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San Diego Physician

100 celebrates

official publication of the san diego county medical society August 2013

years

SDCMS Foundation:

Physicians are our

HEROes

“Physicians United For A Healthy San Diego”


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

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Contents August

Volume 100, Number 8

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder

features SDCMS FOUNDATION: PHYSICIANS ARE OUR HEROES

SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: Robert E. Peters, PhD, MD PRESIDENT-ELECT: J. Steven Poceta, MD TREASURER: William T-C Tseng, MD, MPH (CMA Trustee) SECRETARY: Mihir Y. Parikh, MD IMMEDIATE PAST PRESIDENT: Sherry L. Franklin, MD (CMA Trustee)

12

Physicians: Join Us as the Heart of Project Access BARBARA MANDEL, MBA

14

Project Access San Diego: $7.6 Million Saved! TODD GILMER, PHD

20

Preparing the Next Generation of Physician Leaders: The Role of Organized Medicine

22

r. Stuart A. Cohen: D Completing His Chairmanship of the SDCMS Foundation

23

Susan Kaweski, MD: Grossmont Healthcare District 2013 Healthcare Hero

24

James Schultz, MD: Molina Healthcare 2013 Community Champion

25 September 26 Heroes Event

32 Colorectal Cancer: Prevention Is Building Awareness 33

teven Rojas, MD: Family S Medicine Resident Embodies SDCMS Foundation Mission CAROL L. YOUNG, MD

departments 4 Calendar • Get in Touch • In Memoriam • And More … 8

Lucky in Dog: Are You Here to See Dr. Bressler and Izzy, or Just Izzy?

DANIEL J. BRESSLER, MD

9

What Language Does Your Body Speak?

Combines Music and Physician Recognition: Heroes de la Salud

HELANE FRONEK, MD, FACP, FACPH

26

10

Whatever It Takes: Kaiser Permanente “Team Joel” Receives SDCMS Foundation Above and Beyond Award

28 Bogged Down in EHR Conversion? Help Is at Hand 30 Physician Advocates for Veterans: PAVE-ing the Way ROSEMARIE MARSHALL jOHNSON, MD 2 August 2013

Tracking of Industry Gifts to Physicians Begins in August

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD (A: Susan Kaweski, MD (CALPAC Treasurer)) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD (A: Sunny R. Richley, MD) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD (A: Anthony E. Magit, MD, Sergio R. Flores, MD) LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD (A: Lawrence D. Goldberg, MD) NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD (A: Anthony H. Sacks, MD) SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD (A: Elizabeth Lozada-Pastorio, MD) AT-LARGE DIRECTORS Jeffrey O. Leach, MD (Delegation Chair), Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD (Board Representative), Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Suman Sinha, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, MD, Perry N. Willette, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Theodore M. Mazer, MD (CMA Vice Speaker) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Jason W. Signorelli OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Renjit A. Sundharadas, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Erin Whitaker, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Stuart A. Cohen, MD, MPH CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), 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 AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

CALIFORNIA MEDICAL ASSOCIATION

34

Physician Marketplace: Classifieds

36

San Diego Physician Celebrates 100 Years: August 1893

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.]


Helping you deliver quality care, one square foot at a time. In today’s competitive market, we leverage our extensive experience and exclusive specialization in healthcare real estate to achieve valuable savings and provide optimal solutions for our clients. We share your commitment to enhancing the patient’s experience, maximizing resources and planning for the future. As San Diego’s trusted leader in medical office and healthcare properties, we thrive on saving our clients time and money through our persistent and strategic negotiating style. Whether negotiating a 2,000-square-foot lease renewal or acquiring a 50,000-square-foot building, you will always be in good hands. Put our experience and expertise to work. Contact us today: Paul Braun Managing Director +1 858 410 6388 paul.braun@am.jll.com

Chris Ross Vice President +1 858 410 6377 chris.ross@am.jll.com

www.us.joneslanglasalle.com/healthcare Leases ▪ Renewals ▪ Sales ▪ Strategic Planning ▪ Demographic & Patient Analysis


/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar SDCMS Seminars, Webinars & Events SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@SDCMS.org.

Cal MediConnect: What You Need to Know (seminar) AUG 22: 11:30am–1:00pm New HIPAA Rules Take Effect September 23: Are You Ready? (webinar) SEP 5: 12:00pm–1:00pm Social Media Basics for the Medical Practice (seminar/ webinar) SEP 12: 11:30am–1:00pm

Cma Webinars CMAnet.org/events HIPAA Compliance: The Final HITECH Rule AUG 21: 12:15pm–1:15pm Medicare: Proposed Changes for 2014 AUG 28: 12:15pm–1:15pm California’s Health Benefit Exchange: The Positives and the Perils of Contracting SEP 11: 12:15pm–1:15pm

Community Healthcare Calendar

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.

Noridian “Ask-theContractor Teleconference” AUG 21 at 2:00pm (www. noridianmedicare.com — Accept the “End User Agreement for Providers” and then click on “Schedule of Events.”) Journey Into Healing: The Chopra Center’s Mind-Body Wellness Workshop AUG 22–25 at the La Costa Resort & Spa in Carlsbad, $2,175–$1,675, CMEs available (www.chopra.com — add promo code “MEDICAL” at checkout to receive special price) 4th Annual Percutaneous Catheter Ablation of Atrial Fibrillation: How to Incorporate This Therapeutic Option Into Your Practice AUG 24–25 (www.scripps. org/conferenceservices) National End Stage Liver Disease Training Program and Treatment Update SEP 7 (www.scripps.org/ conferenceservices) New Advances in Inflammatory Bowel Disease SEP 7–8 (www.scripps.org/ conferenceservices) Five-day Comprehensive Diabetes Education and Management Program SEP 11–13, 16, 17 (www.scripps. org/conferenceservices) 1st Annual Scripps Cancer Care Symposium: A Nursing & Advanced Practice Provider Collaboration SEP 27–29 (www.scripps.org/ conferenceservices) 24th Annual Cardiovascular Interventions OCT 1–4 at the Hilton La Jolla Torrey Pines from 6:30am to 6pm, $899 for physicians, 27.5 AMA PRA Category 1 Credits™ (www.scripps.org/ conferenceservices)

There is a crack in everything God has made.

— Ralph Waldo Emerson (1803–1882)

4 august 2013

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 RECRUITING AND RETENTION 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 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


/////////////////////////////////////////////////////////////////////////////////////////////////// In Memoriam

legislator birthdays

Peggy Elliott, Aug. 31, 1921 – May 30, 2013 by Ralph Ocampo, MD Bonnie and I first got to know Peggy during the malpractice crisis of 1972. Her husband, Gladden (SDCMS president in 1968), was in the thick of the fight to pass AB 1xx along with Jim MacLaggan (SDCMS president 1957). Peggy’s grace and understanding of the issues fully complemented the skills of one of our most effective leaders. When Gladden was speaker of the CMA House of Delegates and subsequently our state medical association president, Peggy stood by his side. Peggy’s people-power was as radiant as a finely polished jewel. Were he alive today, Gladden would testify to the unity of purpose both shared. Peggy married her high school sweetheart, Frank Pelot, on April 26, 2003, after Gladden’s death. We extend our condolences to all surviving members of her family. Peggy and Gladden showed us what singleness of purpose can accomplish, and continue to inspire us to be more effective in representing our colleagues and their patients. “Great pictures of great people.”

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! Senator Ben Hueso Email: senator.hueso@sen.ca.gov Capitol Office: State Capitol, Room 2054 Sacramento, CA 95814 Telephone: (916) 651-4040 Fax: (916) 327-3522 District Office: 303 H St., Ste. 200 Chula Vista, CA 91910 Telephone: (619) 409-7690 Fax: (619) 409-7688 Birthday: Sept. 2

— Milton G. Evangelou, MD

“I knew Peggy as a person outside of the medical organizations. She was very fine, very fair, enjoyed humor, and was a real lady.” — Bill L. Pogue, MD

Become an SDCMS Featured Member!

“Gladden and I were fraternity brothers at Washington U in St. Louis, and I knew Peggy then — a great lady.” — H. Glenn Kellogg, MD

“Peggy was a true lady. She and Gladden were a dynamic duo as they made medicine a real cause. She was very gracious and had a wonderful smile. Her life was lived well. In her later years we saw her at special ARCS gatherings and she was always in the moment. It was an honor to have known her, and our lives are richer because of her.” — Fred A. Frye, MD

“Gladden and Peggy — what a combo! We saw Peggy as a profoundly effective and productive member of the Auxiliary. She did it with style and grace. She is missed along with Gladden.” — John S. Hattox, MD

SDCMS would like to feature some of our member physicians for their noteworthy accomplishments in these pages. If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org. Thank you for your membership in SDCMS and CMA!

SAN  DI EGO  PHYSICIAN.org 5


/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// Commercial Real Estate Tips & Trends By Chris Ross Four Steps in Preparing for Your Lease Expiration Whether it’s renewing or extending your current lease, or considering a purchase or relocation, today’s commercial real estate market is opportunistic yet very sophisticated. As a practice owner or executive, the responsibility you have can be daunting — especially when you consider that the typical medical tenant only addresses their real estate situation once every five to 10 years. What steps should you take to ensure the most advantageous outcome? Owners of healthcare real estate are getting more sophisticated than ever before. Insurance companies, real estate investment trusts, and equity funds are made up of some of the most knowledgeable minds in the business. They know healthcare better than you think. They know all about the internal capital constraints you face and the potential exposure to significant out-of-pocket costs. They know how disruptive relocating can be, not to mention the drain on internal resources associated with the design, construction, and moving process. They are betting that you will more than likely opt to stay put and renew or extend your lease. Your job is to pull yourself out of the “captive tenant” pit and put yourself firmly atop the “free agent” market. Level the playing field by proactively considering your options and maximizing leverage. Here are four ways to achieve a competitive advantage and contain occupancy costs:

1. Mark Your Calendar You will always want to allow yourself enough time to consider all options and execute any one of them. The renewal, purchase, or relocation process needs to begin 12 to 24 months prior to your expiration date, depending largely on the size of your medical group or practice and the complexity of the transaction. • If your current lease provides for a renewal option, understand how far in advance you are required to provide notice of your decision to renew. Typically, leases require a notice of intent to renew six to 12 months in advance of the scheduled lease expiration date. • Read the provisions in your lease regarding how the rent and other concessions for the new term are determined. Many renewal clauses require that the tenant provide notice of its intent to renew — which, if provided, may be irreversible — before any initial indication of the business terms have been received by the tenant. For this reason, many leases are extended while acting outside of the renewal option provision. To avoid being locked into renewing, ask the landlord to prepare a proposal or have the landlord respond to a request for proposal

(aka, “RFP”), which should be clearly identified as an early lease extension as opposed to a lease renewal. • If you don’t have the benefit of a renewal option, understand as early as possible which other tenants in the marketplace, if any, have options (or interest) to open, expand, or relocate into your current space. This will serve as an indicator of your leverage position. 2. Know Your Position The answers to these questions can have material impact on your leverage: • Are you (or will you be) a 2% or a 20% occupant of the building? • Does the credit or type of your practice impact the value of your building? • What is the current and historic vacancy of your building and submarket? • What other leases are expiring in your building, and when? Are these tenants with expiring leases likely to stay or go?

SDCMS in Washington, DC

SDCMS physician leaders Drs. Bob Hertzka, Al Ray, and Bob Wailes traveled to Washington, DC, this past July 8–10, along with SDCMS CEO Tom Gehring to meet with our representatives and their staffs and discuss the issues important to San Diego County’s physicians.

2

1

4

1. Representative Darrell Issa at far left. 2. Representative Scott Peters second from right. 3. Representative Juan Vargas second from left. 4. Representative Susan Davis at far right.

3 6 august 2013


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

• Are you, or any other tenants of the building, paying above- or below-market rents? • What is the investment profile of your landlord (e.g., long-term holder or shortterm trader of real estate)? • If you were to vacate your space, how long would it take the landlord to relet your space? • What increased improvement costs and other expenses will the landlord be subjected to in the event you relocated? • What capital investments have you made in your space that will be difficult to replicate or costly to remove? • How is your building financed? Your representative should be armed with answers to the above questions before speaking to the landlord or the landlord’s broker.

we take care of san diego’s

healthcare communit y. 3 income Tax Planning 3 Wealth Management 3 employee Benefit Plans 3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure

3. Know Your Alternatives • What are the competing market alternatives? • What other submarkets should be considered if for no other reason than to add leverage to the negotiations with your landlord? • What trends or events could impact vacancy, rents, and supply?

3 succession Planning 3 Practice Valuations 3 internal Control Review and Risk Assessment

4. Seek Representation Regardless of how many times you have been invited to your landlord’s annual golf outing, your landlord’s ultimate goal is to enhance investor return or stockholders’ equity by maximizing financial gain from each and every square foot of space you occupy — and they have armed themselves with real estate brokers, analysts, and industry experts to help them achieve their goals. It is therefore incumbent upon you to seek thirdparty representation by a real estate professional with at least 10 years of experience in San Diego healthcare real estate. More often than not, the cost of such representation will be absorbed by the landlord. Regardless of how well your space meets the needs of your medical group or practice, you should stay educated on your alternatives while creating a credible threat of relocation. Strategically arm yourself and conduct a fact-based negotiation with the landlord (or in the case of a purchase, the seller). There are no shortcuts to the process. Mr. Ross is vice president of healthcare solutions for Jones Lang LaSalle. He is a commercial real estate broker specializing exclusively in medical office and healthcare properties in San Diego County. He can be reached at (858) 410-6377 or at chris.ross@am.jll.com.

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

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760-431-8440

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ron mitchell, cpa director of health services

Is your rent too high?

Stop throwing money away and Call us for a free lease review.

William L. Strong, Riviera Real Estate — Medical Tenant Representation

760-777-2880 / CA DRE #1802223 / www.RivieraREG.com SAN  DI EGO  PHYSICIAN.org 7


POETRY AND MEDICINE IZZY

Lucky in Dog

Are You Here to See Dr. Bressler and Izzy, or Just Izzy? by Daniel J. Bressler, MD The dog-human bond traces back into the shadows of human history. Dog bones are found in the earliest human dwellings, often interred with their owners. Whether as guardians, hunters, or friends, these near-wolves have found themselves a well-entrenched role in societies worldwide. Most scientists who have studied the dog-human relationship have concluded that part of the bond derives from the uncanny ability of dogs to read and respond to our emotional queues. Dogs may not have the highest IQ of the animal kingdom (that award would go to chimps, apes, or dolphins) but get the trophy for the highest EQ (emotional or empathy quotient). They are supremely skilled at connecting with our faces, our gestures, our moods. Apart from dogs’ practical utility demon8 august 2013

strated from anthropological data, there is a growing body of medical evidence that dog ownership confers a broad array of physical health benefits. A recent article from Circulation, the American Heart Association’s flagship journal, called “Pet Ownership and Cardiovascular Risk” (Levine et al, June 11, 2013), outlines a number of these, including reduced post-myocardial infarction mortality, decreased hypertensive responsiveness to social or physical stressors, increased physical activity, and improved lipid profiles. The article cautiously concludes that dog ownership “may have some role in reducing CVD risk [level of evidence, B].” Studies on the social and psychological effects of human-dog interaction (HDI) are somewhat more complex and contradictory. That said, an emerging and unifying concept correlates the beneficial effects with the enhanced release from the posterior pituitary of the peptide hormone oxytocin (OT). Recall that OT is classically understood as the substance responsible for postpartum milk letdown and uterine contractions. Its name actually comes from the Greek for “quick birth.” We use a synthesized form, Pitocin (or, as the OBs call it, “Pit”) to hasten contractions during delayed deliveries. But more recent research has revealed a huge repertoire of roles for OT in modifying the release of stress hormones (cortisol, epinephrine, and norepinephrine). Moreover, its behavior effects in both humans and multiple animal models include enhancing social bonding, decreasing aggressiveness, and increasing trust. Measurements of blood or saliva levels of OT appear to be an objective and easily measured surrogate for the health benefits of the DHI. And, to abbreviate a large body of research in a bite-sized phrase, it looks like enjoyable interactions between a dog owner and his dog significantly increases OT in both of them. An excellent recent review of this data can be found in “Psychosocial and Psychophysiological Effects of Human-Animal Interactions: The Possible Role of Oxytocin,” by Adrea Beetz, et al., as published in Frontiers in Psychology, July 2012, Volume 3, Article 234, pages 115. About three years ago, we found our service dog, Izzy, after a three-month search. Several of the staff had hounds at home, and, over the previous year, we had experimented with a monthly Dog Friday. I knew

Izzy lives life physical No concepts or abstractions He tilts his muzzle quizzical When a scene arrests his actions Izzy lives life natural He scratches where he itches He eats until his belly’s full He dreams in yelps and twitches Izzy lives life innocent A state without offenses An exaggerated world of scent A cacophony of senses Izzy lives for company I’m safety in his sight He wags his tail and runs to me A bond of mutual delight I took you from that shelter Though even then I knew To this calmness from that welter As they say: Who rescued who?

the logistics could work out if we found the right dog. We did. Izzy, a 32-pound male dachshund-Australian cattle dog mutt, came to us through a wonderful local rescue-and-placement organization called The Barking Lot. During the first trial week, he would spend the day at the office and go back to his foster home in the evening. After that, he started coming home with me at night and became my constant companion. He went through distinct behavioral phases. First, there was tremulous generalized anxiety, then hyper-bonding during which he would not let me out of his sight, and, finally, to relaxing and trusting his new life and so displaying what I consider a healthy mixture of devotion and rebellion. Overall, he’s emerged as a dog who is mellow, attentive, and joyous. The salutary effect on my practice life has been striking. The staff members each receive a daily fix of canine petting and sloppy kisses. Patients seem calmer and more open in his presence. I can’t but believe that everyone’s oxytocin levels are substantially up. We have a sign at the reception area: “Are you here to see Dr. Bressler and Izzy, or just Izzy?” It’s only half in jest. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.


Personal & Professional Development

What Language Does Your Body Speak? by Helane Fronek, MD, FACP, FACPh

Physicians are often criticized for using medical jargon with patients. Truly, it’s best to use words our patients understand, so we can discuss “a test on the electric activity in the brain” rather than an electroencephalogram. Other words are sensitizing and can upset our patients. Better to explain our patients’ “condition” or their “issue” rather than their “problem,” and their “concerns” rather than their “complaints.” While we may alter our vocabulary, our words constitute a minority of our communication … only 7%, according to UCLA’s Albert Mehrabian, professor emeritus of psychology. Thirty-eight percent of the meaning people derive from our speech comes from how our words are spoken, and 55% comes through our body language and facial expressions. As they watch us, patients search for additional meaning regarding their situation, so these aspects of our communication are important. Fortunately, there are simple things we can do to send the right signals and convey the most helpful information to our patients. Mirroring our patient’s body movements and posture as well as his tone of voice is very effective in developing rapport. Adopt-

ing a similar posture, positioning our hands or legs in a similar configuration, and using a tone of voice that matches our patient’s will help him feel comfortable with us. In general, straightforward communication is most appreciated, rather than sarcasm or other subtle forms of humor. Only when we know a patient and are sure she understands our form of humor should we include it in our regular interactions. Certain body language is known to arouse suspicion of our motives or honesty. Folding our arms across our chest, putting our hands in front of our face, or not maintaining eye contact conveys defensiveness and makes our patient feel we are less trustworthy or hiding something. Of all the things we can do, eye contact is probably the most important. Unfortunately, with the intrusion of the computer monitor in our exam rooms, eye contact is harder to maintain. At times, the best we can do is to tell our patient that, although we are not looking at her, we are listening nonetheless. However, when our patient becomes emotional, when he is sharing something difficult, or when we want to emphasize the importance of what we’re saying, eye contact is essential. In addition to eye contact, if we lean forward with our hands in an open, asymmetric position (one hand on a desk, the other hand on our lap), we convey openness and interest in what she is saying. Lastly, never underestimate the power of a smile — when greeting or saying goodbye to our patient, or when the occasion seems appropriate — to clearly say that we like our work and enjoy caring for this particular patient. Physicians spend countless hours studying and keeping up with the rapid advances in medicine so we can help our patients. With these simple tips, we can make sure our bodies are in sync with our intentions, and that our patients derive not only the most accurate information, but also an understanding of our concern for them. 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. SAN  DI EGO  PHYSICIAN.org 9


Practice Management

Tracking of Industry Gifts to Physicians Begins in August

Don’t Miss Your Chance to Challenge False or Misleading Data Before It Goes Public! by The California Medical Association

Beginning Aug. 1, 2013,

manufacturers of drugs, medical devices, and biologics that participate in federal healthcare programs must begin tracking and reporting certain payments and items of value — including consulting fees, travel reimbursements, research grants, and other gifts — given to physicians and teaching hospitals. The new law, known as the Sunshine Act, also requires manufac10 august 2013

turers and group purchasing organizations (GPOs) to report certain ownership interests held by physicians and their close family members. The intention of the law is to increase transparency and reduce the potential for conflicts of interest that can influence research, education, and clinical decision-making. The reports will be submitted to CMS on an annual basis. The majority of the informa-

tion contained in the reports will be made available on a public, searchable website beginning in September 2014. Physicians will, however, have the right to review their reports and to challenge any information that is false, inaccurate, or misleading. By statute, physicians are provided — at a minimum — 45 days to review the transparency reports and make corrections before they are made public. “Data accuracy is the number one goal of our program,’’ said Anita Griner, CMS’s deputy director for the Data Sharing and Partnership Group, speaking to the AMA’s House of Delegates in June. “We want the data put on the public website to be complete and accurate. We do not want it to be disputed. We do not want it to be inaccurate. We do not want to perpetuate any false information about a physician or teaching hospital. So data accuracy is key. And that will come from you tracking your own transfers and checking the website before it goes public.’’ The Sunshine Act covers all physicians who have an active state license, even if they do not participate in federal healthcare programs, but excludes residents and medical students. Payments of less than $10 do not need to be reported, unless

the aggregate amount exceeds $100 annually. The $10 threshold will increase every year, based on the Consumer Price Index. How to Challenge False, Inaccurate, or Misleading Reports Physicians will have 45 days after the annual reports are completed to challenge the data before it is made public. The reports will be available to physicians for their review via an online portal sometime after the close of the calendar year. The portal will also facilitate contact between a physician with a dispute and the manufacturer/GPO that submitted the disputed information. Manufacturers then have 15 days to correct any misinformation. If a resolution is not reached within the allotted time period, the disputed information will be flagged, but the report will be posted on a public webpage. Physicians will, however, have two full years to contest or seek corrections to data contained in the reports, even after it has been made public. Physicians are encouraged to proactively check with any manufacturer from which they have received payments or any items of value to see what information they are tracking and intend to report. If you hold any ownership interests, you should also check to ascertain what they intend to report. (Ownership or investment interests in publicly traded securities and mutual funds are excluded from reporting.) What You Can Do Now to Prepare for the Sunshine Act Update your disclosures regularly. Ensure that all financial disclosures and conflict of interest disclosures required by employers, advisory bodies, and entities funding research, for example, are current and updated regularly.


Key Dates • Aug. 1, 2013: Manufacturers begin collecting and tracking payment, transfer, and ownership information. • Jan. 1, 2014: CMS is expected to launch the physician portal that allows physicians to sign up to receive notice when their individual consolidated report is available for review. This portal will also allow physicians to dispute the accuracy of a report. • March 31, 2014: Manufacturers/ GPOs report 2013 data to CMS. • June 2014: CMS is expected to provide physicians with access to their individualized, consolidated reports for the prior calendar year. Physicians will be able to access the reports online and will be able to seek correction or modification by contacting the manufacturer/ GPO via the web portal. • Sept. 30, 2014: CMS will release most of the data on a public website.

Exemptions The Sunshine Act includes a number of exemptions from the reporting requirements. Among them are: • Samples intended for patient use, including coupons and coupons to obtain samples. • Certified and accredited continuing medical education activities funded by manufacturers. • Educational materials ultimately intended to be used with patients (for example, wall models, or anatomical models). • Buffet meals, snacks, soft drinks, or coffee generally available to all participants of large-scale conference or similar large-scale events. • The loan of a medical device for a short-term trial period. • Discounts (including rebates). • In-kind items used for the provision of charity care. • A dividend or other profit distribution from a publicly traded security or mutual fund.

If you have an NPI, update the information and ensure your specialty is correctly designated. Physicians who have a National Provider Identifier (NPI) should ensure all information in the NPI enumerator database is current and regularly updated as needed. This information will be used by industry reporters, among other unique identifiers, to ensure that they have accurately identified you. Inform your industry contacts that you want ongoing notice of what they report to the government. Ask all manufacturer and GPO representatives with whom you interact to provide you with notice and an opportunity to review and, if necessary, correct all information that they intend to report before it is submitted to the federal government. For More Information • AMA Sunshine Act Resource Webpage: www. ama-assn.org/go/sunshine • CMA ON-CALL Document #1150, “Gifts and Free Services.” ON-CALL documents are free to members in CMA’s online health law library at www.cmanet.org/ cma-on-call. • CMS Sunshine Act FAQ: https://questions.cms.gov/faq. php?id=5005&rtopic=2017

Medical Professional Liability Protection, and more! 800-356-5672 www.caPphysicians.com

San Diego orange LoS angeLeS

Physicians are encouraged to register for the CMS Open Payments listserv to receive periodic email updates about the program. To register, visit http://go.cms.gov/openpayments. Questions about the program can be sent to openpayments@cms.hhs.gov.

PaLo aLTo SacramenTo

Some information in this article was republished with permission from the American Medical Association. For more information, visit www.ama-assn.org/go/ sunshine. SAN  DI EGO  PHYSICIAN.org 11 CAP_1402.indd 1

2/5/13 11:13 AM


Physicians are

HEROes

our

Philanthropy Without the Hassle

Physicians:

Join Us As the Heart of Project Access

by Barbara Mandel, MBA

12 august 2013

The SDCMS Foundation is looking for a few more good specialist physicians to help us with Project Access San Diego! To provide access to specialty care for low-income, uninsured adults in our community, we are in particular need of gynecologists, gastroenterologists, ophthalmologists, and general surgeons. Physicians volunteer to provide consultations for patients at their offices, and procedures if needed at hospitals or outpatient surgery centers where they are credentialed. To date, more than 625 physicians have joined the ranks of Project Access heroes. Many of our volunteers comment that we give them the opportunity to help in the community without any hassles. Our system of intense patient care management assures the least intrusion on the practice office staff, as we handle all patient communications and scheduling, and provide transportation and translation services as needed. Where many insured patients may require an initial consult to determine what labs or imaging are needed for diagnosis, Project Access patients most often have all preliminary work completed prior to the first consultation appointment, making for a more efficient visit for the volunteering physician.

“I find working with Project Access very satisfying,” says Wendy M. Buchi, MD, OB/GYN, SDCMS-CMA member since 1994 and longtime PASD volunteer. “I get a chance to help the community by seeing challenging patients with problems quite different than those in my regular patient population, and Project Access patients get a chance to have much needed and often life-changing surgery. It’s mutually beneficial!” “Most physicians I know would like to contribute in the community, but they are so distracted with the bureaucratic struggles of running a medical practice these days, they just don’t have the time,” says Rosemarie Marshall Johnson, MD, SDCMS and SDCMS Foundation board member and retired ASMG partner anesthesiologist. “Project Access San Diego gives physicians the opportunity to volunteer whenever it fits into their busy schedule and to experience this joy of giving.” As medical community liaison for Project Access San Diego, Dr. Johnson has recruited the majority of the more than 625 specialty care physician volunteers. “I continue to hear the enthusiastic remarks from our volunteers, such as ‘this is why I went to medical school,’ and ‘this is what the practice of medicine is all about,’” says Dr. Johnson. Project Access considers every physician volunteer a hero, and many patients refer to their physicians as their angels, helping them to regain their health. Project Access benefits both the patient and the community as a whole, states Dr. Johnson. “The patients are delighted to get back to work and support their families, family life is improved, and the community saves money that would have been spent in an emergency department. This would not happen without the support of the physician community, as well as the hospitals and outpatient surgery centers, imaging, labs, and other supportive healthcare providers.” Tom Gehring, SDCMS and SDCMS Foundation CEO, acknowledges that Project Access benefits physicians and SDCMS as well. “The work of the Foundation and Project Access sheds a positive light on the physician community. It demonstrates to the community the generosity of physicians that generally goes unnoticed in all the policy battles covered in the media,” says Gehring. One physician who regularly travels to remote locations to volunteer has become a Project Access San Diego champion. Eileen S. Natuzzi, MD, SDCMS-CMA member


since 2010, has seen uninsured patients through the UC San Diego Student Run Free Clinic, and appreciates that she can provide needed surgeries through referral to Project Access. “We in San Diego often think we live in a land of plenty, but there are plenty of people here without healthcare,” says Dr. Natuzzi. “We can care for people more proactively, or we can wait until their situation is much more complicated, and costs the healthcare system more.” Dr. Natuzzi advocates, “Let’s take care of people before they are in crisis, and return people back to a functional life.” While the implementation of the Affordable Care Act will reduce the number of uninsured adults in San Diego County, there will continue to be a significant number of adults who remain without access to insurance. Project Access will continue to be a much-needed program in our community to improve the health and change the lives of those most vulnerable. The SDCMS Foundation is most grateful for all the physician volunteer heroes who give of their time and expertise. For more information on how to get involved in Project Access San Diego, contact Rosemarie Johnson, MD, at RJohnson@ SDCMS.org or call the SDCMS Foundation at (858) 300-2777.

1 2

Ms. Mandel has served as the executive director of the SDCMS Foundation since 2011.

3

4 1. Dr. Natuzzi performs a hernia removal at a Saturday Surgery Day at Carlsbad Surgery Center. 2. Marisol de la Cruz presenting a painting to Dr. Robert Eisenberg in thanks for the care she received. 3. Dr. Lawrence Cooper, longtime Project Access San Diego volunteer, caring for patients whose diminished vision has made it difficult to work. 4. Dr. Buchi has cared for numerous gynecological patients, including Martina Serrano.

SAN  DI EGO  PHYSICIAN.org 13


Physicians are

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primary care provider and specialist, and that the patient understands and is able to comply with their treatment plan.

Project Access San Diego $7.6 Million Saved!

by Todd Gilmer, PhD

14 august 2013

The SDCMS Foundation’s Project Access San Diego (PASD) coordinates a network of specialty healthcare providers who donate medically necessary healthcare to qualified individuals. PASD collaborates with more than 80 referring community clinic sites, 628 volunteer physicians, 10 hospitals, 16 outpatient surgical centers, and multiple ancillary health providers throughout San Diego County. Primary care providers, typically in community health centers, refer appropriate patients in need of specialty healthcare services to PASD. Patient needs can vary from a consultation appointment to complicated surgical procedures. PASD is able to serve most patients needing shortterm specialty care. Currently, resources are limited for treatment of cancer, other chronic diseases, and major non-urgent surgeries. Care management is an essential part of PASD. Patient care managers help patients navigate the healthcare system, advocate for insurance coverage as appropriate, arrange for transportation and language interpretation services as needed, and assure that patients receive necessary testing, imaging, and other services prior to their appointments with specialists. The patient care managers work closely with specialty care office staff to assure an efficient and effective patient visit for the patient, physician, and staff, and follow the patient throughout his or her treatment plan, assuring that follow-up services and visits are scheduled, case notes are communicated between the

Estimating the costs of services provided by PASD Services provided to PASD clients by community physician volunteers are recorded in an electronic health record (EHR). We used the EHR to identify PASD clients who had completed their specialty care plan through May 2012 and to summarize their demographics, including gender, race/ethnicity, primary language, marital status, employment status, and income. We also used the EHR to document utilization and cost of PASD services. The EHR documents the services provided, including their procedure codes. However, since these services are donated, they do not always include information on the costs of the services. It was therefore necessary to estimate the costs of donated services. We applied standard Medicare payment methodologies to estimate service costs. For surgical procedures that required an inpatient stay, we estimated the facility cost of the inpatient stay using the appropriate diagnosis-related group (DRG). We used DRGs to assign payments based on the average cost for treating Medicare patients in that DRG in 2012. For surgical procedures that could be treated in an ambulatory setting, we estimated the facility costs using approved ambulatory surgical center (ASC) payment rates for 2012. We estimated the costs for the surgical procedures that were provided in these settings, as well as the costs for nonsurgical procedures using Medicare’s physician fee schedule, which is based on relative value units (RVUs). We applied facility RVUs to procedures that were accompanied by DRG or ASC facility payments. We applied non-facility RVUs to all other procedures. RVUs can be multiplied by a year-specific conversion factor to estimate costs. We used the 2102 conversion factor: $34.

Estimating Changes in Health Service Costs, Productivity Costs, and Health Status Before and After Receiving Services From PASD Use of health services, days of missed work, and health status in the six months before and six months after receipt of PASD services were ascertained from surveybased self-report. PASD participants


ADVANCED HEART FAILURE. ALLERGY & IMMUNOLOGY. ANESTHE AUDIOLOGY. BLOOD & MARROW TRANSPLANT. CARDIOLOGY. CAR THORACIC SURGERY. CARDIOVASCULAR SURGERY. COLON & REC SURGERY. CONCIERGE MEDICINE. CRITICAL CARE MEDICINE. DER EMERGENCY MEDICINE. ENDOCRINOLOGY. ENDOVASCULAR SURGE GASTROENTEROLOGY. GENERAL SURGERY. GERIATRIC MEDICINE. GYNECOLOGIC ONCOLOGY. HEPATOLOGY. HEMATOLOGY. HYPERBA MEDICINE. INFECTIOUS DISEASES. INTEGRATIVE MEDICINE. INTE RADIOLOGY. LARYNGOLOGY. MALE INFERTILITY. MATERNAL-FETA MEDICAL ACUPUNCTURE. MEDICAL GENETICS. MEDICAL ONCOLO NEONATAL & PERINATAL MEDICINE. NEPHROLOGY. NEUROSURGER NEUROCRITICAL CARE. NEUROLOGY. NUCLEAR MEDICINE. MINIMA INVASIVE SURGERY. OBSTETRICS & GYNECOLOGY. OCCUPATIONA ENVIRONMENTAL MEDICINE. ONCOLOGY. OPHTHALMOLOGY. ORTH SURGERY. OSTEOPATHIC MEDICINE. OTOLARYNGOLOGY. PAIN MA PALLIATIVE MEDICINE. PATHOLOGY. PELVIC FLOOR DISORDERS. P NERVE. PHYSICAL MEDICINE & REHAB. PLASTIC SURGERY. PSYC PSYCHOLOGY. PULMONARY DISEASE. RADIATION ONCOLOGY. RAD REPRODUCTIVE ENDOCRINOLOGY. RHEUMATOLOGY. SPORTS MED SURGICAL CRITICAL CARE. SURGICAL ONCOLOGY. THORACIC SUR TOXICOLOGY. TRANSPLANT SURGERY. TRAUMA. URO-GYNECOLOG

80 + SPECIALTIES OnE numbEr 855-543-0555 gives you access

Physician Access is a dedicated line that allows you to speak directly with one of our physicians at UC San Diego Health System. This number gives you real and immediate access to a fellow physician, and a trusted partner. So whether you want to talk about a particular case, facilitate a transfer or refer your patient for highly specialized care, our physicians are standing by to take your call.

855-543-0555 | health.ucsd.edu/access


Medicine and Supplies $76,192

Evaluation and Management $440,935

Radiology / Laboratory $156,640

Table 1: Summary Characteristics of Project Access Clients in (N=1,846)

No.

%

Male

554

30

Female

1,292

70

Latino

1,624

88

Non-Latino White

148

8

African-American

37

2

Asian

18

1

Other

18

1

Spanish

1,551

84

English

277

15

Other

18

1

Married

923

50

Single

849

46

Other

37

4

Gender

Race / Ethnicity Figure 1: Project Access-donated Services per Medicare Rates: $2.9 Million From June 2009 to May 2012

Surgery $2,237,420

Primary Language Figure 2: Costs of Lost Productivity and Health Service Before and After Receiving Services From Project Access: Decline From $10 Million to $2.4 Million

10

8

Marital Status

Full-Time

359

19

Part-Time

385

21

Unemployed

1,024

56

were surveyed once at enrollment into the program and again at six months following discharge from the program. The survey requested information on the number of inpatient days, emergency department visits, clinic visits, days with symptoms from the condition being addressed, and days in which these symptoms prevented work or caring for others. Cost per inpatient day was estimated to be $1,800 based on analysis of the DRG data described above. Cost per emergency department visit was estimated to be $980, and cost per 16 august 2013

$ Millions

6

Days missed work Clinic visits ED visits Inpatient days

4

Employment Status

Other

$6.41

78

4

$1.24 2

$0.62

$1.64

$1.69 0

$0.42

Pre-Access

clinic visit was estimated to be $212, based on 2008 data derived from the Medical Expenditure Panel Survey trended forward to 2012. Costs associated with lost days of productivity were estimated to be $64 per day based on $8 per hour for an eight-hour day. The question specific to lost productivity used a time window of 30 days, so we extrapolated the responses to the full sixmonth period. The survey also requested health status measured as excellent, very good, good, fair, poor, and satisfaction with PASD physicians and case management.

$0.13 $0.21

Post-Access

Results Summary data on 1,846 PASD clients is shown in Table 1. Overall, 70% were female, 88% reported Latino ethnicity, 84% reported their preferred language to be Spanish, 50% were married, and 56% were currently unemployed. Costs for donated services provided by PASD are shown in Figure 1. Total costs were $2.9 million. The largest component of costs was for surgeries at $2.2 million, followed by evaluation and management at $441,000, radiology and laboratory at $157,000, and medicine


6000

5000

4000

TrusT

Figure 3: Per-person Productivity Costs and Health Service Costs Before and After Receiving Services From Project Access

$3,473

Days missed work Clinic visits ED visits

3000

Inpatient days

2000

$671 $338

1000

$891

$917 0

$230

Pre-Access

$69 $112

Post-Access

Trust us to be your Technology Business Advisor

Figure 4: Self-reported Health Status Increases for Project Access Clients After Receiving Services — Health Status Among Californians Shown for Comparison 100

12.9%

6.3%

hArdwAre  sofTwAre neTworks emr ImplemenTATIon seCurITy  supporT mAInTenAnCe

3.0% 12.2%

25.8%

80

(858) 569-0300

28.0%

41.1%

A Common sense ApproACh To InformATIon TeChnology

www.soundoffcomputing.com

60

40.0% 31.8%

40

34.4% 20

17.9% 24.9%

0

11.2%

10.0%

0.4% Pre-Access

Post-Access

Poor Fair Good Very Good Excellent

Endorsed by

California

SAN  DI EGO  PHYSICIAN.org 17


and supplies at $76,000 (1). Costs resulting from lost productivity and use of health services before and after receiving services from PASD are shown in Figure 2. Overall costs declined by $7.6 million, from $10 million in the six months prior to receiving PASD services to $2.4 million in the six months after being discharged from services. The largest decline was in productivity costs, which declined from $6.4 million to $1.6 million, representing 772 fewer days of lost productivity and accompanied by 2,143 fewer days of experiencing symptoms. Costs of inpatient days declined from $1.7 million to $210,000, resulting from 521 fewer inpatient days. Costs of clinic visits declined from $1.2 million to $420,000 (722 fewer visits), and costs of emergency department visits declined from $620,000 to $130,000 (155 fewer visits). Per person costs are shown in Figure 3. Figure 4 shows changes in self-reported health status before and after receiving services from PASD, and compares health status to a representative sample of Californians from the 2009 California Health Interview Survey. Health status improved substantially among PASD clients. Prior

to receiving services from PASD, 54% reported being in fair to poor health, and 12% reported very good to excellent health. After services, 32% reported fair to poor health, and 28% reported very good to excellent health. Californians overall were generally healthier than PASD clients even after services: 15% reported fair to poor health, while 57% reported very good to excellent health. The client survey showed that PASD clients were overwhelmingly satisfied with the services that they received: 95% were very satisfied or satisfied with their doctors, and 97% were very satisfied or satisfied with their case management providers.

Conclusion Nearly one in four non-elderly adult San Diego residents were without health insurance coverage for all or part of the year in 2009; the majority were employed but did not receive health insurance from their employer. Former members of the U.S. military are often uninsured, as are our manual labor force and part-time employees. Even after the implementation of healthcare reform, many working adults will remain uninsured, particularly hourly workers

or those working for small businesses. Some of these adults will continue to need healthcare services to care and provide for their children and families. An uninsured adult can receive primary care at a community clinic, but is typically left without access to any specialty care or surgery. This report shows that adults in need of specialty or surgical services experience substantial productivity losses and generate excess healthcare costs resulting from clinic visits, emergency department visits, and hospital admissions. These costs decline after receiving services. Once connected with Project Access San Diego, these patients improve their health and can reclaim their lives, get back to work, and care for their families. Todd Gilmer, PhD, is a healthcare economist at UC San Diego. Note: 1. This study standardized donated services at the Medicare rates. Project Access San Diego also tracks donated services as provided by physician offices based on cash payments, and has reported donated services at $6.2 million through March 2013.

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18 august 2013

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www.sdcmsf.org SAN  DI EGO  PHYSICIAN.org 19


Physicians are

HEROes

our

Preparing the Next Generation of Physician Leaders

The Role of Organized Medicine

by the SDCMS Foundation

20 august 2013

Republicans. Democrats. Right. Left. Moderate. Regardless of political persuasion, there is one thing the vast majority of physicians agree on: living up to the Hippocratic oath and providing the best healthcare for their patients. But ensuring that federal and state health policies follow these goals is the role of organized medicine. How do medical students learn about health policy and advocacy? At UC San Diego’s School of Medicine, Introduction to the Politics of Medicine, an elective class taught by Robert E. Hertzka, MD, SDCMSCMA member since 1988, CMA president in 2004–05, and SDCMS president in 1999, provides the background to approximately 25 students a semester to prepare them to be healthcare leaders. “A critical part of physician leadership in the 21st century is to be fluent in health policy,” says Dr. Hertzka. “It is not enough to know how to expertly care for patients. Physicians have to know how to navigate the

policy world to keep our profession viable.” Through the class discussions and opportunities to meet with industry leaders, students understand “there are forces and processes that will have a profound influence on their practice in the future,” says Dr. Hertzka. “And over the course of the class, the students come to realize that organized medicine is the most important way to understand and influence those processes.” Following the completion of the 32-hour fall quarter class, the students are invited to participate in an all-day trip to Sacramento to meet with elected leaders and policy makers. Leadership from SDCMS accompanies and mentors students, and funds from the SDCMS Foundation pay student expenses. “The joint effort between UC San Diego, SDCMS, and the SDCMS Foundation in the education of medical students is unprecedented and unique to San Diego County and the nation,” says Sherry L. Franklin, MD, SDCMS-CMA member since 2002 and immediate past president of SDCMS, who often participates in these legislative training days. “It demonstrates how the three organizations can join to participate in a common goal: the betterment of healthcare for patients and physicians.” Students meet with state legislators and observe their mentors at their best. “The building of relationships with our legislators allows for meaningful discussions at critical points in healthcare policymaking,” adds Dr. Franklin. “There are hundreds of healthcare bills floating through Congress and the state legislature throughout the year. It is imperative that all students and residents at least recognize the process and find leaders to speak on behalf of patients and fellow physicians.” Dr. Hertzka initiated the health politics class in 1988, and began including students in the annual CMA Legislative Day in 1994. One of the attending students told him, “Every student comes back and tells his or her fellow students about what a great day it was.” Word of mouth has expanded the program, and, to date, more than 600 students have enrolled in the elective class during their first or second years of medical school training. “I believe strongly the profession is better because of the training and that the majority of these students have joined their medical society as practicing physicians,” says Dr. Hertzka. “The important message for students to appreciate is that physicians must be regarded as part of the solution rather than the problem in order to facilitate the best healthcare policy out of Sacramento,” says Dr. Franklin.


“A critical part of physician leadership in the 21st century is to be fluent in health policy. It is not enough to know how to expertly care for patients. Physicians have to know how to navigate the policy world to keep our profession viable.”

UC San Diego School of Medicine students, accompanied by Drs. Franklin and Hertzka, visit with elected leaders in Sacramento to learn the politics of medicine.

Dr. Hertzka adds, “These students get a big leg up. They know the issues at graduation, and, when asked about health policy during their residency interviews, which is now a common occurrence, they can nail those interviews.” During the past year, 35 students requested to participate in the Sacramento training day. A fund was established at the SDCMS Foundation in 2010 to support these trips, and funding is needed to keep the program continuing and growing. “It’s a phenomenal investment in our medical students,” says Dr. Hertzka. Physicians interested in supporting the medical student legislative training can do so by calling Barbara Mandel at the SDCMS Foundation at (858) 300-2780 or visit www.SDCMSF.org. “I continue to be impressed with the deep and sincere commitment and compassion the students have for patient care,” adds Dr. Hertzka. “They remind me every year of why I became a physician myself.” SAN  DI EGO  PHYSICIAN.org 21


Physicians are

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“Our board of directors has traditionally been made up of the ‘goodnicks’ that have served on the SDCMS board. While that continues, we saw the need to expand our reach into our local business and professional communities to support the Foundation’s numerous programs.”

Dr. Stuart A. Cohen

Completing His Chairmanship of the SDCMS Foundation

by the SDCMS Foundation

22 august 2013

Stuart A. Cohen, MD, MPH, SDCMSCMA member since 1988, SDCMS president in 2008–09, and a local East County pediatrician with Children’s Primary Care Medical Group, completes his three-year term as chair of the SDCMS Foundation this fall, and will continue on the board as immediate past chair. During his term, the SDCMS Foundation began new health initiatives, including efforts to increase the county adult immunization rates, and outreach to expand the Foundation board of directors to accommodate needed growth. “Adult immunization rates for ACIP-recommended immunizations average at best 10% in San Diego County,” says Dr. Cohen. “I am proud that the Foundation has taken

on this community health issue, particularly because the immunization rates in the lowincome population are even lower than the population in general.” Last fall, the SDCMS Foundation led a countywide collaboration to provide free flu shots at community sites to residents without a medical home. In addition to providing more than 500 free immunizations, the efforts assisted in linking adults with a primary care provider. Efforts have already begun to expand the initiative for this upcoming flu season. “Our board of directors has traditionally been made up of the ‘goodnicks’ that have served on the SDCMS board. While that continues, we saw the need to expand our reach into our local business and professional communities to support the Foundation’s numerous programs,” says Dr. Cohen. In the past two years, Dr. Cohen has been instrumental in recruiting four business executives in healthcare-related fields to the board, with the promise of adding pairs of physician-business leaders in the future. These new board members have been instrumental in promoting the SDCMS Foundation locally and in developing a strong commitment by the board to fundraising and development with the goal of making the Foundation both viable and sustainable in the long term. “When it comes to how best to market ourselves and launch new initiatives, the expertise of these new board members has been invaluable,” says Dr. Cohen. While serving on the SDCMS Foundation board, Dr. Cohen was also recently elected as chair of the American Academy of Pediatrics for California. He also continues as the chair of the AAP delegation at CMA and the vice chair of the AAP delegation at the AMA.


Susan Kaweski, MD

Grossmont Healthcare District 2013 Healthcare Hero by the SDCMS Foundation A healthcare champion on many fronts, Susan Kaweski, MD, SDCMS-CMA member since 1983 and past president of SDCMS, was honored this spring by the Grossmont Healthcare District for her numerous accomplishments. Nominated by the SDCMS Foundation, the May awards luncheon celebrated her service to the community, along with four other honorees. “It’s all about giving back,” says Dr. Kaweski. “Volunteering for [the SDCMS Foundation’s] Project Access is something I can do in the community, and that I hope many others will do as well. It’s paying it forward. God has given me so much; this is the least I can do,” she adds. Dr. Kaweski is a double-board-certified plastic surgeon — by the American Board of Surgeons — with a private practice in La Mesa. She served as president of SDCMS in 2011–12, and is currently a member of the board of directors. She also serves as a District I delegate to CMA’s annual House of Delegates, and has been a member of CMA’s Council on Judicial Affairs since 2008. As a physician volunteer for Project Access San Diego (PASD) since 2010, Dr. Kaweski generously donates her time, care, and expertise to help patients without access to health insurance in East County San Diego. Dr. Kaweski sees patients from community clinics, providing both specialty care consultations and surgical procedures as needed for the low-income, uninsured patients served by Project Access. Dr. Kaweski is known by her patients for her empathetic demeanor, reducing the fear patients feel as they face often debilitating medical conditions. One particularly grateful patient is Gabriella. Gabriella was initially referred to dermatology for severe hidradenitis suppurativa, a condition that left her housebound as it was too painful to

even get dressed and walk her son to school. Dr. Kaweski graciously took the patient’s case and performed multiple excisions on different parts of her body over several months. Gabriella was so thankful, sharing that before having surgery, she felt too embarrassed to be around others. After the first three procedures, her self-esteem improved and she felt more confident being out in public. Gabriella had more than 14 visits with Dr. Kaweski, and soon after, she was able to return to her normal activities, including regaining employment! Dr. Kaweski helped Gabriella to not only improve her health, but to change her life. Dr. Kaweski was acknowledged by the Grossmont Healthcare District for her work in the community and her professional associations, including the American Society of Plastic Surgeons, the California Association of Plastic Surgeons, the International Association of Plastic Surgeons, Association of Military Surgeons of the United States, and many more. Dr. Kaweski is the winner of several prestigious awards, including being elected Woman of the Year by the American Biographical Institute in 2000 and an honoree for Notable American

Woman in 2002. She was a past president of the San Diego Plastic Surgery Society and has served as plastic surgery adviser for the Surgeon General of the Navy. She has also served as chief of plastic surgery at Sharp Memorial Hospital and is a senior staff member at three other San Diego hospitals. She has served as the chair of the Technology Assessment Committee for the American Society of Plastic Surgery. Further, she is a retired captain in the Medical Corp, United States Naval Reserve. Dr. Kaweski advanced the practice of medicine in San Diego County, with particular emphasis in East County, through her years of leadership of SDCMS, culminating with her presidency in 2011–12. These years were pivotal to changes in the healthcare community, including negotiations around healthcare reform, assuring that a significant number of uninsured community members will be able to gain health insurance coverage when the Affordable Care Act is implemented in 2014. Dr. Kaweski has also been published in numerous national and international medical journals and has presented her clinical research results worldwide, helping others to gain from her expertise. When Dr. Kaweski’s not with her patients or fighting the MICRA battle, you can find her teaching the doctors of tomorrow at the UC San Diego Medical School. Visit http://filmsyoufeel.com/More_ GHD_13_Heroes_01b.htm to see a video from the Grossmont Healthcare District awards program. SAN  DI EGO  PHYSICIAN.org 23


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Medical Mission Fulfilled in San Diego James Schultz, MD: Molina Healthcare 2013 Community Champion by the SDCMS Foundation

After medical school, James Schultz, MD, SDCMS-CMA member since 2006 and current SDCMS board member, joined Graybill Medical Group, serving primarily middle-class, insured patients. At the same time, he worked nights at Palomar Medical Center as an admitting physician/ hospitalist and frequently saw patients who did not have a primary care physician or a medical home. In 2001, he felt a calling to work exclusively with the medically underserved. At first, he considered a medical mission assignment overseas, but one of his peers convinced him to look at the need locally. Shortly thereafter, Dr. Schultz joined Neighborhood Healthcare as their chief medical office to care for the underserved 24 august 2013

in our community. “Working with the underserved certainly has its challenges and frustrations, but there isn’t a day that goes by that I don’t feel that I have made a real difference in someone’s life,” says Dr. Schultz. “Our patients have no one else to turn to; if we don’t help them, then they just don’t get help. These are our neighbors and their families; helping them makes us all better.” While our community’s network of community health centers provides primary care to the most vulnerable, uninsured patients have exasperatingly little access to specialty care. Dr. Schultz’s appreciation of the potential impact of the SDCMS Foundation’s Project Access (PASD) attracted him to take on the role of PASD medical director as the program was launching in early 2009. “Project Access enhances what a primary care provider can do by providing access to specialists who volunteer to see our uninsured patients,” says Dr. Schultz. “Many PCPs feel isolated, being asked by patients to provide a level of care more than what we are trained to do. Project Access helps us help our patients.” PASD links low-income, uninsured patients primarily from community clinics with specialty care physicians, hospitals, and ancillary providers who donate their time and expertise to care for this population at no cost. Under Dr. Schultz’s medical direction, the SDCMS Foundation launched eConsultSD in 2011, a HIPAA-compliant PCP-to-specialist electronic consultation that has expanded the capacity of primary care providers to maintain patient care at their medical home. To date, 98% of the eConsults have been resolved through the

sophisticated messaging system without the need for a face-to-face, reducing wait time and costs. “It is great to have the support of specialists to deliver good care for patients, both through Project Access specialty consultations as well as through eConsultSD,” says Dr. Schultz. As PASD medical director, Dr. Schultz meets weekly with PASD staff to evaluate cases that are referred to the program and determines if PASD has the capacity to serve the patients. He also serves on the PASD Leadership Committee and the SDCMS Foundation board of directors, offering his expertise and knowledge to set long-term goals for the organization. Additionally, Dr. Schultz serves as chief medical officer for the Council of Community Clinics (CCC), and plays an integral role in the region’s safety net. Dr. Schultz’s ability to motivate others is what makes him so effective in these leadership positions. Dr. Schultz’s warmth, caring nature, and dedication to providing the best care for a patient inspire those around him. He consistently encourages other clinic medical directors to develop their capacity as primary care physicians, and has helped institute educational workshops to enhance the capacity of primary care physicians to provide certain types of procedures at the community clinic level, including joint injections, minor dermatology procedures, and ophthalmology emergencies. In addition, resident physicians in the UC San Diego School of Medical Department of Family and Preventive Medicine residency program complete a one-month rotation at Neighborhood Healthcare under his direction. Dr. Schultz not only provides procedural training, he also gives resident physicians insight into the experience of caring for patients without health insurance and very limited resources. He teaches these students how community service should be a part of their medical practice, no matter where they decide to build their careers. “If we have talents and gifts to share, it is incumbent on us to use those to give back to those most in need,” says Dr. Schultz. In the next five years, Dr. Schultz’s vision is to improve population health in a meaningful way, as well as continue to care for individual patients — his true passion. Dr. Schultz now plays a key role in the Right Care Initiative, developing strategies to reduce heart attacks and strokes. He also sits on the Quality Committee of the LowIncome Health Program (LIHP), a County initiative that serves as a transitional plan to Medi-Cal for low-income adults. He will continue to make a difference in the lives of individual patients as well as the community as a whole for years to come.


September Heroes Event Combines Music and Physician Recognition

Heroes de la Salud on Sept. 26

by the SDCMS Foundation

Combine physicians with rock ’n’ roll music, and what do you have? A great evening highlighting the heroic efforts physicians make every day: caring for patients. The Sept. 26 Heroes de la Salud event, hosted by the SDCMS Foundation at The Abbey in Bankers Hill, promises to be just that. Join the Foundation board of directors to celebrate the accomplishments of Project Access San Diego physician volunteers, featuring The Ultimate Stones, a rock cover band from Los Angeles that will have everyone on their feet. Tickets are $125, and include buffet supper and signature cocktails. The evening will benefit Project Access San Diego, providing access to specialty healthcare services for low-income, uninsured adults in our community. The SDCMS Foundation recently recognized two physician teams with the Above and Beyond and Spirit awards at the SDCMS White Coat Gala. Additionally, winners of the Legacy, Champion, and Unsung Heroes awards will be presented at the Heroes event in September. For more information or to purchase tickets, visit www.SDCMSF.org/heroes or call (858) 300-2777. SAN  DI EGO  PHYSICIAN.org 25


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Whatever It Takes

Kaiser Permanente “Team Joel” Receives SDCMS Foundation Above and Beyond Award

by the SDCMS Foundation

26 august 2013

Whatever it takes to care for our patients is a commitment physicians live by. That creed is illuminated by the work a team of physicians provided for one patient facing a potentially fatal diagnosis. Joel, a 35-year-old father of two young children, went to his community clinic as he had been suffering with abdominal pain for more than three years, and was referred to Project Access in need of a sigmoidoscopy. At the March 2011 Saturday Surgery Day at Kaiser Permanente, his sigmoidoscopy was increased to a colonoscopy, and Joel was diagnosed with familial adenomatous polyposis, a rare form of genetic cancer. His treatment has included three surgeries, numerous images, radiation, and chemotherapy. What presented as a stage IV cancer looks like a life saved. Additionally, Kaiser provided his children with genetic testing, and his son, also a carrier, will be able to take steps for prevention and early detection. To honor all the physicians who live by the credo, “Whatever it takes,” SDCMS Foundation recognized Daniel “Stony” Anderson, MD, SDCMS-CMA member since 1989; Sandra Freiwald, MD, SDCMS-CMA member since 2010; Marco Tomassi, MD, SDCMS-CMA member since 2013; and Huathin Khaw, MD — the Kaiser Permanente “Team Joel” with the Above and Beyond Award at the June SDCMS White Coat Gala. “San Diego provides so much for us, it is nice to be able to give back,” says Dr. Tomassi. “Healing those in need is why we become

doctors.” Dr. Tomassi has volunteered for three Saturday Surgery Days in addition to the extra care Joel has needed. Dr. Anderson agrees. “I am thankful that the SDCMS Foundation is here to give this award, and that Project Access exists to save Joel’s life,” he says. “It’s wonderful to receive an award for saving a life, and these efforts help us to save others from dying from colorectal cancer.”

Spirit Award Acknowledges Carlsbad Surgery Team The SDCMS Foundation also recognized a team of physicians who “have answered the call, and have helped to increase access to care for our uninsured community,” according to the words of Albert Ray, MD, SDCMS-CMA member since 1993, current SDCMS Foundation Treasurer-Secretary, and SDCMS Executive Committee member. Adam Fierer, MD, SDCMS-CMA member since 2003, and Eileen Natuzzi, MD, SDCMS-CMA member since 2010, have both provided care for those without access in remote spots around the globe. They recognized how impactful that work was: giving life back to those who might have perished without it. So, as partners at the Carlsbad Surgery Center, they took on the leadership roles to recruit their colleagues to have the same impact at home they experienced abroad. Mark Ransom, MD, who heads ASMG’s anesthesiology team, quickly signed on to help, and he recruited other anesthesiologists to join the team. With the blessings and help of Scott Leggett and David Douglas of Surgery One, they bring together a team of physicians, nurses, PAs, and techs to provide surgeries to Project Access’ uninsured patients twice each year. Together, they embody the SDCMS Foundation’s Spirit Award, recognizing a team that displays an exceptional ability to work collaboratively, meet every challenge, and inspire others around them. Anesthesia Service Medical Group (ASMG) has been an important and longtime partner of PASD, providing services for most outpatient and inpatient surgeries. Jeremy Dendle, JD, COO says, “ASMG is proud to accept the Spirit Award on behalf of the many ASMG physicians who have volunteered their time to Project Access. ASMG physicians consider it a privilege to join their surgical colleagues in taking care of those who are truly in need. ASMG pledges its continued support going forward.”


“I am thankful that the SDCMS Foundation is here to give this award, and that Project Access exists to save Joel’s life. It’s wonderful to receive an award for saving a life, and these efforts help us to save others from dying from colorectal cancer.”

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5 1. Joel thanks the Kaiser Permanente staff at the April Saturday Surgery Day breakfast. 2. Joel and his family. 3. Dr. Cohen (left) and Dr. Ray (right) present the Above and Beyond Award to Drs. Anderson and Freiwald of Kaiser Permanente’s “Team Joel” at the White Coat Gala. 4. Receiving the SDCMS Foundation Spirit Award, Dr. Ransom, Mr. Douglas, and Dr. Fierer represent the team from Carlsbad Surgery Center. 5. Dr. Fierer and a grateful patient at the first Saturday Surgery Day at Carlsbad Surgery Center in August 2011.

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Bogged Down in EHR Conversion?

Help Is at Hand

by the SDCMS Foundation

28 august 2013

“I have had my current EMR since 2003 and would never go back,” says G. Ryan Dominguez, MD, SDCMS-CMA member since 2003. “It is impressive how much more efficient the electronic office is. Chart accessibility was one of the biggest advantages both between staff in the two offices and my ability to log on from home when on call. But now with electronic prescribing and electronic faxing, I find interfacing with other physicians and pharmacies is also easier.” Many physicians swear by the efficiencies electronic health records have brought to their practices. Others swear at it. The difference in satisfaction is often the workflow adaptations needed, says SDCMS Founda-

tion IT project manager Victor Bloomberg, LCSW. As a therapist, he can relate to the disruption and chaos that implementing an electronic health record system can cause a practice. “Leadership from the physician and the office manager is essential to the transition to electronic health records,” says Bloomberg. “This is a challenge in a smaller-size practice because the team already has task overload. Learning new things about EHRs can add information overload to the pile. We can provide guidance and support so that the path is smoother and decisions are well-informed.” The SDCMS Foundation partners with the Council of Community Clinics on a contract with CalHIPSO to provide free assistance to small practice primary care providers to achieve meaningful use stage 1 and receive the federal CMS incentive funds. Bloomberg says the temporary decrease in productivity should be three months or less. The short-term hassles are rewarded by improved revenue capture, increased efficiency, and, for many practices, incentive funds. “Virtually all physicians with whom I have spoken and who have chosen good EHRs have said that revenue capture has improved. E-prescribing, lab interfaces, and patient portals have created efficiency and lowered operating costs.” Achieving a return on investment is a


“Be prepared to do your homework and lose time in the beginning. Don’t go it alone; there are resources to help guide your selection and adoption. Spend more time to set up the system to have the best workflow in your practice, and later you won’t waste time and money to fix things.”

realistic goal, even for smaller practices. According to study conducted by researchers at UC San Francisco (The Value of Electronic Health Records in Solo or Small Group Practices, http://content.healthaffairs. org/content/24/5/1127.full#R11), practices were able to cover the cost of the EHR in approximately 2.5 years and then received an average of approximately $23,000 per year per full-time employee in net benefits. This study also notes that much of the ROI Project4:Layout 1

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consisted of efficiency gains and increases in revenue. The increases in revenue arose primarily from more accurate, higher level coding, but some providers also were able to see additional patients due to time saved from using an EHR. Electronic health records can improve standardization and the time it takes to locate and assemble various pieces of the patient’s record, according to Rob Yeates, IT project manager at the SDCMS Foundation and the Council of Community Clinics. Rafael Garcia, MD, FAAP, SDCMS-CMA member since 2006, is one of the physicians who have benefited from the SDCMS Foundation’s assistance. “For the past eight months, Victor has been helping our medical office, implementing appropriate changes in the way we use our electronic medical records,” he says. “He has delineated specific guidelines on how to travel the road to meaningful use, and has answered all kinds of questions regarding these important changes in our practice.” Providers are challenged by numerous distinct drivers: the Affordable Care Act, the HITECH Act, Medi-Cal reimbursement and administrative changes, Medicare sequestration, IPA business decisions, and wide

disparities in IT competencies and IT products/services. Bloomberg advises, “Consult with local experts to sort the wheat from the chaff in terms of EHR products, regulations, and resources to be successful. We are here to provide high-value assistance and have a track record the physician can trust.” For those practices not yet electronic, Yeates advises, “Be prepared to do your homework and lose time in the beginning. Don’t go it alone; there are resources to help guide your selection and adoption. Spend more time to set up the system to have the best workflow in your practice, and later you won’t waste time and money to fix things.” 286 primary care providers in practices of 10 or fewer have already received free assistance with system selection, workflow adaptations, CMS registration, and technical assistance. Those in practices of up to 20 providers can also receive free assistance through the SDCMS Foundation’s contract with the San Diego Regional Health Information Exchange. Assistance is available to specialist practices on a moderate fee basis, with discounts for SDCMS members. For more information, contact Victor Bloomberg at Victor.Bloomberg@SDCMS.org, or call the Foundation at (858) 300-2777.

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Physician Advocates for Veterans PAVE-ing the Way

by Rosemarie Marshall Johnson, MD

30 august 2013

Physician Advocates for Veterans (PAVE), a group of retired physicians affiliated with the SDCMS Foundation, is gearing up to provide guidance beginning late this fall to returning veterans and their families seeking healthcare services. Under the leadership of Harvey Shapiro, MD, retired UC San Diego anesthesiologist, and myself, the steering committee of eight and growing is laying plans to assist returning veterans in navigating the healthcare maze. “Both active and retired physicians often give of their time and advice to friends and family who need a better understanding of a diagnosis and their potential treatment options,” says Dr. Shapiro. “The only twist here is offering this service in a quasi-advocacy role to veterans to help them better understand, participate in, and improve their own medical care.”


PAVE Steering Committee: • Harvey Shapiro, MD • Rosemarie Marshall Johnson, MD • Albert Breland, MD • Steven Davis, MD

• Arnie Gass, MD • Martin Glasser, MD • Eric Marcus, MD • Robin Rowland, MD

While about 15% of veterans generally receive care through the Veterans Healthcare Administration, many former military often have no idea how to seek healthcare services, or how to interpret and deal with a diagnosis or prescribed treatment plan.

(L–R) Dr. Rosemarie Johnson, Dr. Arnold Gass, and Dr. Harvey Shapiro, volunteers helping at the July 2013 Stand Down for veterans.

Dr. Shapiro contacted me with his concept for PAVE in November 2012. “Probably the main thing pushing me forward was the PBS NewsHour custom of showing photographs and brief bios of the men and women who have died in combat,” says Dr. Shapiro. “I kept wondering how I might be able to help, and then realized that I’ve been doing advocate volunteer work with my friends and family for years and that that model might be transferable to helping our veterans.” While about 15% of veterans generally receive care through the Veterans Healthcare Administration, many former military often have no idea how to seek healthcare services, or how to interpret and deal with a diagnosis or prescribed treatment plan. This is where PAVE volunteers can assist. One of the issues the steering committee

emphasizes is “not to become intrusive in the ongoing relationship between the physician and patient, while at the same time believing we can increase the efficiency of that interaction by properly preparing a patient for their next healthcare visit,” says Dr. Shapiro. The mission statement defines PAVE’s activities: “Retired physicians have the time, knowledge, and skills to offer a direct and unique resource for veterans. PAVE physicians do not provide medical services and are not part of any existing healthcare organization. We are not a substitute for any of the veteran’s clinicians, including the VA system or other health service providers.” Rather, PAVE physicians will assist veterans and their families on a one-to-one basis to access healthcare efficiently, to understand their medical conditions, and to learn to advocate for their medical needs. The volunteer can choose the amount of participation. It is quite hassle-free. There are minimal rules, so the physician and veteran can carve out the type and extent of the advocacy experience. And most of all, it is very gratifying, just like the SDCMS Foundation’s Project Access San Diego, which provides specialty care for low-income, uninsured adults in San Diego County. While there are numerous organizations in our region focused on veterans, “Not a single one of them offers the option of sitting down for a lengthy discussion with an experienced physician,” says Dr. Shapiro. “Our maturity and ability to help them navigate healthcare issues is unique. Our main gift is offering time with a doc who

has the veteran’s interests at heart.” A recent program of the Retired Physicians Society that introduced PAVE was a lecture on post-traumatic stress disorder (PTSD) by Sonia Norman, PhD, a renowned PTSD expert and professor at UC San Diego School of Medicine. Approximately 30 physicians attended, and some stayed to learn more about PAVE. After learning PTSD was rampant among the veteran population, including families, I turned to the San Diego Psychiatry Society and quickly received enthusiastic participants for the steering committee. Besides the psychiatrists, the steering committee includes other prominent retired physicians who have brought needed organizational talents. We are further compiling a list of retired physicians interested when the program is launched this fall. “We offer an option for physicians to become engaged not only with deserving veterans but also by creating an esprit de corps among those of us who chose this option for voluntary service,” says Dr. Shapiro. “One quick look at our excellent steering committee is enough to verify that statement.” To get involved in PAVE, contact Harvey Shapiro, MD, at mdwritr@yahoo.com, or call the SDCMS Foundation at (858) 3002780. Dr. Johnson, longtime SDCMS-CMA member and past president of SDCMS, serves as the retired physician director on the SDCMS board, co-chairs the Retired Physician Society for the SDCMS Foundation, and serves as the Foundation’s medical community liaison and ex-officio board member. SAN  DI EGO  PHYSICIAN.org 31


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The key is regular screening. For uninsured and underinsured individuals, access to screening colonoscopies is unaffordable; however, recent research from the American Society of Gastroenterologists, the American Gastroenterology Association, and the U.S. Preventive Services Task Force has shown that the annual use of a FIT test is as effective as a colonoscopy every 10 years for identifying cancers.

Debra Aitken and Lindsey Smith (sixth and seventh from left, respectively) are surrounded by professional improvisation actors at the June 15 fundraising event.

Colorectal Cancer

Prevention Is Building Awareness

by the SDCMS Foundation

32 august 2013

Colorectal cancer can be prevented and treated early with great success, according to Daniel “Stony” Anderson, MD, SDCMSCMA member since 1989, and SCPMG gastroenterologist and chair of the California Colorectal Cancer Coalition (C4). The key is regular screening. For uninsured and underinsured individuals, access to screening colonoscopies is unaffordable; however, recent research from the American Society of Gastroenterologists, the American Gastroenterology Association, and the U.S. Preventive Services Task Force has shown that the annual use of a FIT test is as effective as a colonoscopy every 10 years for identifying cancers. Anderson is leading efforts at the SDC-

MS Foundation to improve colorectal cancer screening rates among the low-income communities served by the community health clinics through the use of FIT tests, and, when needed, diagnostic colonoscopies through the semiannual Saturday Surgery Days. “According to the American Cancer Society, the best screening test is the one that’s done,” says Dr. Anderson. “We’ve known for more than 10 years that we did not have the capacity to perform all the screening colonoscopies that would be needed. The FIT test gives us a reliable, effective means of screening the growing 50-plus population.” Debra Aitken is a colorectal cancer survivor who knows firsthand how important cancer screening can be. Four years posttreatment, Debra and colleague Lindsey Smith are raising awareness and funds to assure others may be saved the traumatic experience. They recently formed Smith + Aitken 4 Awareness, and organized a fundraising event for the SDCMS Foundation’s colorectal cancer programs with Finest City Improv on June 15. The comedy night included Aitken’s first experience with improvisation, telling stories from her life that were enhanced by the professional performers. “At the March Saturday Surgery Day, we were struck by seeing and hearing Joel and his family tell their story,” says Smith. “You can’t put a price on that life. It was really touching to hear from a colorectal cancer survivor and how thankful he is to Project Access and Kaiser Permanente.” Watch for news on their September Bingo Bash in Rancho Santa Fe and other events leading up to their Putt for the Butt golf tournament in Fall 2014!


Steven Rojas, MD

Family Medicine Resident Embodies SDCMS Foundation Mission

Dr. Rojas celebrates his UC San Diego School of Medicine graduation with his son, Steven Benjamin Rojas.

by Carol L. Young, MD

Steven Rojas, MD, SDCMS-CMA member since 2013, is taking the lessons from his time at the UC San Diego Student Run Free Clinic to the first months of his family medicine residency at Scripps Mercy Hospital Chula Vista to get in touch with the community and understand available resources. The day he spoke to this writer, he had been to a binational free clinic in Tijuana run by UC San Diego and UABC, the medical school just across the border. During the community medicine month prior to his in-hospital work, Dr. Rojas visited the Chula Vista Farmers Market, took a tour of a Women, Infant, Children (WIC) nutrition center, and learned about resources for seniors, in addition to touring the community health centers in South Bay. While providing community service at the UC San Diego Student Run Free Clinic, Dr. Rojas had provided care for numerous uninsured patients, several of whom he had referred to the SDCMS Foundation’s Project Access for surgical procedures. His interest in caring for the underserved, the core of the SDCMS Foundation’s mission, was a critical factor in being selected as the 2013 Resident Scholarship winner by the Foundation. Each year, the Foundation supports UC San Diego’s incoming first-years and graduating medical students through scholarships to lighten the burden of medical school expenses. Dr. Rojas demonstrates an impressive commitment to caring for the medically underserved, to mentoring minority undergraduates, to practicing leadership, and to learning and growing his professional skills in patient care and clinical research. His family medicine residency, and his plans to

“Primary care and family medicine are a good fit for me. I think primary care is the most relevant with the direction medicine is heading; prevention is critical for keeping folks out of the hospital, so everyone wins.” practice primary care, give us hope that Dr Rojas’ already dedicated medical career will continue to grow in San Diego. Over Dr. Rojas’ three-year residency, he will see patients receiving care at Scripps and may follow them for outpatient primary care services through San Ysidro Health Center. “I may help a woman deliver her baby at the hospital, and see them for wellbaby care in the months that follow,” says Dr. Rojas. “Working with the underserved, it is important to have a broad spectrum of skills,” adds Dr. Rojas. “Primary care and family medicine are a good fit for me. I think primary care is the most relevant with the direction medicine is heading; prevention is critical for keeping folks out of the hospital, so everyone wins.” During Dr. Rojas’ interview with the SDCMS Foundation Medical Student Scholarship Committee, he asked the committee members how residents could be more involved with the Foundation. Now recognizing that during the first two years, he is committed to up to 80 hours of work a week, that interest may need to be deferred, but we are confident he will inspire his fellow residents to engage in the work of the Foundation during their careers. Congratulations, Steven Rojas, MD, and to all the new residents from UC San Diego’s School of Medicine! Dr. Young, SDCMS-CMA members since 1980, is a rheumatologist practicing in Escondido, serves on the SDCMS Foundation Scholarship Committee and the SDCMS Foundation Board of Directors, and is the immediate past president of the SDCMS Foundation. She served as president of SDCMS in 2005. SAN  DI EGO  PHYSICIAN.org 33


classifieds PHYSICIAN POSITIONS AVAILABLE PHYSICIAN WANTED FOR OUR GROWING ORGANIZATION: Full- and part-time, flexible schedules available. Variety of locations in San Diego. 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] FAMILY PRACTICE / INTERNAL MEDICINE PHYSICIAN NEEDED to help two physicians in Chula Vista. Reasonable salary and package, four weeks’ leave, light call commitments, and cheerful work environment. Nursing home, hospital, and teaching opportunities optional. Please send CV or questions to geriatricpractice@gmail.com. [156] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing 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 (619) 9925330 or email CV to drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [037] PART-TIME PHYSICIAN NEEDED FOR URGENT CARE IN SCRIPPS RANCH: Board-certified in family practice / IM or ER. PA considered with minimum of three years urgent care experience, DEA licence, and control substance class. Please email your CV to mdtodayurgentcare@ gmail.com or fax to (858) 622-1417. Please include references. [147] SHARP HEALTHCARE IS SEEKING A PHYSICIAN REVIEWER: For the medical direction of Authorization Review for Sharp Health Plan, and to ensure quality of care and appropriate utilization in the most cost-effective, appropriate, and professional manner. Must have an MD degree, current license, and five years minimum experience practicing primary care physician with knowledge of managed care and the process for prior authorization review required. To apply online, please visit http://bit.ly/10DvzMU. Sharp Experience is our unique, system-wide commitment to transforming the healthcare experience in San Diego by becoming the best place to work, practice medicine, and receive care. EOE. [143] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org

or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912] 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) 5045830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE WANTED WE BUY URGENT CARE OR READY MEDCLINIC: 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 HEALTH CENTER OFFICE SPACE TO SUBLEASE — 477 EL CAMINO REAL, ENCINITAS: Beautiful office space available, 2100 square feet, at the 477/D Building. Occupied by vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. 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 (858) 452-0306. [153] SCRIPPS XIMED MEDICAL CENTER BUILDING OFFICE SPACE TO SUBLEASE — LA JOLLA: Occupied by vascular and general surgeons. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, Scripps XiMed Medical Center Building is the office space location of choice for anyone doing surgeries at the hospital or seeking a presence in the La Jolla area. Support staff may be available if needed. Full ultrasound lab on site / procedure room. For more information, call Irene at (619) 840-2400 or (858) 452-0306. [154] OFFICE SPACE AVAILABLE IN SANTEE: We are located at 9456 Cuyamaca St., #102, Santee, CA 92071. There are 2 exam rooms and 2 doctors offices, private bathroom and a patients bathroom, kitchenette, large waiting room, a front office area, and a billing office area. Our parking lot is huge! It would be ideal for a psychiatrist or psychologist. Please email stacey.sdgi@gmail.com or call (619) 270-5665. Or contact Dr. A. Reddy at (619) 5655138 or via email at areddyp.ca@gmail.com. [150]

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 august 2013

BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care doctor (or two) to help curb overhead and help with acute overflow patients needs. Also can provide opportunity to get into clinical research. Contact Cindy at allmedgrp@hotmail.com. [146]

CreekView Medical Park in Vista Quality Medical / Office Condos or Buildings / For Sale Lease. New sustainable construction near Tri-City Hospital, Healing Environment, Signage Available / Perfect opportunity for inpatient & overnight stay facility, assisted living, skilled nursing, educational, research, hospice, therapy, specialty hospitals, surgery centers, rehabilitation facilities, medical & dental offices & more! 1,494 - 48,268 SF Available 1910-1968 Via Centre Drive, Vista Visit www.creekviewmedical.com Call 760.431.4201

SUBLEASE IN PRESTIGIOUS UTC BUILDING: Sublease beautifully appointed 2100-square-foot office in prestigious building in UTC, starting on July 1, 2014. Ideal for plastic surgeon, urologist, orthopedic surgeon, or pain specialist. Direct access to AAAASF-certified surgical center with existing contracts with Blue Cross, UnitedHealthcare, workers’ compensation, and Aetna. Fraxel repair laser, hand fluoro, endoscopic and powerassisted liposuction equipment available at premises. Please call or email Ines Ustare at (858) 4578686 or ines@solteromd.com. [145] OFFICE SPACE TO SHARE: Office space to share in National City with a well-respected physician who has been in private practice for 30 years. Office is about 900 square feet with two exam rooms and an additional office/multi-purpose space. Office is currently being used part-time, Monday through Wednesday, but hours are flexible to accommodate another part-time practice. Physician planning to retire within one year. Bilingual (English/Spanish) speaking helpful. If interested, please contact me at bpmedina@msn.com. [141] OFFICE SPACE AVAILABLE IN MISSION VALLEY: Seeking psychologist / psychiatrist or other similar provider for Mission Valley office space. Beautiful large room available in centrally located urgent care / family practice / occupational medicine practice. Psychologist or psychiatrist would be optimal provider, as we will be happy to refer you patients in need of your services — a win-win situation. Please contact Brenda at brenda@missionvalleymedical.com or myself at drpohl@missionvalleymedical.com, or on my cell at (619) 8468156. Office is available on July 1. [140] OFFICES FOR RENT: UTC/La Jolla area, full-time office in 8th-floor suite with established psychologists and psychiatrists. In Class A building with pleasant view. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Telephone Manuel D. Tobias, PhD, or Thomas J. Wegman, PhD, at (858) 362-8779. [139]


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]

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]

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]

PART-TIME OR FULL-TIME NP OR PA: Island Family Medicine is looking for a part-time or fulltime NP or PA who loves primary care and wants to work with both adults and children of all ages. Busy practice in Coronado with a small-town feel. Experience preferred, but I am willing to consider a motivated new graduate. Compensation based on experience. 401K for PT and FT. Vacation pay and health insurance for FT. Apply by sending resume to CoronadoMedPeds@gmail.com. [155]

POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sq-ft 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 the week. Contact Nerin at the office at (858) 5210806 or at mzarei@cox.net. [873] 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]

NONPHYSICIAN POSITIONS AVAILABLE

NURSE PRACTITIONER NEEDED FOR LOCAL HOSPICE: Majority of visits are house calls. Flexible schedule. $53/hour. Mileage and cell phone reimbursement. Laptop provided. Part-time with full-time potential. Please send resume or CV to KLewis@SDCMS.org. [149] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician in San Diego. Part-time, flexible days/hours. Competitive compensation. Call (619) 992-5330 email drhunt@ thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or

email drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [152] MEDICAL RECEPTIONIST / SECRETARY: Cosmetic / plastic surgical practice in Bankers Hill. Must possess proper phone etiquette and have a professional attitude and appearance. 32 hours, Monday – Thursday. AS degree plus 2 years experience in a medical office. Contact Grace at (619) 297-4433, ext. 308. [144] NEED A PART-TIME NURSE PRACTITIONER: Apreva Hospice needs a part-time nurse practitioner for home hospice visits. Once a week at this time, but opportunity for more work available. Please email KLewis@SDCMS.org. [138] MEDICAL EQUIPMENT ELECTRONIC TOUCH SCREEN MEDICAL CHECK IN SYSTEM FOR SALE: Eliminate staff interruptions and increase your office efficiency with this easy-touch patient sign-in kiosk in your waiting room. The average sign-in time for patients with a Medical Check In touchscreen kiosk takes fewer than 10 seconds. With this reduction in interruptions and the clear, organized communication of patient information to your receptionist’s computer, Medical Check In will reduce the time for the patient sign-in process, reduce congestion for your reception area, and save you money. Compatible with all electronic health records. Still under warranty. Cost for new Medical Check In is $2,500. Great price for this at $995. For more information, please see medicalcheckin.com. Email KLewis@ SDCMS.org. [982]

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

SAN  DI EGO  PHYSICIAN.org 35


San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society August 1893

In celebration of 100 years of publication of San Diego Physician (formerly known as The Bulletin), we will be reprinting throughout the year excerpts from past issues. This Letter, published in the January 1972 edition of San Diego Physician and edited here for length, was written in 1893 by Dr. Fred Baker, San Diego County Medical Society president in 1891, to Dr. Fred Burnham, president in 1893

the bulletin

The Imperial, New York City, 18 August 1893 long We arrived here on a hot day in June after a weekless journey from San Diego. The heat is humid, breath The usual. as on goes life , theless Never and exhausting. the streets are crowded with carriages, trolley cars and hand. your in life your take You s. new safety bicycle cost Prices are high. A dinner at Delmonico’s last night week. a dollars 14 is room hotel our almost a dollar, and I spent the first week looking up old friends and in the getting my bearings. I took out visitor’s tickets mornPolyclinic and in the Postgraduate School. Each many ing we look over the bulletin board. Operations of pick kinds are announced in the various hospitals. We at oons aftern the spend and see to the ones we want doing. the Polyclinic where there is always something time Sometimes two lectures are going on at once. At no was did the whole class number more than 20, so there lly. carefu case each study to ample opportunity I was tremendously impressed with the Roosevelt is one Hospital on Ninth Avenue and 59th Street. This surof the 19th century wonders. Dr. McBurney is chief Syms the d donate his of friend a that it geon. Rumor has operating theater with the stipulation that Dr. McBur . charge ney was to be in Before the anesthetized patient is rolled in, an astray sistant brings in all instruments in a large wire boilwhich he drops into a vat of water kept constantly ,I ing. At the same time a nurse brings in a full bushel hot bishould think, of towels which are wrung out of washchloride of mercury solution. Others fill trays and placed bowels with antiseptic solutions. The patient is ary. on the table and wrapped in blankets as far as necess thickThen above the blankets are wrapped several t nesses of towels, gradually covering the whole patien nose, until nothing shows but the part to be cut and the , eyes and the mouth. The hair is bound up in wet towels other and even the inhaler is. Then the soap poultices or and dressings are removed, the final cleansing is done,

36 august 2013

nurses the operation begins. As it progresses, one of the or lays on fresh towels. Whenever there is any soiling a until it covers towel fresh a , ination contam possible ed dozen or more thicknesses are in place. None is remov until the wound is closed and ready for dressing. At the old German hospital (now Lenox Hill) I was under fortunate in missing a rib resection on a youngster brucocaine which nearly caused a riot in the class by its cancer for stomy gastro a do r Gerste saw I tality. Later ly ous closure of the esophagus under cocaine — possib t had unique on this account. For three weeks the patien ation been kept alive by nutrient enemas. Great prostr l aneswith a weak and intermittent heart made genera not thesia unwarrantable. The operation was neatly but with it h throug went t patien the and done, brilliantly little or no shock. s In my field I found especially profitable five lecture by Dr. Myles at the city morgue. They gave me a chance , and to do the new mastoid operation, a tracheotomy s. I various kinds of drainage procedures on the sinuse of d metho er’s O’Dwy ing practic hours long also spent on rapid intubation of the trachea. The fight still rages tion, the comparative value of tracheotomy and intuba ess but the ease of inducing parents to agree to a bloodl intufor ntly eloque argues etic anesth t withou method simple bation. Dropping a tube through the larynx is so a preas done ntly freque is it that expert an for a matter cautionary measure in early cases. We saw much beautiful work and much that was petenunsatisfactory, either from carelessness or incom than West the in s doctor of n opinio better far a cy. I have actuI ever had before. New York ophthalmologists are imbalally behind us in the field of extraocular muscle Infirance. Roosa, the dean at Manhattan Eye and Ear s. muscle the of tests no make to orders given mary, has in this With Dr. Savage of Nashville the best authority confield, we outside barbarians can hold our own. I am better vinced that the average work in ophthalmology is in the West than it is in New York.


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August 2013