August 2014

official publication of SDCMS august 2014

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Contents

Volume 101, Number 8

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: J. Steven Poceta, MD PRESIDENT-ELECT: William T-C Tseng, MD, MPH (CMA Trustee) TREASURER: Mihir Y. Parikh, MD SECRETARY: Mark W. Sornson, MD IMMEDIATE PAST PRESIDENT: Robert E. Peters, PhD, MD

6 4 P O R P O T NO Y A S , S U N I O J 12

feature 14

Vote No on 46: Increased Costs • Losing Your Doctor • Threatening Your Privacy

BY RICHARD THORP, MD, PRESIDENT, CMA

Choosing Wisely: Five Things Physicians and Patients Should Question

BY THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY

16

Fate: Life Is Measured Out

BY DANIEL J. BRESSLER, MD, FACP

18

departments

Be a Role Model for Your Patients! Learn How the SDCMS Foundation Can Help

4 Briefly Noted: Calendar • Welcome New Members • And More …

BY BARBARA MANDEL AND KATHLEEN KRAMBERG

6

Physician Marketplace: Classifieds

Report From AMA’s Annual Meeting: June 2014

8

Rising Number of Infectious Disease Cases Creates Patient Safety Issues

BY THE DOCTORS COMPANY

10

Sports Physical Goal: Reduce Liability Risks While Assessing Student Fitness

BY THE DOCTORS COMPANY 2 august 2014

26

28

Choose Freedom: When Will You Take a Stand for Your Life?

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD, Alt: Susan Kaweski, MD (CALPAC Treasurer) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD, Alt: Thomas J. Savides, MD KEARNY MESA: Sergio R. Flores, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Eileen R. Quintela, MD LA JOLLA: Geva E. Mannor, MD, Marc M. Sedwitz, MD, Alt: Lawrence D. Goldberg, MD NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD, Alt: Anthony H. Sacks, MD SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD, Alt: Elizabeth Lozada-Pastorio, MD AT-LARGE DIRECTORS Lawrence S. Friedman, MD, Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Stephen R. Hayden, MD, Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Holly B. Yang, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Jeffrey O. Leach, MD, Toluwalase A. Ajayi, MD, Phil Kumar, MD, Wayne C. Sun, MD, Kyle P. Edmonds, MD, Carl A. Powell, DO, Marcella M. Wilson, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Sherry L. Franklin, MD (CMA Trustee) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Spencer D. Fuller OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Daniel D. Klaristenfeld, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Diana C. Gomez, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA SPEAKER: Theodore M. Mazer, MD CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEES: Robert E. Wailes, MD, Erin L. Whitaker, MD CMA SSGPF Delegate: James W. Ochi, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

BY HELANE FRONEK, MD, FACP, FACPH

18

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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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.

31st Annual UCLA Intensive Course in Geriatric Medicine & Board Review SEP 10–13 [Los Angeles Airport Marriott, geronet.ucla. edu/ic, (310) 312-0531] SDCMS Foundation Solana Beach Sunset 5K Run/Walk SEP 27 (sdcmsf.org/ events/5k)

calendar SDCMS Seminars & Webinars SDCMS.org

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

How to Hand Reportable Events Such as Abuse, Loss of Consciousness, and the Impaired Provider (seminar/webinar) SEP 11: 11:30am–12:30pm

HIPAA Compliance Update (webinar) SEP 25: 11:30am–1:00pm SDCMS Leader’s Toolkit (workshop) SEP 27–28 Payor Denials & Appeals: Effective Management and Best Outcomes (seminar/ webinar) OCT 9: 11:30am–1:00pm Free Work-Life Balance Workshop for Physicians (workshop) OCT 11: 9:00am–12:00pm

Physician Networking Opportunity & Mixer at the Rock Bottom Restaurant & Brewery in La Jolla (social) SEP 12: 5:30pm–8:30pm

Covered California: What Your Healthcare Team Needs to Know (seminar/webinar) OCT 16: 11:30am–1:00pm

Taming Microsoft Outlook (workshop) SEP 13: 8:30am–11:30am

Covered California: What Your Healthcare Team Needs to Know (seminar) OCT 16: 5:30pm–7:00pm

Covered California: What Your Healthcare Team Needs to Know (seminar/webinar) SEP 18: 11:30am–1:00pm

Pain Management Strategies to Decrease Liability Risk (seminar/webinar) NOV 13: 11:30am–12:30pm

4 august 2014

Cma Webinars CMAnet.org/events HIPAA Update: Are You Compliant With the Final Omnibus Rule?

SEP 10: 12:15pm–1:15pm Managing Difficult Employees and Reducing Conflict in the Practice SEP 17: 12:15pm–1:15pm Informed Consent for Psychotropic Medications: What’s Required of Physicians, Hospitals, and Nursing Homes SEP 25: 12:15pm–1:15pm Family Medicine: Frontline of Care OCT 1: 12:15pm–1:15pm Protect and Preserve Your Patient Relationships OCT 8: 12:15–1:15pm Managing Up! For Managers OCT 29: 12:15pm–1:15pm

The Heart Course: Emergency OCT 2–5 (Aria Resort and Casino in Las Vegas, www.theheartcourse.com) 25th Annual Cardiovascular Interventions OCT 21–24 (www.sdcms. org/Portals/18/Assets/pdf/ seminars/Cardiovascular InterventionsBrochure2014. pdf) Physicians of Exceptional Excellence (Top Doctors) Gala NOV 1 (Birch Aquarium) The 2014 San Diego Day of Trauma NOV 7 (www.sdcms.org/ Portals/18/Assets/pdf/ seminars/Trauma%20 2014%20Brochure-.pdf) Essential Tools in Serving Diverse Populations NOV 18 (Scottish Rite Event Center on Camino Del Rio South, registration open in September)

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FEATURED

MEMBER

SDCMS features member physicians for their noteworthy accomplishments in these pages. If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org.

Thank you for your membership in SDCMS and CMA!

SDCMS-CMA Membership

Welcome Our New Members!

Karen J. Hanna, MD General Surgery Vista (360) 621-8795 Swati Lavu-Rao, MD Emergency Medicine San Diego (760) 846-2389 Stephen W. Munday, MD, MPH Occupational Medicine El Centro (760) 482-4429 Eric J. M. Reed, MD Pediatrics La Mesa (858) 499-2701

“

It is in moments of illness that we are compelled to recognize that we live not alone but chained to a creature of a different kingdom, whole worlds apart, who has no knowledge of us and by whom it is impossible to make ourselves understood: our body.

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SAN DI EGO PHYSICIAN.org 5

AMA

would also study the requirements and portability of state licensure as it impacts the provision of telemedicine services.

3 4

New policy opposing the sale and marketing of electronic cigarettes to minors in a stricter, more comprehensive fashion than previous AMA policy.

Call for further review of maintenance of certification and maintenance of licensure requirements, including the time and dollar costs these recertifications have on physician practices as well as the impact on workforce, patient safety, and outcomes.

5

Policy aimed to improve electronic data interchange, calling on the federal government and EHR vendors to improve transparency and the exchange of data through different systems. Additional new policy called for EHR vendors to address issues with the EHR–physician interface to improve the usability of EHRs.

Report From AMA’s Annual Meeting June 2014

Note: James T. Hay, MD, SDCMS-CMA member since 1979, and Robert E. Hertzka, MD, SDCMS-CMA member since 1984, are both delegates to AMA. Albert Ray, MD, SDCMS-CMA member since 1984, and Lisa S. Miller, MD, SDCMS-CMA member since 1992, are both alternate delegates to AMA. On June 7, 2014, the AMA Annual Meeting convened in Chicago. Delegates Jim Hay and Robert Hertzka and alternate delegates Al Ray and Lisa Miller represented San Diego in the Pacific Rim Delegation.

Some of the important takeaways from the meeting included: 6 august 2014

1

The decision to ask President Obama, as a means of relieving the access pressure for veterans to receive timely care through the VA system, to allow veterans to obtain care through community physicians.

This measure would address the current delays in the Department of Veterans Affairs healthcare system. The letter to the president would include a request to establish a registry of physicians willing to provide this care.

2

Policy establishing principles for the coverage and payment for services provided via telemedicine. AMA

6 • • • • • • • • • • • • • • • • • •

• •

Other issues addressed during the meeting included: health insurer code of conduct public reporting of quality and outcomes the ACA grace period ICD-10 transparency and conversion alternatives to value-based modifiers delays in Medicaid payments the use of hospital observation status network adequacy models for medical healthcare teams clinical data registries lung cancer screening mail order prescription copays fairness in pharmaceutical pricing e-prescribing and meaningful use patient protection from forced switching of patent-protected drugs graduate medical education funding and quality of resident education nutrition labels genomic-based approaches to the risk assessment, management, and prevention of type 2 diabetes antibiotic use in food-producing animals medical student debt

Further information regarding AMA and the Annual Meeting can be found on the AMA website at www.ama-assn.org/ama.

90%

90% 90%

90% 90% SAN DI EGO PHYSICIAN.org 7

Risk Management

• Complying with state laws for the provision of vaccines to healthcare workers. For more information, go to www2a.cdc.gov/nip/ statevaccapp/statevaccsapp/default.asp.

• Notifying those who may have come in contact with an infected individual that they should see a physician.

• Ensuring that all office staff members are trained in the use of personal protective equipment and on proper isolation techniques when working with patients who present with symptoms of an infectious disease.

Rising Number of Infectious Disease Cases Creates Patient Safety Issues Contributed by SDCMS-endorsed The Doctors Company.

For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Physicians are reporting communicable, or infectious, diseases that were thought to have been controlled in the United States. New cases of whooping cough (pertussis) and, most recently, measles (rubeola) are making headlines.

During the first half of 2014, there were more reported cases of measles than for any year since the disease was eliminated from the country in 20001.

8 august 2014

In addition, newly classified infectious diseases are emerging, like Middle East Respiratory Syndrome.

To protect staff and patients, medical offices need to have established protocols that limit the exposure risk from individuals who come into the office with one of these debilitating, if not fatal, conditions. Medical malpractice liability risk may grow as reports of infectious

diseases continue.

Your practice can reduce liability risks and promote patient safety by: • Documenting all discussions with patients and parents of minors regarding infectious diseases, including the risks and benefits of inoculation.

• Documenting all discussions about serologic evaluations with patients who are unsure of their immunity status.

• Ensuring that all immunization tracking is up to date so that patients remain on a timely immunization schedule.

• When possible, allowing only staff members who have demonstrated evidence of immunity to work with patients suspected of having a communicable or infectious disease.

Follow these tips if you or your staff suspects a patient has an infectious disease: • Minimize risk of exposure by moving the patient from the waiting area and isolating him or her in an exam room.

• For airborne diseases, place a surgical mask on the patient and ensure that all office staff members wear protective equipment, including gloves, eye protection, masks, or an N-95 particulate respirator, if needed.

• Follow standard disinfection and sterilization procedures for exam rooms.

• Report suspected cases to the local health department and obtain specimens for disease testing.

• Consider making postexposure prophylaxis available to those who have been exposed.

1) CDC: Highest number of U.S. measles cases since 2000. CNN Health. http://www.cnn.com/2014/05/29/ health/cdc-measles/. Published May 30, 2014. Accessed June 5, 2014.

Risk Management

Sports Physical Goal

Reduce Liability Risks While Assessing Student Fitness Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

10 august 2014

Summer is the time for sports physicals. Physicians should be aware, however, of the potential malpractice risks of these examinations, especially in cases where no physician-patient relationship exists.

Depending on the legal venue, courts may hold that merely conducting a sports physical serves to create a physician-patient relationship with the same legal duties as that of an established, private practice patient. In these cases, physicians should explain the precise nature and scope of the physician-patient relationship, emphasizing that it is related solely to the examination and does not replace an annual well-child exam performed by the student’s primary care physician. In all cases, physicians should ensure that the parents or legal guardians provide consent for the student to be evaluated.

Cardiovascular screening, including failure to discover a latent, asymptomatic cardiovascular condition, is a major area of liability risk when performing a sports physical.

However, for the physician to be found at fault, it must be shown that the physician deviated from the standard of care. Generally, most courts have found that physicians who provide medical clearance for participating in competitive sports are not legally liable for injury or death caused by an undisclosed, asymptomatic cardiovascular abnormality, as long as the physician followed current consensus guidelines for conducting sports physical evaluations.

When conducting a sports physical, it is essential to take a complete medical history.

This can help reduce the risk of claims for missed or delayed diagnosis of cardiovascular conditions. Patients with a personal or family history of the following may be at increased risk for cardiovascular conditions: • exertional chest pain/discomfort • syncope/near-syncopal episodes • excessive, unexpected shortness of breath • excessive, unexplained fatigue with exercise • heart murmur • elevated systemic blood pressure • cardiovascular disease These exams also give physicians the opportunity to establish a cognitive function baseline that can be used to improve outcomes in the event of future head injury. It is important to establish this baseline because head injuries are becoming more common in young athletes. In the event of a head injury, the record of baseline cognitive function can not only help improve a student’s outcome but can also serve as a factor in determining whether the student is ready to return to play after injury. These are important steps to reduce the liability risks associated with treating concussions.

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PUBLIC HEALTH

Choosing Wisely

An Initiative of the American Board of Internal Medicine (ABIM) Foundation SDCMS is publishing various Choosing Wisely® lists of “Things Physicians and Patients Should Question.”

Choosing Wisely — see page opposite — is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

12 august 2014

Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter Into Practice grant, leading medical specialty societies, along with Consumer Reports, have identified tests or procedures commonly used in their fields whose necessity should be questioned and discussed. The resulting lists of “Things Physicians and Patients Should Question” will spark discussion about the need — or lack thereof — for many frequently ordered tests or treatments.

How The List on Page 13 Was Created The American Society of Clinical Oncology (ASCO) has had a standing Cost of Cancer Care Task Force since 2007.

The role of the Task Force is to assess the magnitude of rising costs of cancer care and develop strategies to address these challenges. In response to the 2010 New England Journal

of Medicine article by Howard Brody, MD, “Medicine’s Ethical Responsibility for Health Care Reform — the Top Five List,” a subcommittee of the Cost of Cancer Care Task Force began work to identify common practices in oncology that were both common as well as lacking sufficient evidence for widespread use. Upon joining the Choosing Wisely campaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items were supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force.

The initial draft list was then presented to the ASCO Clinical Practice Committee, a group composed of community-based oncologists as well as the presidents of the 48 state and regional oncology societies in the United States. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input, and supported the list. The final Top Five list in oncology was then presented to, discussed, and approved by the Executive Committee of the ASCO Board of Directors and published in the Journal of Clinical Oncology.

ASCO’s disclosure and conflict of interest policies can be found at www.asco.org.

For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org.

Choosing Wisely: An Initiative of the ABIM Foundation

Five Things Physicians and Patients Should Question by the American Society of Clinical Oncology Note: These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional.

Patients with any specific questions about the items on this list or their individual situation should consult their physician.

1

Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.

• Studies show that cancer-directed treatments are likely to be ineffective for solid tumor patients who meet the above stated criteria.

• Exceptions include patients with functional limitations due to other conditions resulting in a low performance status or those with disease characteristics (e.g., mutations) that suggest a high likelihood of response to therapy.

• Implementation of this approach should be accompanied with appropriate palliative and supportive care.

2

Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

• Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types; however, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.

• Evidence does not support the use of these scans for staging of newly diagnosed low grade carcinoma of the prostate (Stage T1c/T2a, prostate-specific antigen (PSA) <10ng/ml, Gleason score less than or equal to 6) with low risk of distant metastasis.

• Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

3

Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

• Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types; however, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.

• In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT, or radionuclide bone scans in asymptomatic individuals with newly identified ductal carcinoma in situ (DCIS), or clinical stage I or II disease.

• Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

4

Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

• Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g., colorectal). However for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients.

• False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

5

Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication.

• ASCO guidelines recommend using white cell stimulating factors when the risk of febrile neutropenia, secondary to a recommended chemotherapy regimen, is approximately 20% and equally effective treatment programs that do not require white cell stimulating factors are unavailable.

• Exceptions should be made when using regimens that have a lower chance of causing febrile neutropenia if it is determined that the patient is at high risk for this complication (due to age, medical history, or disease characteristics).

SAN DI EGO PHYSICIAN.org 13

California’s nonpartisan Legislative Analyst has taken a close look at Prop.

46 and concluded that it could increase state and local government healthcare costs by “hundreds of millions of dollars annually.”

If the trial lawyers get their way, medical lawsuits and payouts will skyrocket and someone will have to pay the price.

We know that these increased costs would reduce funding available for vital state and local government services like police, fire, social services, parks, libraries … and the list goes on. Really, this is just another example of trial attorneys pulling money directly out of the healthcare delivery system and our communities to line their own pockets.

As physicians, it is our job to provide care for and protect our patients — but Prop. 46 does just the opposite.

Prop. 46 is being disguised by the trial lawyer sponsors as a measure that will “increase patient safety,” but we know it’s really just about seeking change to a current law that will allow proponents to file more medical lawsuits against healthcare providers.

On Nov. 4, 2014, voters will be asked to weigh in on Proposition 46, a costly ballot measure that will make it easier and more profitable for lawyers to sue doctors, community health clinics, and hospitals, resulting in billions in increased healthcare costs annually.

Dear San Diego County Physician:

* Ple ase post i n physician com mon are as*

Richard Thorp, MD President, California Medical Association

Sincerely,

As we forge ahead to Election Day, I ask each of you reading this to take action and get involved in the No on Prop. 46 campaign. To find out more information about the issue and how you can help educate your colleagues, patients, and neighbors, visit NoOn46.com today.

If you haven’t signed a “No On Prop 46 Commitment Card” or pledged to be a coordinator at your hospital, visit cmanet.org/micra and sign up today.

Prop. 46 was written by trial attorneys for trial attorneys — not for the patients of California who will be forced to pay, plain and simple.

If you haven’t signed up to oppose Prop. 46, please visit NoOn46.com and join the coalition today — the price to our patients is too great to risk it.

That’s just how Prop. 46 will impact state and local government costs. An independent study estimates that this proposition will increase healthcare costs across all sectors by almost $10 billion annually.

How does that affect patients throughout California? It translates to about $1,000 per year in higher healthcare costs for a family of four. For many families, that’s the difference between being able to afford groceries or healthcare each month.

As physicians, it is our job to provide care for and protect our patients — but Prop. 46 does just the opposite. Taxpayers across the state will be on the hook for hundreds of millions of dollars in increased state and local government costs each year and could lose critical state and locally provided services that so many count on.

POETRY AND MEDICINE

Fate

Life Is Measured Out

by Daniel J. Bressler, MD, FACP

In the mythology of ancient Greece, the Fates were envisioned as three sisters.

Clotho spun the thread of life. Lachesis measured out the specific length allocated to a person. Atropos — the most feared of the sisters — cut the life-thread when their time had come. So powerful was their work that even the Olympian Gods had to defer to them. The words “fatal” and “fatalism” carry the meaning into English.

Modern medicine is assigned the task of interrupting the work of these sisters.

Reproductive technologies allow the life thread to be spun where it would otherwise not be possible. Day-to-day medicine and surgery extends the length of the life thread of patients with everything from abdominal aortic aneurysm to zoster.

Emergency interventions in the ED, OR, and ICU push away the horrible scissors of 16 august 2014

Life Is Measured Out Atropos, at least for a while.

And yet we know our medical victories are only temporary. Sometimes I only half-jokingly say to my long-term primary care patients that medicine doesn’t really prevent anything, it just delays things. Our work puts off fate — the Fates — for another day, but only does that. The patient whose unstable angina has been relieved by a stent or bypass is still at high risk for progressive atherosclerosis. The cancer patient in remission knows all too well that hidden chemoresistant malignant cells pose a recurrence threat. Even the most successful total hip replacement has a limited durability. In medicine we know that we will eventually lose the war with disease. It is our particular and distinct assignment to win as many battles as we can on the way to that loss.

Life Is Measured Out is an acknowledgement that all human endeavors operate inside the limits prescribed by the fates of our genes and our circumstances. We learn, along with the proud and powerful Olympian gods, that the Three Sisters will have their due.

Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

Life is measured out in string Each day a portion’s severed No prayer or magic spell can bring The separate ends together Life is measured out in thread A hidden spool unraveling Influencing till you’re dead The boundaries of your traveling Life is measured out in rope Silken bits and knotted Fashioned into dream and hope And wrapped round your carotid Life is measured out in string Each day you get your section A fickle circumstantial thing Sent off in one direction Life is measured out in thread Some longer, others shorter All your rush to get ahead Will scarce affect that order Life is measured out in rope A final length is scissored Years of “yes” then one last “nope” You’re off to see the Wizard.

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Be a Role Model for Your Patients!

Learn How the SDCMS Foundation Can Help

BY BARBARA MANDEL AND KATHLEEN KRAMBERG

18 august 2014

T

he key to creating a healthier society starts in the doctor’s office.

Patients look to their physicians for guidance on how to take care of themselves, very often emulating their doctors’ actions. With this in mind, physicians are critical to improving community health.

“Physicians serve as role models to their patients, their staff, and even their friends and family,” says Mihir Parikh, MD, a volunteer physician with Project Access San Diego, the SDCMS Foundation’s flagship program. “Their sphere of influence extends beyond the office they practice in, so it’s very important for doctors to use this influencing force and serve in the communities in which they practice and reside. It’s very easy: Just get involved! Run in the local 5K, speak up at health events, volunteer in community groups. I think doctors who do this will very quickly realize this is even more satisfying and rewarding than their ‘day job.’ Improving the health of the community builds a more vibrant, active, engaged population.”

Physicians Advocating Healthier Habits and Improving Community Health The important role that physicians play in community health has led the SDCMS Foundation to create opportunities for physicians to become more actively engaged in advocating healthier habits and improving community health. The SDCMS Foundation is moving from its origins of only treating illness to creating wellness through new programs that focus on education and prevention.

In 2010, the County of San Diego Health and Human Services Agency released a study showing that primarily preventable, chronic diseases are playing a significant role in the deaths of people living in San SAN DI EGO PHYSICIAN.org 19

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Jump Start for Health Jump Start for Health will focus on helping patients adopt healthier habits to prevent diabetes. The majority of patients seen through Project Access are suffering from many co-occurring conditions, with diabetes being the most prevalent. Complications from diabetes, such as cataracts, are one of the most frequent illnesses Project Access patients are treated for. Changing three habits — eating healthier foods, increasing physical activity, and ceasing tobacco use — can go a long way to help prevent chronic diseases like certain cancers, heart disease, stroke, type 2 diabetes, and respiratory conditions. Al Ray, MD, president of the SDCMS Foundation, works as a family medicine physician where preventable

orange LoS angeLeS PaLo aLTo SacramenTo

20 august 2014 CAP_1402.indd 1

Diego County. In fact, they discovered that three behaviors — diet, exercise, and tobacco use — contributed to the four diseases that caused 50% of the deaths in the county.

The report emphasized the importance of changing these behaviors and the profound impact such a change would have not only on the lives of San Diego residents but for the community as a whole.

Since then, the County of San Diego has launched its Live Well San Diego initiative, focused on improving the health, safety, and wellbeing of all residents. With prevention playing such a huge role in this initiative, physicians can serve as health role models for patients while at the same time offering their expertise and guidance to the community. The SDCMS Foundation has created two new programs, aligned with Live Well San Diego, to provide physicians with the opportunity to do just that.

2/5/13 11:13 AM

The important role that physicians play in community health has led the SDCMS Foundation to create opportunities for physicians to become more actively engaged in advocating healthier habits and improving community health. chronic diseases such as type 2 diabetes are seen all too frequently. “As the saying goes, an ounce of prevention is worth a pound of cure. If we can prevent patients from becoming diabetic with the complications that could ensue, we are providing them with a recipe for a longer and healthier life,” says Dr. Ray. Patients are coming to the Project Access program sicker and in need of more intensive treatment. It has become clear that preventive healthcare services are imperative to improving the health of the community.

Eileen Natuzzi, MD, another Project Access San Diego volunteer, was instrumental

Physicians: You are a Health Role Model Model healthy living to patients and staff by inviting them to JOIN YOU at San Diego County Medical Society Foundation’s Solana Beach Sunset 5K Run/Walk September 27!

Lead a team of 20 or more patients and staff and receive FREE your own team t-shirts with your practice/team identification.

Visit www.sdcmsf.org/5K to sign up.

For more information email kathleen.kramberg@sdcms.org.

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“If we can prevent patients from becoming diabetic with the complications that could ensue, we are providing them with a recipe for a longer and healthier life.”

in the creation of Jump Start for Health.

Through her work as a general surgeon and her volunteer efforts overseas, she saw firsthand the important role a physician plays in assisting their patients in living healthier lives. She is especially vocal about the increased need for specialty physicians, specifically surgeons and emergency room physicians, to educate patients on wellness and healthy living.

Dr. Natuzzi believes that when a patient is seen at a specialty healthcare appointment or presents in the emergency department, a critical teaching moment occurs. Unlike at a routine physical where there are usually no health issues to address, patients being seen by a specialist or in the emergency department are worried about their health.

Advice from a doctor at that point in time can be very persuasive. Dr. Natuzzi believes specialists and emergency physicians have a duty to use this moment to benefit the patient. Dr. Natuzzi believes these acute care situations provide “opportunities to initiate healthy behavior education during this receptive ‘teachable’ period.”

Because of this, Dr. Natuzzi helped the SDCMS Foundation create Jump Start for Health to focus on helping at-risk patients prevent diabetes through an initial intervention in the emergency department. After the intervention, patients will be connected to a health coach at the SDCMS Foundation who will guide them through gradual behavior changes designed to improve their health.

Jump Start for Health will begin through a partnership with the UC San Diego Health System emergency department. Physicians there will be trained in interventions with patients that present with symptoms indicative of a predisposition to developing diabetes. Patients will work one on one with specially trained health coaches over a period of one year and will eventually be trained to serve as health coaches for others in the community.

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“Physicians are the obvious leaders to promote health and wellness, and, if each doctor made their community better by being a good role model, I think we can make San Diego the healthiest and finest city in America.”

Live Well San Diego Speakers Bureau The SDCMS Foundation is also partnering with the County of San Diego Health and Human Services Agency to provide physicians with another avenue to further promote wellness within the community.

Through the Live Well San Diego Speakers Bureau, physicians will speak throughout the county on topics focused on wellness, prevention, and other related healthcare issues. During the first year, the SDCMS Foundation hopes to partner with at least

20 physicians. Through this program, physicians will have the chance to offer their expertise and engage community members outside of the medical profession.

Inaugural Solana Beach Sunset 5K Run/Walk These wellness initiatives will kick off with the SDCMS Foundation’s inaugural Solana Beach Sunset 5K on Saturday, September 27. The family fun run/walk on the beach at sunset will be followed by a wellness expo featuring local businesses that focus on healthy living. Physicians are encouraged to sign up teams composed of their patients and office staff. Each physician team of 20 or more will receive free personalized team t-shirts. Similar to “Walk with a Doc” programs, run/walk teams where physicians participate alongside their patients will allow physicians to motivate their patients to get active and live healthier lives.

Wendy Buchi, MD, another Project Access San Diego volunteer physician, has already signed up a team. “People’s behaviors, especially good diets and exercise, can affect health as much if not more than medical treatments,” says Dr. Buchi. “As a doctor, I know that it is much easier for me to counsel

my patients about healthy habits if I am living them too. Doctors really need to practice what they preach. This is why I am happy to be the captain of Team IGO, a team of physicians, staff, and patients for a healthier San Diego.” Funding from the 5K will benefit the Jump Start for Health program.

Physicians are encouraged to sign up teams. For more information on creating teams, please contact Kathleen Kramberg at Kathleen.Kramberg@SDCMS.org or at (858) 565-7930.

Conclusion Through each of these initiatives, the SDCMS Foundation hopes to make it easy for physicians to improve community health.

Perhaps Dr. Parikh sums the impact physicians can have on community health best by saying, “Physicians are the obvious leaders to promote health and wellness, and if each doctor made their community better by being a good role model, I think we can make San Diego the healthiest and finest city in America.”

Ms. Mandel is executive director of the SDCMS Foundation, and Ms. Kramberg is its grants and communications manager.

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All San Diego County Physicians Join SDCMS for a networking opportunity and mixer

Friday, September 12 5:30 p.m. to 8:30 p.m.

Rock Bottom Restaurant & Brewery 8980 Villa La Jolla Drive, La Jolla, CA 92037

All physicians are welcome and encouraged to attend.

Come mingle, socialize, and network with your fellow San Diego County physicians! Complimentary hors d’oeuvres and drinks will be served!

To RSVP, email your name and telephone number to Jen at JOhmstede@SDCMS.org. Questions? Call Jen at (858) 300-2781.

SAN DI EGO PHYSICIAN.org 25

classifieds PHYSICIAN POSITIONS WANTED LOOKING FOR PART-TIME POSITION IN PEDIATRICS: My name is Rafael Garcia, and I have been a board-certified pediatrician since 1996. I am looking for a part-time, outpatient position in pediatrics. I can work Tuesdays from 1pm to 11:00pm, and I can also work evenings from 5pm to 11:00pm (Monday–Wednesday). I have been in practice for 20 years, recertified in pediatrics in April 2013. My phone number is (619) 990-6218 (I can be reached after 5pm), and my email is garadr@cox.net. [246] PHYSICIAN POSITIONS AVAILABLE PSYCHIATRY PHYSICIAN OPPORTUNITIES: South Bay practice seeking a B/C, B/E psychiatrist licensed to practice medicine in the state of California. Opportunity for clinical research / clinical trial duties in an outpatient office setting. Professional liability insurance required. Contract salary of $200,000, or commensurate with experience.

Please send CV/resume to pbhatiaxj@gmail.com. [274] SEEKING LICENSED PRIMARY CARE, INTERNAL MEDICINE, EMERGENCY ROOM, AND FAMILY PRACTICE MD’S: American Correctional Solutions (ACS) is currently seeking licensed primary care, internal medicine, emergency room, and family practice MDs to work within California State facilities. Named one of INC Magazine’s fastest growing private companies, ACS offers healthcare professionals full-time, part-time, and per-diem opportunities. Our primary care, family medicine, or internal medicine physicians will provide primary care medical services at a facility housing patients with high-risk chronic care issues. Typical patients have multiple medical problems, including chronic hepatitis C virus (HCV) infection, cirrhosis of the liver, hypertension, diabetes, and chronic pain disorders. Our PCPs will also treat common illnesses managed in an adult urgent care setting. Send CV to lisa@correctionalsolutions.com or call (877) JAIL-DOCS. To hear why physicians enjoy working for ACS, please view our testimonials video at www.correctionalsolutions.com. [269] LOOKING FOR EXPERIENCED GENERAL PRACTICE / EMERGENCY MEDICINE PHYSICIAN: Full-time or parttime position available for experienced general practice / emergency medicine physician in a busy urgent care center. Must be available to work days, evenings, weekends, and holidays. Please send your CV along with references to lohara@san.rr.com or fax to (858) 274-9614. Pacific Beach Urgent Care established since 1982. Open weekdays 8–8 / weekends & holidays 8–4. [271] PSYCHIATRISTS NEEDED: Full-time or part-time positions available for a well managed program at San Diego County correctional facilities. Telepsychiatry position also available. Flexible hours with very competitive pay. Send CV to steve@cpmedgroup.com or call (619) 885-3907. [272] PRIVATE PRACTICE, PART-TIME IM/FP OPPORTUNITY: Unusual and exceptionally attractive private practice, primary care opportunity in beautiful North San Diego County. Well-established, collegial, single-specialty internal medicine group with >30 years in the community, exceptional office staff, and very high quality patient care set this far apart from many other situations. Option for 1–2 days/week with flexible scheduling; very attractive opportunity as an add-on to other part-time work. Interested in board-certified IM or FP applicants with EHR experience. Please email CV to portofino3@aol.com or call (619) 248-2324. [263] SEEKING FAMILY PRACTICE / INTERNAL MEDICINE PHYSICIAN: Join an exciting group with tremendous growth potential in a collegial atmosphere! Artemis Medical Group is currently seeking a part-time possible fulltime family practice / internal medicine physician to join our new medical group in Hillcrest. The right candidate will be at the forefront of launching this clinic. Candidate must be able to work independently, must have strong leadership skills and excellent communication skills. Able to provide supervision to mid-level providers. Knowledge of EMR/EHR and bilingual (English/Spanish) helpful. We offer a full benefit package. Competitive salary. Board cer-

tified a plus. Please email CV to artemismedicalgroup@ gmail.com. [262] PHYSICIAN WANTED — LA MESA / EL CAJON: Busy internal medicine practice with strong focus in geriatric patients is currently hiring a physician. Efficient, team player with compassion towards patient care is expected. Ability to use computerized EHR is important; Speech recognition Program is available for efficient documentation. 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.

Opportunity to enhance the income by rounding at Grossmont Hospital and skilled nursing facilities is provided . Internal medicine work experience is desired; compensation is competitive and partnership opportunity is offered. You can apply with your CV to vprabaker@yahoo.com. [261] 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, pain management, oncology, cardiology, gastroenterology, 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., at 1855 B Street, Suite 200 B, San Diego, CA 92101; phone (619) 793-7988; or email house.call.physician@gmail.com. [260] SEEKING P/T PEDIATRICIAN to join fun, well established pediatric practice. Opportunity to grow and longterm commitment for the right candidate. Office has EMR and stable staff. No nighttime call and occasional weekend clinic. Great family location. For more information, send CV to cvp315@sbcglobal.net. [259] OPHTHALMOLOGIST NEEDED: Part-time to work in a North County office, 2 to 3 days per week. Potential for full-time or buy-in. If interested, please respond to sd_I_ doc@yahoo.com. All replies confidential. [257] BE IN CHARGE OF YOUR OWN DESTINY! If you are a general internist interested in becoming your own boss, this may be the opportunity for you. Patients from the practice of a retiring general internist on the campus of Scripps La Jolla need a new physician. You would be sharing an office and overhead with another general internist who is well established on the campus and can help you make all the connections to accelerate and grow your practice. Part-time practice is even possible. Interested?

Please email XimedMD@gmail.com. [254] PART-TIME INTERNIST NEEDED: Work in an outpatient office on the campus of Scripps La Jolla. Must be board certified and have had experience treating in the primary care setting. Available immediately, with flexible hours and days. For more information, please send a CV or request for more information to XimedMD@gmail.com. [255] DERMATOLOGIST NEEDED: Board-certified or board-eligible dermatologist is needed for busy, wellestablished East County San Diego (La Mesa) private practice. We currently have an immediate opening for a CA-licensed dermatologist to work 2–3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service dermatology office providing general, cosmetic, and surgical services, including Mohs surgery, and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV to swagner@virtualdermatology.com. [253] LOOKING FOR FULL-TIME FAMILY PRACTICE PHYSICIAN: Neighborhood Healthcare is an award-winning organization that is known for excelling at its mission. The mission has remained the same over the years: to provide quality healthcare and promote wellness to everyone in our communities. We are looking for a full-time family practice physician to provide comprehensive medical services for members of the community, regardless of age or sex, on a continuing basis at our busy healthcare clinic

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.

26 august 2014

in Temecula. Great benefits. Requirements: CA license, DEA license, CPR certification, obtain and maintain board certification. To apply please send your resume to jobs@ nhcare.org. [247] PHYSICIAN WANTED, BEAUTIFUL NORTH SAN DIEGO COUNTY: Ambitious and attention to detail general family medicine / geriatrics / long-term care physicians to join our team of professionals that make “housecalls.” We serve chronically ill patients in their homes. No hospital call, M–F, 8–5, independent contractor, occasional on-call pager, 10–12 patients per day. We are a very relaxed, professional practice environment. We very much look forward to your call at (760) 591-9975. [242] SEEKING PER-DIEM, BOARD-CERTIFIED FAMILY MEDICINE PHYSICIAN: The Sycuan Band of the Kumeyaay Nation, located in east El Cajon, is seeking a per-diem family medicine physician for our medical clinic. Must have current, unrestricted CA and DEA licenses, at least three years of experience working as a medical physician, and CPR certification. Bilingual English / Spanish preferred. Salary commensurate with experience, malpractice coverage provided. Please email CV to Teresa Mogielnicki, MD, at teresam@sycuanmed.org or fax to (619) 445-0988. [243] LOOKING FOR A DERMATOLOGIST: Medical spa located in East County looking for a dermatologist who would like to buy into a very lucrative practice or willing to be a medical director. For more information, please call Dr. Shirin Dorin at (619) 456-4555. [238] LOOKING FOR A RETIRED PHYSICIAN: Medical spa located in East County looking for a retired physician for a part-time position as a medical director. For more information, please call Dr. Shirin Dorin at (619) 456-4555. [239] BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a fulltime opportunity may be offered to the right candidate.

Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 5692590. Visit www.DoctorsExpressSanDiego.com for more information. [229a] SEEKING A PART-TIME BC/BE INTERNAL MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine physician to join our staff at our Genesee location. We offer a first-year competitive-compensation guarantee and an excellent benefits package. Please email CV to lori.miller@sharp.com. [204] SEEKING A PART-TIME BC/BE INTERNAL MEDICINE / PEDIATRICS OR FAMILY MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine / pediatrics or family medicine physician to join our staff at our Carmel Valley location.

We offer a first-year competitive-compensation guarantee and an excellent benefits package. Please email CV to lori.miller@sharp.com. [205] 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 jeff@eastcountyurgentcare. com or fax to (619) 442-2245. [161] 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 drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [037] 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. EEO Employer/Vet/Disabled/AA [912]

SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tailcovered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds. sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE FOR SALE SOLO OPHTHALMOLOGIST PRACTICE FOR SALE IN NORTH COUNTY: Physician retiring. Earn-out possible.

If interested, please respond to sd_I_doc@yahoo.com. All replies confidential. [258] LOW-STRESS, GYNECOLOGY-ONLY PRIVATE PRACTICE FOR SALE: Turnkey operation. One employee and low overhead, month-to-month lease. Minimal HMO. Perfect part-time work or add obstetrics. Various arrangements available. Email drjenma@pacbell.net. [203] PRACTICE FOR SALE: Comprehensive Sleep Medicine Practice with Integrated American Academy of Sleep Medicine-accredited Sleep Testing Center. 2013 revenue $550,000. Well-known for expertise in the diagnosis and treatment of sleep disordered breathing and offering the full range of treatment options (PAP therapy, dental appliances, surgery). Both facility-based and home sleep testing performed with active referrals. Attractively furnished with up to date equipment and furnishings.

Third-party appraisal available. Selling due to health issue, and offered for quick sale at a very attractive price.

Small practice subset in minimally invasive nasal and sinus treatment may also be included in any transaction. Please contact adowslt@gmail.com. [250] OFFICE SPACE WANTED BANKERS HILL PRIMARY CARE / HEALTHCARE PROFESSIONAL & RESEARCH OFFICE SPACE TO SUBLEASE: 50-year established primary care practice and clinical research office, with currently two internists, have space to sublease to another primary care or primary care / subspecialist, or other independent healthcare professional, to help curb overhead and, if primary care, help with acute overflow patients’ needs. Also can provide opportunity to get into clinical research. Contact Jeff at crf@att.net. [265] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800SF available for lease.

Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.75+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134, ext. 13, or at shamshoian@coveycommercial.com. [234] HAND SURGEON LOOKING FOR PART-TIME OFFICE LOCATION: Looking for space to share in La Jolla to Del Mar areas. Limited space and time needs. One-half to one day per week. We have flexibility to accommodate your schedule and staffing. Please contact me at greg@thehanddoctor.com. [231]

stalled. Free patient parking. Close to public transportation and freeways. 969 square feet. $1,500/month. Contact ucsurgeon@gmail.com. [266] DEL MAR / CARMEL VALLEY MEDICAL OFFICE FOR SUB-LEASE: Available October 2014 (4765 Carmel Mountain Rd., San Diego, CA 92130). 1,000SF. Two treatment / consultation rooms / office reception / photography room / break room. Unlimited patient free parking. Call (858) 481-4888 or email mobyrne61@gmail.com. [252] SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE AVAILABLE: Vascular & General Surgeons have space available. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, The Scripps Ximed Medical Center is the office space location of choice for anyone seeking a presence in the La Jolla/UTC area. Reception and staff may be available. Complete ultrasound lab on site for scans or studies. Full-day or half-day timeslots. For more information, call Irene at (619) 840-2400. [154] NORTH COAST HEALTH CENTER, 477 EL CAMINO REAL, ENCINITAS, OFFICE SPACE TO SUBLEASE: Well-designed office space available, 2,100SF, at the 477D Bldg. Occupied by Vascular & General Surgeons. Excellent and central location at this large medical center. Nice third-floor window views, all new exam tables, equipment, furniture, and hardwood floors. 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 interest. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [153] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee Ave. — great location by the front of the main entrance of the hospital between I-5 and I-805. Multidisciplinary group. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] 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 kathysutton41@yahoo.com. [173] SCRIPPS ENCINITAS CONSULTATION ROOM/EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed.

Contact Stephanie at (760) 753-8413. [703] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467SF 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 mzarei@cox.net. [873] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835]

OFFICE SPACE AVAILABLE OFFICE SPACE AVAILABLE FOR SUBLEASE ON SHARP CHULA VISTA CAMPUS: One to four days per week available — currently leased to neurologist one day a week. 600 square feet, two treatment rooms, one consultation room, bathroom, reception — all rooms furnished.

Beautiful view of the coast, short walk to the hospital lobby. Pharmacy in the building. Free parking. Ideal satellite office to establish presence in the area. Cost $450/month/ day. Contact Dr. Walter M. Shaw at (619) 472-1555. [268] MEDICAL OFFICE IN LA MESA — LOW PRICE! Fully functional medical office, ready for move in. In perfect condition. Fully furnished or empty, depending on your needs. Large reception area, one office, two exam rooms, restroom. Lots of storage space. Internet, phones — in-

SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building.

Medicare certified ambulatory surgery center next door.

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

is accountable for the effective and efficient daily operation of the clinic(s) regarding patient satisfaction and business and financial matters. Requirements include a bachelor’s degree and four years of experience as a clinic manager or administrator in ambulatory health center or community health clinic. Please visit us at www.syhc.org and reference job number 14-0416. [270] PSYCHIATRIC NURSE PRACTITIONER NEEDED: For part-time or full-time work at San Diego County correctional facilities. Flexible hours and very competitive pay. Send CV to steve@cpmedgroup.com or call (619) 885-3907. [273] POSITION OPEN FOR A CALIFORNIA LICENSED PSYCHIATRIC PA/NP IN IMPERIAL COUNTY: The ideal candidate is a self-driven individual interested in relocating to Imperial County, who is able to communicate in Spanish, computer skilled, and likes the challenge of working in an underserved community. Experience is not required; we will train you. Relocation expenses are covered. Base salary plus productivity bonus. Our community qualifies for loan repayment program. Part-time positions also available. For more information, contact Cruz Lopez-Castleberry at (760) 355-0161 or at orclc@ sunvalleyb.com. [251] BEHAVIORAL HEALTH CONSULTANT: The behavioral health consultant, as part of the primary care treatment team, identifies, triages, and manages primary care patients with medical and behavioral health problems.

In addition, the BHC will provide skill training through psycho-education and patient education strategies and develop specific behavioral change plans for patients.

The BHC assists primary healthcare providers in recognizing and treating mental disorders and psychosocial problems, assists in detection of “at-risk” patients, and assesses the clinical status of patients referred by the PCP. Education / Certification: PsyD/PhD in psychology or LCSW; CPR certification (including BLS). Contact Araceli Mercado at araceli.mercado@nchs-health.org or at fax (760) 736-870. [244] SUPERVISORY RN — MISSION MESA PEDIATRICS: Under the direction of the health center director / practice manager, and in collaboration with the nursing services director, supervise the delivery of quality medical care with optimal efficiency and patient satisfaction. Job Skills: Ability to relate to and work with people of all ages, social and ethnic backgrounds, and maintain patient confidentiality. Ability to work independently and as part of a team. Knowledge and Education: Current California state registered nurse license, current CPR certificate required.

Bilingual (English / Spanish), baccalaureate level of conceptual thinking. Experience: Four or more year’s general nursing experience in ambulatory care, including one year supervisory experience. Please apply at https://rew31.ultipro.com/NOR1021/JobBoard/ListJobs.aspx. [241] BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a fulltime opportunity may be offered to the right candidate.

Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 5692590. Visit www.DoctorsExpressSanDiego.com for more information. [229b] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com.

Visit www.thehousecalldocs.com. [038] MEDICAL EQUIPMENT MEDICAL CHART RACKS FOR SALE: We have five seven-foot-tall chart racks, each one three feet wide with seven shelves. They are sturdy and tan or putty-colored.

Price negotiable. Call Linda at (760) 724-8749. [267]

NONPHYSICIAN POSITIONS AVAILABLE / WANTED LOOKING FOR A CLINIC SERVICE MANAGER: San Ysidro Health Center is a growing community-based health clinic. We are looking for a clinic service manager to join the organization. Under the supervision of the director of clinics and the mandate of Federally Qualified Health Centers (FQHC), the clinic services manager (CSM)

ENT AND FACIAL PLASTIC EQUIPMENT FOR SALE: We have ENT general office and exam room as well as OR equipment available. Also many excellent plastic surgery instruments for sale. ENT chairs, powered exam table, ear microscope, Kay strobe and Endodigi video unit, autoclave, ultrasonic cleaner, portable suctions, etc. Photos available. Call if interested: (858) 458-1287. [264] SAN DI EGO PHYSICIAN.org 27

Personal & Professional Development

Acknowledge your courage, your dedication to your own freedom and your own life.

Choose Freedom When will you take a stand for your life?

by Helane Fronek, MD, FACP, FACPh

Funny thing about

freedom. We Americans believe strongly in the concept of freedom and will risk our lives for freedom around the world.

And yet, many people live day to day with no sense of freedom at all — they feel trapped in their own lives. What keeps us wrapped in a straightjacket of work and personal responsibilities, unable to create a life of our choosing?

Often we are lulled into the feeling that life will go on for28 august 2014

ever and a better time will come for those things we want to do.

Tomorrow, I’ll call that friend.

I’ll finish that project next month. Next year, I’ll take that vacation. As we all know, time goes by in its stealthy way. We never get around to many things and feel heavy with regret. We had so many dreams when we were young — how did we let our life slip by without making them a reality?

In other ways, we feel as if we are living in a box, unable

to penetrate beyond its walls where we imagine fun, excitement, and personal growth might reside. Instead, the responsibilities of work and life expand to fill our time. “It’s just the way it is,” we say to ourselves.

But if we look, we see people who have climbed over the walls of their boxes. They cast aside the same limitations that keep us contained and demanded the freedom that we yearn for.

What makes it possible for them and not for us?

One factor that keeps us stuck is the negative messages we tell ourselves. “You’ll never be able to do that.” “What gives you the right to do that?” Do these messages sound familiar? Consider what you would really do if that

voice weren’t filling your mind and defeating your spirit.

Reinforcing that box around us is the impression that we need to make big changes in order to create the shifts that will lead to a happier and more fulfilled life. It’s important to not let the perfect be the enemy of the good. Even small things can make a difference. And as our life becomes more fulfilling, we’ll have more confidence that we can accomplish even greater and more meaningful change.

So when will you take a stand for your life? Let’s all honor the revolutionary spirit of those who fought for our freedom by getting in touch with our own bravery and making choices that will mold our days into the life we want to be living. Pick one thing you have wanted to do. What needs to happen for you to make it a reality? What obstacles need to be moved?

What steps can you take now to add it to your life? Once you’ve accomplished it, take a moment to savor how good it feels. Acknowledge your courage, your dedication to your own freedom and your own life. And then decide what you want next.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy.

Read her blog at helanefronekmd. wordpress.com.

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