San Diego Physician
official publication of the san diego county medical society Nov 2013
Your stories Voices in Medicine
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Volume 100, Number 11
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
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)
VOICES IN MEDICINE: YOUR STORIES
Are You Ready? The Future Quality of Medical Care
BY RALPH R. OCAMPO, MD
“ Leave Chloe With Dad and Me”: Moms in Medicine BY GERALDINE CHANG, MD
My Journey in the World of Medicine: It Has Been a Great Trip
BY CARLOS J. SANCHEZ, MD
departments 4 Briefly Noted: Calendar • Featured Member • Commercial Real Estate Tips & Trends • And More … 10 CMA Legislative Wrap-up BY THE CALIFORNIA MEDICAL ASSOCIATION
I Wish for … Making Strides Towards Our Ideals
Avoiding the Effects of Prescription Drugs on Driving Performance
BY WILLIAM T-C TSENG, MD, MPH
BY LINDA L. HILL, MD, MPH
An Interview With Dr. James H. Schultz Jr. BY VIMAL NANAVATI, MD
No Excuses BY DANIEL J. BRESSLER, MD
Are You a Photocopier Away From a $1 Million Fine? BY THE CALIFORNIA MEDICAL ASSOCIATION
22 Risks for BRCA-based Breast Cancer BY THE DOCTORS COMPANY
24 Is It Time to Break Your Shell?
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) AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, 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
BY HELANE FRONEK, MD, FACP, FACPH
34 Physician Marketplace Classifieds 36
24 2 novem b er 2013
San Diego Physician Celebrates 100 Years: September 1969
Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]
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/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar Cma Webinars CMAnet.org/events ICD-10 Documentation for Physicians: Part 1 DEC 5: 12:15pm–1:15pm ICD-10 Documentation for Physicians: Part 2 DEC 12: 12:15pm–1:15pm ICD-10 Documentation for Physicians: Part 3 DEC 19: 12:15pm–1:15pm Update on Medicare Physician Incentives: What’s New for 2014 JAN 22: 12:15pm–1:45pm
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. Conference on Practice Improvement NOV 21-24 (www. stfm.org/conferences/ practiceimprovement) Gingerbread City: Yearly Gala of the Epilepsy Foundation of San Diego County DEC 3 (http:// gingerbreadcity.org/home/) The 3rd Annual International Hawaii Symposium on Diagnostic and Therapeutic Modalities in Heart Failure DEC 5–7 (www.ccmmeetings. com)
C.A.R.E. 4 (Comprehensive Aesthetic Restorative Effort) Free Continuing Medical Education and Training: The 2013 Gene Vance Jr. Foundation 6th Continuing Medical Education and Training at the United States Department of the Navy — Breakthrough Multidisciplinary Care for the Wounded Warrior and Traumatically Injured. Civilian and military medical providers in all fields are invited to attend four days of state-of-the-art training, new discovery, and innovation. Location: Naval Medical Center, San Diego, California. DEC 5–8 (www.genevancejr. org/SUMMIT2013.htm) Update in Rheumatology 2013: Highlights from the ACR and EULAR Meetings DEC 14 (https://cme.ucsd. edu/rheumatology) Health IT Program Held by the Institute for Health Technology Transformation JAN 21–22 (ihealthtran.com)
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
14 Annual UCSD Heart Failure Symposium for Primary Care and Internal Medicine Physicians JAN 25 (www.ccmmeetings. com)
DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org
Melanoma 2014: 24th Annual Cutaneous Malignancy Update JAN 25–26 (www.scripps.org/ events/melanoma-annualcutaneous-malignancyupdate-january-25-2014)
GENERAL SUGGESTIONS SuggestionBox@SDCMS.org
11th Annual Natural Supplements: An EvidenceBased Update JAN 29–FEB 1 (www.scripps. org/events/11th-annualnatural-supplementsjanuary-29-2014)
Erratum In the “Know Your MICRA History” article in the September 2013 issue of San Diego Physician, we mistakenly wrote that on Oct. 15, 1985, the California Supreme Court declined to review Lawrence Fein v. Permanente Medical Group. It was, in fact, the U.S. Supreme Court that declined to review the case. 4 novem b er 2013
get in touch
OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@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-Olivera 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
/////////////////////////////////////////////////////////////////////////////////////////////////// from our members I just wanted to thank everyone at SDCMS for the opportunity to attend the 2013 annual meeting of the CMA’s House of Delegates. I learned so much and was thrilled to be able to participate! In my 10 years of medical training, from med school through residency and the first two years of fellowship, I have never had such an experience or this type of exposure to the politics and policy-making behind medicine. It was an incredible window into the processes that exist and the means by which we can catalyze change. I also had the opportunity to meet some incredible and inspiring people, from both within our district and outside. Everyone was so welcoming and willing to share their expertise and knowledge with us “newbies.” I will highly recommend this opportunity to other housestaff. It is so important to understand what is going on behind the scenes and outside of the textbooks, especially early in one’s career. Thank you for facilitating this and for all the work you do in helping trainees make a confident and informed transition into post-residency/fellowship practice. I absolutely hope to stay involved with SDCMS and the CMA. Thank you again!
— Nina Shah, MD
“Join the San Diego County Medical Society? I already belong to too many societies, and each one wants more and more dues each year.” Well, when was the last time you called one of your societies and an hour later the CEO called you back and gave you his/her cell phone and said if your problem isn’t resolved, call him/her personally? That’s right, SDCMS’s CEO called me after I had a question and gave me his private number to make sure any questions I had were resolved. And Marisol! She is the contact point for all doctors, and she gets things done! “Marisol, I need a new HIPAA form to give my patients.” Soon afterward there was a CMA document in my email with all the forms I needed! And even free lunches! My office manager goes to meetings, almost monthly, at the SDCMS building where speakers, who have absolutely nothing to sell, inform her on billing, security, hiring and firing, etc. There are a zillion more reasons, but, while I am personally reviewing the various and numerous specialty societies I belong to, as long as I’m in practice, I’ll be a member of the San Diego County Medical Society. They’ve been here for me for almost 40 years, and I appreciate it. This is from me personally, not sponsored by anyone.
— Steven D. Emmet, MD
One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! Congressman Duncan D. Hunter (District 52) E: (via website) hunter.house.gov Capitol Office: United States Congress 223 Cannon House Office Building Washington, DC 20515 T: (202) 225-5672 • F: (202) 225-0235 District Office: 1611 N. Magnolia Ave., Ste. 310, El Cajon, CA 92020 T: (619) 448-5201 • F: (619) 449-2251 Birthday: DEC. 7
Harold J. Simon, MD, PhD
SDCMS-CMA member since 1969, Dr. Simon passed away on Aug. 6, 2013.
Richard P. Walls, MD
SDCMS-CMA member since 1982, Dr. Walls passed away on Sept. 13, 2013.
Theodore M. Mazer, MD Dr. Mazer was elected speaker by the CMA House of Delegates at its annual meeting in October in Anaheim. Dr. Mazer, a boardcertified otolaryngologist, SDCMS-CMA member since 1989, and past SDCMS president, runs a small, solo practice. He served on the CMA Board of Trustees from 2002 to 2010 and has chaired various committees, including those focusing on medical services and access to specialty care. Dr. Mazer had served as vice speaker of the CMA House of Delegates since 2011. Congratulations, Dr. Mazer!
SAN DI EGO PHYSICIAN .org 5
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Vacancy Rates by Submarket
North County Coastal
Kearny Mesa/Mission Valley
Escondido/San Marcos Tenants slow to relocate west, gradual shift occurring.
Kearny Mesa/Mission Valley
Around the County in 8 Words
Direct Asking Rental Rates by Submarket
North County Coastal
Forecast A gradual decline in vacancy is expected in the near future as larger health systems and medical groups and other practices that are experiencing growth keep demand at steady levels. Supply will be kept in check as very little new construction is anticipated in the next 24 months. A number of new developments will be announced in 2014 and 2015,
Direct Vacancy (%)
Market Conditions and Trends As we gear up for the implementation of the ACA in January, healthcare providers of all sizes are proving to be as strategic, creative, and opportunistic as ever. This certainly holds true when it comes to their assessment and planning of real estate. “Occupancy cost” is now a common word around conference room tables and physician lounges as members of the healthcare community review their leases and facilities in an attempt to aid the bottom line. The countywide average asking rate is now at $2.48/SF, slightly up from 12 months ago, but tenants are finding it difficult to find quality space under $2.75/SF in most submarkets.
There still exists a premium for on-campus or adjacent-tocampus buildings, although to a lesser degree than in the past. Well-located Class A and B space is in particularly high demand as providers focus more and more on the patient experience. As a whole, the county’s vacancy has hovered around the healthy 12% mark for two years now.
Average Asking Rent/SF
By Chris Ross
Medical Office Update: Q3 2013
Commercial Real Estate Tips & Trends
Oceanside/Vista Vacancy still high, opportunistic providers are taking advantage.
I-15 corridor Activity relatively good among condominiums and newer buildings.
North County Coastal Tight vacancy, tenants have little reason to move.
La Jolla/UTC/Sorrento Dynamic submarket strong as ever, vacancy declining consistently.
Uptown Hillcrest Submarket could use a new development, maybe condos.
Kearny Mesa/Mission Valley Frost Street rents rising, other good alternatives available.
East County Tenants content, owner-user sales closing regularly.
South County Low rents and low vacancy, little recent change.
6 novem b er 2013
but most of them will require at least 35–50% pre-leasing. Even with that accomplishment and the securement of financing, most of these developments are in the early design and permitting stages and will not deliver until 2016. So what are San Diego providers facing? Rising rents and declining vacancy, conditions that come with positive sentiment in the investment and development community but create challenges for tenants. The process and strategies that are executed when providers assess and negotiate their space will play a key role in controlling occupancy costs.
Key Market Indicators LastQuarter Change
12- Month Forecast
Total Vacancy Rate
YTD Net Absorption
12-month Rent % Change
Average Asking Rent
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 email@example.com.
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The No. 1 cause of unintentional deaths in San Diego County is from drugs, with almost one person a day dying in our county from this preventable cause. The San Diego and Imperial County Prescription Drug Abuse Medical Task Force is a coalition of medical leaders who have joined efforts to reduce deaths and addiction due to prescription drugs. The task force includes pain specialists, internal medicine physicians, emergency physicians, psychiatrists, dentists, pharmacists, hospital administrators, health department administrators, and our local DEA. The task force also includes broad health partners, including Kaiser Permanente, Scripps Health, Sharp HealthCare, UC San Diego Health System, Palomar Health, and the Community Clinics. The task force encourages all medical practitioners to use the materials provided at www.SanDiegoSafePrescribing.org to improve patient care.
PaLo aLTo SacramenTo
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Complete and pass The Doctors Company’s online Patient Safety/Risk Management Exam. You will need to create a user ID and password (at The Doctors Company website (www.thedoctors.com/KnowledgeCenter/PatientSafety/CME/index.htm) and provide some identifying information. From the Education and CME page on The Doctors Company’s website, click on the “Risk Management and Patient Safety Exam” link.
Complete and pass the written version of The Doctors Company’s Patient Safety/ Risk Management Exam and return it to The Doctors Company, Attention: Patient Safety Dept., 185 Greenwood Rd., P.O. Box 2900, Napa, CA 94558-0900, or fax it to The Doctors Company at (707) 226-0162.
Attend one (1) of The Doctors Company webinars. Upcoming webinars: • “The Top Five Risks in the Office Practice” on Nov. 26, 12 p.m.–1 p.m. • “Lessons Learned When the Power Goes Out” on Dec. 4, 9 a.m.–10 a.m. • “HIPAA: Yesterday, Today, and Tomorrow” on Dec. 12, 12 p.m.–1 p.m. • “Health Literacy: Do Your Patients Understand?” on Dec. 17, 9 a.m.–10 a.m. • “Medication Management in the Office Practice” on Dec. 18, 12 p.m.–1 p.m.
5 8 novem b er 2013
Attend in person (at SDCMS’s offices) or online a scheduled Doctors Company/SDCMS co-sponsored educational seminar or webinar.
Contact a Doctors Company patient safety representative at (800) 421-2368, ext. 4265, to schedule a live presentation at your practice location.
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The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against SDCMS members who are also members of The our members are won without a settlement or trial, and we win 87 percent of the cases that do Doctors Company receive a 5%More program discount they go to court. So what dowill you get for your money? than a fighting chance, forwhen starters. The San Diego County Medical Society has exclusivelyon-demand endorsed our medical malpractice insurance complete the new complimentary, CME module— program since 2005. To learn more about our program benefits for SDCMS members, call Risk and Complications of Opiates. The Doctors Company (800) 852-8872 or visit www.thedoctors.com.
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The MICRA fight is on. The initia-
tive to eviscerate MICRA has been rolled out for signature gathering! Thank you to the following hospitals for contributing toward its defense: Alvarado: $10,000 • Chief of Staff: Frederick M. Howden, MD • Chief of Staff Elect: Richard O. Butcher, MD Grossmont: $33,000 • Chief of Staff: Brian S. Moore, MD • Chief of Staff Elect: C. Eric Orr, MD Palomar: $33,000 • Chief of Staff: Richard C. Engel, MD Paradise Valley: $10,000 • Chief of Staff: Paul J. Manos, DO • Chief of Staff Elect: Dorothy E. Hairston, MD Pomerado: $33,000 • Chief of Staff: Roger J. Acheatal, MD Rady Children’s: $33,000 • Chief of Staff: Gail R. Knight, MD • Chief of Staff Elect: Mary Hilfiker, MD San Diego Imaging: $12,000 San Diego Pathologists Medical Group: $10,000 Scripps Encinitas: $10,000 • Chief of Staff: Ron J. MacCormick, MD • Chief of Staff Elect: Scott A. Eisman, MD Scripps Memorial: $33,000 • Chief of Staff: Shawn D. Evans, MD • Chief of Staff Elect: M. Jonathan Worsey, MD Scripps Mercy Chula Vista: $33,000 • Chief of Staff: Juan M. Tovar, MD • Chief of Staff Elect: Thomas C. Lian, MD, PhD Sharp Chula Vista: $10,000 • Chief of Staff: Errol R. Korn, MD • Chief of Staff Elect: Sharp Coronado: $20,000 • Chief of Staff: Kevin C. Considine, DO • Chief of Staff Elect: Roger Oen, MD Sharp Memorial: $33,000 • Chief of Staff: Ronald C. MacIntyre, MD Tri-City: $5,000 • Chief of Staff: Juan C. Deza, MD • Chief of Staff Elect: The California Hospital Association matches hospital medical staff contributions 2:1! In other words, medical staffs have raised $888,000, plus the $22,000 from San Diego Imaging and San Diego Pathologists Medical Group, or almost $1 million for San Diego!
4/15/13 11:57 AM
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SAN DI EGO PHYSICIAN .org 9
CMA Legislative Wrap-up
What Would Have Happened This Year Without CMA and SDCMS? 10 novem b er 2013
Please check out the following CMA-SDCMS track record on legislation. • 9/9 CMA-opposed Bills in California Killed or Modified to Acceptability • 4/6 CMA-sponsored Bills Signed Into Law If you are not a member, ask yourself what would have happened without SDCMSCMA, and then go to www.SDCMS.org to join. If you are a member, thanks for paying the dues that make it happen!
CMA Legislative Wrap-up: • In a major CMA victory in the Legislature, no bills were even submitted to
repeal MICRA. The trial lawyers are now attempting to qualify a measure for the November 2014 ballot. We will be successful in this fight, but victory will not come overnight, and we will need every physician to enter the fray. • After failing to reverse the 10% MediCal physician reimbursement cut with CMA-sponsored legislation — SB 640 and AB 880 — introduced in both houses in 2013, CMA filed a petition with the U.S. Supreme Court on Sept. 20 to block the cut. • By sponsoring SB 21, which the governor signed, CMA successfully secured
an annual $15 million appropriation to fully fund the University of California, Riverside School of Medicine, the first new four-year medical school established in California in over 40 years. AB 565 and AB 1288, sponsored by CMA and signed into law, will fund physicians (through medical school loan repayment) to locate their practices in underserved regions of the state, a long-term solution to California’s physician distribution issues — as opposed to expanding allied health professional scope of practice. SB 191, co-sponsored by CMA and signed into law, extends the current Jan. 1, 2014, sunset date for ER funding, a.k.a. Maddy Funds, to Jan. 1, 2017, raising $50 million to augment local county EMS funds to allow counties, hospitals, and physicians to continue providing emergency services in their communities. Without expanding or modifying physical therapists’ scope of practice, AB 1000, co-sponsored by CMA and signed by into law, clarifies an existing ambiguity in the law so that physical therapists can continue to work within the legal boundaries of medical corporations as they have for decades. CMA killed SB 117, which would have endangered patient safety by allowing for the treatment of cancer patients with methods that have not been scientifically proven. CMA killed SB 266, which would have placed the onus on medical groups to inform patients whether individual providers within the group are outside the patient’s network — a health plan responsibility, not a medical group’s. CMA killed SB 312, which would have placed school district governing boards squarely in the middle of the physicianpatient relationship. CMA killed SB 430, which would have put determination of standard of care into the hands of legislators. CMA killed SB 491, an attempt by nurse practitioners to gain a plenary license to practice medicine independently in California. CMA killed AB 591, which would have created a slippery slope of “what specialty physician would be required to be on-call next in every general acute care hospital with an emergency department? Pediatricians? Ophthalmologists?” etc. CMA killed SB 492, an attempt by optometrists to practice ophthalmol-
ogy, specifically to treat and diagnose disease, prescribe and administer drugs, perform surgical procedures, order laboratory and diagnostic tests, and more. CMA-supported SB 352, which was signed by the governor, will prohibit nurse practitioners, certified nursemidwives, and physician assistants from authorizing medical assistants to perform any clinical laboratory test or examination for which they are not authorized. CMA helped kill AB 975, which would have made it extremely difficult for hospitals to be classified as nonprofit. (A big issue for hospital chiefs of staff.) CMA-supported SB 494, which was signed by the governor, amends statute to include physician assistants (PAs) — while maintaining that PAs must operate under the supervision of a physician as primary care providers and increases the number of enrollees assigned to PAs in Medi-Cal managed care plans. CMA soundly defeated a proposal to expand the MBC’s authority to limit a physician’s prescribing authority with a lower standard of evidence. With CMA-supported-and-signedinto-law SB 809, CMA secured ongoing funding for and upgrades to the CURES database, California’s prescription monitoring program, as well as a streamlined CURES application process, a reduced fee impact on physicians, no mandated physician participation, and more. CMA-supported-and-signed-into-law AB 154 expands access to abortion by medication or aspiration techniques in the first trimester of pregnancy while ensuring patient safety and physician supervision. CMA-supported (after amendment) AB 361 (signed by the governor) authorizes the DMHC to create a health home program for enrollees with chronic conditions, as authorized under federal law. CMA significantly narrowed a pharmacists’ proposal (SB 493), ensuring that pharmacists can provide reasonable services in an integrated and safe manner that promotes collaboration with physicians. In addition to defeating an effort to shift the investigative authority from the MBC to the DOJ (in SB 304), CMA ensured issues raised (expert witness, 820 evaluations) were addressed in its favor.
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Prescription Drug Abuse
Driving Under the Influence
Avoiding the Effects of Prescription Drugs on Driving Performance by Linda L. Hill, MD, MPH
Acknowledgments: Dr. Hill would like to acknowledge the contributions of Thu Truong and Tiep Ly, PharmD candidates, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego. Prescribed medications, overthe-counter (OTC) medications, and abused drugs, including alcohol, have the potential to interfere with the ability to drive safely. Physicians have a responsibility to their patients and the public to minimize this risk in their prescribing practices, their patient counseling, and in reporting to the Department of Motor Vehicles. The potential for impaired driving differs by age group; younger drivers are more likely to drive impaired due to abused drugs, while older adults are more likely to be taking prescribed medication, and engage 12 novem b er 2013
in polypharmacy and the inherent drug interactions. A study by the AAA Foundation for Traffic Safety found that 78% of drivers 55 years old and older are using at least one prescription medication with the potential to impair driving. And only 28% of senior drivers were aware that their medications had this potential effect. Unfortunately, only half of these drivers (52% â€” 58% of women vs. 46% of men) have talked to a healthcare provider about the possible effect of these drugs on their ability to drive (December 2011 AAA survey). Prescription medications will be reviewed here in an effort to raise awareness of drug-driving interactions and to reduce driving injuries, a major cause of disability and death across the age spectrum. The classes of prescription drugs and their potential side-effects are outlined in
Table 1. The main side-effects that impair driving skills include drowsiness, confusion, hypotension and possible associated syncope, hypoglycemia, poor muscle tone or incoordination, and less common problems such as double vision, nausea, blurred vision, and memory impairment. For all drugs, minimizing use to only those needed, stopping drugs in a timely manner, and using the lowest dose to achieve the desired effect will help reduce side-effects. Patients need to be educated on the effects of medications on driving. Anticonvulsants are used for treatment of seizures but have other indications, including migraine headaches, mood disorders, and neuropathy. Seizure disorders, when uncontrolled, can interfere with driving, of course, but anticonvulsants may cause drowsiness, confusion, ataxia, nausea, and double vision. The response to the medication varies by individual, and may not always be linearly correlated with dosage. Blood drug levels are helpful in some drugs, such as phenytoin, where high blood levels are correlated with ataxia. Psychotropics are another example where both the medication and the disease being treated can affect driving safety. There is evidence that the crash rate in individuals with depression is three times higher than unaffected individuals. However, the
Poor Muscle Tone, Incoordination
Confusion, Poor Judgment
double vision, neuropathy, nausea, ataxia
tricyclics, trazodone, mirtazapine, MAOIs
SSRIs, SNRIs, buproprion
promethazine, metoclopramide, prochlorperazine, chlorpromazine
blurred vision, hyperkinesia
diphenhydramine, chlorpheniramine, hydroxyzine, dimenhydrinate, meclizine
loratadine, cetirizine, fexofenadine
atropine / diphenoxylate, benztropine, oxybutynin, trihexyphenidyl, dicyclomine, belladonna alkaloids X
β blockers, calcium channel blockers, clonidine
ACEIs, ARBs, thiazide entacapone, tolcapone, amantadine
dizzy, nausea, headache
trihexyphenidyl, benztropine, selegiline, rasagiline, ropinirole, pramipexole, rotigotine
emotional labiality, tremor
insulin, sulfonylurea, glinides (repaglinide, nateglinide), exenatide, liraglutide
Metformin, gliptins (sitagliptin, saxagliptin, linagliptin), TZDs (pioglitazone, rosiglitazone)
prazosin, terazosin, doxazosin
PDE-5 inhibitors Marijuana
treatments for depression may be associated with side-effects that interfere with driving as well. Even one psychotropic prescription drug increased the crash risk more than two-fold for drivers over 45 years of age, with dramatic increases to eight-fold for more than two CNS-affecting drugs. The tricyclic antidepressants have higher rates of hypotension and drowsiness, one of the reasons they are prescribed at night to help
class effect X
Diabetes and diabetic drugs are associated with hypoglycemia, and diabetics should be cautioned to check their sugar before driving, and periodically on long trips.
SAN DI EGO PHYSICIAN.org 13
Prescription Drug Abuse
There is evidence that the crash rate in individuals with depression is three times higher than unaffected individuals. However, the treatments for depression may be associated with side-effects that interfere with driving as well.
with depression-associated insomnia. They have been associated with a more than twofold crash risk in the elderly. Anxiolytics, especially the benzodiazepines, can cause drowsiness, confusion, and amnesia, and may interfere with muscle tone and coordination, and 10mg of Valium have been found to be equivalent to a BAC of 0.10. Antipsychotics and psychosis, similarly, may both affect judgment, with the drugs causing nausea and drowsiness. Diabetes and diabetic drugs are associated with hypoglycemia, and diabetics should be cautioned to check their sugar before driving, and periodically on long trips. While hypoglycemia is especially a risk during medication adjustments, it can occur at any time with changes in food intake, activity, or acute illnesses. Diabetic drugs have many interactions with other medications that can potentiate their hypoglycemic effects. In addition, diabetic patients are at risk of a myriad of eye diseases affecting vision and driving safety. Routine eye care and good glucose control play a role in mitigating that effect but don’t eliminate the risk. Chemotherapy can also impair driving 14 novem b er 2013
skills by increasing the risk of nausea, confusion, drowsiness, poor muscle tone, and dehydration, with associated hypotension and syncope. The frailness alone, associated with cancer and chemotherapy (and other treatments), reduces driving skill and increases crash risk. Individuals under acute care for cancer should be advised to find alternative transportation when the chemotherapy is associated with these common side-effects. Narcotic analgesics, especially but not exclusively in the acute setting, are associated with impaired judgment, confusion, drowsiness, and nausea, all likely to impair driving safety. These individuals are at risk of being charged with “driving under the influence” if stopped for driving impairment, even if they have prescriptions for these drugs. Driving should be stopped when narcotics are first prescribed, and only resumed once the level of impairment is felt to be low enough not to interfere with safe driving. While marijuana is often used illegally, the increasing number of prescriptions for medical marijuana is changing the patterns of impaired driving. Marijuana can affect driv-
ing through altered judgment, motor control, and concentration. The effects of marijuana may persist for hours after use, though the acute blood levels from use generally fall within four hours. When prescribing marijuana, driving timing should be discussed relative to use. The effect of alcohol on driving safety is profound due to both the level of impairment and the high prevalence of use. Alcohol is estimated to be implicated in 60% of traffic fatalities, a greater influence than any other substance. While the standard BAC of 0.08 is considered the legal level of impairment, driving skill is reduced at lower levels as well. The designated driver should abstain from alcohol to avoid the effects, a practice that is even more important in the older driver. Patients should understand the medications they are taking and whether they, in conjunction with their condition and OTC medications, can impair driving ability. With the majority of drivers 55 years old or older on one or more prescription medications, this has become a great safety concern. Healthcare providers should discuss possible interactions and effects with all patients on one or more prescription medications. California is one of nine states requiring mandated reporting to the Department of Health Services for lapses of consciousness (see San Diego Physician article “Mandated Disease Reporting Requirements: A Roadmap”; Volume 98, Number 10) associated with an underlying condition. Lapses include loss of consciousness, dementia, seizures, or other conditions that cause a reduction in alertness. The list of reportable conditions in California has been recently updated and can be found at www.cdph.ca.gov/HealthInfo/ Pages/ReportableDiseases.aspx. Conditions other than lapses of consciousness may also be reported if the physician feels the driver is at risk to themselves or others. Resources for further information on the topic of medication, medical conditions, and driving include: • Roadwise Rx: www.roadwiserx.com, sponsored by AAA • The National Highway Traffic Safety Administration Report DOT HS 809 725, 2004. • Medical Conditions and Driving: A Review of the Scientific Literature: DOT HS 809 690, 2005. • http://treds.ucsd.edu Dr. Hill, SDCMS-CMA member since 2010, is clinical professor and director of preventive medicine residency in the Department of Family and Preventive Medicine at UC San Diego.
*COMPARED TO STANDARD CHEST X-RAYS
POETRY AND MEDICINE
No Excuses by Daniel J. Bressler, MD The term “qualia” is used in philosophy and neuroscience to denote the internal and personal experience of a labeled fact about the world. When you say, “Throw me that blue beach ball,” one might assume that the “blueness” of the ball is the same for you and for the friend who you hope will pick it up and toss it your way. But we have no way of knowing whether her blue is the same as your blue. For normally sighted (and cooperative) people, we can come up with reliable designations (she picks up the blue beach ball and not the red one when requested), but that is not the same as equality of private experience. Perhaps, in her head, what looks blue to me “in fact” looks red to her. We have no precise way of knowing, even with sophisticated fMRI or EEG correlation tests. It seems there is a feature of irreducible ambiguity when one makes the journey from objective materiality to subjective consciousness. In taking a history from a patient, I am trying to get them to describe both external events (“I was hospitalized for a head injury when I was 16”) and internal experiences (“My headaches are typically preceded by waving lights and a vague sense of déjà vu”). Sometimes the gap between what they are trying to explain and what I can understand (and, moreover, put into a coherent narrative of a disease process) is maddeningly yawning. I ask, tell me the story again. Are there any pieces 16 novem b er 2013
you’ve left out? Even after 30 years of practice, I shake my head sometimes at the sheer incomprehensibility of another person’s inner experience. Most of the time, I think I “get it,” but even then doubts persist. Perhaps this doubt is a good thing. Perhaps this is simply me brushing up against that irrefutable inexactitude of language, of inter-subjectivity, of communication. It doesn’t relieve me of trying to understand a patient’s strange set of symptoms any more than it exonerates me from the responsibility of communicating back to the patient what I know. It does, however, provide a kind of humbling reassurance that I’ll never get it just right. Try as we may (and try we must), there remains a bedrock mystery to what I can know. This poem, No Excuses, is an attempt to cheer myself on when the “yawning gap” seems daunting. Other than taking a vow of silence — an option not widely available — it seems that we have no excuses and, in fact, no choice.
And then, informed humility aside, to go for it: To attempt the impossible task of saying Exactly what you mean, what you see and feel, And worry later (like now) whether anyone can really understand.
Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.
So don’t try to tell me “there are no words for it.” There are no words for anything. Invent the metaphor. Create the simile. Construct the illustration. Stuff the scribbled message in the bottle Already, and toss it out to sea.
Not just poetry But all language is an Assault on the inexpressible A coarse and comical pantomime Performed in dim light across a Grand Canyon You standing on the North Rim of your experience And me on the South Rim of mine. Given the folly of conveying even one dull thing, (“chipped red brick,” or “one cup of coffee, regular”) How dare we attempt the task of saying, “God in heaven” or “I love you?” And yet we laugh at the same jokes (fooled again!) And cry at the same sad news of loss. We imagine precise empathy in a way we might conclude Synchronous swimmers are all thinking one yoked thought. But as with hard science, so with soft syllables: The art is knowing how and how much To trust the approximation; each article of speech bounded By confidence intervals, each with its own standard deviation.
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Are You a Photocopier Away From a $1 Million Fine? New HIPAA Rule Goes Into Effect by the California Medical Association 18 novem b er 2013
A New York health insurer called Affinity Health Plan really got a shock when it was informed by CBS Evening News that, as part of an investigatory report, it had purchased a photocopier previously leased by Affinity that still contained protected health information for more than 300,000 patients.
Do you or your staff scan patient health records on a leased copy machine? You might be violating the Health Insurance Portability and Accountability Act (HIPAA), putting private patient data at risk and opening yourself up to massive fines and other penalties. Many of these copy machines have an internal memory that, unless proper safeguards are in place, may allow unauthorized people to access patient data. The U.S. Department of Health and Hu-
man Services (HHS) recently released new regulations that made important changes to the privacy and security requirements under HIPAA. These new regulations, known as the HIPAA Omnibus Rule, implement many of the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The new rules took effect in March and physicians had until Sept. 23, 2013, to update practice policies and procedures to comply with the new regulations. Are your policies and procedures up to date? While the copier infraction is not new, it does illustrate how physicians and medical office staff must think about potential risks to protected patient health information and identify and improve privacy and security vulnerabilities in office business practices. In this instance, a New York health insurer called Affinity Health Plan really got a shock when it was informed by CBS Evening News that, as part of an investigatory report, it had purchased a photocopier previously leased by Affinity that still contained protected health information (PHI) for more than 300,000 patients. In August 2013, the federal Office for Civil Rights (OCR), which is charged with enforcing the HIPAA privacy laws, settled with the plan for $1 million. The investigation revealed that Affinity failed to incorporate the electronic PHI stored on the photocopier hard drives in its analysis of risks and vulnerabilities as required by the HIPAA security rule and failed to implement policies and procedures for securing or deleting that data when returning the photocopiers to its leasing agent. If you think that you are too small a practice to run afoul of HIPAA, think again. Small practices are not exempt from the HIPAA requirements, and any physician practice that uses electronic means to engage in designated transactions — including health claims, remittance or payment advice, claim status inquiries, eligibility inquiries, enrollment and disenrollment,
referral certification and authorization, and coordination of benefits or health plan premium payments — is a covered entity and must comply with HIPAA or be subject to enforcement actions. But Will OCR Come After the Little Guys? OCR has initiated enforcement actions on practices big and small. Last year, a small cardiac surgery practice in Arizona agreed to pay a $100,000 settlement fine after it was found to have been sending PHI through an unsecured, web-based email program. In addition to using unsecured email to send PHI, the practice was also posting patient appointments on an Internet-based calendar, which was publically accessible. With a careful assessment of their business practices and risks, physicians should be able to implement HIPAA compliance plans in their practices to protect patient information and reduce their risks of violating HIPAA and state privacy and security laws. What’s New? Some of the key changes made by the HIPAA Omnibus Rule include, but are not limited to, an updated definition of a business associate, new rules surrounding certain permitted uses and disclosures of PHI, such as the sale of PHI and the use of PHI for fundraising and marketing, and rules controlling how patients can obtain medical records that are kept by a physician electronically. It also made significant changes to the PHI breach notification rule. Physician offices will, at a minimum, need to review and update their business associate agreements, office privacy and security policies, and notice of privacy practices in order to bring their offices into compliance with the new rule. In the end, your practice doesn’t have to be locked down like Fort Knox, but you must be able to demonstrate that your practice has taken “reasonable” measures to protect SAN DI EGO PHYSICIAN.org 19
The U.S. Department of Health and Human Services recently released new regulations that made important changes to the privacy and security requirements under HIPAA.
the privacy and security of PHI. Each practice will differ in some detail. As doctors and staff learn more about HIPAA, your staff should be able to determine what you need to do if you have not already implemented your safeguards. This means using appropriate and reasonable administrative, technical, and physical safeguards for all health information. Every staff member has an obligation to protect this information. This includes keeping doors properly locked, keeping computer passwords secret, securely transporting and using portable and mobile computers and devices that access PHI, and speaking softly when discussing medical information in publicly accessible areas. The law also requires every practice to designate a Privacy and Security Official, whether it is the physician, an associate, or staff member, to oversee the practice’s HIPAA compliance plan. This person will be key to developing and implementing policies and procedures, receiving complaints, and knowing where documentation of your processes are kept; he or she will be responsible for thinking ahead about compliance, and can help or lead your office through an audit.
This person needs to understand computers, but does not have to be a “techie.” They will, however, require some education and some support. Information technology (IT) is involved, but this is NOT an IT project. Keeping your practice in compliance with HIPAA will ultimately require the whole organization’s cooperation and support. Where Can We Get Help? The California Medical Association (CMA) has a number of resources that are useful in understanding and for getting medical practices practice up to par on the HIPAA rules. These and other resources are available at www.cmanet.org/hipaa. • Sample Documents: For more information and for an updated sample notice of privacy practices and business associate agreement, see the California Medical Association’s (CMA) ON-CALL documents #4101, “HIPAA ACT SMART: Introduction to the HIPAA Privacy Rule,” and #4103, “Business Associates.” These documents are available free to members. Nonmembers can purchase docu-
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ments for $2 per page. • On-demand Webinar: CMA recently hosted a webinar, “HIPAA Compliance: The Final HITECH Rule,” available for on-demand playback at your convenience. • Frequently Asked Questions: CMA has produced a brief resource document, “HIPAA Omnibus Rule Compliance Frequently Asked Questions,” which answers common questions about the new HIPAA regulations. • HIPAA Compliance Toolkit: The CMA/ PrivaPlan HIPAA Toolkit is a comprehensive online resource to assist physicians in complying with the HIPAA privacy and security rules and California law. It contains detailed sample forms, policies, procedures for compliance tailored for California physicians, training materials, and resources to help physicians with implementation and planning. SDCMS-CMA members can purchase the toolkit from PrivaPlan by calling (877) 218-7707 or visiting PrivaPlan’s website at www.privaplan.com. The cost is $325 per practice for members or
$495 for nonmembers. Annual updates to this program cost $75 for SDCMSCMA members. A coupon code is required to access this discount. Visit www.cmanet.org/benefits or call CMA’s member service center at (800) 786-4262 to obtain the code. • HIPAA Training Tool: PrivaPlan also offers an online HIPAA Training Tool that is an easy and affordable way to train staff. This comprehensive course can be taken online at anytime, anywhere. It features videos and online quizzes to help just about anyone understand HIPAA and what policies and procedures must be put into place. SDCMS-CMA members can purchase the HIPAA Training Tool at $129 for SDCMS-CMA members or $169 for nonmembers. For more information and resources, visit www.cmanet.org/hipaa. The California Medical Association (CMA) represents more than 38,000 physicians in all modes of practice and specialties. CMA is dedicated to the health of all patients in California.
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The law also requires every practice to designate a Privacy and Security Official, whether it is the physician, an associate, or staff member, to oversee the practice’s HIPAA compliance plan.
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A recent malpractice case highlights the failure of missing an early diagnosis.
Risks for BRCA-based Breast Cancer Avoid Missed or Delayed Diagnosis
by SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety. Recent news coverage has brought BRCA gene-based breast cancer into the spotlight. Actress Angelina Jolie’s decision to get a preventive double mastectomy after testing positive for the BRCA gene may cause patients to ask physicians if they are at risk. Physicians should be aware of the risk factors for BRCA gene-based cancer in order to identify those who need testing and to avoid delayed or missed diagnosis. A recent malpractice case highlights the failure of missing an early diagnosis. A 22 novem b er 2013
33-year-old woman had two female relatives, including her mother, who had breast cancer in their forties. At 31, she began getting annual screening mammograms, which showed dense breasts. She complained of a small, palpable mass. However, no mass was seen on a mammogram, and the diagnosis was fibrocystic changes. No additional tests were ordered. Within six months, the mass was enlarging, and she was diagnosed with infiltrating ductal cancer that had advanced from a Stage I to a Stage III. Based on her
history, she should have been tested for the BRCA mutation and given various treatment options. Additionally, no ultrasounds or MRIs were done, which possibly could have detected the cancer at an earlier treatable stage. A woman’s risk of developing breast and/ or ovarian cancer greatly increases if she inherits a BRCA1 or BRCA2 gene mutation. Widespread screening is not required because together these mutations account for only 5–10% of breast cancers. Those with the BRCA1 mutation have a 55–65% chance of developing breast cancer by age 70, and those with the BRCA2 mutation have a 45% chance. Women have about a 2% chance of getting ovarian cancer, but if they have a BRCA2 mutation, that risk increases to 40–60%. Physicians should watch for the following BRCA mutation risk factors and discuss genetic testing with patients at risk: • Maternal or paternal blood relatives with breast cancer diagnosed before the age of 50. • Certain cancers in a patient’s family, such as pancreatic, colon, or thyroid. • Both breast and ovarian cancer in a patient’s family, especially in one individual. • Women in a patient’s family with cancer in both breasts. • Patient with Ashkenazi Jewish heritage. • A male in the patient’s family with breast cancer. • Relative with BRCA1 or BRCA2 mutation. If the patient does test positive for the BRCA mutation, it is essential to remind her that this does not indicate she will get cancer. Patients can reduce risks of cancer with prophylactic surgery, hormonal treatment, and lifestyle changes.
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Personal & Professional Development
Is It Time to Break Your Shell? by Helane Fronek, MD, FACP, FACPh
With my knees shaking, terrified that I would fall, I tentatively paddled along with the swimmers and divers who were also in the water.
Most of us value safety. We wear seatbelts to protect us in case of an accident. We attend conferences and read journals to learn the most effective ways to treat our patients so they will be healthy and we will avoid malpractice litigation. We give prophylactic medications against DVT and infections. There are certainly many appropriate situations for safety. And there are times when our desire for safety gets in our way. While chicks gestate, they are enveloped in a hard shell — to maintain a nourishing environment and protect them from injury. But if they remain in their shells, they would never develop into the chickens they were meant to be. Similarly, too often we play it “safe” and deprive ourselves of experiencing, becoming, creating, or enjoying those things that would give our lives greater meaning and satisfaction. A friend recently shared with me an important realization about the shells we keep ourselves in. At a small weeklong conference, she encountered an antagonistic 24 Novem b er 2013
person whose ire she did not want to provoke. Wanting to remain “safe,” she avoided this difficult person for several days. The irony was that as long as she remained within her artificial “shell” of safety, allowing her fear to control her actions, she continued to feel unsafe. It wasn’t until she broke out of her shell and stepped up to an honest conversation with the person that she realized she didn’t need protection — she felt safer and more powerful speaking with the person than she had felt while “protected” in her shell of avoidance. I often joke that I’ve seen too many IMAX movies about the power of the ocean when people ask why I don’t surf. We live near the ocean and I’ve been a swimmer most of my life. But images of surfers being smashed into the ocean floor and the knowledge that there are unknown creatures lurking beneath the surface (not to mention my terrible sense of balance) have kept me from venturing into the waves. Fortunately, my creative and persistent surfer husband convinced me to try stand-up paddle-boarding. With my knees
shaking, terrified that I would fall, I tentatively paddled along with the swimmers and divers who were also in the water. Suddenly, I realized that I was actually standing up and paddling. I noticed how beautiful the day was — the sun was shining, the rolling waves created a soothing movement that I enjoyed riding on — and my fear eased. Even as I write this, I’m aware how excited I feel about the next time I’ll be in the ocean. Is there a fear that you are holding onto, a shell you have kept around yourself in order to feel “safe” that you are willing to break out of? I invite you to experiment by breaking that shell, even if it’s just to poke your beak out, and see if you don’t find your fear dissolve and a meaningful experience on the other side. 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.
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medicine Voices in
Are You Ready? The Future Quality of Medical Care
By Ralph R. Ocampo, MD
Your Stories We all bring to the practice of medicine a unique set of life experiences that, to a greater or lesser degree, have influenced the character of the doctor we’ve become. Whether we grew up in a large city or small town, on this side of the tracks or that, whether we benefited from the full support of family and friends — financial, emotional, or otherwise — or had to struggle every step of the way, the slate was not clean that sunny day we first slipped on our white coat. In the following pages, find strength — and beauty — in the stories your colleagues have chosen to share with you. And please consider sharing your own story for publication in a future issue of San Diego Physician — email us at Editor@SDCMS.org.
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J.W. Erkenbeck, MD, joined
the San Diego County Medical Society in 1918. He was a family physician who had been a medical missionary for the Seventh-day Adventist Church in Jalisco, Mexico. He arranged for the adoption of my mother by my grandmother and also delivered me at Paradise Valley Hospital in 1931. His selfless care for Spanish-speakers in San Diego was legendary. After finishing a residency in general and vascular surgery at the San Diego County Hospital, I went into practice hoping to emulate Dr. Erkenbeck. Among the many rewarding experiences were volunteering at “The Chicano Clinic” and “The City Rescue Mission,” but it was the operating room that was spellbinding. That spell was broken by the medical malpractice crisis of 1972 and further trampled by government and insurance company collusion in controlling fees. The coup de grâce was managed care. The prediction made by Reichstag Deputy Rudolf Virchow in 1882 that governmentcontrolled healthcare would destroy self-regulation of the medical profession has been fulfilled. Today lawyers, accountants, and MBA managers have more to say about the delivery of healthcare and its quality than the medical profession. Theodor Billroth, the most famous surgeon of the 19th century, fought against many of these same problems. He and Virchow lost their battle to preserve self-regulation of the profession to Otto Von Bismarck. We have lost it to bureaucrats at every level of government. In 10 years or less, most physicians will be employed by hospitals and managed care consortia (Accountable Care Organizations?). Young physicians will rely on large employ-
ers to avoid constant confrontation with government and insurance companies. Physician families are seeking more flexible work hours to allow for time with family and such things as raising children. There can be no turning back from the new paradigm of healthcare because, for better or worse, it is what the American public wants! Physicians can affect the quality of medical care in the future through proactive organizations. Local, state, national, and specialty societies must lobby and even harass legislators to defend the American public from quacks, including those with an MD. Every state and national medical regulatory body must be monitored on a daily basis, and membership criteria should include enough expert physicians to stop illadvised initiatives before they happen. Finally, medical leaders must think of medical students and house officers as their own children, just as Theodor Billroth did in the 1860s. The house of medicine will survive and grow, but new professionals must give it time — and mature professionals both time and financial resources to get the job done. Are you ready? Dr. Ocampo, currently retired, first joined SDCMS-CMA in 1967.
“Leave Chloe With Dad and Me” Moms in Medicine
By Geraldine Chang, MD My parents emigrated
from Korea to America with hope of providing a better future for their unborn children. Fast-forward 28 years and here I am, the product of their sacrifice. My name is Geraldine Chang, but I go by Geri. I guess we can add the MD after the name since I graduated from medical school two years ago. I am currently a radiology resident at UC San Diego Medical Center. After four years of college and four years of medical school, I am now in year three out of five in order to complete my residency to become a board-certified
radiologist. Somewhere in the middle of this process, I met the love of my life, Chuck, and we got married a little over two years ago. He’s also a resident in the field of orthopedic surgery in year five of six. If that wasn’t complicated enough, I got pregnant, and on Jan. 3, 2013, Chloe Chang was born into this world. I spent my maternity leave in Orange County with my parents, which was the hardest thing I’ve ever done. The anxiety of becoming a new mom was compounded with the idea of going back to residency. I was foolish enough to think during pregnancy that I could handle the demand of being a parent (more like single parent, given Chuck’s hours) and a radiology resident (not as intense but also not very flexible). I had chosen a day care, planned for a part-time
nanny, and had a list of potential babysitters. It wasn’t long into my maternity leave that I realized the hours and demand of residency was impossible with raising a child in a way that would protect my sanity and wellbeing. It was then that my mom sat me down and said, “Leave Chloe with Dad and me.” It sounded crazy, but when she made that offer there was no other way to do it. I’m sure some would argue with this statement, but, for me, this was the best care that no amount of money could purchase. These are the two people who have raised me to be the person I am today. It was the hardest decision I’ve ever made but it meant Chloe would get the care and attention that neither Chuck nor I could provide her. Thus, seven weeks later, I left Chloe in Orange County to resume my residency. When I returned, everything changed but nothing changed. Residency is still residency. There is work to do and an endless list of expectations. I feared the judgment from other people.
How can a mom be away from her baby? The judgment I feared was worse than I expected. I heard so many snide remarks ranging from it being child abuse for not breastfeeding the entire first year of life to me not worthy of being a mom if I can’t take care of my baby myself. The list goes on and on. Everyone had a say in this situation. I was told that multiple people weren’t sure I would make it when I was pregnant as a first-year radiology resident. But I don’t blame them. I know for sure I wouldn’t have made it. I’m lucky if I get to see Chuck for dinner, and, on a really lucky day, I’ll make it in time to take my dog out for a walk. But usually, we don’t. Even if we do, he has to do his pre-operative planning for the next day while I try to decompress all the new knowledge I learned that day and try to add more to an evergrowing knowledge base of radiology. My husband was given the “advice” that he had too many “distractions” and what he really needs is a stay-at-home wife who could fully support his career. That one really got to me. We are a rare entity. I am the only wife in his program who is also a physician, but we are definitely not the only couple with a child. However, I also get where they are coming from. Chuck would have it a lot easier if he could have a wife who took care of him and his child. Everyone in the family could be cheering him on and supporting him while he did his training. Instead, both of us are trying to take care of each other when we don’t even have time to
In my short 10 months I’ve been a mom, I already know that yes, I love being a doctor, but I was born to be a mom.
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take care of ourselves. I do think we do our best to understand each other, and who better to understand the life of a resident than another resident? But they obviously don’t see it that way. This is my declaration to everyone and their opinions. Yes, I am a resident, and yes, I am also married to a surgical resident. We both put in our time to get to this point in our careers, and we both deserve to finish and earn the title of attending physicians. I am also a 28-year-old married female who wanted to start a family and, in turn, had a baby during training. What I learned in my time back to residency is that, simply put, these two roles are exceedingly difficult individually and near impossible together. I echoed the sentiments of AnneMarie Slaughter’s article, “Why Women Still Can’t Have It All.” I’m an ambitious person, always striving to be the best. As a medical student, I published multiple, first-author papers. Outside of working out and the occasional yoga, my world was committed to my future career. Becoming a wife and mom changed my life, but I want
My only wish is that if Chloe decides to become a physician and also decides to start a family during training, that there will be more support and resources.
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to disagree with Anne-Marie Slaughter in that I can’t have it all. Yes, at one time, my definition of having it “all” revolved around attaining the highest possible academic and career achievements. I agree if that continued to be my definition than I would fail. As a mom to a daughter, this is not what I want to say, but I don’t say it with pessimism. Right now, the two worlds have not yet collided. I look forward to the day I am in a place to set the work and home balance. In my short 10 months I’ve been a mom, I already know that yes, I love being a doctor, but I was born to be a mom. Every day I have to remind myself this is just temporary. I may never be a pioneer in the field of radiology, but I will be there for every birthday and Christmas for Chloe. I will know the names of all her friends and teachers. I am going to make up for all the lost time during residency. I am doing what I think is best for my daughter, and that will never stop regardless of
where I am in my career. To me, I am on my way to achieving both personal and professional satisfaction. I want to be a good radiologist and physician, but I want even more to be the best mom to Chloe. At the end of the day, regardless of everyone else’s opinion and judgment, I feel very blessed because I know I will have it all. My only wish is that if Chloe decides to become a physician and also decides to start a family during training, that there will be more support and resources. I hope my story has echoed the sentiments of other moms in medicine. It’s been really lonely trying to figure out all of the above alone. This is my small way of letting all the beautiful physician moms out there know that superheroes exist. We’re living proof. Dr. Chang has been a member of SDCMS-CMA since 2012.
Now medicine is on that pedestal because science is the god of medicine and no longer the mythological figures of the past.
My Journey in the World of Medicine It Has Been a Great Trip
By Carlos J. Sanchez, MD Talking about a trip, what a journey in the world of medicine it has been: 1957 — Brigham Young University, Pre-med 1966 — St. Louis University School of Medicine 1967 — Internship 1969 — U.S. Navy Medical Doctor 1970 — Mercy Hospital Internal Medicine Residency 1972 — UCSD Pediatric Residency And that was the end of a long training in which the doctors were on a pedestal from the time of Hippocrates. Thanks
to television sitcoms like Dr. Kildare, Ben Casey, Marcus Welby, M.D., movies and novels like Not as a Stranger by Morton Thompson, the people had an idealistic thought of what a doctor should look and be like, and what made admission to medical schools so difficult because we had to play those roles, and worse — in my case — look the part. In other words, be a Superman, which I was far from being, but I played the role. Those years were the ’50s, ’60s, ’70s, and ’80s. So, I could say that medically speaking, I was a descendant of long-gone demigods in the likes of the great four physicians: Welch, Halstead, Osler, Kelly and their long line of students — some of whom were my professors who also were on a pedestal. Confident of my profession and respected by all: hospital administrators, nurses, and, more than anything, for my patients I also was on a pedestal. In 40 years of practice here and as a missionary globetrotter to faraway worlds, I was a man with a destiny and a mission, but as the years waned, changes came with every decade. I saw firsthand all the changes that are now taking place at light-speed that I am still bewildered of how fast it is happening. I could say that I lived the good, the ugly, and the bad, and not necessarily in that order. For I feel that whatever tumultuous change this great country of ours has been through, like the Revolutionary War, Civil War, racial strife, gender equality, the results have always turned out for the better — true, painful history but with good results, and that is what makes our America what it is — the best that all of humanity is possible to be. So, for the medical profession the past was great, the doctors were on a pedestal because we could talk our
way in the incipient science of medicine, but now medicine is on that pedestal because science is the god of medicine and no longer the mythological figures of the past. We doctors can no longer talk our way into the unknown world of what pure science has to offer. Now it is we who have to walk the road in an advancing medical field and are no longer on a pedestal; medicine is, and that is good. For those of us who have lived long enough, we are now the dinosaurs of the profession and have fallen flat on our four feet to become a platter to serve medicine and not to serve ourselves. So it is time for the old to give way to the young and time to realize that what is happening will eventually turn good in spite of the medical establishment. In the end, the patients and humanity are the beneficiaries, and we doctors are just part of the big picture. Thus, let medicine take its course and have faith in our country that painfully gets to the core of what we are, a great nation that polishes itself with the arrival of new ideas to better the world. In conclusion, for me, medicine has been a great trip. With all its faults, I have aged to be at peace with how the profession is turning out. I am glad that I don’t have to be a Superman anymore, but just a man that wants to help humanity and myself. So goodbye Asclepius, it has been a great journey. Dr. Sanchez, currently retired, first joined SDCMS-CMA in 1974.
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At an early stage in my medical career, patients often questioned my age, my ethnic background, and my training as soon as I walked into the exam room.
I Wish for … Making Strides Towards Our Ideals
By William T-C Tseng MD, MPH In 2000, I joined Southern California Permanente Medical Group in San Diego. In the midst of my job search, I made a conscious decision to live and work in California, where there is an acceptance of ethnic diversity in communities as well as workplaces, and where there’s a sense of appreciation and celebration for multiculturalism. Being an Asian-American physician, it is comforting for me to know that I am among groups of “diverse” colleagues. Personally, diversity provides a sense of inclusion, without feeling pressured to cast aside ethnic-social identity to be “like everyone else” and just assimilate. Diversity provides a platform for me to creatively share, while recognizing different
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perspectives of my colleagues as the common ground. I serve on the Diversity Council at Kaiser to further promote inclusiveness and integrate diverse professional talents with local community organizations. Many physician colleagues I serve with would attribute organizational initiatives that embrace diversity as the key to recruitment and retention of exceptional physicians and professional medical staff. Through a medical proficiency language certification program offered, my colleagues and I are preparing to serve San Diego’s increasingly diverse and expanding bilingual patient population. Physicians who are able to break language and social barriers with their patients open the door to patients’ willingness to trust. With shared cultural/ ethnic perspectives, the foundation for a solid patient-doctor relationship is immediately laid, leading to enhanced diagnostic accuracy and effective information transfer. In clinic and in the hospital, on occasion, I like to break the ice with my patients by greeting them in different languages. Bridging the communication gap helps tremendously in conveying empathy to my patients and their families as well as in allowing them to make a connection in order to address their very personal concerns. On the flip side, I have also encountered cases where my initial doctor/patient encounters were filled with frustration due to the growing diversity in the medical landscape. Some barriers were very entrenched and not easily removable. At an early stage in my medical career, patients often questioned my age, my ethnic background, and my training as soon as I walked into the exam room. Some patients were even skeptical of my English-language proficiency. Some demanded a second opinion from a Caucasian colleague, and others declared that seeing an Asian doctor was considered to be at odds with their family members’ wishes. Ironically,
I have also been specifically chosen by patients because of my surname. The bar was immediately set higher. Assumptions made were that I would be a smarter doctor, a more patient doctor, a doctor who is always in ZEN. These patients expected that I would have all the answers, that I should know all about herbal, alternative, and holistic medicine. Ideally, I wish I had all the answers for all my patients; I wish for more institutional support for educating the public and health professionals on the value of cultural competence; I wish for a surge of multilingual physicians to meet the challenges of caring for San Diego’s patient population undergoing unprecedented demographic transformations. I wish for …. Luckily for now, I can turn to my colleagues at Kaiser SCPMG and the San Diego County Medical Society for help and support while we make strides toward our ideals. Dr. Tseng, SDCMS-CMA member since 2000, is a board-certified internal medicine physician with the Southern California Permanente Medical Group and current treasurer of SDCMS.
nized medicine so that I could help positively impact our fellow physicians in all modes of practice to address the issues of medicine as a united entity. Only in this manner can we hope to improve healthcare delivery. Dr. Nanavati: Why should a physician in San Diego consider joining SDCMS?
An Interview With Dr. James H. Schultz Jr. One in an Occasional Series of Interviews of SDCMS Physician Leaders
By Vimal Nanavati, MD Dr. James H. Schultz, Jr.,
SDCMS-CMA member since 2006, is board-certified in family medicine and chief medical officer of Neighborhood Health Care. Dr. Nanavati: What brought you to SDCMS?
Dr. Schultz: I was initially in private group practice for 13 years. Then I joined Neighborhood Health Care, which exposed me to the world of underserved patients. It turns out that about 950,000 patients in San Diego County fall into the category of the unfunded or underinsured. Essentially, they have little or no resources to obtain healthcare. This is the world of community health centers throughout the county. In order to bring a primary care voice for the underserved patients to organized medicine, I decided to join SDCMS. I also wanted to have a voice in orga-
Dr. Schultz: Education and to learn the travails of fellow physicians in specialties and modes of practice other than my own. SDCMS is the only venue by which physicians such as an ophthalmologist in La Jolla, an interventional cardiologist in the South Bay, and a family physician in Escondido can all sit in one room and learn from each other. It plays a unique and critical role in San Diego, where you can go your entire career without meeting a fellow physician from the other side of town. We can work together, learning from each other and united for the cause of improved patient care. On a purely practical, pocketbook basis, physicians who join SDCMS get a 5% discount on their malpractice insurance rates if they belong to The Doctors Company. That discount alone will take care of 50% of the annual SDCMS dues. There are many other discounts afforded to SDCMS-CMA members. Just go to www. SDCMS.org.
Joining SDCMS is joining organized medicine, which is the only voice for doctors in an increasingly hostile environment — a world where doctors are finding themselves more and more marginalized by more powerful factions like insurance oligarchies and large healthcare systems. Dr. Nanavati: What are three or four main issues impacting the effective practice of medicine and healthcare delivery today? Dr. Schultz: Medi-Cal reimbursement rates. The state of California has the dubious distinction of having the lowest Medicaid reimbursement rates in the nation. Medi-Cal reimburses 51% of Medicare’s reimbursement rate for the same services compared to 66% of Medicare’s rates nationally. Despite a three-judge panel overturning a district court ruling to stop a planned 10% cut, in May 2013, the full 9th Circuit Court upheld the cut. CMA is now appealing to the U.S. Supreme Court. The problem is that primary care physicians who accept Medi-Cal patients have a hard time finding a specialist to
SDCMS plays a unique and critical role in San Diego, where you can go your entire career without meeting a fellow physician from the other side of town.
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Great mentors and teachers can be very influential, but make sure you are pursuing that specialty because you are interested in it, not just because of the positive impact of a great mentor.
accept their patients. This ties the hands of the primary physician and limits their ability to deliver quality healthcare. Moreover, patients’ access to specialty care is very limited. In San Diego, 42% of all physicians don’t accept Medi-Cal. Why? The low reimbursement rates don’t even cover the ongoing cost of providing medical care (paying for rent, salaries, equipment, and consumables, etc.). Ultimately, Medi-Cal patients are hurt by these cuts by not getting the access to essential medical care that they need and deserve; this, in many ways, results in a two-tiered health delivery model (one for the well-insured and another for the rest). Another issue is lack of information flow — “One hand doesn’t know what the other hand is doing.” When one physician orders a lab or X-ray test, the other physicians who are also taking care of the patient do not know the results. This results in unnecessary duplication of tests and sometimes unnecessary interventions (unnecessary blood draws and
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even unnecessary invasive tests). Other than that, there’s increased demand for medical care, especially primary care, without a cogent plan to handle it, and threats to MICRA. Dr. Nanavati: What is the one thing you would do to change medicine to improve the lot of all MDs and their patients, irrespective of their modes of practice? Dr. Schultz: I would change the present billing and coding infrastructure. Billing issues have become so problematic that an entire industry has been created just to deal with it. This is mostly because of insurance companies putting roadblocks, bureaucratic red tape, and other obstacles designed to avoid paying physicians and other members of the healthcare team fairly and in a timely manner. The billing, coding, and reimbursement mechanism in place adds no value to the system, does not help the patient, hinders the provision of care, and results in costs and a countless amount nonproduc-
tive time spent by healthcare providers and patients. Dr. Nanavati: What advice would you give a medical student? Dr. Schultz: Keep an open mind and don’t have any preconceived notions about a specialty. Experience each rotation as if you plan to go into it. Experience all your third-year clinical rotations before making up your mind. Figure out what field you like to work in, one in which you won’t mind putting in the effort and hours to excel. What field captivates you and “lights your fire”? It is easy to pursue a specialty based on a great faculty member or attending. Great mentors and teachers can be very influential, but make sure you are pursuing that specialty because you are interested in it, not just because of the positive impact of a great mentor.
YOU ARE OUR HERO thank you for giving access to healthcare for those without!
San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.
You are the Heart & Soul of Project Access San Diego Through your support of our flagship program, Project Access San Diego, we have been able to assist over 2,200 uninsured adults in our community to improve their health through access to specialty healthcare services. You have provided over $7 million in contributed healthcare services to community members since our program’s beginnings in December 2008!
Thanks to our Sponsors Sept. 26, 2013 Event
Thanks to more than 625 volunteer physicians providing specialty healthcare services to those who most need our help, we are getting people back to work, and able to care for their families. You are our Heroes! Without the generous support and dedication of all of our physician volunteers, hospitals and outpatient surgery centers, imaging, labs, physical therapy, and other ancillary health providers, hundreds of hard-working but uninsured adults would go without care every year. Thank you for being a hero to our community!
The Doctors Insurance Agency
Get Involved San Diego County Medical Society Foundation needs you! Join us to volunteer for Project Access, or provide specialty consultations to primary care physician colleagues through eConsultSD, our HIPAA-compliant, web-based system from the comfort of your home or office. Attend an event, assist us to recruit fellow physicians, or provide educational opportunities for primary care physicians or medical students. We hope you will join us at the Aces for Health Golf Tournament at Del Mar Country Club on Thursday, March 13, 2014. And please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or contact Kristina Starkey, Resource Development Director, at 858.565.7930 or Kristina.Starkey@sdcms.org.
5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n
www.sdcmsf.org SAN DI EGO PHYSICIAN.org 33
classifieds PHYSICIAN POSITIONS AVAILABLE INTERNAL MEDICINE AND PSYCHIATRY PHYSICIANS: South Bay private practice seeking both internists and psychiatrists licensed to practice medicine in the state of California. Current DEA license and malpractice insurance required. BC/BE preferred. Independent contractor opportunity for providing services to area hospitals, nursing homes, and B&C. Please fax CV to (619) 327-0164 or send to email@example.com.  PHYSICIAN WANTED — LA MESA / EL CAJON: Busy internal medicine practice with strong focus in geriatric patients is currently hiring a physician. Efficient, hard working, team player with compassion towards patient care is expected. Ability to use computerized EHR is important. Weekly / biweekly education program, including specialists’ topic discussion as well as patient case presentation are provided. Hard work, dedication, compassion, and communication skills are required. Job satisfaction will be guarantied. Willingness to participate in patient care at Grossmont Hospital and skilled nursing facilities is preferred. Internal medicine work experience is desired; compensation is competitive. You can apply with your CV to firstname.lastname@example.org.  JOIN HOUSE CALL DOCS INC., a dynamic group of pioneering healthcare practitioners striving for excellence while developing sound socioeconomic models of healthcare delivery. Our mobile primary care / specialty practice complements our panoramic outpatient practices in primary care, oncology, cardiology, gastroenterology, gynecology, infectious diseases, and psychiatry. Pay is among the best in the country, with part-time income in the $150K range (exclusive of incentives / bonuses). A good fit is essential. Interview questions should be directed to Dr. Wolfram Forster, Senior Partner, House Call Docs Inc. (1855 B Street, Suite 200, San Diego, CA 92101, phone 619-793-7988)  INTERNAL MEDICINE OR FAMILY PRACTICE, FULL-TIME OR PART-TIME, FLEXIBLE HOURS: National Health Service Corps — Loan Repayment Eligible Site Imperial Beach Community Clinic. A community-focused health center committed to being responsive to the healthcare needs of our area. Physician needed with license to practice medicine in the state of California. Board-certified. Imperial Beach Health Center Attention: Jorge Gutierrez — Human Resources Director, 949 Palm Ave., Imperial Beach, CA 91932. Phone (619) 628-5564. Email email@example.com.  PHYSICIAN OR NURSE PRACTITIONER TO PERFORM HOUSECALLS: In North San Diego County Monday through Friday. 10–12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NPs: Home health experience a plus. Please respond by email only to firstname.lastname@example.org. Thank you. [165a] ADULT PRIMARY CARE OPPORTUNITIES: Family medicine, internal medicine, and urgent care openings throughout Southern California. The Southern California Permanente Medical Group (SCPMG) boasts nearly 60 years of experience in delivering high-quality, innovative healthcare. With sub-specialists in virtually every area of medical and surgical practice, SCPMG is home to more than 6,000 physicians serving over 3.3 million members. SCPMG prides itself on attracting outstanding physicians and offers them the opportunity to have sustained, fulfilling careers in their practices while enjoying the
benefits of a large, stable medical group. Full-time physicians have access to a compensation and benefits package that’s designed to impress you. Per diem opportunities offer flexible schedules as well as the chance to earn supplemental income. For consideration, please visit and apply at our website at http://physiciancareers.kp.org/scal, call (877) 6080044, or email email@example.com. We are an AAP/EEO employer.  FULL-TIME OR PART-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a full-time and/or part-time physician. Good hours (mostly 9:00am–5:30pm weekday shifts with some weekends from 9:00am–4:00pm and closed on major holidays) plus good pay. Please send CV to firstname.lastname@example.org or fax to (619) 442-2245.  PSYCHIATRIC CENTERS AT SAN DIEGO (PCSD) IS LOOKING FOR A PSYCHIATRIST: to work for the George F. Bailey Detention Facility, full-time, Monday– Friday, 8:00am–4:30pm. Must be licensed to practice medicine in the State of California by the Medical Board / Osteopathic Board of California. Must maintain a BLS and DEA. Must have a valid certificate in psychiatry. Salary DOE. PCSD will cover malpractice insurance. Medical, dental, 401k offered. If you are interested in making a difference and becoming part of the PCSD team of professionals, please fax your cover letter and CV to Jada Brathwaite, director of operations, at (619) 528-4625. EOE (157) PSYCHIATRIC CENTERS AT SAN DIEGO (PCSD) IS LOOKING FOR A PSYCHIATRIST: to work for the Las Colinas Detention Facility, part-time, Monday–Friday, 1:00pm–4:30pm, and every other Saturday 8:00am–4:00pm. Must be licensed to practice medicine in the State of California by the Medical Board / Osteopathic Board of California. Must maintain a BLS and DEA. Must have a valid certificate in psychiatry. Salary DOE. PCSD will cover malpractice insurance. If you are interested in making a difference and becoming part of the PCSD team of professionals, please fax your cover letter and CV to Jada Brathwaite, director of operations, at (619) 5284625. EOE (158) PHYSICIANS WANTED FOR OUR GROWING ORGANIZATION: Full, part time or per diem, flexible schedules available at locations throughout San Diego. As the second largest community health organization in the nation, 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 email@example.com. 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.  PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($140– $220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 992-5330 or email CV to firstname.lastname@example.org. Visit www.thehousecalldocs.com. 
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.
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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  SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds. sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time).  PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766.  OFFICE SPACE / REAL ESTATE UTC/LA JOLLA MEDICAL OFFICE SPACE TO SUBLEASE: Spacious, modern, brand new and fully furnished medical suite with beautiful reception area and waiting room, two exam rooms, and one window doctor’s office / consultation room. (Also space for 2 office staff and 1 med tech of your own.) Available for sublease either half day or whole day. Ideal for primary care or specialist. Some space available for storage of your materials. Amazing location across from the UTC Mall on Executive Drive near the 5, 15, and 805. Reasonably priced. Please contact Miriam at (858) 997-9727. Available November 1, 2013.  SPACE AVAILABLE TO SUBLET: Space available in suite with busy internal medicine practice located in Escondido. Exam rooms and office space. Call (760) 432-6886, ext. 354.  BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50-year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care MD (internal medicine or subspecialties / family practice) to help curb overhead and see acute overflow patients. Also can provide opportunity to get involved with clinical research. Flexible terms/space. Free parking, close to hospital, easy access to freeways. Contact Cindy at email@example.com.  SUBLEASE MEDICAL SUITE IN ENCINITAS: Ready to lease 1,120-square-foot suite with a beautiful reception area and waiting room, three exam rooms, lab and conference room. Plenty of parking space in complex. Some furniture available in suite. Available November 1, 2013, or sooner if needed. Please contact Cristina at (760) 944-1000, ext. 106, for more information.  POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to firstname.lastname@example.org. 
CLASS “A” MEDICAL OFFICES, VISTA Upgrade to a new Class “A” medical office at no cost in TriCity’s leading outpatient health center. Collegial environment with more than 40 physicians in 15+ specialties. Strong primary care referral base. Fully renovated offices with today’s modern finishes. Close hospital proximity. Multiple sizes available ranging from 1200, 1600, 2400, 4000-5700. For more information, including floor plans, please call Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/ leasing
CLASS “A” MEDICAL OFFICE, ENCINITAS Join over 250 doctors and dentists representing nearly 50 specialties in North County’s leading outpatient health center. Office being fully renovated to Class “A” standard at owner’s expense. Strong referral potential. 2,300 SF including: 4 exam rooms, large office, lab, nurse station, ADA bathroom, back office, wait/reception, dual entry, and more. For more information, including a floor plan, please call Greg Petree at (858) 792-0696 x112 or visit www.northcoasthealthcenter.com/leasing LEASING MEDICAL OFFICE SPACE IN ESCONDIDO: 2,450 square-foot office building in downtown Escondido, adjacent to large imaging center. Three examining rooms, two consulting rooms, and an office designed to be completely HIPAA compliant. Also, a leaded room suitable for radiographic services. Available for rent February 1, 2014. Apply to Physicians’ Medical Building, 355 E. Grand Ave., Escondido, CA 92025.  ENCINITAS OFFICE SPACE TO SUBLEASE — 345 SAXONY ROAD, ENCINITAS: Shared office space available, 1700 square feet total. Occupied by one dermatologist. Easy-to-find location just off the I-5 with all new decor. Spa-like waiting room and friendly, professional front desk staff. Will sublease one or two exam rooms, half or full day. Exam rooms complete with electronic fully adjustable chair, cabinets, and sink, and great windows provide ocean views and plenty of light in the rooms. Plenty of free parking. For more information, call Elizabeth at (760) 2302537.  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.  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 / pro-
cedure room. For more information, call Irene at (619) 840-2400 or (858) 452-0306.  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 power-assisted liposuction equipment available at premises. Please call or email Ines Ustare at (858) 457-8686 or email@example.com.  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.  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) 7538413.  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) 521-0806 or at firstname.lastname@example.org.  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 email@example.com or (619) 504-5830.  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.  NONPHYSICIAN POSITIONS AVAILABLE / WANTED Experienced, Part-time Biller/Coder for Sports/Spine/Pain Practice (Encinitas): Growing medical practice seeks experienced, motivated, consistent biller/coder to work 1-2 days per week in our Encinitas office. Experience with coding details and orthopedic/pain billing a plus. Please reply with resume and letter of interest: firstname.lastname@example.org.  PSYCHIATRIC NURSE PRACTITIONER OPPORTUNITY: South Bay private practice seeking licensed psychiatric NP with a minimum three years experience to work with psychiatrist in hospital and nursing home settings. Current license is required. Please submit CV to (619) 327-0164 or send to drbhatia@phwsd. com. 
PART-TIME PA OR NP NEEDED FOR FAMILY PRACTICE: Located in Eastlake / Chula Vista area. Must have 1–2 years experience in family practice. Will perform complete physical exams, including pap smears, must be able to diagnose and treat acute and chronic problems. This includes ordering and interpreting diagnostic tests. Patients of all ages. We are open Monday through Friday, 8:00am to 5:00pm. Seeking part time, 16+ hours. Days and times are negotiable. Hourly rate is competitive. Physician may require more coverage if out of office. Please contact Norma at (619) 946-4073.  FULL-TIME PHYSISIAN’S ASSISTANT: Looking for a physician’s assistant to join a busy academic private spine surgeon’s practice in La Jolla area. Preferred candidate should have 3–5 years of previous experience. Responsibilities to include but are not limited to: Examine patients to obtain information about their physical condition; provide physicians with assistance during surgery or complicated medical procedures; interpret diagnostic test results for deviations from normal; visit and observe patients on hospital rounds or house calls; update charts; order therapy; and report back to physician. Compensation based on experience. Please send CV to email@example.com.  PHYSICIAN OR NURSE PRACTITIONER TO PERFORM HOUSECALLS: In North San Diego County Monday through Friday. 10–12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NPs: Home health experience a plus. Please respond by email only to firstname.lastname@example.org. Thank you. [165b] PART-TIME NURSE PRACTITIONER: A concierge internal medicine practice in La Jolla is hiring a parttime nurse practitioner, to ultimately transition to fulltime with benefits. 20% clinical visits + 20% health coaching + 30% phone calls / emails + 30% care coordination. Preferred Skills: excellent bedside manner, articulate communicator, electronic charting experience, detail-oriented, ability to function autonomously, and experience in geriatric medicine. Requirements: current California registered nurse license and nurse practitioner certificate from the State of California, with furnishing license; DEA number; American Heart Association Healthcare Provider BLS card required by hire date; participation in after-hours call. Salary is based on qualifications; long-term commitment rewarded. Email Kirstin at email@example.com.  NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner or physician assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefits package that provides malpractice coverage, CME allowance, as well as excellent professional growth potential. Please email your curriculum vitae/résumé to firstname.lastname@example.org.  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.  PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Parttime, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email email@example.com. Visit www.thehousecalldocs.com.  MEDICAL EQUIPMENT
LOOKING FOR NP OR PA: Busy internal medicine practice located in Escondido looking for NP or PA. Call (760) 432-6886, ext. 354. 
NEOMATRIX HALO BREAST PAP TEST CONSOLE: Excellent condition. One owner in private GYN practice. Call (619) 220-0999.  SAN DI EGO PHYSICIAN.org 35
San Diego Physician Celebrates 100 Years!
The Bulletin of the San Diego County Medical Society September 1969 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.
Coffee Talk By Al Shumacher
As a starter this month, I ran across an item calcul ated to restore anyone whose faith in human nature is flagging. Jack Stevens had his father visiting from Massachusetts and took him to the beach for a day’s worth of swimming and sunbathing. While in the water, the senior Stevens discovered that he and his dentur es had parted company. Son Jack made a number of heroic dives through the surf in a vain attempt to recover the vital appliance. This was followed by fruitless attempts to locate a dentis t who could replace the precious plate in short order. As a last resort, they checked with the lifeguard station — and found to their surprise that some honest and thoughtful soul had indeed discovered the denture and turned it in. the finder did not leave his name, however, and so we are left to speculate on exactly how he made his find.
Noory Masliyah told me about a woman referre d to him for evaluation of chronic, intermittent abdominal pain. Her history was rather complicated, and a large body of diagnostic studies had been performed. Noory sifted throug h the mass of information, conducted an exhaustive examination, and ordered studies as required. When the patient returned for the rendering of an opinion, Noory made it plain that it was his opinion that she was not suffering from any serious underlying disease. “Mada m,” he said, “I believe that your pain is due to gas.” “But Doctor,” she demurred, “that couldn’t be. I have an all-electric home.” Bob Bridge wrote such a glowing article in Medic al Economics on the virtues of a houseboat vacation that I predict a veritable logjam of houseboaters — medical ones — by next summer. Society President-elect Mike Feeney walked to the doctors’ parking lot at Sharp and discovered that his car was not where he had left it. At least, not where he thought he had left it — he looked here and there — hither and thithe r — but no car. Thinking that the car was in another lot, he searched all the other lots at the hospital — but no car. He checked with the engineering department; then with administrati on — but no car. Reluctantly, he concluded that it had indeed been stolen. As he prepared to call the police to report the theft, the tangled threads of the mystery began to unravel. It seems that Jim Phalen had driven Mike’s car away in error. A most remarkable error, too — since the car was the same make but a different year and color than his own. Even more remarkable was the fact that Jim used his own keys. Jim’s only comment: “I thought that key was a little stiff.” San Diego entered a new era in its history with the passing of the Coronado Ferry on August second. Now we have a bridge — and among the first to cross our span at the Silver Gate was a group of between two and three hundred bicycl ists. Included in this august assemblage was an enterprising gentleman riding his offspr ing’s tricycle (one hell of a go uphill, I’ll wager). At the head of the procession was Bob Bond and wife Suzanne. Information pertinent to the type of bicycles (or bicycle) used has not reache d my eager ears — but I report that Cliff Graves did not ride his tricycle. Thanks-to-Neil-Morgan-Department: Myron Schon brun delivered a new son to the Vern Kents. Vern has ventured the opinion that a new physician has been born — his son’s first action was to try and grab the suture out of Myro n’s hand. Did I say physician? It seems I meant Surgeon.
36 novem b er 2013
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