 2010 National Health Interview Survey, only 59.7% of seniors and 18.5% of other high-risk adults received one. The


most concerning coverage level is for Tdap/ pertussis vaccine. We had a giant outbreak of pertussis in California in 2010 with over 1,000 cases in San Diego County and two infant deaths. What are the national rates for Tdap vaccine in adults? 8.2 %! San Diego rates are not much different from the national ones. In the 2010–11 season, 72.9% of seniors had received an influenza vaccine. The results from local telephone interviews conducted in 2010 show that 57.7% of highrisk younger adults had received a pneumococcal vaccine, and 24.7% of adults had received a Tdap. We need to do better. So, what immunizations do adults need? How can you convince your patients to get immunized? What systems do you need in place in your office to do a good job immunizing? What resources are available for you and your patients? Let’s look at each of these questions. All adults need protection from pertussis. We have clearly learned that adults get pertussis and transmit it to others. We also know that immunity from natural disease or childhood vaccination wanes over time. CDC now recommends that all adults, regardless of age, receive one dose of Tdap (tetanus, diphtheria, acellular pertussis) vaccine. As a reminder, this recommendation extends to adults 65 years of age and older and is particularly important for pregnant women, new parents, and others, including grandparents who are around young infants. Adults bring pertussis to newborn babies who often become severely ill. The only way to protect babies is to get those around them immunized. The 8.2% coverage level is not enough. We need to do better. Since 2010 influenza vaccine has been recommended for all adults. It is no longer necessary to focus on specific age groups or patients with high-risk conditions. Everybody every year needs influenza immunization. The H1N1 pandemic reminded us that even healthy adults can become severely ill from influenza. The 2012–13 vaccine composition is different than last year’s, making it particularly important that adults get immunized. Pneumococcal immunization is important for adults 65 years of age and older and younger adults with chronic medical conditions. In June 2012 the Advisory

Committee on Immunization Practices recommended that immunocompromised patients, such as those with HIV infection and malignancy, receive the 13-valent conjugated pneumococcal vaccine (Prevnar 13-Pfizer) in addition to the 23-valent polysaccharide (Pneumovax-Merck) you are used to giving. The ideal sequence is to give the conjugate vaccine first, followed by polysaccharide vaccine, but even those previously immunized with polysaccharide vaccine should receive a boost with conjugate vaccine. This new recommendation should be published soon on the CDC Immunization Program website: (www.cdc. gov/vaccines/recs/default.htm#acip). There’s more! Don’t forget hepatitis A vaccine for adults who travel or those with chronic liver disease, measles/mumps/ rubella (MMR) vaccine for traveling adults and those working in healthcare, varicella vaccine for adults without a clear history of chickenpox, and zoster vaccine for those 60 years of age and above. Young adult men and women should receive human papilloma virus vaccine. Selected adults need hepatitis B vaccine and meningococcal vaccine. If you’ve lost track of all the vaccines adults need or are not sure of the specific recommendations, the adult immunization schedule is available for download from CDC and can be posted in your exam rooms and nursing stations (www.cdc.gov/vaccines/schedules/easy-to-read/adult.html). Knowing the schedule is not enough. Pediatricians learned long ago that their offices must gear up to make sure immunizations are delivered well. Every patient visit is an opportunity to immunize, even acute-care visits. The office nurse or medical assistant can screen each patient’s immunization record. Many practices use standing orders to assure that missing vaccines are given as long as there is no contraindication. This takes the doctor out of the loop for most patients. In order for that to work you need easy access to each patient’s record. Make sure every patient’s record is updated in your chart or EMR. Make sure your EMR is linked to the San Diego Immunization Registry that contains immunization data on patients from across San Diego County. It is also essential that patients know that you support immunizations and

So, what immunizations do adults need? How can you convince your patients to get immunized? What systems do you need in place in your office to do a good job immunizing? What resources are available for you and your patients? recommend them strongly. Hopefully, this is reflected in the fact that you, your staff, and your family are up-to-date with their immunizations. A personal recommendation from a doctor is the single most important thing that motivates adults to get immunized. If you, your staff, or your patients have questions about vaccine, there are numerous resources available to help. Take a look at the following websites: • CDC (www.cdc.gov/vaccines) • AAFP (www.aafp.org/online/en/ home/clinical/immunizationres.html) • American College of Physicians (www. acponline.org/clinical_information/ resources/adult_immunization) • American College of Obstetrics and Gynecology (www.immunizationforwomen.org/resources/acog_resources) • Immunization Action Coalition (www.immunize.org) • National Network of Immunization Information (www.immunizationinfo.org) Immunizations are one of the top public health achievements of the 20th century, yet many patients don’t benefit from them. We all need to do more to get our adults protected at the same levels that our children are through immunization. We need to do better, and it only hurts a little. Dr. Sawyer, SDCMS-CMA member since 2010, is professor of clinical pediatrics at the UC San Diego School of Medicine and Rady Children’s Hospital San Diego and sits on the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission.

SAN DIEGO PHYSICIAN.org 21


Infectious Disease

Infection Prevention and Legislation/ Regulation 2011–12 It’s Not Just Hospitals Anymore! By Frank Meyers and Kim M. Delahanty, RN, BSN, PHN, MBA, CIC

22 Oc tober 2012


2011–12 has brought more legislation around infection prevention, and it has also required much more public reporting of outcomes. CMS is the newest actor in requiring public reporting. Because California has been on the forefront of public reporting, much of the requirements are redundant and pose no extra workload on hospitals. Colon surgery and central-line-associated blood stream infections (CLABSI) were both already reported in California. Abdominal hysterectomies and catheter-associated urinary tract infections (CAUTI) in intensive care units were not reported. Beginning January 1, 2012, both were required for reporting. Just as the common cold is the most common infectious disease, CAUTIs are the most common healthcareassociated infections, and, as with colds, in comparison to other healthcare-associated infections, the rate of attributable mortal-

2011 in particular took non-risk-adjusted data and non-standardized case definitions resulting in a hodgepodge of data of dubious value. The next SSI report is expected to have better data quality supplied by the hospitals. Unfortunately, recent literature suggests that too much variation still exists in interpretation of the definitions and the robustness of the surveillance systems, meaning the data will not be of academic research quality. Because any links to particular reports will become obsolete as new ones are generated, it is best to access the following website monthly to look for updates: www.cdph. ca.gov/programs/hai/Pages/default.aspx. It should be noted that the data in the reports has yielded some findings that have the potential to be very useful in infection prevention. The central line insertion practice (CLIP) bundle report unsurprisingly showed rates of compliance differing when third parties completed the form or when the inserter completed the form. However, the report also gave us what percentage of central lines inserted in the ICU were femoral lines. As femoral lines are associated with higher CLABSI rates, this comparative information can be useful in helping a facility determine if their rate of femoral line insertions can be reduced. The public reporting trend is also moving out to long-term care (LTC) hospitals, dialysis centers, inpatient rehabilitation facilities, and outpatient surgery centers. In October 2012, LTCs will begin reporting their CLABSI rates, and inpatient rehabilitation facilities will report their CAUTI rates. And by October 2013, outpatient surgery centers will begin reporting their influenza vaccination rates among their staff. The interest in influenza vaccination

Just as the common cold is the most common infectious disease, CAUTIs are the most common healthcareassociated infections, and, as with colds, in comparison to other healthcareassociated infections, the rate of attributable mortality with CAUTI is very low compared to other conditions. ity with CAUTI is very low compared to other conditions. These two additional data sets will most likely be first reported in 2013. Meanwhile, the state has gathered a lot of data and has been publishing it regularly with some meaningful analysis. The analysis sections of these documents have been useful in discussing the limitations of some of these reports. The surgical site infection report (SSI) January 2009–March

SAN DIEGO PHYSICIAN.org 23


Infectious Disease among healthcare workers has also resulted in additional legislation. California Senate Bill 1318 appears to be headed towards law, having made it through the Senate. This bill will require clinics and health facilities to offer employees vaccines at no cost (already required under Cal-OSHA’s aerosol transmissible disease standard) and to have their employees, contractors, and medical staff accept the influenza vaccine or wear a mask for the duration of the influenza season. This law reflects the growing practice of vaccinate or mask at many institutions. California Department of Public Health (CDPH) Health Care Associated Infections Advisory Committee (HAI AC) was developed with the intention to give recommendation to the state of California on how to implement SB 739, 1058, and 158 CA HAI legislation. This committee was made up of multiple stakeholders to include infection preventionists, consumers union, hospital epidemiologists, integrated health systems, local public health officers,

university systems, quality officers, CEOs, etc. The charge of the committee was to make recommendations to improve the morbidity and mortality around preventable healthcare-associated infections for Californians. A lot of work has been done by the current HAI AC in the last five years to meet and exceed that charge. There has been a lot of turnover at the CDPH camp to include a new governor. With that change in leadership brings change in programs and prioritized focus. New bylaws to govern the HAI AC were developed by the chief deputy director, which has morphed the focus of the HAI AC. Having said that, the current membership has been asked to resign and reapply, if they so wish, under the new bylaws to be considered for a position on the committee. New membership rules are a minimum of one and a maximum of three members from these categories: department staff, local health department officials, healthcare infection control professionals, physicians with expertise in

infectious diseases and hospital epidemiology, healthcare providers, hospital administration, integrated healthcare systems, and healthcare consumers. Keeping in mind all of these, members, per SB 739 1288.5(b), need to have the following credentials: “HAI AC members shall be individuals with expertise in the surveillance, prevention, and control of HAIs.” This next wave of HAI AC members will be interesting to watch. If there is no institutional memory maintained by recruiting prior HAI AC members, the HAI program and what that means to Californians could have unintended consequences. The new healthcare reform act will also play a role in the outcomes of this committee. It is a wait-and-see game for now. Mr. Meyers and Ms. Delahanty sit on the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission. Ms. Delahanty is administrative director, Infection Prevention Clinical Epidemiology/TB Control, at UC San Diego Health Systems.

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Infectious Disease Antimicrobial stewardship is a novel strategy

The Infectious Disease Pharmacist’s Role in Antimicrobial Stewardship By Maggie Brownell, PharmD

26 Oc tober 2012

utilized in health systems to improve patient outcomes by maximizing the effectiveness of anti-infective therapy while minimizing the unintended consequences of antibiotics. The goals of antimicrobial stewardship include attenuating or reversing bacterial and fungal resistance, preventing antimicrobial-related toxicity, and reducing the costs associated with inappropriate antibiotic use and healthcareassociated infections. In order to have successful antimicrobial stewardship, a multidisciplinary team is necessary, which includes an infectious disease pharmacist and physician as core members, in addition to an infection control professional, a clinical microbiologist, an information system specialist, and a hospital epidemiologist. Infectious disease pharmacists (IDP) emerged as a response to the need to better utilize antibiotics for the obvious reason that their use is associated with rapid rises in extremely resistant strains of bacteria and fungi, which in turn leads to the need for a more sophisticated approach in the strategies to treat infections. Pharmacists play a key role in this endeavor. In order to be qualified to do this, an IDP needs to have extra training, generally completing two post-graduate years with a specialty residency in infectious disease. In addition, they attend specific certification programs, which are designed to increase knowledge in microbiology, pharmacology, and disease state management. The collaborative relationship between the infectious disease physician and pharmacist is key for successful stewardship. Most often, the physician’s full-time responsibilities are not completely devoted to antibiotic stewardship. He or she provides guidance to the stewardship team, while being responsible for their patients on the infectious disease consult team and clinic patients. Ideally, there is a dedicated fulltime pharmacist devoted to antimicrobial stewardship who collaborates with the physician to help accomplish the daily activities and efficiently manage the physician’s time. The IDP plays several roles. One of the more important responsibilities is to ensure the optimal use of antimicrobial agents


throughout the health system. These activities may include aiding in appropriate antibiotic selection and dosing, proper monitoring, and de-escalation of antibiotics to the most-narrow-spectrum agent that will successfully treat the infection. It has been shown that unnecessary use of broadspectrum antimicrobial agents leads to evolution of bacterial resistance and development of super-infections such as Clostridium difficile, which emphasizes the importance of rapid antibiotic de-escalation when possible. Pharmacists are involved in developing clinical pathways to guide appropriate antibiotic selection for common infectious disease states encountered in the hospital, such as community-acquired pneumonia and surgical prophylaxis. Additionally, IDPs assist in developing guidelines to doseoptimize and renal-adjust antimicrobials, as well as facilitate the parenteral to oral conversion of antimicrobials with equiva-

lent bioavailability. Many health systems implement “restriction criteria” on certain antimicrobials based on therapeutic efficacy, potential for misuse, toxicity, and costs. Antimicrobial restriction through either formulary limitation or preauthorization with justification is the most effective method of controlling antimicrobial use. Studies have demonstrated this strategy has led to short-term increase in bacterial susceptibilities, cessation of Clostridium difficile outbreaks, morbidity prevention, and cost savings. Since the pharmacist reviews all medication orders, they play a key role in ensuring restricted antimicrobials are dispensed according to the pre-specified criteria and help monitor appropriate utilization. Education is an essential element of any program designed to influence prescribing behavior, including antimicrobial stewardship. These efforts may include activities

Dr. Brownell sits on the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission. She is the infectious diseases clinical pharmacist at Scripps Memorial Hospital and an assistant clinical professor at UCSD Skaggs School of Pharmacy.

U N I V E R S I T Y

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such as conference presentations, house staff teaching sessions, and provision of written guidelines or email alerts. Education with incorporation of active interventions has demonstrated a more sustained impact compared to education alone. In summary, antibiotic stewardship is a multi-disciplinary approach in which a pharmacist is a key member. Antimicrobial resistance continues to increase while the development of new antimicrobials is decreasing. Antimicrobial stewardship is everyone’s responsibility; pharmacists should be utilized to help ensure and promote judicious use of antimicrobials.

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Infectious Disease

Hantavirus Pulmonary Syndrome A Rare but Deadly Disease By Robert E. Peters, PhD, MD, FAAFP

28 Oc tob er 2012


Nine confirmed cases of Hantavirus Pulmonary Syndrome have been confirmed in visitors staying at Curry Village, Yosemite National Park, since June, according to the National Park Service. More specifically, public health officials believe the visitors were exposed to hantavirus while staying at the signature tent cabins in Curry Village. In one case the person camped and hiked in the park’s High Sierra Camps this summer. Three of the nine diagnosed individuals have died. The early symptoms of this potentially fatal viral infection — now of concern in

San Diego County — may mimic a typical case of “flu,” causing a significant differential diagnostic problem. Hantavirus was first described in 1951 when a hantavirus was confirmed to have caused hemorrhagic fever with renal syndrome (HFRS) in North and South Korea. It took many years before the virus was isolated from its rodent reservoir and identified as being in the Bunyaviridae family. The virus that caused HFRS in Asia was later categorized and grouped as an “Old World Hantavirus.” In May 1993 an outbreak of an unexplained pulmonary illness occurred in the southwestern United States, first noted primarily among Native Americans in the “Four Corners” area, where Arizona, New Mexico, Colorado, and Utah share a common border. A young, physically fit Navajo man suffering from shortness of breath was taken to a hospital in New Mexico, where he was admitted. He died shortly after admission. Investigation confirmed that the young man’s fiancée had died a few days previously and that she had exhibited similar symptoms. Dr. James Cheek of the Indian Health Service noted, “I think if it hadn’t been for that initial pair of people who became sick within a week of each other, we would never have discovered the illness at all.” An investigation across the Four Corners area identified several additional cases of the disease. Lab tests had failed to identify any of the deaths as caused by a known disease, such as bubonic plague. Exhaustive analysis of tissue samples sent to CDC (using techniques to pinpoint virus genes) linked the pulmonary syndrome seen in the Four Corners area with a previously unknown type of hantavirus. Researchers were aware that hantaviruses were typically transmitted to people by proximal contact with mice and rats. The deer mouse was found to be the primary carrier. About 30% of the deer mice in the subject Four Corners area that were tested were confirmed to have evidence of hanta-

virus infection. In November 1993 the specific hantavirus that caused the Four Corners outbreak was isolated by the Special Pathogens Branch at CDC. The CDC work was confirmed independently by the U.S. Army Medical Research Institute of Infectious Diseases. The new virus was initially labeled the “Muerto Canyon Virus.” The name was later changed to the “Sin Nombre Virus.” The resulting disease caused by the Sin Nombre virus is identified as Hantavirus Pulmonary Syndrome (HPS). While HPS was not known to the epidemiologic and medical communities, the periodic disease occurrence was recognized by the Navajo medicine men and the “host” articulated before CDC identification of the virus and host. The Navajo recognized a similar disease from their medical traditions and actually associated its occurrence with mice. They also recognized that heavy snows and above normal rainfall helped enrich the population of rodents to larger than usual numbers. After further investigation, it was determined that HPS caused by hantavirus was not a new disease. Other early cases of HPS were discovered by screening for the viral genes associated with the Sin Nombre virus in frozen samples of lung tissue from people who had died in prior years of unexplained lung disease. At the time the virus was not characterized (nor recognized) as a hantavirus. By retroactive studies, the earliest case of HPS among the stored samples was confirmed to have occurred in a 38-year-old Utah man in 1959. Sin Nombre hantavirus is one of several New World hantaviruses found in the United States and Canada. Hantaviruses are enveloped viruses with a genome that consists of three single-stranded RNA segments. The Sin Nombre hantavirus is responsible for the majority of cases of HPS identified to date. The primary host of the Sin Nombre hantavirus in the Southwestern United States is the deer mouse, which is found throughout the western (and

SAN DIEGO PHYSICIAN.org 29


Infectious Disease central) United States and Canada. Several other hantaviruses found in the United States are also capable of causing HPS. The New York hantavirus, hosted by the white-footed mouse, is associated with most of the HPS cases reported in the northeastern United States. The Black Creek hantavirus, hosted by the cotton rat, and the Bayou hantavirus, hosted by rice rats, are variants reported in the southeastern United States. HPS has also been confirmed elsewhere in the Americas, including in Canada, Argentina, Bolivia, Brazil, Chile, Panama, Paraguay, and Uruguay. In the western United States, deer and harvest mice are the main carriers of hantavirus, as mentioned. The disease is not known at this time to have any deleterious effects on the infected mice. In San Diego County, deer mice are found most frequently in rural areas where humans live and in the more remote desert and mountain areas. Cases of HPS occur sporadically and are most often observed in patients

who live in rural areas where forests, fields, and farms offer suitable habitat for the rodent hosts that live proximal to humans. Hantavirus is transmitted as an airborne disease, and infection occurs when airborne virus particles generated from disturbed fresh rodent urine, fecal droppings, or nesting material are stirred up and inhaled. Researchers believe that one may also become infected if virus-contaminated urine or rodent droppings are touched and then the person’s nose or mouth touched. Companion animals such as dogs and cats may serve to bring the infected rodents or rodent materials into contact with humans. Consumption of food contaminated by rodent proximity may also lead to illness. Rodent bites may spread infection, but this transmission route is thought to be rare. The Sin Nombre virus is not believed to be spread from person to person through blood transfusion. (It should be noted that an outbreak of HPS in Argentina in 1996, however, suggested there may be hantavi-

rus strains that are transmissible by blood transfusion, needle stick, etc.) Diagnosing HPS in an individual who has been infected within the past few days can be difficult for the attending physician. Earliest symptoms are very similar to, and easily confused with, an influenza infection. Due to the small number of HPS cases studied to date, the Sin Nombre virus incubation period is not definitively understood. Universal early symptoms typically include fatigue, fever, and muscle aches (especially in thighs, hips, back, and sometimes shoulders). About one-half of diagnosed HPS patients also experience headaches, dizziness, chills, and abdominal problems such as nausea, vomiting, diarrhea, and abdominal pain. Late symptoms begin to appear four to 10 days after the initial “flu-like” phase of the illness. These later symptoms include coughing and shortness of breath, the sensation of a “tight band around the chest,” and/or the sensation of breathing as if there is a pillow over the

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face, both the result of the lungs’ beginning to fill with fluid. HPS is often fatal. About 38% of the patients diagnosed with the virus have died as a result of the acute infection. No symptoms of chronic infection have been observed, at least as yet, in humans. There is currently no specific recommended acute treatment beyond supportive care. At this time there is of course no vaccine to prevent hantavirus infection. It should be noted: Infected individuals who are diagnosed quickly and who receive supportive medical care, often in an intensive care unit, have an improved probability of survival. For “New World” hantavirus infections, intravenous ribavirin has not been shown to be effective for treatment despite its success in reducing case-fatality for patients with HFRS, which is caused by Old World hantaviruses. Prevention of potential infection remains the primary action to be taken. Rodent control in and proximal to the home

(and outbuildings) remains the primary strategy for preventing hantavirus infection. Seal potential rodent access holes and gaps in the home or garage. Practice historic rodent control measures, cleaning up after meals, precluding access to food in the home in garbage cans or unsealed containers, etc. Campers must practice similarly careful foodstuffs control — before and after meals — to avoid attracting mice and rats to the camp area. Interestingly, Navajo medical beliefs going back prior to the Four Corners outbreak of 1993 concur with public health recommendations for preventing the disease. Elimination and minimization of potential contact with rodents in the home, outbuildings, workplace, or campsite is, sadly, the best medical advice to be rendered, which is of course more a “public health” function than one of typical physician-patient contacts. As a physician, we should, however, particularly in the San Diego area, suspect HPS if an otherwise healthy individual is

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suddenly experiencing more significant symptoms of fever, fatigue, and shortness of breath, and especially if the presenting patient has a history indicating recent rodent exposure. Investigate the potential for increased recent rodent contact via “rural” visits, camping, or travel. Consider the possibility the early symptoms may be indicative of a critical infection of hantavirus, rather than simply “flu.” Dr. Peters, SDCMS-CMA member since 2000, is a board-certified family physician in private practice and a member of Sharp Community Medical Group. He is president-elect of SDCMS, sits on SDCMS’ GERM Commission, is chair of CMA’s Council on Ethical Affairs, and sits on the San Diego Academy of Family Practice board of directors. Dr. Peters earned a PhD in biochemistry from the University of California in 1975. He serves as a consultant to the biomedical community and lectures on infectious disease and disaster preparedness. Dr. Peters received a Physicians of Excellence Award, Top Doctors, in 2011.

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BE OUR HERO give access to healthcare for those without!

San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

Volunteer for Project Access San Diego Through our flagship program, Project Access San Diego, we have been able to assist over 1.700 uninsured adults in our community to improve their health through access to specialty healthcare services. Join our more than 625 volunteer physicians to provide specialty healthcare services to those who most need our help. You decide how many patients a month or a year you are able to serve. We make your volunteer experience easier and more rewarding, and less taxing to your office staff with comprehensive patient care management, labs, imaging and other ancillary health services. Your consultations will be efficient for you and life-changing for your patients.

Volunteer in Your Pajamas Provide your primary care physician colleagues HIPAA-compliant, web-based patient consultations from the comfort of home or office. eConsultSD increases the capacity of primary care physicians at our community health centers to maintain care of their patients by receiving answers to clinical questions from volunteer specialists. eConsultSD is an easy way for specialist physicians to volunteer when they are not able to provide direct patient care.

Get Involved San Diego County Medical Society Foundation needs you! Attend an event, assist us to recruit fellow physicians, or provide educational opportunities for primary care physicians or medical students. Our first annual Golf Tournament is scheduled for Thursday, February 28, 2013 at Del Mar Country Club; we hope you can join us! Please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or call us at 858.300.2777.

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classifieds PHYSICIAN POSITIONS AVAILABLE RESEARCH PHYSICIAN / PRINCIPAL INVESTIGATOR: Profil Institute for Clinical Research is looking for a research physician / principal investigator. Requirements: three years MD experience in clinical adult medicine + unrestricted California MD license. Research experience not necessary. Responsibilities: Serve as subinvestigator or principal investigator on studies. Perform medical histories, physical exams, admit, discharge, and monitor subjects, including reviewing labs results, EKGs and telemetry as part of clinical research trials. Weekday shift hours + limited on-call hours and strong benefits plan. Interested parties please apply online at www. profilinstitute.com under “Career Opportunities.” If you have further questions, please contact Robyn Nielsen, recruitment manager, at (619) 419-2048. [082] SUPERB INTERNAL MEDICINE PRACTICE OPPORTUNITY: The position is available in August of 2013. You will be joining one of the premier internal medicine groups in North County San Diego. No hospital work or ER call. Competitive salary including benefits plus the opportunity to begin a partnership track if desired. Beautiful office building, excellent staff, ideal for either first year in practice or for an experienced practitioner. Contact Jon LeLevier, MD, at (760) 310-2237 or Jeff Leach, MD, at (760) 846-0464 for more information. [081] SENIOR PHYSICIAN: The County of San Diego HIV/ STD/Hepatitis clinic has an immediate opening for a licensed physician at least three (3) years of recent postinternship training or experience in internal medicine or as a general practitioner to manage a team responsible for planning and directing clinic services. Must be available to work flexible schedules at multiple sites, including some evenings is expected. Application and CV can be submitted online at www.sdcounty.ca.gov/hr. For questions, please contact Gloria Brown, Human Resources Analyst, at (858) 505-6525 or at Gloria.Brown@sdcounty.ca.gov. [078] SEEKING A FAMILY PRACTICE PHYSICIAN: To join a small but growing group in North County San Diego, CA. The perfect doctor for the position will be one who has strong communication skills and great bedside manner. The physician should have a good background in procedures (dermatologic, orthopedic, etc.). I am looking for a physician who will take personal pride in the growth of this unique practice. We emphasize quality of time with the patients rather than the number of patients seen. Hours will be 8–5 Monday–Friday with no hospital call. Once hired you will be provided with an LVN/scribe for all EMR notes and to assist in procedures. We are inviting you to join an extraordinary clinic in a beautiful location with a fantastic staff. Salary will be competitive for the region along with bonuses for exquisite performance. Please email me at psexton@encinitasfamilycare.com. [077] CONTRAST SUPERVISING PHYSICIAN NEEDED: Independent diagnostic imaging facility seeks physicians to monitor patient examinations requiring contrast. We are looking for physicians to work various Saturday/ Sunday shifts scheduled from 8am to 5pm on a per diem basis. Shifts are available on an ongoing basis. Please contact Eva Miranda at (858) 658-6589 for more information. [076] MEDICAL DIRECTOR: The County Psychiatric Hospital needs a full-time medical director. This is a key leadership role in our very physician-friendly, dynamic Behavioral Health system. Facility includes an inpatient unit and a very busy psychiatric emergency unit. Medical director does limited direct clinical care. Required: three years of psychiatrist experience, including one year of managing a psychiatric hospital or multi-disciplinary medical and mental health facility. Competitive salary and excellent County employee benefit package offered. San Diego combines the lifestyle of a resort community and the amenities of a big city. The hospital is centrally located, minutes from many recreational opportunities and great residential communities with wonderful yearround weather. CV can be submitted online at www.sd-

county.ca.gov/hr. For questions, please contact Darah Frondarina, human resources specialist, at (858) 5056534 or Darah.Frondarina@sdcounty.ca.gov. [072] FAMILY PRACTICE MD FOR URGENT CARE CLINIC: San Ysidro Health Center (SYHC) is currently searching for a family practice MD for our Chula Vista Urgent Care Clinic. Since 1969, SYHC has been providing quality, lowcost, primary healthcare services to South Bay and Central San Diego residents. SYHC offers an extensive array of family-oriented primary healthcare services, including pediatrics, OB/GYN, adult medicine, dental care, and mental health. The family practice MD manages and provides acute, chronic, preventive, curative, and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics, and internal medicine. APPLY ONLINE AT WWW.SYHC.ORG. [071]

Doctor for Lake Tahoe Practice: All specialties considered. Excellent compensation and full benefits. No call. No weekends. Start at 3 days per week and will grow if desired. Flexible hours. Incentive bonus plan. Paid relocation expenses to winter and summer paradise. No hospital rounds or meetings. Resume: southshoretahoe@aol.com or Ms. Forster, PO Box 5910 Stateline, NV 89449 SOUTHERN CALIF REGIONAL MEDICAL DIRECTOR (RMD): Your Neighborhood Urgent Care (YNUC) is recruiting two RMDs for its 10 urgent care clinic network in Orange County and San Diego County. BC in emergency medicine or in family practice, internal medicine with urgent care experience required. Management/administrative experience in previous healthcare positions very desirable. Independent Contractor for two years, then equity available. Position is based at the MSO and is 20 hours per week clinical and 20 hours per week quality improvement. Very attractive hourly. Contact ramster@ ynuc.us now! [070] COUNTY OF SAN DIEGO: PHYSICIAN-12419307: Salary: $103,376.00–$125,652.80 annually. Serving the citizens of San Diego with excellence. This is a series recruitment that will remain open until the position has been filled. Are you looking for a rewarding career in public health, providing care at the community level in a team environment? An exciting and challenging career as a physician awaits you at the County of San Diego. The Health and Human Services Agency’s Public Health Services is seeking qualified applicants for the position of physician to fill a vacancy in the Tuberculosis (TB) Clinic located at 3851 Rosecrans St., San Diego, CA 92110. As a physician, you will deliver professional medical services in the area of tuberculosis treatment and prevention. Please visit www.sdcounty.ca.gov/hr/ for a complete job description, including essential functions, required education / experience, working conditions, etc. [069] SUPERVISING CHILD PSYCHIATRIST, COUNTY OF SAN DIEGO: BC child psychiatrist to serve as supervising child psychiatrist for Child, Youth and Families (CYF) Behavioral Health and as deputy to the clinical director of the Behavioral Health Division of County of San Diego Health & Human Services Agency (HHSA). Significant administrative / managerial experience required; to provide clinical supervision in a variety of CYF County-operated programs. Applications and CVs must be submitted online at www.sdcounty.ca.gov/hr. For further information please email Marshall Lewis, MD, Clinical Director, at marshall.lewis@sdcounty.ca.gov or call (619) 563-2771, or email Katie Astor, Assistant Deputy Director, at katie. astor@sdcounty.ca.gov, or email Lita Santos, Human Resources, at lita.santos@sdcounty.ca.gov. [068]

OPPORTUNITY KNOCKS FOR BC/BE PEDIATRICIANS: Live in one of the country’s most desirable locations and practice with a premier San Diego multispecialty medical group! Sharp Rees-Stealy Medical Group is looking for BC/BE Pediatricians. Competitive first-year compensation guarantee, excellent benefits, and shareholder eligibility after two years. Unique opportunity for professional and personal fulfillment while living in a vacation destination. Please send CV to Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 2334730. Email: Lori.Miller@sharp.com. [064] PHYSICIAN — SAN DIEGO COUNTY: Are you looking for a rewarding career in public health, providing care at the community level in a team environment? An exciting and challenging career as a physician awaits you at the County of San Diego. The County has a physician opening in the Public Health Services’ TB clinic located in San Diego (92110). Incumbents will deliver professional medical services related to tuberculosis treatment and prevention. Valid NPI, current California licensure, MD or DO degree, and one year of post-graduate experience required. For more information and to apply, visit www. sdcounty.ca.gov/hr, recruitment #12419307. Open until filled. Contact darah.frondarina@sdcounty.ca.gov for questions on the application process. [063] PHYSICIAN NEEDED — FULL- OR PART-TIME SCHEDULES AVAILABLE: Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent comprehensive benefits package that includes: malpractice coverage; NHSC loan repay eligibility; and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd.org. If you would like to fax your CV, fax it to (619) 876-4426. To apply, visit our website and apply online at www.fhcsd.jobs. [046] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com ) is a fast-growing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [037] PHYSICIANS WANTED: Vista Community Clinic, a private, nonprofit clinic serving the communities of North San Diego County, has openings for part-time and per-diem positions. Five locations in Vista and Oceanside. Family medicine, OB/GYN medicine, pediatric medicine. Requirements: California license, DEA license, CPR, board certified, one (1) year post-graduate clinic experience. Bilingual English / Spanish preferred. Benefits: malpractice coverage. Email resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit website at www.vistacommunityclinic.org. EOE/M/F/D/V [035] 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]

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 Oc tober 2012


PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008] OFFICE SPACE / REAL ESTATE NORTH COAST OFFICE SPACE TO SUBLEASE: North Coast Health Center, 477 El Camino Real, Encinitas, office space to sublease. Newly remodeled and beautiful office space available at the 477/D Building. Occupied by seasoned vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab and tech on site for extra convenience. Will sublease partial suite for two exam rooms and office work area or will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [041] SHARE OFFICE SPACE IN PLASTIC & RECONSTRUCTIVE SURGERY CLINIC IN UTC: Office space and practice support for full- or part-time surgeon available immediately. Equipped with two operating rooms accredited by the AAAASF, private entrance, three exam rooms, two of them also consults rooms, two private bathrooms, and staff room with kitchen. Ideal for orthopedic, urologist, plastic or general surgeon. Surgical center contracted with Anthem Blue Cross, United Health Care, Aetna, and workers’ comp. Call (858) 457-8686 or email drsoltero@ solteromd.com. [074] FULL- AND PART-TIME OFFICE SPACE IN UTC: in 8th floor suite with established neuropsychologists 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 parking. Contact Christine Saroian, MD, at (619) 682-6912. [862] CLAIREMONT MESA OFFICE SPACE FOR LEASE: Clairemont Mesa Medical Arts Center is a medical office building conveniently located in Kearny Mesa, close to the 15, 163, 52, and 805 freeways. Available for lease September 1, 2012. 520 square-foot suite, currently configured as three room (lobby, exam, and office), located on the second floor. Call Alex at (858) 268-1111, ext. 311, for inquiries and viewing. [066] MEDICAL OFFICE SPACE FOR LEASE: Medical office space of 1,846 square feet located at 15721 Pomerado Road, Poway, CA 92064 in the Gateway Medical Center

available for immediate lease. This recently remodeled facility has a shared waiting room, medical records storage area, front desk reception area, three exam rooms, nursing station, private office, shared bathroom. The larger space is shared with an internal medicine group and is blocks away from Pomerado Hospital. Imaging is located in an adjacent building. The lease rate is $1.69/SF NNN with a 3% annual increase. The NNNs are currently running $0.73/SF. Tenant will be responsible for pro rata share of utilities and janitorial in addition to NNNs. Great opportunity in this affluent community. Call Angie at (858) 605-9966. [065] OFFICE FOR LEASE SCRIPPS MEMORIAL HOSPITAL MEDICAL OFFICE BUILDING: La Jolla multi-specialty group, excellent referral base, great location, corner office large windows, full- or part-time space available (one doctor retiring). Please call Dr. Shurman cell (858) 3449024 or office (858) 320-0525. [058] 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] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] NEW — EXTREMELY LOW RENTAL RATE INCENTIVE — EASTLAKE / RANCHO DEL REY: Two office/medical spaces for lease. From 1,004 to 1,381 SF available. (Adjacent to shared X-ray room.) This building’s rental rate is marketed at $1.70/SF + NNN; however, landlord now offering first-year incentive of $0.50/SF + NNN for qualified tenants and five-year term. $2.00/SF tenant improvement allowance available. Well parked and well kept garden courtyard professional building with lush landscaping. Desirable location near major thoroughfares and walkable retail amenities. Please contact listing agents Joshua Smith, ECP Commercial, at (619) 4429200, ext. 102. [006] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sqft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease/satellite location, flexible days of

Place your advertisement here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] 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 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] NONPHYSICIAN POSITIONS AVAILABLE FULL-TIME NURSE PRACTITIONER: Busy internal medicine practice in Hillcrest seeking a full-time (Monday– Friday) licensed nurse practitioner. Minimum of one (1) year nurse practitioner experience preferred. Experience with EMR helpful. Qualified candidate should submit a current CV or resume to pmason@hillcrestinternal.com. Salary based on knowledge and experience. No calls. [083] PHYSICIAN ASSISTANT / NURSE PRACTITIONER: Gastroenterology specialty practice located in North San Diego County is seeking a PA or NP for our five-physician group. The candidate will be dependable, detail-oriented, and a team player. We offer a competitive salary and benefits. PA or NP will be responsible for assessing patients, obtaining patient histories, and performing physical exams. They would order/perform routine diagnostic procedures, develop treatment plans, and monitor the effectiveness of therapeutic interventions as directed by the physicians. Physician Assistant: Certified California State Medical Board for Physician Assistants. Nurse Practitioner: Current licensure as RN in the State of California. Advanced practice degree. Email Javaid Shad at jshad@ ncgastro.com. [080] NURSE MANAGER: Seeking nurse manager for our AAAHC GI facility in Oceanside, California. The ideal candidate will be dependable, detail-oriented, and a team player. Competitive salary and benefits. NM is responsible for accountability of clinical care and productivity, including assessing, implementing, and evaluating processes, technology, personnel, and facility needs required to achieve patient outcomes safely. Is responsible for coordination and direction of patient care services and other service areas in the facility. Responsible for quality improvement, identifying opportunities to improve services, recommending and implementing actions to meet the goals of the facility. RN State of California. ACLS certification. Email Kathy Moore at kmoore@ncgastro.com. [079] FRONT OFFICE RECEPTIONIST POSITION: Dermatologist in Hillcrest needs a special individual for computer billing, typing, front office, mature, experienced. Friendly environment. Email resume to eydiekornberg@ gmail.com. [075] NURSE PRACTITIONER WANTED: Nurse practitioner wanted for internal medicine and pediatrics practice in Coronado. Enthusiasm, dependability, and a love of learning are musts! Full-time with benefits. Experience preferred. Please send your resume to CoronadoMedPeds@ gmail.com. [067] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/hours. Competitive compensation. Call (619) 9925330. [038]

SAN DIEGO PHYSICIAN.org 35


UC san diego Health Sciences

White Coat Ceremony 2012

Note: The following speech was delivered at UCSD’s August 31 White Coat Ceremony by Sherry L. Franklin, MD, SDCMS president. Good afternoon and welcome to UCSD’s White Coat Ceremony. Welcome to our new students and our new families. My name is Sherry Franklin. I’m a pediatric endocrinologist and the current president of your Medical Society. The San Diego County Medical Society is thrilled to be participating in this symbolic day, where you join this noble profession by getting your white coat. Today you become part of a tradition that goes back over twenty-five hundred years. Physicians first wore the white coat as a means of maintaining hygiene. In time, the white coat became a symbol of authority and the validation of the practice of medicine. Patients came to recognize it as a symbol of the profession. The white coat ceremony was conceived, in part, as a vehicle to help establish a psychological contract with you. When the white coat is presented to an entering class, it is a gift of faith, confidence, and compassion. I know what many of you are thinking. I thought the same thing. I’m going to medical school to become a great doctor. My parents raised me well. I’m compassionate. I’m a good person. I’m here to learn the 36 Oc tober 2012

things I don’t know yet. I’m here to learn about physiology, pathology, disease process, pharmacology, and surgery. Trust me, you will all learn those things and more. It is the more that makes or breaks you. A friend of mine once told me that medicine attracts the best and the brightest, but I am quite sure, and lucky for me, that being the brightest in organic chemistry does not make one a great doctor. It is the respect and compassion you show that defines the profession you have chosen. Just this week, I saw an extremely anxious mother of an adopted teenager with autism. The boy took at least 10 supplements and had a very structured special diet to help him function. The diet restricted fruits and some vegetables secondary to glycemic index concerns. The boy had been having panic attacks over the last two months, after starting therapy with a thyroid supplement to help his energy level, fatigue, daytime sleeping, and help with constipation. It was obvious to me that the thyroid supplement was the cause of the boy’s panic attacks and the lack of fruits and vegetables were contributing to his constipation. Labs confirmed my suspicion. I asked Mom to stop the thyroid supplement, but she was incredibly resistant. It took 30 minutes and a few backed up angry patients to get to the root of the real problem. My patient had great difficulty sleeping. Mom had done a considerable amount of research on sleep problems and found a website on obstructive sleep apnea. She knew her son would not be able to wear a mask at night. So this amazing, supportive, well-educated mom spent her time looking for other ways to help her son. This is how he ended up on the thyroid medication. The extra 30 minutes I spent were in attempting to ease Mom’s anxiety about getting a diagnosis and helping her to understand that all sleep disorders are not sleep apnea. In fact, the sleep study revealed that the boy wasn’t spending enough time in the deeper stages of sleep. A simple medi-

cation to help improve his quality of sleep was all that was needed. I admit, sadly, that there may have been a few times in my career where I might not have taken the time. I might have simply discontinued the thyroid medication, repeated the labs, and explained that the symptoms this child had been experiencing were simply not related to the thyroid. I’m happy to say that this was not one of those times and that this child and this mother received the care and compassion all of our patients deserve. The last few years of my life, my journey in the practice of medicine has completely changed my views. The last few years, I have been on the other side of the stethoscope. My mother died in January of 2011, and my grandmother died in January of 2012, exactly one year later to the day. During hospitalizations, people were hurried and just trying to get through their day. I know the feeling. You have a certain number of people to care for and only so much time in the day to get it done. Otherwise, you’re going to be there all night. Despite my understanding of the schedule, the shift changes, the jobs being done by alternating people, daily nurse changes … I was scared, hurt, and knew this wasn’t the way things are supposed to be. This was my mother, my grandmother. I wanted someone to slow down and simply let me know that they knew us, they cared about us, they would be back to explain things to us. Unfortunately, that never happened. We can do better. The white coat you put on today should remind you that we can all do better. The white coat you are receiving today is a tangible reminder of the contract you will make with every patient you treat. Every time you put it on I’d like you to be reminded that your heart is as important as your mind. Remember that you too will be on the other side of the stethoscope one day. Remember that all of your patients are just like you. Remember the strength and power you hold. Use it with compassion. Try to remember that being a physician is more than the science you learn. You have earned the white coats you are about to wear. Now you must work even harder to earn the right to keep them. Thank you.


We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

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

For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like Irvine internal medicine specialist James Strebig, 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 11,500 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection. 37

mayapri 2011 SAN DIEGO P HY SICIA N. o rg 37 l 2012 SAN DIEGO PHYSICIAN.org


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October 2012