September 2015

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september

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Volume 102, Number 9

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EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD • James Santiago Grisolía, MD • Theodore M. Mazer, MD • Robert E. Peters, MD, PhD • David M. Priver, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: William T-C Tseng, MD, MPH President-elect: Mihir Y. Parikh, MD Secretary: Mark W. Sornson, MD Treasurer: David E. J. Bazzo, MD, FAAFP Immediate Past President: J. Steven Poceta, MD GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt.) • Jay P. Mongiardo, MD • Alexandra E. Page, MD • Venu Prabaker, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt.) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD • John G. Lane, MD • Anthony E. Magit, MD (Alt.) • Eileen R. Quintela, MD (Alt.) La Jolla: Geva E. Mannor, MD, MPH • Marc M. Sedwitz, MD, FACS • Wayne C. Sun, MD (Alt.) North County: Neelima V. Chu, MD (Alt.) • Michael A. Lobatz, MD • Eileen S. Natuzzi, MD • Patrick A. Tellez, MD South Bay: Elizabeth Lozada-Pastorio, MD (Alt.) • Reno D. Tiangco, MD • Michael H. Verdolin, MD

features

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Do No Harm: Using CURES and CURES 2.0 to Treat the Prescription Drug Abuse Epidemic

BY SAYONE THIHALOLIPAVAN, MD, MPH

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DMP / CURES Registration: P Application Instructions

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San Diego Death Diaries

BY RONEET LEV, MD

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departments 4

riefly Noted: Calendar • Welcome B New & Returning Members • Physician Health & Behavioral Issues • Volunteer Opportunities • In Memoriam • And More …

22

re You Using a Medication A Agreement? FAQs

6 So Your Patient Asks About Toilet to Tap …

BY RONEET LEV, MD

BY JAMES BEAUBEAUX

8 Performing Exclusions / Sanctions Screening (5th in Our Series on Compliance Programs)

BY HEIDI KOCHER, ESQ.

AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali DO, MPH • Steven L-W. Chen, MD, FACS, MBA (Alt.) • Stephen R. Hayden, MD • Phil Kumar, MD (Alt.) • Vimal I. Nanavati, MD, FACC, FSCAI (Alt.) • Robert E. Peters, MD, PhD (Alt.) (Delegation Chair) • Carl A. Powell, DO (Alt.) • Peter O. Raudaskoski, MD • Kosala Samarasinghe, MD • Thomas J. Savides, MD • James H. Schultz Jr., MD, MBA, FAAFP (Board Rep) • Karl E. Steinberg, MD, FAAFP (Alt.) • Erin L. Whitaker, MD (Alt.) • Marci M. Wilson, MD (Alt.) • Holly B. Yang, MD (Board Rep) OTHER VOTING MEMBERS Communications Chair: Sherry L. Franklin, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Sandeep Prabhu OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Quinn C. Meisinger, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (CMA Trustee, At-large AMA Delegate) CMA Speaker: Theodore M. Mazer, MD (At-large AMA Alternate Delegate) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate) • Ralph R. Ocampo, MD, FACS CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

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On Alert: What All Doctors Need to Know About Alzheimer’s Disease

Y CYNTHIA MORRISON, RN, ARM, B CPHRM

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Physician Marketplace: Classifieds

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september 2015

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ost and Found L Y DANIEL J. BRESSLER, MD, FACP B

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 //////////////////////////////////////////////////////////////////////// Cardiovascular Interventions OCT 27–30 at the Hilton La Jolla Torrey Pines UC San Diego Perinatal Symposium OCT 30 at the San Diego Marriott Del Mar

calendar SDCMS Events SDCMS.org

For further information or to register for any of the following SDCMS events, visit SDCMS.org or email Seminars@SDCMS.org.

10th Annual San Diego Emergency Care Summit (conference) OCT 15: 7:00am– 3:30pm Work-Life Balance Workshop for Physicians OCT 17: 9:00am– 12:00pm — Email Dr. Fronek at hsfronek@ aol.com Physician Networking Opportunity & Mixer (social) OCT 23: 5:00pm– 8:00pm Physician Networking Opportunity & Mixer (social) NOV 18: 5:00pm– 8:00pm

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.

20th Anniversary of the Community Health Improvement Partners (CHIP) OCT 14 at the Joe & Vi Jacobs Center Meeting of the Minds — Mental Health America of San Diego County OCT 22 at the Sheraton San Diego Hotel & Marina People, Planet, Purpose: Global Practitioners United in Health & Healing OCT 24–29 at Paradise Point Resort, San Diego

SCOPE of Pain: Safe and Competent Opioid Prescribing Education NOV 6 at the Catamaran Resort Hotel and Spa, San Diego The 2015 San Diego Day of Trauma NOV 6 at the Kona Kai Resort, San Diego Surgical Stabilization and Rehabilitation of the Unstable Shoulder NOV 18 at Scripps Green Hospital Update in Rheumatology: Highlights From the ACR and EULAR Meetings DEC 5 at the UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences Musculoskeletal Ultrasound in Hemophilia DEC 16–18 at the UC San Diego Hemophilia & Thrombosis Treatment Center

PHYSICIAN HEALTH AND BEHAVIORAL ISSUES

… in Your Medical Staff or Medical Group A new service, launched in June, makes consultants from California Public Protection & Physician Health (CPPPH) available to assist individual medical staffs and medical groups in their own settings as they address physician health and behavioral issues. Consultants with experience and expertise can work with you in your hospital or your group, assisting you to implement your policies and procedures and giving specific, individualized recommendations. For more information, see www.CPPPH.org, email CPPPHInc@gmail.com, or call Ashley Burke at (415) 764-4822.

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september 2015

quote of the month

“

To see things in the seed is genius.

”

— Laozi (also Lao-Tzu or Lao-Tze), Ancient Chinese Philosopher and Poet

SDCMS-CMA Membership

Welcome New and Returning SDCMS-CMA Members!

New Members Iris R. Arrieta, MD Obstetrics and Gynecology San Diego (858) 292-7200

Sayone Thihalolipavan, MD Public Health and General Preventive Medicine San Diego (858) 694-3900

Melissa E. Bishop, MD Family Medicine Escondido (760) 520-8372

Abel C. Toledo, MD General Practice San Diego (619) 427-7181

Audrey P. F. Calzada, MD Otology / Neurotology La Jolla (858) 909-0770

Sarah A. Wilkinson, MD Obstetrics and Gynecology San Diego (858) 455-7520

Mark C. Cannis, MD Emergency Medicine San Diego (619) 686-3800

RETURNING Members

Catherine V. Carroll, MD Internal Medicine San Diego (858) 552-8585 Kaitlin W. Hoover, MD Obstetrics and Gynecology San Diego (858) 292-7200 Young H. Lee, MD Dermatologic Surgery San Diego (858) 521-2393 Young S. Suh, MD Family Medicine Alpine (619) 445-1188

Matthew S. Bidlack, MD Family Medicine Carlsbad (619) 556-4235 Teresa M. Dudarewicz, MD Family Medicine Poway (858) 485-5301 Nora M. Faine, MD General Preventive Medicine Poway (858) 614-1590 David P. Folsom, MD Psychiatry San Diego (858) 233-8500 Lisa C. Underwood, DO Obstetrics and Gynecology San Diego (858) 292-7200

/////////////////////////////////////////////////////////////////////////////////////////////////// giving back

VOLUNTEER OPPORTUNITIES Email Your Physician Volunteer Opportunities to Editor@SDCMS.org SDCMS Foundation Project Access: Volunteer specialty physicians are needed for the following specialties: gynecology, pulmonology, urology, general surgery, ENT or head and neck, ophthalmology, GI, rheumatology, and endocrinology. We are seeking these specialists throughout all regions of San Diego.

Commitment can vary by practice. The mission of the SDCMS Foundation’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism.

Help us help the most vulnerable population seek care. For more information, please call Barbara Mandel at (858) 300-2780 or email Barbara.Mandel@SDCMS.org, or visit our website at www.SDCMSF.org.

Interested in Becoming a Preceptor for Osteopathic Medical Students?

Midwestern/AZCOM osteopathic medical school in Phoenix has third- and fourth-year medical students in San Diego looking for clinical rotations, particularly in pediatrics, psychiatry, general surgery, and OB/GYN. Requirements: Either MD or DO; physicians interested must commit to minimum one four-week rotation per year/or more as desired (2–3 preferable) and to FT hands-on training for each student as is reasonable

in memoriam MARGARET FARROW, MD, 41-year member of SDCMS-CMA, passed away on April 1, 2015, at the age of 73.

NICK S.-C. HUANG, MD, one-year member of SDCMS-CMA, passed away on June 15, 2015, at the age of 48.

PHILIP R. HUMBER, MD, seven-year member of SDCMS-CMA, passed away on June 5, 2015, at the age of 65.

for the duration of the rotation. Compensation and CME provided. If interested, please contact Dr. Kevin Considine at kconsidine@ sbcglobal.net for more information.

Humanitarian Teams Need Medical Volunteers for Haiti: We are looking for physicians and mid-level providers for one-week primary care medical clinics in rural Haiti in February and June 2016. This is a rewarding opportunity to work with the people of Haiti and provide care in a very austere environment in a medically underserved area. Seattle-King County Disaster Team — a U.S.-based nonprofit — has been operating these clinics since 1998. We coordinate all in-country travel and logistics.

Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink.net if you are interested in applying. Visit www.skcdteam.org for further information.

Physician Volunteer Opportunity: Established in 2011, Flying Samaritans of SDSU provides free healthcare to the underserved community of Ejido Matamoros, Mexico (15 minutes away from the border) through monthly medical and dental clinics (every second Saturday of the month), seeing 60–80 patients/medical clinic and 10/ dental clinic. Visit www.sdsuflyingsamaritans. org for details, or email FlyingSamaritansSDSU@gmail.com.

NORMAN W. PINCOCK, MD, 38-year member of SDCMS-CMA, passed away on May 31, 2015, at the age of 77.

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THOMAS E. WILSON, MD, 22-year member of SDCMS-CMA, passed away on May 25, 2015, at the age of 82.

JOSEPH H. WOOD, JR., MD, 36-year member of SDCMS-CMA, passed away on March 7, 2015, at the age of 84.

Endorsed by

PHILIP E. YOUNG, MD, nine-year member of SDCMS-CMA, passed away on Feb. 4, 2015, at the age of 75.

SAN DIEGO PHYSICIAN.org

5

P u b l i c H e a lt h

A concerned patient comes in with an article about Pure Water San Diego and asks you if this toilet-to-tap water will harm them or their family. The questions and answers below will help you understand this new local drinking water supply source so you can provide excellent care to your patients.

Is the Pure Water San Diego program “toilet to tap”?

No. The water purification process involves a sophisticated, tried-and-true, technological process that further cleans recycled water so it is similar to distilled water before it is added to drinking water taps. Additionally, the newly purified water is subject to strict testing requirements and is monitored continuously to ensure it meets drinking water standards. Since there is no new water on Earth, all water goes through a natural cycle and is essentially recycled water before it is treated, tested, and then returned to homes and businesses as drinking water.

What is the source water for the Advanced Water Purification Facility?

The source water is reclaimed or recycled water from the North City Water Reclamation Plant. When wastewater leaves homes and businesses, some of it is sent to this facility where it is further cleaned to a level safe for irrigation and industrial purposes — it has been “reclaimed” and can now be “recycled” for a variety of irrigation or industrial uses. This same water will be sent to the Advanced Water Purification Facility to be cleaned further and made drinkable.

So Your Patient Asks About Toilet to Tap …

by James Beaubeaux, SDCMS COO and CFO

6

september 2015

What are the steps of the water purification process?

The water purification process includes membrane filtration, reverse osmosis, and advanced oxidation through the use of ultraviolet light and hydrogen peroxide.

Is Pure Water San Diego proven to be safe?

Yes. Since August 2011, one million gallons of purified water have been produced and tested daily at the City’s Advanced Water Purification Facility. More than 28,000 laboratory tests have been conducted on 342 chemical and microbial constituents and water quality parameters. All samples have confirmed that the purified water meets all federal and state drinking water standards.

Does the Pure Water advanced water purification process remove pharmaceuticals and personal care products?

Yes. The presence of pharmaceuticals and

personal care products is monitored at each step of the water purification process.

Results have shown that the reverse osmosis and advanced oxidation processes are effective at removing pharmaceuticals and personal care products. The City of San Diego has tested for all regulated drinking water contaminants and 111 unregulated contaminants found in treated wastewater.

All test results were well below EPA Health Reference levels or at non-detection levels.

What other places safely use water purification?

The same three-step water purification process that San Diego plans to implement has been used successfully for many years in Orange County as part of its Water Factory 21 and now their Groundwater Replenishment System (GWRS). The Orange County Water District’s GWRS has produced 70 million gallons of purified water every day since it came online in 2008.

Their first project expansion now means 100 million gallons of purified water per day are part of their drinking water source — enough water for 850,000 people. Other places that use water purification safely and effectively include Singapore, Virginia, and Texas.

When will this water be coming to my home?

In 2021, the first full-scale water purification facility located at the North City Water Reclamation Plant will begin operating and producing up to 30 million gallons of purified water per day.

How much of San Diego’s water will be produced by water purification?

The long-term goal is to have one-third (83 million gallons of water per day) of San Diego’s water supply produced by water purification technology by 2035.

Who will be receiving this water?

Upon completion, Pure Water will be distributed throughout the City of San Diego’s entire water service area.

San Diego currently depends on importing 85% of its water from the Colorado River and northern California. Pure Water San Diego will provide a new local drinking water supply that is safe, reliable, and drought proof.

To learn more about the testing and research done to confirm the feasibility and safety of purifying recycled water, visit www.PureWaterSD.org/reports. Sign up for a free tour of the city’s demonstration Advanced Water Purification Facility at www.PureWaterSD. org/tours.

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SAN DIEGO PHYSICIAN.org

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c o m p l i a n c e p r o g r a m s — 5 th i n a s e r i e s

Performing Exclusions/Sanctions Screening

by Heidi Kocher, Esq.

Last month we discussed the types of exclusions and highlighted some of the consequences of exclusion. This month we will discuss some of the mechanics of performing an exclusion screening. (Note: Many compliance professionals also refer to this as “sanctions screening,” as you will see why below.)

The main agency responsible for exclusion is the Office of the Inspector General of the U.S. Department of Health and Human Services (the “OIG”). The OIG maintains a database of individuals and entities that are excluded. This database includes not only physicians but also dentists, nurses, chiropractors, home health agencies, DME companies, and every other kind of healthcare provider. The database also includes individuals who are not healthcare providers but who provide services to healthcare providers, i.e., accountants, billing companies, and even attorneys and elected officials. The OIG’s exclusion database is searchable online for one or a few names, or it can be downloaded if you wish to perform multiple searches. The OIG also publishes a monthly update that includes that month’s new exclusions and reinstatements. If you download the database, make sure to download the monthly supplements as well.

The online searchable database can be found at https://exclusions.oig.hhs.gov.

You can enter the name of a single individual or up to five individuals or entities.

Any results are returned in a table format, detailing the full name, type of provider/ entity and specialty, statutory reason for exclusion, and a link to verify the individual or entity is the same as the one you are searching by entering a Social Security number or an EIN (Picture 1). Verification of identity is a very important step.

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september 2015

Picture 1

Picture 2 

If there is no match, the website returns that information as well (Picture 2). When searching individuals, you should always print off the verification that the individual is not excluded and maintain this in either the appropriate HR or credentialing file.

The next question is how often should you perform sanctions screening? At a minimum, you should perform a sanctions screen at the time of hiring an individual or entering into a contract with an entity

or individual, and then at least annually thereafter. Why should you screen more often than annually? Because if an individual in your employment or an entity affiliated with your practice is excluded, you will have to refund all of the federal funds associated with the services provided by that individual or entity back to the date of exclusion. And those monies must be refunded within 60 days of discovery. If you performed a sanctions screening in, say,

Advancing Awareness, Prevention and Treatment of Cardiovascular Disease

2015 Sharp Grossmont Hospital Heart and Vascular Conference Cardiovascular disease is the leading cause of mortality in the U.S. As the prevalence of this condition continues to rise, so does the need for primary care physicians and multidisciplinary clinicians to have comprehensive knowledge about available treatment modalities and their role in managing at-risk patients.

Sharp Grossmont Hospital is hosting a conference recognized as one of the region’s premier events for cardiovascular disease education. The 2015 conference will feature a range of experts who will address topics related to medical management, interventional therapies, and surgical options for heart and vascular conditions.

8 a.m. to 4:30 p.m., Saturday, Nov. 7, and 8 a.m. to 1 p.m., Sunday, Nov. 8, 2015 Rancho Bernardo Inn 17550 Bernardo Oaks Drive San Diego, CA 92128 This activity has been approved for AMA PRA Category 1 Credit™.

Registration Complimentary for all physicians, physician assistants, nurse practitioners and Sharp HealthCare employees. Fee is $250 for nonSharp-affiliated nurses and allied health care professionals.

To learn more or to register, visit www.sharp.com/heartconference or call 1-800-82-SHARP (1-800-827-4277).

SAN DIEGO PHYSICIAN.org

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GH215A ©2015 SHC

c o m p l i a n c e p r o g r a m s — 5 th i n a s e r i e s

March, and the individual was excluded in April, you will be responsible for paying back nearly a year’s worth of reimbursements. Be aware also that if you accept Medicaid, the Medicaid rules require monthly sanctions screening. Finally, many private payer contracts also require you to perform sanctions screening, and many of those require monthly screening as well.

There are additional federal databases that need to be checked. The first is the General Services Administration’s System for Award Management (SAM). This database lists individuals and entities excluded from receiving federal funds due to violations in relation to other governmental programs. Thus, an entity that engaged in contract fraud and debarred from participating in any federal programs would be listed here. Here is the page for those online searches: www.sam.gov/portal/ SAM/##11#1. Again, any results returned provide the ability to verify the potential match.

Other federal databases that should be included in your screening protocol are the FDA’s debarment list (www.fda.gov/

ICECI/EnforcementActions/FDADebarmentList/default.htm), the DEA’s debarment list (www.deadiversion.usdoj.gov/ crim_admin_actions/index.html), and the Treasury Department’s Office of Foreign Asset Control’s Specially Designated Nationals list (money laundering, www. treasury.gov/resource-center/sanctions/ SDN-List/Pages/default.aspx).

But don’t stop at screening just the federal databases. Many states (39 at last count) maintain their own exclusions or sanctions databases. You should be checking these for your state, as well as for any state where any employed or affiliated individuals or entities are licensed. Do not assume that anybody on a state-excluded providers list automatically shows up on the OIG’s list and vice versa — there are numerous instances where a name is on one list but not the other.

A key factor in efficient and effective sanctions screening is to make sure you have the correct information to start with.

Bad data leads to bad results. To that end, when you hire or contract with an individual or entity, you should obtain (1) the full legal name, including middle names for

Where are your patients coming from?

Each month, every practicing physician in San Diego County receives a copy of San Diego Physician magazine. What better way to ensure that other physicians know about your medical practice than through a referral advertisement in this highly regarded publication? Advertising packages are available at very attractive price points, and for a limited time SDCMS member physicians receive 50% off by mentioning this ad.

10

september 2015

“…patients…get nearly 70% of specialist referrals from their primary care doctors.”

“…most experts say referral marketing will only become more entrenched as health care cuts continue.”

individuals; (2) complete Social Security number or EIN; (3) complete correct address; (4) for individuals, date of birth, and (5) all license numbers ever held.

As you can see, performing sanctions screening properly can be a daunting proposition for a small practice, and even for larger practices. There are a number of services that will provide sanctions screening for physician practices, usually for a relatively reasonable fee. This is one area where physicians should seriously consider outsourcing, as the consequences for bad results can be devastating.

Next month we will discuss auditing in your practice.

Ms. Kocher is counsel with the law firm of Liles Parker.

In addition to serving as a chief compliance officer and chief privacy officer, she has almost 20 years of experience advising and defending clients on legal and regulatory matters affecting providers of all sizes. Ms. Kocher can be reached at hkocher@lilesparker.com or (214) 952-5169.

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R i s k M a n ag e m e n t

On Alert What All Doctors Need to Know About Alzheimer’s Disease

by Cynthia Morrison, RN, ARM, CPHRM, Patient Safety Risk Manager, The Doctors Company

12

september 2015

Alzheimer’s disease is the sixth leading cause of death in the United States and is the only disease in the list of top 10 diseases that cannot be prevented, slowed, or cured (1). Reports indicate deaths related to Alzheimer’s have increased more dramatically than those related to other diseases.

From 2000 to 2013, deaths attributed to Alzheimer’s increased 71%, while those attributed to the number-one cause of death — heart disease — decreased 14% (1).

Only 45% of people with Alzheimer’s disease or their caregivers report being told of the diagnosis, whereas 90% of people with the most common types of cancer have been told of their diagnosis.

Alzheimer’s disease is the leading cause of dementia, accounting for about 65% of dementia cases in individuals over age 60.

Early diagnosis of dementia, requiring the expertise of a neuropsychiatric physician who specializes in it, is essential to allow for maximum quality of life (2,3). Physicians of all specialties should become familiar with the early signs of this disease in order to refer patients with symptoms to a specialist for further testing.

Typically, Alzheimer’s progresses slowly in three stages — mild (early-stage), moderate (middle-stage), and severe (late-stage) — with symptoms worsening over time. On

average, a person with Alzheimer’s lives four to eight years after diagnosis, but can live as long as 20 years, depending on other factors (3).

The early signs of Alzheimer’s are: • Memory loss that disrupts daily life (e.g., forgetting important dates or events).

• Difficulty completing familiar tasks at home, work, or leisure (e.g., trouble driving to a familiar location or remembering the rules of a favorite game).

• Confusion with time or place.

• New problems with words in speaking or writing.

• Decreased or poor judgment.

• Changes in mood and personality.

Physicians should also assess for other conditions that may mimic or exacerbate dementia, such as vitamin deficiencies, heart conditions, or sleep apnea.

Only 45% of people with Alzheimer’s disease or their caregivers report being told of the diagnosis, whereas 90% of people with the most common types of cancer have been told of their diagnosis (1). Studies have revealed that physicians and other healthcare providers recognize the benefits of disclosing Alzheimer’s, but, despite this, there is a reluctance to do so.

The benefits of clearly explaining the Alzheimer’s diagnosis include: • Improved Decision-making: When patients are fully aware of their diagnosis in the early stages of the disease, they are more likely to be competent to understand options and provide informed consent for current and future treatment options. When patients are actively involved in decision-making about their care, they are more likely to be compliant.

• Access to Services: Knowing the diagnosis allows caregivers to obtain information about support services and plan ahead.

• Safety: Awareness of the diagnosis allows caregivers to take steps to ensure the patient is in a safe environment and identify certain activities that may need to be curtailed, such as driving.

• Social Support: Knowing the diagnosis helps affected people focus on spending quality time with loved ones.

Once a patient has learned of his or her illness, physicians should:

• Educate caregivers and patients on ways to promote activity. As the disease progresses and cognitive and functional abilities decline, patients have difficulty moving and, therefore, are more vulnerable to infection.

Pneumonia is often a contributing factor to the death of patients with Alzheimer’s disease.

• Facilitate consults and have a system in place to track and recall patients to ensure there is appropriate follow-up.

• Consider referring patients to a mental health professional. Depression occurs in 40% of Alzheimer’s patients, and a mental health professional can help provide treatment. Other team members may include home healthcare workers, social workers, and psychologists.

There is hope for brain disorders like Alzheimer’s, with recent focus from a government initiative to improve scientific understanding of the human brain. In April 2013, President Obama announced the BRAIN Initiative to uncover new ways to treat and cure brain disorders like Alzheimer’s and other neurological disorders. More than $300 million in public and private investments are supporting this initiative. Since the announcement of the BRAIN Initiative, dozens of leading technology firms, academic institutions, scientists, and other key neuroscience contributors have made significant commitments to advancing the initiative (4).

References 1. Alzheimer’s News: New Alzheimer’s Association report finds less than half of people with Alzheimer’s disease say they were told the diagnosis. Alzheimer’s Association website. www.alz.org/news_ and_events_facts_figs_told_diagnosis. asp. Published March 24, 2015. Accessed June 8, 2015.

2. Dementia Advocacy and Support Network. www.dasninternational.org.

Accessed June 11, 2015.

3. 2015 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association. www. alz.org/facts/downloads/facts_figures_2015.pdf. April 2015. Accessed June 10, 2015.

4. BRAIN Initiative. White House website. www.whitehouse.gov/share/braininitiative. Published September 30, 2014.

Accessed June 11, 2015.

SAN DIEGO PHYSICIAN.org

13

CURES

Do No Harm Using CURES and CURES 2.0 to Treat the Prescription Drug Abuse Epidemic

by Sayone Thihalolipavan, MD, MPH

14

september 2015

Special thanks to Dr. Wilma J. Wooten, Dr. Eric C. McDonald, Dr. Roneet Lev, Heidi Lowe, and Angela Goldberg for their assistance in writing this article.

S

ince its launch in the late 1990s, physician involvement in the Controlled Substance Utilization Review and Evaluation System (CURES) database has helped prevent and mitigate prescription drug abuse (PDA). Physician participation empowers prescribers, pharmacists (dispensers), law enforcement, and others to access accurate information in a timely manner to make data-driven choices that

There were 244 unintentional prescription-drug-related deaths in San Diego County in 2014, and 5,723 emergency department painkiller-related discharges in 2013.

Use one doctor, one pharmacy for all chronic controlled prescriptions.

Use CURES — it makes you a better doctor.

Use a medication agreement for patients who need controlled substances for three or more months (but not as a “free ticket” for refills).

Follow the emergency department and urgent care guidelines.

Avoid the combination of opioids and benzodiazepines.

Figure 1.

One San Diego Mission

can help curb the PDA epidemic.

PDA is an issue that all physicians continue to be vested in, since we pledged to do no harm during our white coat ceremonies in medical school. As the PDA Report Card shows, there is still room to improve: There were 244 unintentional prescription-drugrelated deaths in San Diego County in 2014, and 5,723 emergency room painkiller-related discharges in 2013 (1). To further reduce PDA in San Diego County, all physician prescribers are asked to actively use CURES, as well as other actions outlined in the One San Diego Mission (see Figure 1). Prescription drug monitoring programs such as CURES are deemed as promising state-level interventions to decrease PDA (2). Simply put, using CURES makes you a better doctor.

You may have heard about the next version of CURES, commonly referred to as CURES 2.0. This next version is being tested and is expected to be fully implemented by January 2016 (3). In its initial testing, issues such as browser incompatibility, which some early adapters may have experienced, were identified and are being fixed. CURES 2.0 will have many welcome features and functionalities (4). For example, it will: • simplify the process of registering and re-registering; • generate alerts automatically to certain prescribers and dispensers based on certain medication combinations or doctor/pharmacy shopping; • allow for secure communication with other prescribers and dispensers; • allow for interstate information sharing; • and much more ….

CURES 2.0 will allow prescribers, dispensers, and others to easily prevent and mitigate PDA. Law enforcement and the Department of Justice will be able to perform parameter-based searches and create ondemand variable parameter-based reports to help them intervene when necessary.

Prescribers are encouraged to register for CURES access as soon as possible in observance of mandates established by SB 809.

Specifically, California Health & Safety Code section 11165.1 (a)(1)(A) now states that healthcare practitioners authorized to prescribe Schedule II, III, or IV controlled substances must submit an application for approval to access information online regarding the controlled substance history of a patient before Jan. 1, 2016. Information on applying for CURES access can be found

on the San Diego County Health and Human Service Agency (HHSA) CURES website at www.sandiegocounty.gov/content/sdc/ hhsa/programs/phs/PDMP-CURES.html.

Since HHSA started registering providers in December 2014, 50 prescribers have used our service to register through the end of August 2015 (5). Note that in the near future, when CURES 2.0 is fully rolled out, you will be able to register online. Currently, use of CURES is voluntary in California; however, mandated use may be considered by the Legislature, especially if prescribers and dispensers are not fully utilizing it. Due to many factors including low compliance, 10 states have mandated use of their respective prescription-drug monitoring program (6).

Please register for CURES and start implementing its use into your workflow as soon as possible. Information on applying can be found on the San Diego County Health and Human Service Agency CURES website. Again please note that when CURES 2.0 is fully rolled out, you will instead be able to register online.

Notes: 1. Prescription Drug Abuse Task Force of San Diego County. The Status of Prescription Drug Abuse in San Diego County; 2015 (data used with permission from upcoming report).

2. Centers for Disease Control and Prevention. Prescription Drug Monitoring Programs (PDMPs) website. Page last updated 5/5/2015 and accessed 8/12/2015.

3. California Department of Justice Office of the Attorney General. Prescription Drug Monitoring Program website. Accessed 9/9/2015.

4. Prescription Drug Monitoring Program Training and Technical Assistance Center. CURES Today and CURES 2.0 PowerPoint presentation by California Department of Justice. June 2013. Accessed 8/12/2015.

5. Office of Vital Records and Statistics.

Public Health.

6. Lauer, George. CURES Controversy Rekindled. California Healthline; Published and accessed 8/13/2015.

Dr. Thihalolipavan, SDCMS-CMA member since 2015, is the deputy public health officer for the County’s Health and Human Services Agency, as well as a member of the San Diego County Prescription Drug Abuse Task Force.

SAN DIEGO PHYSICIAN.org

15

CURES

PDMP/CURES Registration Application Instructions

In order to obtain access to the CURES/PDMP system, prescribers and pharmacists can use a notary-free, noappointment process to complete their applications via the San Diego County Public Health Officer. These are the steps to complete:

1

Pre-register Online Complete the registration application at https://pmp. doj.ca.gov/pmpreg.

2

Print the Registration Confirmation Upon completion/ submission of the online registration, immediately print your registration confirmation. The confirmation page is the user application form, which must be signed and submitted to the County Public Health Officer along with copies of all of the following supporting documents: a. Copy of medical license or pharmacy license; b. Copy of Drug Enforcement Administration Registration; and c. Copy of governmentissued identification

3

Reply to Email Verification Within 72 Hours Upon submission of the online pre-registration, applicants will receive an email requesting verification of their email address.

Applicants must complete the email verification within 72 hours of receipt of the notice.

4

Submit Completed Application Package to the County Public Health Officer in Person Public Health Services Office of Vital Records 3851 Rosecrans Street, Suite 802, San Diego, CA 92110 (619) 692-5550 M–F • 9am–5pm • No Appointment Necessary!

Completed Application Package Checklist • Copy of Application Form, Signed and Submitted to DOJ Online • Copy of Medical License or Pharmacy License • Copy of Drug Enforcement Administration Registration • Copy of Governmentissued Identification Additional Instruction: • Email Verification (within 72 hours)

What is the Expected Timeline?

As of July 1, 2015, with the CURES 2.0 launch, the estimated process times are: • Office of Vital Records and Statistics: 1 Week • Department of Justice, CURES Office: 6–8 Weeks

Revised July 27, 2015

16

september 2015

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CURES

D

San Diego Death Diaries

by Roneet Lev, MD

oes your name show up on a CURES report of someone who died from a medication you prescribed? 713 caring, well-meaning physicians wrote prescriptions to patients who died from accidental prescription drug overdose in 2013.

The San Diego Medical Examiner’s office analyzed a 12-month CURES report from date of death on 254 people who died accidentally from prescriptions. These CURES reports read as “death diaries,” showing a story of multiple prescribers, drug interactions, escalating dosages, and doctorshopping. There were also patients who were “double-dipping,” i.e., seeking two providers and two pharmacies on a regular basis. There were others who received their monthly clonazepam only to die from oxycodone that was never prescribed and no clonazepam in the system. Unfortunately, some medications we prescribe with good intentions end up causing harm. (Should we compare our patient satisfaction scores to the number of patients who end up in the morgue?)

San Diego has a Prescription Drug Abuse (PDA) Medical Task Force with providers from various specialties. The task force has come up with the emergency department safe prescribing guidelines that are in effect across the state of California, a medication agreement available in English and Spanish, and treatment guidelines.

We have a One San Diego Vision for prescribers — regardless of your medial specialty. Please follow these five principles: 1. 1 Provider and 1 Pharmacy for All Chronic Medications (chronic = 3 months or more) 2. Use CURES, It Makes You a Better Doctor (it’s not just for doctor-shopping) 3. Use Medication Agreements (but not as a “free ticket” for monthly drugs) 4. Don’t Mix Opioids and Benzodiazepines (more than 50% of death diaries include this combination) 5. Honor the Emergency Department Guidelines Other helpful tips: Opioid and Benzodiazepines: In a study of 254 San Diego deaths involving prescription drugs, 55 (21%) included an opioid-benzodiazepine combination.

CURES reports were available on 186 of the 254 deaths, and, of those, 100 (54%) of the CURES reports of deceased people involved the combination of opioids and benzodiazepines.

If you use a drug interaction checker and put in Vicodin and Ativan, you will get an alert: “Significant — Monitor Closely.”

18

september 2015

The American Society of Interventional Pain Physicians (ASIPP) states that one should not combine pain medications with sedative hypnotics, benzodiazepines, or barbiturates unless indicated. The recommendation stems from the additive sedation effects of opioids and sedatives.

Benzodiazepines are related to more than 30% of opioid-related deaths, more than any other class of drugs.

CURES 2.0 will include an alert when the combination is prescribed. The VA system has a policy of not allowing this medication combination and has only a handful of residual patients that are not weaned off.

As an emergency physician, when I review a medication list and see this combination, I alert the patient. I tell them that they have medications with drug interactions that they need to discuss with their doctor.

I warn them not to take the two types of medication at the same time.

Soma: Don’t prescribe Soma, carisoprodol.

Thirty patients who died were given this medication, which is addictive and abused.

Soma is metabolized to meprobamate, an anxiolytic, known for its addictive potential, and is no longer available on the market because of this problem. Meprobamate was first synthesized in 1950 and marketed as Milltown. It was a pharmaceutical superstar thought to be a minor tranquilizer that is addiction-free and overdose-free.

It turned out to be neither. Soma is rapidly absorbed in the GI track and quick to hit the CNS. The half-life of carisoprodol is only 100 minutes, but the half-life of meprobamate is 6 to 17 hours. This is why you are really prescribing a tranquilizer and not a muscle relaxant.

Sweden took Soma off the market in 2007, and Norway in 2008. The European Medicines Agency recommended suspension of all medications that contain methobamate “due to serious side effects,” and “concluded that the benefits of meprobamate do not outweigh its risks.” The European Union advises against the use of Soma for chronic back pain. In Canada, Soma is a Schedule I prescription drug. In the United States, Soma became a Schedule

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IV medication in 2012. The Indian Health Council has taken it off its formulary. You will find carisoprodol listed in CURES. Xanax: According to the 2012 Medical Examiner Report, San Diego County suffered 55 deaths related to alprazolam (Xanax), close to the total in the same period of 59 oxycodone deaths. Xanax is the most prescribed and the most addictive of all benzodiazepines in the United States.

We write more than 50,000 prescriptions a year for Xanax. The problems with sedative medications are creeping up to the problem with opioids.

Xanax can be used for treatment of panic disorder, anxiety, and in combination with other medications for chemotherapyinduced nausea. It is quickly absorbed, peaking 1–2 hours after taking the pill. It is therefore effective for immediate relief of symptoms. However, the clinical effects last only five hours, so patients come back for more and more and can develop addiction.

Tolerance, and psychological and physical dependence may occur in as little as 10 days.

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19

CURES someone who died from prescriptions. The data is eye-opening and makes you think about whether your prescriptions are helping or hurting.

When it comes to prescriptions, we have to follow the Goldilocks Rule: “Not too much, not too little, just right.”

If you want to be part of the PDA Medial Task Force, contact Roneet Lev, MD, chair, at roneet@cox.net, or Angela Goldberg, facilitator, at angelagoldberg@sbcglocal.net.

The PDA Medical Task Force has a website with educational information and interesting newsletters: www.SanDiegoSafePrecribing.org. Refer patients to addiction treatment at www.SanDiegoRxAbuseTaskForce.org.

medication. If your patients are reporting strange behaviors while on this medication, such as driving while asleep, it is probably wise to determine whether the side effect outweighs the benefit of the drug. Sleep hygiene and stimulus control are important behavioral treatments that should be used along with any sleep medication. If a sleep aid is required for longer than two weeks, it is not as effective as it was initially. In addition, Ambien is habit-forming and can have withdrawal symptoms with long-term use.

Bipolar and mania is a relative contraindication for Xanax because it can exacerbate mania. The benefit of benzodiazepines appears to peak at about 4–10 weeks into therapy with limited benefit after four months. There is evidence that long-term use increases baseline anxiety levels over time, exacerbating conditions such as panic disorder. There is also a study demonstrating an association between long-term use of alprazolam and iatrogenic depressive disorder. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), which do not have tolerance and abuse potential, remain first-line therapy for anxiety disorders. The American Psychiatric Association guidelines recommend benzodiazepines such as Xanax for short-term use only.

Benadryl: How could Benadryl be dangerous? Just because it’s over-the-counter does not make it safe. Whitney Houston had Benadryl in her system when she died and so did 28 San Diegans in 2013. CNS depressants have additive effects, and, therefore, even when given in the correct dose, depressants can have bad results.

Methadone: Methadone should be used only with the most compliant patients with strong consideration for genetic testing to determine if they can metabolize the drug to avoid cardiac toxicity. One hundred percent of deaths from methadone prescriptions were given by primary care.

Dr. Lev, SDCMS-CMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the San Diego and Imperial County Prescription Drug Abuse Medical Task Force, and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP).

The PDA Medical Task Force is working with the San Diego medical examiner’s office to communicate with physicians when their name shows up on a CURES report of

Tramadol (Ultram): We are seeing increased prescriptions of tramadol, and therefore increased deaths (19 in 2013). Ultram is falsely advertised as “non-narcotic” and “non-addictive.” This is not true. Ultram is a synthetic opioid and is addicting.

One tablet of 50mg of tramadol has more morphine equivalents than one 5/235 tablet of Norco.

Street Value of Prescription Medications

Ambien: Ambien is the number-one drug of abuse among addicted physicians under treatment at the Betty Ford Center. Fortythree patients who died were given this

Hydrocodone (Vicodin, Lortab, Norco)

$5–$8 each

Vics, Norcos, Watsons

Oxycodone (Percocet, Percodan)

$5–$10 each $30 for 30mg tabs

Percs, Roxies

OxyContin

$45–$80 for 80mg

OC, Beans, Cookies, Dootins

Methadone

$10 for 10mg $5 bulk

Wafers

Alprazolam (Xanax)

$2–$10 each

Zanies, Bars, Z-Bars, Bricks, Ladders

Diazepam (Valium)

$1–$3 each

Vals

Carisoprodol (Soma)

$3–$5 each

Somes

Adderall

$5 each

San Diego County Deaths: Data From San Diego Medical Examiner Office

Alprazolam

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

0

5

1

7

6

15

13

13

15

23

28

52

55

27

30

Diphenhydramine

2

5

14

13

14

10

14

21

17

21

21

30

25

30

26

Hydrocodone

10

14

23

23

26

21

32

28

34

44

37

52

49

48

34

Methadone

7

10

18

20

29

32

35

43

47

41

53

53

44

47

30

Oxycodone

8

17

21

16

16

19

17

45

52

43

48

65

59

49

71

Diazepam

16

18

34

38

36

28

35

46

50

47

48

40

59

35

33

Fentanyl

7

5

9

9

8

19

23

20

23

23

12

14

12

14

16

Tramadol

5

5

2

10

8

2

4

8

4

10

17

16

19

19

20

Carisoprodol

5

2

7

6

16

2

10

10

9

15

14

19

15

10

16

Zolpidem

0

1

4

6

4

5

3

10

10

16

19

17

11

19

10

20

september 2015

HEALTH HERO

As a Physician, You’re a Natural Educator

Join the San Diego County Medical Society Foundation’s Live Well Special San Diego thanks to John Han, PharmD, Regents Pharmacy in Physicians’ Speakers Bureau.

La Jolla for his help to assure Physicianspatients volunteer to with are able to comply physician orders.interactive Project Access provide pro bono recently partnered with Alison SATURDAY, NOVEMBER 14 presentations (30–60 Gordon Cohn, MD, and Elizabeth FLETCHER COVE, SOLANA BEACH Viriya, MD, of Gordon-Weiss-Schanzlin minutes) near where they Vision Institute; ASMG; and Outpatient Centerof of La Jolla, work or live, to Surgery groups to assure that eight patients regained youths, adults, seniors, their sight with cataract surgeries.

Volunteer to Build the Physicians: But the necessary prescriptions employees, and more.

We Knowledge, would have cost Project Access a YouPublic’s are a Health Role Model SATURDAY, NOVEMBER 14 will provide adaptable prohibitive $600 per patient! John Skills, and Positive Han was able to facilitate reduced COVE, SOLANA BEACH presentation materials.

ModelAttitudes healthy living to FLETCHER patients and staff by inviting them to cost prescriptions down to $175 About Health per patient, a 70% savings!

JOIN YOU at San Diego County Medical Society Foundation’s Solana Beach Sunset 5K Run/WalkToluwalase November John and his wife also provide Ajayi, 14 at 3 PM! MD, educating college preparatory middle school students about “Easy Ways to Eating Right for a Healthy Body and Mind”

for Project Access Live Well Sanongoing Diegosupport Physicians’ through their Charity Support Speakers Bureau Presentations: Program; for each prescription filled »» Living Your Life

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CURES

Are You Using a Medication Agreement?

FAQs

by Roneet Lev, MD What’s in the Agreement?

The medication agreement states that patients should take medication only as prescribed, not share medication, not drive while not fully alert, not ask for refills from the emergency department, and use only one provider and one pharmacy for their medication. There are other responsibilities and acknowledgements in the agreement.

Who Needs a Medication Agreement?

A medication agreement should be considered for any patient who is on a controlled medication for three months or more — three months is the definition of chronic use.

In 2013, according to CURES, more than 800,000 individual San Diego County patients received a prescription for a controlled medication. Of those, 13,567 required a controlled medication for more than three months. These 13,000+ patients can benefit from a medication agreement.

Which Specialists Need to Use a Medication Agreement?

Primary care specialists prescribe the majority of controlled medications. However, there are plenty of psychiatrists, surgical specialists, and dentists whose patients can benefit from this agreement. Pain specialists have been using medication agreements for a long time.

22

september 2015

Who Is Using the Agreement Now? March was Prescription Drug Awareness Month as well as when the Prescription Drug Abuse Medical Task Force held a media event to roll out the Medication Agreement. Speaking at the event was Dr. Jim Schultz from Neighborhood Health Clinic representing the community clinics, Dr. Robert Smith representing the VA San Diego Healthcare System, Dr. Marie Mutuc-Wurst representing Kaiser Permanente, and Dr. Joel Mata representing Sharp Rees Stealy. These institutions use a medication agreement, but there are many other physicians who follow this practice as well.

What Does the Agreement Do? The medication agreement is not a legally binding document. It simply sends a strong message to the patient that there are rules, responsibilities, and dangers in using these medications.

Why Should I Use the San Diego Countywide Medication Agreement?

The San Diego County Medical Society developed a medication agreement that has endorsements by the Hospital Association and Health Department of San Diego and Imperial County. The agreement has gone through health literacy so it reads at a fifth-grade level. There is a long version and shorter version of the agreement that you can choose to use.

This agreement unites our medical community in sending a similar message to all our patients. If our patient sees a primary care physician, a psychiatrist, an orthopedic surgeon, a dentist, and then goes to the emergency department, we are all following the same guidelines for controlled medication.

If you do not like the County version, or prefer to use our own agreement, that is OK. The importance is that we give the same message to our patients.

Do I Have to Use a Medication Agreement?

No, you don’t have to. There is no mandate; it’s just a good practice.

Where Can I Get a Copy?

There are copies of the medication agreement in English and Spanish, long version and short version, at www.SanDiegoSafePrescribing.org.

Dr. Lev, SDCMS-CMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the SDCMS Emergency Medicine Oversight Commission (EMOC), and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP).

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SDCMS Physician Networking Opportunity and Mixer Wednesday, November 18 , 5:00-8:00 p.m. Handlery Hotel, Mission Valley This event will provide an opportunity for physicians to learn about companies that offer practice management resources. Physicians (both SDCMS members and nonmembers) are encouraged to attend. Complimentary beer, wine, and light hors d’oeuvres will be served.

Raffle Grand Prize: One night stay at The Lodge at Torrey Pines, plus dinner for two at A.R. Valentien

Interested in event sponsorship? Contact Dari Pebdani at (858) 231-1231.

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september 2015

SATURDAY, NOVEMBER 14 FLETCHER COVE, SOLANA BEACH

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 November 14!

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

Visit www.SB5K.org to sign up.

For more information email Carlos.Medina@sdcms.org.

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classifieds PHYSICIAN POSITIONS WANTED SHORT-TERM LOCUMS AVAILABLE! D. (Doyle) Eugene Johnson, family physician with a wealth of experience, looking for short-term locums, preferably in North County. Have been a full-time practicing certified family physician for 50+ years and would like to continue seeing patients on a part-time basis. Had one of the largest solo family practices in San Diego for 25+ years. Excellent references! Continually certified in family practice, ACLS, BLS, regularly use computerized records. Please email d.eugenejohnsonMD@ gmail.com with particulars. [301] PHYSICIAN POSITIONS AVAILABLE FAMILY PRACTICE PHYSICIAN FOR A BUSY FEDERALLY QUALIFIED HEALTH CENTER: Mountain Health is a mission-driven organization that serves both rural and urban residents of San Diego County.

We have been in business for 40 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, CME reimbursement, and license reimbursement. Board-certified and bilingual English/ Spanish preferred. Send CV to tfindahl@mtnhealth. org or (619) 478-9164. You may contact HR directly at (619) 478-5254, ext 30. Visit www.mtnhealth.org.

[416] INTERESTED IN BECOMING A PRECEPTOR FOR OSTEOPATHIC MEDICAL STUDENTS? Midwestern / AZCOM osteopathic medical school in Phoenix has third- and fourth-year medical students in San Diego looking for clinical rotations, particularly in pediatrics, psychiatry, general surgery, and OB/GYN. Requirements: Either MD or DO; physicians interested must commit to minimum one four-week rotation per year / or more as desired (2–3 preferable) and to FT hands-on training for each student as is reasonable for the duration of the rotation. Compensation and CME provided.

If interested, please contact Dr. Kevin Considine at kconsidine@sbcglobal.net for more information. [408] PSYCHIATRISTS / FAMILY MEDICINE / INTERNISTS: San Diego professional group has great opportunities to join a talented, dedicated physician group specializing in addiction medicine. Flexible full-time or part-time work schedule working in San Diego and/or Murrieta, CA. Competitive salary with additional compensation for call time. To get more information regarding this great opportunity in making a difference in the lives of clients in their recovery from drug and/or alcohol addictions, contact Cynthia Bekdache at (951) 894-8623 or at cbekdache@contactaac.com. [407] SEEKING PART-TIME INTERNIST: If you’re tired of the bureaucracy of working for a large organization with no voice in how you do things, this is a great opportunity to try private practice. You will have a guaranteed salary with production-based bonuses and the potential for future growth. You will work on the campus of Scripps La Jolla with a respected internist who has been on campus >10 years and will help run the business side of the practice. Email resume to XimedMD@gmail.com. [399] SEEKING BOARD-CERTIFIED PEDIATRICIANS: UC San Diego, Dept. of Pediatrics, and Rady Children’s Hospital, San Diego, is seeking clinicians to provide patient care at the urgent care clinics of the Division of Emergency Medicine. Clinicians should be boardcertified pediatricians with a minimum of two years experience in general pediatrics/urgent care. RCHSD, a level-1 trauma center, is the major regional primary and tertiary pediatric hospital, and is the clinical home of UCSD Department of Pediatrics. The Division has a strong commitment to clinical care, teaching, and research. Interested persons should contact Dr. Katherine Konzen, Director, Pediatric Urgent Care, at kkonzen@rchsd.org. [398] SEEKING PER DIEM DERMATOLOGIST: Well-established dermatology practice in La Jolla is seeking a

26

september 2015

part-time or full-time per diem dermatologist for immediate hire. Prefer at least two years of experience outside of residency. This practice has thrived for over 30 years and is situated just blocks from some of San Diego’s most beautiful beaches. Very friendly staff, and access to an in-house Mohs surgeon and dermatopathologist. We have two locations and offer flexibility in schedule and encourage a healthy work-life balance. Required experience: Prefer a candidate with two years of experience outside of residency, but will consider all applicants; board certification and California medical license required. Email CV to Sasha Lepes at sasha@compassdermpath.com. [397] IMMEDIATE OPENING FOR MEDICAL DIRECTOR AT GROWING COMMUNITY HEALTH CENTER IN LINDA VISTA: Seeking a highly motivated medical director with innovative ideas and a vision for the future in community medicine. Outstanding leadership and clinical opportunity for an MD who will clinically see adults, while also leading clinical management.

Reports to CEO. Experienced internal medicine providers preferred. Competitive salary and benefits, with retirement match. May be eligible for loan repayment.

No hospital call required. Please email CV to awalton@ lvhcc.com. [396] SEEKING PSYCHIATRISTS: Senior Medical Associates, Inc., seeks board-eligible / board-certified adult and child psychiatrists to join a cohesive team committed to clinical excellence for work at a well-run, supportive, comfortably paced, nonprofit, outpatient clinic serving a persistently mentally ill population in North San Diego County. $240,000 in compensation and bonus, or $160/hour. An additional $15,000 or $9.50/hour if child psychiatry fellowship trained.

Full-time benefits include health, life, long-term disability, vision, matching 401K retirement plan, CME reimbursement. Five weeks vacation / sick / CME paid time off. Compensation prorated for part-time employment. Additional pay for optional daytime call responsibility. Position contingent on contract award. Please send your CV to Pardeep at office@seniormedicalassociates.com or call (619) 299-1419. [392] EMERGENCY MEDICINE: BC emergency medicine or family medicine trained physicians needed to join Sharp Rees-Stealy Medical Group’s Urgent Care Department. Competitive compensation and benefits package. Unique opportunity for professional and personal fulfillment. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [391] INTERNAL MEDICINE: Sharp Rees-Stealy Medical Group is seeking full-time or half-time (job share) BC/ BE internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@ sharp.com. [390] PRIMARY CARE POSITION: San Diego area. Outpatient only. No calls. No hospital and no weekends. Email sandiegoprimarycare@yahoo.com. [388] BOARD-CERTIFIED FAMILY PRACTICE PHYSICIAN MD/DO WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [387] FAMILY OR INTERNAL MEDICINE PHYSICIAN: Graybill Medical is one of the region’s largest independent, multi-specialty groups. We are currently looking for a general family medicine physician (Escondido or Temecula) and an internal medicine physician (Temecula) to provide quality patient care to all ages of patients in a full-time, traditional practice. Conduct medical diagnosis and treatment of patients, including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board-eligible; bilingual Spanish/ English preferred. Check out a full list of our benefits at www.graybill.org. Send CVs to humanresources@

graybill.org, apply online, or fax to (760) 738-7101.

[385/386] SPANISH-SPEAKING FAMILY PRACTICE OR INTERNAL MEDICINE: Spanish-speaking family medicine or internal medicine physician for Borrero Medical Group located in south San Diego next to Chula Vista.

The practice is growing and needs to hire a new physician. Borrero Medical Group is a well-established practice, 22 years in the community, exceptional office staff. Every member of our team plays an important role in improving the health of our patients. We offer an excellent comprehensive benefits package that includes malpractice coverage, health insurance, competitive and attractive salaries and bonus. If interested, please submit inquiry and CV to rosa10borrero@ att.net. [384] SEEKING HOSPICE AND PALLIATIVE MEDICINE PHYSICIAN: The Elizabeth Hospice has a full-time position for a physician whose duties will include performing home visits, attending IDTs (interdisciplinary meetings), and assisting with certification of terminal illness. Hospice and Palliative Care Certification preferred. If interested, please contact Dr. Glenn Panzer at glenn.panzer@ehospice.org. [382] KAISER PERMANENTE — SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP IS CURRENTLY LOOKING TO HIRE EXCEPTIONAL PHYSICIANS FOR FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, AND URGENT CARE OPPORTUNITIES IN SAN DIEGO: As part of our practice, you’ll be working in a progressive environment that encourages cross-specialty collaboration, professional autonomy, and work-life balance. We offer a competitive salary and one of the most comprehensive benefits packages. If you would like to work with an organization that gives you the tools, resources, and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente.

For consideration or to apply, please visit our website at http://physiciancareers.kp.org/scal. For questions or additional information, please contact the recruiter Bettina Virtusio at (877) 608-0044. [372] FAMILY PRACTICE AND INTERNAL MEDICINE NEEDED: Part-time or full-time physicians needed to work at correctional facilities. Work as an independent contractor with very competitive pay. Contact Steve at steve@cpmedgroup.com or at (619) 885-3907. [371] GENERAL, FAMILY, OR INTERNAL MEDICINE PHYSICIAN NEEDED IMMEDIATELY: This opening is an independent contractor position. We are a housecall practice located in beautiful North San Diego County. We will also provide paid training on our EMR. 8–5, Monday–Friday, 10–12 patients per day. No rounds or hospital duties. If interested please submit your CV to julie@sandiegomobiledoctor.com. We are very anxious to fill this position, and we look forward to hearing from YOU! No agencies please. [348] 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: Internal medicine and family medicine physician positions currently open. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County with openings for full-time, part-time, and perdiem positions. Current CA and DEA licenses required.

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] OFFICE SPACE AVAILABLE ESCONDIDO OFFICE AVAILABLE FOR SUBLEASE:

Four exam rooms with reception and waiting area, located near downtown. Available full and half days.

Please email staff@palmedinc.com for info. [417] OLD DEL MAR MEDICAL OFFICE SPACE FOR LEASE: 317 14th St., Del Mar, CA. 1,400 square feet / $3 square foot gross rent — located in the heart of Del Mar in an established medical complex. 3–5 year terms with TI allowances available. Email inquiries to richcardow@yahoo.com or call (970) 390-7026. [406] LA JOLLA (NEAR UTC) MEDICAL OFFICE FOR SUBLEASE OR SHARE: Scripps Memorial medical office building. Great location, steps to main hospital entrance. 9834 Genesee Ave. between I-5 and I-805.

Up to four exam rooms and private or shared consult office available. Please call (858) 622-9076 and ask for Jennifer. [394]

LAST CLASS “A” MEDICAL OFFICE AVAILABLE, VISTA Upgrade to Class “A” medical office in TriCity’s leading outpatient health center.

1,250 RSF office for lease. 3 large exam rooms, MD office, nurse station, ADA restroom, and ample waiting. Will be completely rebuilt. Reserved physician parking & ample surface patient parking. One block from TriCity Medical Center. More than 40 physicians and strong primary care referral base.

Contact Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/ suite-265

VISTA MEDICAL OFFICE SPACE FOR LEASE: Offered at $1.40/ft2. 1.1 miles from Tri-City Hospital. Ideal place for solo practitioner. Ground floor, 1,424ft2, has break room, which is leaded for radiology if needed, two bathrooms, two exam rooms, spacious waiting room, ample room for support staff, physicians private office, excellent parking with seven spaces per 1,000ft2. Also available in same building, office space to share with pediatrician. Ideal for solo practitioner, either family practice or pediatrics. Space portioned off with separate wing and includes three exam rooms, two offices, shared reception area and lobby with access to two bathrooms. Area under city renovation, and lots of new business starts surround. Contact Jill at (760) 630-4715. [393] MEDICAL FACILITY AVAILABLE FOR SUBLEASE: Orthopedic group in central San Diego looking to sublet space to an orthopedic surgeon with an expertise in hand, spine, general, or non-operative orthopedic care, or rheumatologist; primary care physician. Medical office is located in Sorrento Valley at a class A medical building with a surgery center as the anchor tenant, onsite large conference room and learning center with cadaver wet lab, physical therapist next door, and easy freeway access. Opportunities for investment, ER call, and patient referrals. For more information, please contact Jeff Craven at jeff@sdmiortho.com or at (858) 245-9109. [383] DEL MAR MEDICAL OFFICE AVAILABLE: Turnkey office available in Class A medical office building in prime location in Carmel Valley, San Diego. Full- or part-time occupancy for medical professional. Dedicated parking garage for patients / clients. 1,000ft2suite with two large treatment rooms, breakroom, photography, and reception area. Rates dependent on use. Contact Margaret O’Byrne, MD, at mobyrne61@ gmail.com, (619) 218-8980 (mobile), (858) 481-4888 (office). [369] $3,147 / 1,701FT2 — 1,701FT2 MEDICAL OR BUSINESS USE FLEX SPACE (5330 CARROLL CANYON RD.): 1,701ft2 office space available approved for

medical or business use. Fully built out. First floor with extensive window line. Two entrances. Excellent highway access. Short- or long-term lease available. Easy patient / client parking. Contact Margaret O’Byrne, MD, at mobyrne61@gmail.com, (619) 218-8980 (mobile), (858) 481-4888 (office). [368] HILLCREST OFFICE SPACE: Office space available in beautiful, updated Hillcrest medical office that also houses a fully accredited ambulatory surgery center.

Great opportunity for a plastic surgeon, facial plastic surgeon, oculoplastic surgeon or dermatological surgeon. Office is conveniently located minutes from freeway access and downtown San Diego. Please contact via email at info@drhilinski.com. [355] NEW MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN KEARNY MESA: Brand new office suite located at 3750 Convoy Street with nine exam rooms and digital X-ray, hi-speed wireless, free parking for patients and staff, conference room in building.

Several minutes from Sharp Memorial Hospital and Children’s Hospital. Convenient freeway access to 163 and 805. Multiple half-day clinics available days, evenings, and weekends. Please contact Lisa Vaughn at (858) 278-8300, ext. 210, for more information. [343] 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] 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. Fullday 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 477-D 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] 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] BUILD TO SUIT: 950SF 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 six gated parking spaces, two entryways, restrooms, lighted tower sign space. Build-out allowance to $10,000 for 4–5 year lease, rent $1,800 per month gross (no extras). Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: Two exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital.

Very reasonable rent. Please email KLewis@SDCMS. org for more information. [867]

NONPHYSICIAN POSITIONS AVAILABLE SAN DIEGO MEDICAL GROUP SEEKS A NURSE PRACTITIONER: San Diego Medical Group (SDMG) is a well established and thriving internal medicine private practice located in Hillcrest directly across the street from Scripps Mercy Hospital in the prestigious Mercy Medical Building.

The office is staffed by two internists, one nurse practitioner, and seven staff. SDMG seeks another experienced, fulltime nurse practitioner to manage patients in our growing practice. This is a unique opportunity to work in a small private practice with seasoned, excellent providers and staff in an efficient, cohesive work environment providing medical care to a wide variety of patients. SDMG envisions an incoming nurse practitioner who has direct experience with the practice of internal medicine, is capable of immediate management of patients, can quickly learn and use SDMG’s EMR (eClinicalWorks), is positive, outgoing, compassionate, and a hard worker. The position is Monday through Friday, 8am–5pm (some flexibility) with a competitive six-figure salary, health benefits, retirement benefits, life insurance, paid continuing education, and paid vacation. There is no call. Interested applicants, please send your resume to sdmg@sdmedgroup.com. [365] ADMINISTRATIVE ASSISTANT FOR TWO-SURGEON OFFICE IN EAST COUNTY / GROSSMONT AREA: Previous experience and general knowledge of medical office procedures and the responsibilities of various positions, assisting office manager in employee management and HR. Business office assistance with HIPPA, meaningful use, physician meetings/schedules, credentialing, contracting etc. Possibility of becoming office manager. Part time to start going to full time.

Email resume to LMop202@gmail.com. [395] PHYSICIAN ASSISTANT POSITION IN PAIN MANAGEMENT UNDER THE DIRECTION OF THE PHYSICIAN: Apply and modify the principles, methods, and techniques of medicine to provide comprehensive pain management, medical services, and procedures. Diagnose and treat a variety of injuries, chronic and acute pain symptoms. Full-time position. Competitive salary, sign-on bonus, and vacation package bonus after one year. Education: Physician assistant applicants must have certification and degree from an accredited college organization. Experience: Previous experience in pain management preferred. License / Certification: Certification of physician’s assistants; current / valid CA state PA license, DEA, and NPI. Current CPR, BLS, and ACLS certifications. EOE / Minorities / Females / Vet / Disability. Email hillycarr1@yahoo.com. [379] 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. Parttime, flexible days / hours. Competitive compensation.

Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] MEDICAL EQUIPMENT / OFFICE FURNITURE FREE EQUIPMENT FOR DONATION: Defibrillator — Zoll AED Plus and Inovo Oxygen tank. Interested parties please email lisas@sdsm.net. [389] CLINICAL TRIAL VOLUNTEERS NEEDED BIPOLAR DISORDER CLINICAL TRIAL VOLUNTEERS NEEDED: UCSD is conducting a longitudinal study on how inflammatory biomarkers and mood fluctuations among those diagnosed with bipolar disorder may be predicting factors to decline in their cognitive functioning over time. We are recruiting people between ages 35–60 who are diagnosed with Bipolar I Disorder. They must consent to three blood draws a year, clinical assessments, neurocognitive batteries, and use of smartphone. There is monetary compensation for their participation. No medication is involved in this study. If you have any referrals or would like more information, please contact the study recruiter, Nana Kori, at nkori@ucsd.edu or at (858) 534-9439. [405]

SAN DIEGO PHYSICIAN.org

27

Poetry and M edicine

Lost and Found

by Daniel J. Bressler, MD, FACP

A few weeks ago I temporarily lost my cell phone. It must have dropped off its holster while we were walking to a neighborhood restaurant on a Friday night. I noticed it was gone during the walk home. We retraced our steps and found nothing. Once home (and suppressing my panic), I discovered that the Motorola Android phone has a built in location device that signals its whereabouts via GPS. The phone, as it turned out, was lying by the side of the road a few blocks from our previous path to and from the restaurant. I can only surmise that someone picked it up, and then having discovered that access to it was locked by a passcode, discarded it. The phone was undamaged. Lucky me.

The incident got me to thinking about all the aspects of life that involve losing and finding. We, along with our patients, can lose our health and need to find our way back to it. We can lose our professional momentum and — if we’re lucky — find it again.

We might fall out of love and again, if we’re lucky, fall back in it, even with the same person.

Many people experience loss not just in specific spheres of their life but

28

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in their overarching sense of meaning.

It seems that this is particularly common in middle age — a club of which I am a member — when the initial questions about building a career and having a family have been answered.

Unlike my phone, lost meaning does not generate a GPS signal. Each person must seek it uniquely based on his or her own personal history, interests, and values. One can take heart, perhaps, by realizing that getting lost seems to be one prerequisite to growth. It motivates us to find ourselves on a broader or deeper level.

This poem, “Lost and Found,” catalogs many of the ways in which we can get lost. However gloomy you might find the observations of the poem to be, remember that being lost is the launching-off point of selfrenewal.

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

Lost and Found A church bell tolls the morning in The day gets dragged along Car doors slam and children call Cacophony and song The whole chaotic enterprise Unfolds the world around As dreams dissolve in things to do And lives are lost and found.

The streets are filled with wandering souls Dressed in vacant looks Following directions learned From parents, priests, and books Their eyes inquire, why are we not By now sweet homeward bound?

But the next appointment’s waiting As each is lost and found.

The television teases, The screen provokes to sell Bringing higher definition To lower rungs of hell The oh-so-human spectrum From corrupting to profound That titillates and elevates And leaves us lost and found.

This chest pain only seizes me When I’m twisted and upset When the scale of mortal tragedy Breeds frustration and regret My shrink tells me it’s in my head But my surgeon’s gloved and gowned Is it grief or circulation?

Diagnosis: lost and found.

The park is edged by gravestones A playground laughs nearby This ancient eucalyptus Pulls my vision to the sky Are the answers to my questioning Found beneath a burial mound?

The sunset’s revelation says That we all are lost and found.

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