June 2016

official publication of SDCMS june 2016

San Diego County Physician Workforce & Compensation

“Physicians United for a Healthy San Diego”

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june

Contents

Volume 103, Number 6

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, 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 (CMA Trustee) 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

6 feature

14

ighlights From SDCMS’s 2015 H Physician Workforce & Compensation Survey

BY TOM GEHRING

12

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)

departments 4

Briefly Noted: Calendar • Welcome New and Returning Members • In Memoriam • Physician Wellbeing • Bioethics • And More …

OTHER VOTING MEMBERS Communications Chair: J. Steven Poceta, 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

8

eadership Series: James E. L LaBelle, MD

BY SHERRY NOORAVI, PSYD

10

12

BY SUSAN SHEPARD, MSN, RN

Y THE CALIFORNIA MEDICAL B ASSOCIATION

Relocating, Merging, or Closing Your Medical Practice? Follow These Tips

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

The California End-of-Life Option Act: FAQs

21

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 (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

Practice Management Tip of the Month

Y THE CALIFORNIA MEDICAL B ASSOCIATION

26 Physician Marketplace: Classifieds 28

Finding Peace and More Power Beyond Our Stress

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june 2016

Y HELANE FRONEK, MD, FACP, B FACPh

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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SAN DIEGO PHYSICIAN.org

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// calendar

MEMBERSHIP

Welcome New and Returning SDCMSCMA Members!

New Members Bryan M. Clary, MD General Surgery San Diego • (619) 471-9398 Ivan P. Cubas, MD Gastroenterology San Diego • (619) 266-3332 Mehboob Ghulam, DO Internal Medicine Brawley • (760) 351-4892

SDCMS-CMA Webinars & Events

Community Healthcare Calendar

For further information or to register for the following, contact Jen at (858) 300-2781 or at JOhmstede@ SDCMS.org.

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.

DMHC IMR and Other Complaint Processes: Tips and Best Practices for Physicians (webinar) JUN 22: 12:15–1:15pm CHPI Physician Quality Rating Program: Navigating the Review and Corrections Process (webinar) JUN 29: 12:15pm–1:15pm HIPAA Compliance: Key Risks All Physicians Should Know (webinar) JUN 30: 11:30am– 1:00pm Physician Networking Opportunity & Mixer (social) AUG 5: 5–8pm at 57 Degrees in Mission Hills

“

Red Shoe Day to Support Family Care at San Diego’s Ronald McDonald House JUN 23 Across San Diego County SDAFP Annual Family Medicine Update JUN 24–26 at Paradise Point Hotel in Mission Bay Superficial Anatomy and Cutaneous Surgery JUL 9–17 at the San Diego Marriott Del Mar

33rd Annual Primary Care Summer Conference AUG 5–7 at Loews Coronado Bay Resort 4th Annual Stroke Conference AUG 20 at the University of San Diego Joan B. Kroc Institute for Peace and Justice Keys to Physician Wellness: From Burnout to Professional Satisfaction AUG 24 at the Anaheim Marriott (Jointly Provided by the California Society of Addiction Medicine and the California Public Protection & Physician Health, With CME Credits and NAMSS Accreditation)

june 2016

Carlton W. Thomas, MD Gastroenterology San Diego • (619) 266-3332 Joy X. Ye, MD Internal Medicine San Diego • (619) 952-8365 Returning Members Lisa B. Arian, MD Internal Medicine San Diego • (858) 277-0696 Donald R. Bennett, MD Emergency Medicine San Marcos • (619) 952-2269 Richard A. Chaffoo, MD Plastic Surgery La Jolla • (858) 623-6333 John R. Harper, MD General Practice San Diego • (760) 789-2629 Jeffrey A. Ramos, MD Internal Medicine San Diego • (858) 626-7780

”

Everybody is ignorant,

only on different subjects.

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Jason M. Phillips, MD Urological Surgery Carlsbad • (760) 637-2500

— Will Rogers, American Cowboy, Vaudeville Performer, Humorist, Newspaper Columnist, Social Commentator, and Stage and Motion Picture Actor (1879–1935)

IN MEMORIAM Robert (“Bob”) J. Hye, MD, 21-year member of SDCMSCMA, was recently discovered to have passed away on Feb. 22, 2016. Our sincere condolences go out to the family and friends of Dr. Hye.

/////////////////////////////////////////////////////////////////////////////////////////////////// BIOETHICS

Distributive Justice

PHYSICIAN WELLBEING

Confidentiality and Reporting Requirements Physicians and other members of health system physician wellbeing committees participated in a discussion on confidentiality and reporting requirements at a May 7 meeting of the California Public Protection and Physician Health, Inc. (CPPPH), hosted by Champions for Health. Attorneys from Procopio, Cory, Hargreaves & Savitch, LLP, educated the group on existing regulations requiring reporting when a physician has been referred for impairment recognition and when reporting is required by the wellbeing committee to the medical executive committee of the hospital or health system.

CMA comments that “it’s important to identify the role of the committee as advisory in nature, and not as a substitute for a personal physician or a disciplinary body.” The committee must safeguard the confidentiality of any records it receives in performing its function. Furthermore, CMA states that the committee should only report to the referral source and the physician in question, except in instances when there is a “serious risk of harm to patients.” Considerable discussion followed around the meaning of serious risk of harm.

According to current standards, further reporting to the MBC is required only when the action of the MEC is based on medical disciplinary cause or reason, where the competence or professional conduct is reasonably likely to be detrimental to patient safety or to the delivery of patient care.

For more information, contact CPPPH at www.cppph.org or at cppphinc@gmail.com. Meetings of members of wellbeing committees are held three to four times each year in San Diego, and several regional workshops are also available.

Nearly 30 members of SDCMS’s Bioethics Commission met at SDCMS on April 27 to discuss distributive justice in the context of medical rationing. Three commission members spoke on the topic: • Nancy L. Vaughan, Esq., an attorney who has specialized in all aspects of healthcare law, including medical malpractice cases and bioethics matters.

• Donald Stouder, DMin, a healthcare chaplain and crisis counselor who works with organ donor families as part of UC San Diego Medical Center/Lifesharing Community Organ and Tissue Donation.

• Lawrence J. Schneiderman, MD, professor emeritus in the departments of family medicine and public health and medicine at UC San Diego, who has had a distinguished career in medicine and ethics.

Ms. Vaughan spoke about the “brave new (expensive) world” of medical care, who gets it, and whether Americans have a “right” to it. Reverend Stouder spoke about utility (“maximizing expected net amount of overall good”), justice (“fairness in distribution and access”), and autonomy (“respect for persons”) in the context of organ transplantation and the requirements of the final rule of the National Organ Transplantation Act of 1984. And Dr. Schneiderman laid out his case for, as his presentation was titled, “The Unbearable Rightness of Rationing: Just Medical Care.” A lively and enlightening panel discussion ensued from the three presentations.

SDCMS’s Bioethics Commission comprises physicians, nurses, pastors, social workers, professors, attorneys, students, and others from across the county who meet quarterly to promote best and innovative practices in bioethics, including clinical, organizational, systems issues, and bioethics committee functions. Our next meeting is on Wednesday, July 27, from 6 p.m. to 8 p.m. at SDCMS’s offices — with dinner available.

If you would like more information on how you can get involved, email Kyle Lewis at KLewis@SDCMS.org.

SAN DIEGO PHYSICIAN.org

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/////////////Briefly /////////////////Noted ///////////////////////////////////////

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Trust us to be your Technology Business Advisor hArdwAre  sofTwAre neTworks emr ImplemenTATIon seCurITy  supporT mAInTenAnCe

PHYSICIAN SOCIALS More than 300 SDCMS physicians, family, and friends enjoyed an entertaining evening of fun and learning at SDCMS’s April 26 physician social at the Reuben H. Fleet Science Center. Attendees enjoyed the exhibits while they mingled, socialized, and networked. The Center was closed to the public during the event.

Be sure to mark your calendars to attend our next physician networking opportunity and mixer on August 5 at 57 Degrees Wine Bar (5–8pm) — complimentary hors d’oeuvres and drinks will be provided. Our socials are open only to physicians and their guests, and RSVPs are required. Contact Jen Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org for details.

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UC San Diego medical students presented the 21st edition of The Human Condition at a reception at the Medical Education and Telemedicine Building on Thursday, May 12. An annual literary arts magazine, The Human Condition showcases creative works by the UC San Diego School of Medicine community and strives to promote artistic and humanistic endeavors. New this year, proceeds from the sale of artwork will go to support the UCSD Student-Run Free Clinic Project. For further information, email Elizabeth Roderick, MSIV, editor-in-chief, at eroderic@ ucsd.edu.

San Diego Physician will publish works by the UC San Diego School of Medicine community throughout the year.

///////////////////////////////////////// / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Maximizing the bottom line, PHYSICIAN WELLNESS

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Callers are quickly connected to a physician with extensive experience in helping health professionals having problems with stress, substance abuse, or mental health issues. Callers receive the support and referrals needed to better manage whatever issues with which they may be struggling.

Who Should Call: If you’re a physician looking for help with substance abuse or a psychological or emotional problem, we’re here to help. If you’re a colleague, family member, or friend of a physician in need of assistance, please don’t hesitate to call.

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SAN DIEGO PHYSICIAN.org

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L e a d e r s h i p — 5 th i n a S e r i e s

Dr. LaBelle, 13-year member of SDCMSCMA, is board certified in internal medicine, practices emergency medicine, and is chief medical officer of Scripps Health, whose network has 2,600 affiliated physicians and annually treats 600,000 patients. Dr. LaBelle can be reached at (858) 678-7711 or at labelle.jamese@ scrippshealth.org.

James E. LaBelle, MD Chief Medical Officer Scripps Health

by Sherry Nooravi, PsyD

The following interview is part five of an eight-part leadership series, with interviews conducted by organizational psychologist Dr. Sherry Nooravi. See the January issue for an interview with Dr. Paul Bernstein, medical director and chief of staff at Kaiser Permanente San Diego; the February issue for an interview with Dr. Wendy Buchi, CEO of IGO Medical Group; the March issue for an interview with Dr. Steven Green, CMO, Sharp Rees-Stealy Medical Group; and the May issue for an interview with Dr. John Jenrette, CEO of Sharp Community Medical Group.

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Question: What is your leadership philosophy?

Answer: I don’t have a single philosophy, rather lessons that got transformed into wisdom that came from mistakes. It distills down to a few things. The first thing is that, as a physician leader, you have direct control over nothing. In order to get anything done, you need to figure out the value proposition for the change you desire to make. You have to understand that others’ perception of you is their reality, and you have to address their reality. To be a leader, you have to sit in somebody else’s seat and develop the humility to realize that pretty much everyone is smarter in the subject matter domain for the problem you want to solve than you are. The only way to approach them is to have the discipline to say the magic words, “I have a problem, and I need your help.” Once you get that, get engagement. Wisdom always comes from the pain and suffering of doing, making a mistake, and learning; you can’t learn that in an MBA program.

Question: What should physicians do to prepare for the future of healthcare?

Answer: Maintain the primary relationship with the patient and the connection. We get all tied up in the business of medicine, the burden of measurement, and the accountability around performance indicators, which may or may not mean anything. The superpower of the physician is the relationship and connection to the patient. If there is anything we can do to help prepare us, it is to push further with the patient as the center of our universe.

We are the most intensely connected. That is our superpower and how we’ll make changes to the system. There are policy makers swirling around, but all I have to do is align with physicians around the patient.

Physicians will focus on their patients and community. We have let society damage that superpower.

Question: What advice do you have for young/incoming physician leaders?

Answer: Before you even consider leadership, you have to become a master in your field — you are not a master clinician out of residency. Expect to spend the first 8–10 years becoming a master clinician, until you’ve experienced the healthcare system and the emotional connection to the patient. If you spend 10 years serving the patient and experiencing the dysfunction of the healthcare system and understanding what it takes, then you can take on real physician leadership issues. You just can’t be a physician leader who can drive change until you are a master clinician. Then it’s about developing yourself to understand change management and integrate quality and finance. You will need to learn to course correct and be wrong most of the time, which I am. Early on, just become an excellent physician and don’t distract your attention away from that.

Question: What does organizational culture mean to you and how do you drive it?

Answer: It is many layered and doesn’t emanate from the top, and, in many ways, is driven by our incentive system. In other ways, it’s a reaction to the needs of the organization and the community around us, which means a heterogeneous set of cultures in a health system is a good thing.

How do we transform into one in which we experience what the patient experiences?

How do we frame problems?

Transforming culture means stopping and deeply exploring the problem you are trying to solve and recognizing that you don’t change culture by saying, “Go do this.” You change it by saying, “Explore with me this problem.” How the problem is framed drives how the problem is viewed.

What problem are we trying to solve?

I once had a disruptive physician who was damaging the clinical care environment. Rather than immediately going to discipline, I talked to him and learned he was taking ER call, had most of the adult medicine panel abdicated to him, and was working on-call 26 days a month. He had an enormous burden of patients, and his life was melting down around him. Somehow, I had the wisdom to ask how I could help him and the outcome was to establish a hospitalist group, which has improved care in terms of the patient experience and has led to an

“The superpower of the physician is the relationship and connection to the patient. If there is anything we can do to help prepare us, it is to push further with the patient as the center of our universe. We are the most intensely connected to the patient. That is the physician leader’s superpower and how we’ll make changes to the system.” extraordinary financial turnaround for the hospital. This also catapulted the physician into an extraordinary leader. The leadership lesson is, when you have a problem you can’t solve, there is probably a meta-problem you may need someone else to look at.

Question: What has worked for engaging your staff that CEOs and leaders in other industries can learn from?

Answer: We demand that people deliver.

It’s important to set up a dynamic where your people can tell you when they need help breaking down a barrier. Hire the right people, articulate expectations and accountabilities, and listen to what they are saying. When you do this, they understand that you support them as much as they support you and it’s amazing what can be accomplished.

Dr. Nooravi is an organizational psychologist and CEO of Strategy Meets Performance, a leadership consulting firm that focuses on helping CEOs of fastgrowth companies shape engaging, innovative, and customer-driven cultures through executive coaching and senior team facilitation. She has been named “Trailblazer of the Year” for her research on the best practices of CEOs of high performing organizations. She can be reached at sherry@ strategymeetsperformance.com or at (312) 286-0325.

Points to Consider

1.

Connecting With Your Patients: What are you doing to maintain your relationship and connection to your patients? What is one extra step you can take to connect (for example, patient callbacks, taking extra time to read the patient’s body language and unspoken words)?

2.

Working With Different Personalities: When there is a “difficult” physician or situation, what can you do to ask and read “the question behind the question”?

3.

Talk to Me: How are you creating a culture where physicians and staff feel comfortable coming to you with their questions and concerns?

SAN DIEGO PHYSICIAN.org

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

Physician practices undergo closure for many reasons, including physician illness, death, relocation, or the physician’s decision to sell, practice solo, join another group, or retire. Especially in this time of healthcare mergers, more physicians and practice administrators are facing changes.

Of paramount concern during any change in practice is the continuity of patient care to ensure that no patient is neglected.

Relocating, Merging, or Closing Your Medical Practice?

Follow These Tips by Susan Shepard, MSN, RN 10

june 2016

Ensuring Patient Safety in an Emergent Practice Change If the practice change is abrupt, as in the circumstance of a death, the following safety measures will assist in ensuring patient safety and continuity of care: • Review all previously scheduled appointments to determine the appropriate action. Immediately contact a physician of the same specialty to arrange patient care, or provide patients with a list of practitioners of the same specialty within the area. Transfer all inpatient care to another physician immediately. Use the services of the hospital risk manager if you are unable to locate an available physician.

• Ensure the availability and accessibility of office medical records as needed for the continuity of patient care.

• Post a notice of closure in the office and in the local newspaper.

• Inform all physicians who customarily refer patients to the practice and all contracted managed care organizations, local hospitals, and the medical malpractice carrier.

Important Steps for All Practice Changes In any type of practice change, notify the following individuals and entities: • All patients and legal representatives in the “active” caseload. This includes any patient seen in the past six months to three years or others the physician considers “active,” and any patient in an acute phase of treatment.

• All peer physicians within the community.

• Local hospitals and medical societies.

• All third-party payers (to include Medicare and Medicaid) and managed care organizations.

• The DEA (if you are retiring or if you are moving to another state).

• The state licensing board.

• Professional associations in which you hold membership.

• Your CPA or financial adviser.

• Your employees.

• Landlords, lenders, and creditors.

• Insurers that cover the practice, the employees, and the physical facility.

Project4:Layout 1

9/22/08

Draft a letter to each patient that contains all of the necessary details. The same letter can be used for everyone listed above. It is recommended, if possible, that letters be sent by first-class mail and that a copy of the letter with the return receipt be kept. If a patient is considered high risk, consider sending the letter certified with return receipt requested. Post a notice in a local newspaper for at least one month to inform inactive patients or those who have moved away. Include directions for obtaining acute, critical, or emergency care if a new physician has not been selected by the time the practice closes.

Send the notice at least 60 days prior to the anticipated closure. This gives patients an opportunity to locate a new physician and to obtain copies of their medical records without undue stress.

Of paramount concern during any change in practice is the continuity of patient care to ensure that no patient is neglected.

Ms. Shepard is director of patient safety education for SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www. thedoctors.com/patientsafety.

11:22 AM

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SAN DIEGO PHYSICIAN.org

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END - OF - LIFE MEDICAL CARE

On Oct. 5, 2015, California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. A.B.X2-15 — the “End of Life Option Act” — permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. Following are questions answered in CMA’s ON-CALL document #3459, “The California End of Life Option Act” — available free at www.cmanet.org.

4.

Are there documentation and witness requirements for oral and written requests?

The California End of Life Option Act Do You Know the Answers to These Questions? by the California Medical Association

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june 2016

1.

When does the End of Life Option Act become effective?

(Answer: Thursday, June 9, 2016)

2.

Who can make an aid-in-dying request under the act?

3.

How does a patient make an aid-indying request?

5.

Are there additional documentation requirements?

6.

Are particular forms required by the act?

7.

Can an interpreter be used?

8.

Who is a “healthcare provider” under the End of Life Option Act?

9.

Can any physician receive a request for an aid-in-dying drug?

10.

What are the obligations of the attending physician who receives a request?

11.

What is required for an initial determination that a patient is “qualified” to request an aid-indying drug?

12.

Can a terminally ill patient with a mental disorder be “qualified” to request an aid-indying drug?

13.

Does a patient’s request for an aidin-dying drug mean the patient needs someone else to make decisions for them?

14.

Are there specific requirements to ensure that the patient is making an informed decision?

30.

Are physicians required to participate in the End of Life Option Act?

15.

Is a referral to a consulting physician required for every patient?

16.

Does the act contain safeguards against coercion and undue influence?

17.

Will the patient be counseled about taking an aid-indying drug?

18.

What are the final steps before an aidin-dying drug can be prescribed?

19.

How does a qualified patient obtain the aid-in-dying drug?

20.

Who can be a consulting physician and what are their responsibilities?

21.

Is a mental health specialist assessment required for every patient who requests an aid-indying drug?

22.

31.

23.

Can a patient change his or her mind to use an aidin-dying drug?

24.

Does the patient have any additional obligations once the aid-in-dying prescription is written?

25.

Does the act specify what aid-in-dying drug can be prescribed?

26.

What should be stated as the official cause of death on the death certificate?

27.

What are the attending physician’s reporting requirements?

28.

What are the aid-indying data collection and publication requirements?

29.

Are there legal protections if a physician chooses not to participate?

32.

Can medical staff members, employees, and others be prohibited from participating?

33.

What is considered “participation” in activities authorized by the act?

34.

Does the act require notice of a prohibiting employer or healthcare provider’s policy prohibiting participation in activities under the act?

35.

Are there limits on a prohibiting employer or healthcare provider’s ability to prohibit participation in activities under the act?

36.

Can a physician be disciplined for violation of a prohibiting employer or healthcare provider’s policy prohibiting participation in the act?

37.

Can a physician be reported to the medical board solely for violation of a policy prohibiting participation under the act?

38.

Are there protections and immunities for physicians who choose to participate?

39.

What is considered criminal conduct under the act?

40.

How does the act impact insurance policies and contracts?

What happens to unused or excess aid-in-dying drugs?

Who can serve as a mental health specialist under the act and what are their responsibilities?

SAN DIEGO PHYSICIAN.org

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PHYSICIAN WORKFORCE & COMPENSATION

Highlights From SDCMS’s

2015

Physician Workforce & Compensation Survey

By Tom Gehring, Retired CEO, SDCMS

14

May 2016 june 2016

Note: SDCMS member physicians wishing to receive the complete report of our 2015 physician workforce and compensation survey should email Editor@SDCMS.org.

Table of Contents A. Background and History....................................15 B. Physician Respondent Demographics.......15 C. San Diego County Physician Workforce Demographics.................................15 D. Physicians and Medicare....................................18 E. Physicians and Medi-Cal.....................................18 F. Physicians and Covered California...............18 G. Physician (Dis)Satisfaction With the Practice of Medicine............................................20 H. Perceived Physician Shortages....................20 I. Specialty-specific Perceived Physician Shortages............................................20 J. General Physician Recruiting.........................20 K. Specialty-specific Physician Recruiting...20 L. Physician Retention.............................................20 M. Physician Work Hours........................................20 N. Physician Satisfaction With Time Spent With Patients..............................................22 O. New Patient Waiting Times for an Appointment......................................................22 P. On-call Behavior.....................................................22 Q. Physician Compensation...................................22 R. Physician Compensation Trends.................. 24 S. Physician Compensation by Specialty..... 24

A. Background and History In 2002, SDCMS conducted San Diego County’s first physician workforce and compensation survey. The results provided SDCMS and local healthcare policymakers with their first insights into physicians’ attitudes toward their work, as well as San Diego County’s physician compensation environment. Subsequent SDCMS surveys — conducted in 2005, 2007, 2009, 2011, 2013, and again in 2015 — continue to yield valuable data and insights for our San Diego County physician community and local and state legislators.

B. Physician Respondent Demographics The response rate to the 2015 survey was impressive and continues to improve. We received 948 valid responses (from among a population of 7,200, giving us a 99% confidence level), up from 886 in 2013, 757 in 2011, and 580 in 2009. The preponderance of respondents were SDCMS members; however, the distribution of respondents was consistent with the San Diego County physician community across modes of practice, age, geography, gender, and primary care vs. specialty care.

C. San Diego County Physician Workforce Demographics The data for 2015 is consistent with the continuing evolution of the modes of practice for the physician workforce. An approximation for the San Diego County workforce distribution is roughly as follows: • 25% solo and small-group physicians (1–4 doctors) • 25% medium-group physicians (5–150 doctors) • 30% large-group physicians (>150 doctors) • 10% academic physicians (UC San Diego) • 10% other physicians [community clinics, government-employed (excluding Navy), and miscellaneous] Note: These percentages specifically do not include the sizable physician population at the Naval Regional Medical Centers at Balboa and Pendleton.

When lumped together, solo and small-group physicians made up 22% of the respondents. The number of solo respondents has consistently decreased over the surveys, consistent with the continuing shrinkage of the solo community. The percentage of academic physician (specifically UC San Diego) responders (20%) was

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PHYSICIAN WORKFORCE & COMPENSATION

higher than their representation in the community (about 10%).

San Diego’s doctors are, on average, slightly younger than the national average (just under 52 years of age), 64% male and 36% female (not unexpectedly, the proportion of female physicians has steadily increased over the years of this survey), and 35% primary care vs. 65% specialty care. The demographics of respondents were consistent with the physician community.

D. Physicians and Medicare Physicians were asked whether they took Medicare three years ago and whether they take Medicare now. With the 2015 passage of the Medicare Access and CHIP Reauthorization Act (MACRA), much of the concern about Medicare participation has vanished. When pediatricians are factored out of the data, every statistical grouping except solo physicians takes Medicare at or near 100% — consistent with past surveys.

About 87% of non-pediatric solos and small-group doctors take Medicare, almost identical to 2013. Of non-pediatric solo and small-group physicians who took Medicare three years ago, 97% take Medicare today.

This continues the almost

total retention by Medicare providers. If Medicare rates are unchanged, a political certainty given the passage of the MACRA, it is clear that the access to doctors taking Medicare is universally likely to improve.

For all groups except solo and small-group physicians, there is no change or a slight increase in Medi-Cal acceptance; however, the percentage of solo and small-group physicians currently taking Medi-Cal who would continue to do so with no rate increase decreases dramatically from 60% in 2013 to 44% in 2015.

Physicians who currently take Medi-Cal were asked if they would change their behavior vis-à-vis Medi-Cal with a 10% Medi-Cal increase, i.e., restoring the 10% cut of several years ago. The “across-the-board” behavior is clear: no change in MediCal acceptance for simply restoring the 10% cut.

However, the behavior of solo and small-group doctors taking Medi-Cal is dramatically different for a significant increase of Medi-Cal rates to parity with Medicare. Almost half would increase or significantly increase their acceptance of Medi-Cal. Of solo and small-group physicians

not taking Medi-Cal now, 35% would accept Medi-Cal if rates were increased to parity with Medicare.

Today, only 31% of solo and small-group doctors — the majority of whom are specialists — take Medi-Cal. Absent any action on Medi-Cal rates, 55% of solo and small-group doctors will reduce or eliminate their Medi-Cal patient hours, resulting in approximately 14% of San Diego solo and small-group physicians’ taking unrestricted Medi-Cal, 56% of mediumgroup physicians, 53% of largegroup physicians, and 83% of UC San Diego physicians.

E. Physicians and Medi-Cal Physicians were asked whether they took Medi-Cal three years ago, whether they take MediCal now, and what they would do in the face of no change in Medi-Cal rates, a 10% increase in Medi-Cal rates (i.e., restoring the 10% cut of several years ago), and if Medi-Cal rates achieved parity with Medicare.

The analysis of Medi-Cal F. Physicians and Covered rates is particularly important California given the dramatic increase of San Diego’s doctors were asked California Medi-Cal patients, about Covered California. Table now approaching one-third 1 below presents their opinions of California’s population. On about whether they do or do average, 65% of physicians took not (or don’t know yet) take Medi-Cal in 2015, versus 55% Covered California patients. in 2013, 62% in 2011, 59% in Solo and small-group physi2009, 63% in 2007, and 70% cians stand out for their unin 2005. When examined by willingness to accept Covered mode of practice, the accepCalifornia. tance rate for Medi-Cal in 2015 varies significantly: 100% for the100 community clinics, 94% Table 1: Acceptance of Covered California, by Mode of Practice for UC San Diego, 67% for 14% large groups, 72% for medium 100 27% groups, 33% for small groups, 14% and80 30% for solos. Notewor42% 51% thy is an increase in Medi-Cal 27% acceptance among large and 80 43% 42% medium groups.

60 51% Physicians who currently take Medi-Cal were asked 48% if 43% they would change their be40 vis-à-vis 21% Medi-Cal with 42% 60 havior no change in Medi-Cal rates.

48%

20

28%

40

25%

43%

21%

42%

16%

0 UCSD

Large Group

Medium Group

43%

Solo & Small 20 Group

28%

Accepts all Covered CA Insurance

25%

Accepts some Covered CA Insurance Do not accept Covered CA Insurance

16%

0 UCSD

Large Group

Medium Group

Accepts all Covered CA Insurance Accepts some Covered CA Insurance Do not accept Covered CA Insurance

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june 2016

Solo & Small Group

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PHYSICIAN WORKFORCE & COMPENSATION

G. Physician (Dis) Satisfaction With the Practice of Medicine The dissatisfaction of physicians with the practice of medicine in San Diego County is strong, but 2015 data does not reflect significant changes from 2013 — or prior years.

Overall, 55% are less satisfied with the practice of medicine than they were five years ago, as compared with 56% in 2013, 59% in 2011, 54% in 2009, 50% in 2007, and 53% in 2005.

Doctors reported that 12% are more satisfied and 33% see no change in their satisfaction with the practice of medicine.

The dissatisfaction among solo and small-group physicians continues to be extraordinarily high. Doctors practicing in large groups are the least dissatisfied, followed closely by UC San Diego and government physicians.

Primary care physicians are significantly less dissatisfied (49%) than specialists (58%) — consistent with 2013 data.

The dissatisfaction of physicians with medicine over time in practice has flattened out.

In prior years’ surveys, we saw a distinct upward slope in dissatisfaction: the more time in practice, the unhappier. Now the curve is much flatter, with little change in satisfaction over time.

H. Perceived Physician Shortages Physicians were asked whether they felt there was a physician shortage, and, if so, in what areas. Overall, 49% (a significant jump over the 40% of surveyed physicians in 2013 and prior years) felt there was a physician shortage. Of note, community clinic physicians overwhelmingly (80%, up from 66% in 2013) feel there is a physician shortage.

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june 2016

I. Specialty-specific Perceived Physician Shortages Every respondent was asked which specialties were experiencing shortages. The results were tabulated to identify in what specialties there was a consensus of shortage. The following is a priority listing of specialties where more than 5% of respondents felt there were shortages. Of those listed, some specialties had longerthan-average wait times for a new patient appointment — an informal indicator that a perceived shortage by physicians is translating into a real problem for patients. The top five areas of shortage are identical to 2013, and the list is identical (except for obstetrics and gynecology, which dropped) in membership to 2013: family medicine, internal medicine, psychiatry, neurology, pain medicine, endocrinology, pediatrics, rheumatology, hospice and palliative medicine, general surgery, dermatology, gastroenterology, hospitalist, urology, and neurosurgery.

J. General Physician Recruiting The recruiting picture appears to have gotten much worse since 2013. Of those who were involved in recruiting, 43% (up from 33% in 2013 and 39% in 2011) reported some difficulty in recruiting; 25% (identical to 2013) reported significant difficulties in recruiting. Everyone, including large groups, is having difficulty recruiting.

When examined more closely, solos (1–2 physicians) are having significantly more difficulty recruiting than small groups (3–4 doctors).

K. Specialty-specific Physician Recruiting Specialty-specific data was then analyzed to identify those specialties with recruiting problems. While the degree of difficulty in recruiting is somewhat subjective, analysis of the data indicates the following: • “Significant difficulty” was indicated for the following specialties (sorted alphabetically): family medicine, internal medicine, orthopaedic surgery, psychiatry, pulmonology / critical care.

• “Some difficulty” was identified for the following specialties (sorted alphabetically): allergy and immunology, anesthesiology, cardiology, emergency medicine, endocrinology, general surgery, hematology and oncology, hospitalist, neurology, obstetrics and gynecology, pathology, pediatrics, radiology, and urology.

L. Physician Retention The 2015 survey projects 73% of San Diego County physicians will maintain their practice “as is” for the next three years, down from 79% in 2013, and 82% in 2011 and prior years.

This is a significant and clear warning sign of physician dissatisfaction. Physicians were asked what they intend to do with their practice in one to three years: 4% will leave the practice of medicine in one year; 4% will reduce hours in the practice of medicine in one year; 12% will leave the practice of medicine in three years; and 7% will reduce hours in the practice of medicine in three

years. When analyzed by mode of practice, the overall trend is duplicated in every mode of practice — retention is dropping across the board.

When analyzed by geography, East County, North County (inland), and Hillcrest are predicted to have higherthan-average reductions in the doctor workforce. Not surprisingly, of those physicians likely to change their practice mode, there was a clear drop-off for physicians in practice for more than 30 years, with 47% saying they would be in practice in three years, the lowest retention percentage since 2007. There is very clearly a “cliff” of retirements coming as doctors who worked through the recession are now thinking of retiring — compounding the normal retirement rate.

M. Physician Work Hours The average number of total hours worked by full-time, active San Diego County physicians, including clinical and nonclinical hours, was 56 hours per week, essentially unchanged from the last four surveys. On average, female physicians are working 53 hours per week, and male doctors are working 58 hours.

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PHYSICIAN WORKFORCE & COMPENSATION

N. Physician Satisfaction With Time Spent With Patients Physicians were asked whether they felt that the time spent with patients was adequate.

62% responded that time with patients was adequate, while 38% said time was inadequate.

This is consistent with prior surveys. However, when the data was analyzed by mode of practice, differences emerged (percent satisfied with the time spent with patients): 20% for community clinics, 72% for government, 67% for large groups, 61% for medium groups, 66% for small groups, 66% for solos, and 55% for UC San Diego.

Of note, UC San Diego’s physician satisfaction with time spent on patient care was less in 2015 than in prior years.

Specialists are overwhelmingly satisfied with time spent with patients, at 65%, consistent with 2013. Primary care physician satisfaction with time spent with patients was unchanged since 2007, at about 57%. One significant anomaly is that primary care physicians at UC San Diego were less satisfied with the time spent with patients than their peers in solo and small groups, and medium and large groups.

O. New Patient Waiting Times for an Appointment Physicians were asked how long, in weeks, it took to schedule an appointment for a new patient. The average time for a new patient to obtain an appointment, for doctors taking new patients, was 2.2 weeks, or 11 business days — essentially unchanged from prior years.

When compared to prior survey data, there is no significant change in the wait-time distribution for new appointments: 35% in 1 week; 30% in 2 weeks; 14% in 3 weeks; and 21% in 4 weeks. Of note, community clinics had the longest wait times, while solo, small-group, and medium-group physicians had the shortest wait times.

The data was analyzed to determine any variance by physician gender, physician experience, or whether the physician was a specialist or a primary care physician. It takes, on average, one business day longer to see a female doctor than a male doctor. There is no significant difference between average specialist and primary care physician wait times. There was no significant difference between wait times based on physician time in practice. There is significant variation between modes of practice. Solo, small-group,

and UC San Diego waits are increasing, while medium-group and large-group wait times are decreasing.

As would be expected, the data indicate significant variation between specific specialties. Data for those specialties receiving fewer than five physician responses were removed from the chart, and only specialties at or above the average of 11 days were included.

The following are wait times in days for new appointments by specialty: • orthopaedic surgery: 11.0 • family medicine: 11.1 • gastroenterology: 11.7 • nephrology: 11.8 • endocrinology: 12.5 • obstetrics and gynecology: 12.5 • pulmonology: 12.5 • urology: 12.5 • otolaryngology: 12.8 • ophthalmology: 13.0 • dermatology: 13.1 • psychiatry: 13.5 • cardiology: 14.5 • physical medicine and rehabilitation: 15.0 • rheumatology: 16.3 • neurology: 17.9 Several specialties had higher-than-average wait times for the five surveys (2007, 2009, 2011, 2013, and 2015): neurology, psychiatry, ophthalmology, and nephrology. Several specialties had higher than average wait times for the last four surveys: urology and gastroenterology.

Several specialties had higher than average wait times for the

last two surveys: cardiology, obstetrics and gynecology, and endocrinology. There were four new specialties for 2015 with longer-than-average wait times: pulmonology, otolaryngology, orthopaedic surgery, and dermatology. Hematology/ oncology, vascular surgery, and pain medicine had belowaverage wait times and were dropped off the list. New to the above-average wait times for 2015 were family medicine, physical medicine and rehabilitation, and rheumatology.

When the primary care physicians (family medicine, obstetrics/gynecology, internal medicine, and pediatrics) were analyzed, there was also significant variation: 9 days for pediatrics; 11 days for internal medicine and family medicine; and 13 days for obstetrics and gynecology.

P. On-call Behavior Physicians were asked to identify the number of days per month they took call, with and without stipends. There is no significant change since 2009.

While the percentage of solo and small-group doctors taking uncompensated call is low, the number of days of uncompensated call is much higher than for the other cohorts.

Q. Physician Compensation The net compensation for full-time active physicians was unchanged from 2013.

Table 2: Average Pay of Full-time Active Physicians Over Past Surveys

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june 2016

Year

Average Compensation

2015

$235,000

2013

$235,000

2011

$215,000

2009

$210,000

2007

$180,000

2005

$160,000

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PHYSICIAN WORKFORCE & COMPENSATION

Table 3: Reported Pay for Primary Care vs. Specialty Care Physicians

Average Primary Care Physician Compensation

Average Specialty Care Physician Compensation

2015

$210,806

$247,545

2013

$192,632

$255,939

2011

$166,000

$235,500

2009

$171,000

$229,000

Table 4: Physician Pay Distribution by Mode of Practice

Mode of Practice

Average Compensation

Academic Physicians

$223,292

Solo and Small-group Physicians

$216,667

Medium-group Physicians

$237,574

Large-group Physicians

$275,330

Community Clinic Physicians

$161,905

The difference between primary care physicians and specialists continues, but the gap between primary care and specialty care is closing. In 2015, the reported pay for primary care went up by $18,000, while the reported compensation for specialty care doctors went down by $8,000.

The differences in pay distribution for physicians based on mode of practice continues.

The pay distribution and the average compensation for solo and small-group physicians have not changed significantly in the last three surveys. Compensation for medium- and large-group physicians has steadily improved since 2007, but there is a drop between the 2013 and 2015 compensation. A significant difference is emerging between large-group

24

june 2016

physician compensation and medium-group doctor pay. For example, the weighted average pays for large is $275,000 vs. $236,000 for medium group.

The gender gap in pay is real but is closing. The average pay, across all modes and specialties, is $252,000 for men (unchanged since 2013) and $202,000 for women (up from $183,000 in 2013). However, the number of hours worked must also be factored into the picture: On average, female doctors work 53 hours per week vs. 58 hours per week for male physicians. So, when adjusted for total hours, the gap normalized to hours worked is not quite as large.

When active, full-time physician compensation is examined over the quarters of the doctors’ professional life cycle,

an interesting trend emerges.

The first three quarters (0–10 years in practice, 11–20 years in practice, and 21–30 years in practice) are all roughly equivalent, but there is a dramatic falloff for 31+ years in practice.

Said differently, there are small longevity raises for doctors in the first 30 years of practice, and there is a clear falloff in the final quarter of practice.

R. Physician Compensation Trends Physicians were asked whether their compensation went up, stayed the same, or went down relative to their compensation three years ago: 39% indicated their pay went up; 26% said their pay went down; and 35% reported their compensation was flat.

The female physicians’

opinion of compensation trends is more positive than their male counterparts’. Significantly more females than males have increasing compensation.

When the physicians’ opinions about compensation trends are reviewed by mode of practice, several interesting trends appear: government and community clinic physicians believe that their pay is improving; solo, small-group, and medium-group physicians think that their pay is decreasing; large-group and UC San Diego doctors are sensing that their pay is improving.

The perception of compensation by primary care physicians increased significantly, while, relative to three years ago, the perceived compensation trend of specialists has been flat. When analyzed for years in practice, the trends are not surprising: Younger physicians see their compensation increasing, midcareer doctors see their compensation as flat, and end-of-career physicians see their pay as decreasing.

S. Physician Compensation

by Specialty The five lowest-paid specialties with 10 or more respondents are (listed alphabetically): endocrinology, family medicine, internal medicine, pediatrics, and psychiatry. The five highest-paid specialties with 10 or more respondents are (listed alphabetically): dermatology, general surgery, orthopaedic surgery, radiology, and urology.

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Interested in board-certified IM or FP applicants with EHR experience. Please email CV to portofino3@aol.com or call (619) 248-2324. [462] SEEKING EXPERIENCED, HIGHLY MOTIVATED FAMILY OR INTERNAL MEDICINE PHYSICIAN: Federally qualified health center (FQHC) clinic site in Linda Vista seeks an experienced, highly motivated family or internal medicine physician with a vision for the future of community medicine. San Diego Family Care operates seven clinic sites in San Diego to serve the primary care needs of our diverse communities. PCMH model operational and EHR system in place. NCQA recognized. Visit our website at sdfamilycare.org. Must have CA license. Competitive salary/benefits with retirement match. Looking for a special doctor, committed to our mission! Send CV to Arthur “Tony” Blain, MD, MBA, FAAFP, Medical Director, at aablain@lvhcc.com or call (858) 248-1509. [440] PRIMARY CARE POSITION: San Diego area. Outpatient only. No calls. No hospital and no weekends.

Email sandiegoprimarycare@yahoo.com. [495] FULL OR PART-TIME BC/BE DERMATOLOGIST TO JOIN OUR TEAM: Two employment opportunities with a premier dermatology practice. One position to cover our Oceanside / Escondido / Murrieta locations, and a second separate position to cover our Murrieta / Temecula locations. Full or part-time BC/BE dermatologist to join our team. This is a busy, eight physician, three physician assistants, and seven office practice. Dermatology Specialists is well established in the local communities with a wide referral base and good patient mix. Candidate will have the flexibility of practicing general, surgical, and cosmetic dermatology. This is an excellent opportunity for a physician who is team oriented, motivated, enthusiastic, and caring to join a well-established, busy, and stable practice. We offer a generous base salary plus production incentive and benefits. This is a practice opportunity without the hassle of managing and partnership obligations. If you are interested in finding out more information concerning employment opportunities with Dermatology Specialists, Inc., please forward your CV to Jane Lisk, administrator, via fax at (760) 828-9140, via email at dsioceanside@aol.com, or call (760) 828-9129. [494]

SHARED PARTNERSHIP PRACTICE: Seeking internal medicine physician to join a shared-expense private practice partnership in Vista, California. Wonderful opportunity to join a well-established internal medicine group that has a history of over 30 years of outstanding care in the community. Established EMR system and exceptional office staff. CA license, board-certified IM physicians should send CV to dene@ncim.sdcoxmail. com or call Dene at (760) 726-2180. [492] 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] SEEKING EXPERIENCED, HIGHLY MOTIVATED FAMILY OR INTERNAL MEDICINE PHYSICIAN: Federally qualified health center (FQHC) clinic site in City Heights seeks an experienced, highly motivated family / internal medicine physician with a vision for the future of community medicine. San Diego Family Care operates seven clinic sites in San Diego to serve the primary care needs of our diverse communities. PCMH model operational and EHR system in place. NCQA recognized. Visit our website at sdfamilycare.org. Must have CA license. Excellent salary / benefits with retirement match. Looking for a special doctor, committed to our mission! Send CV to Diana Marquardt, MD, Medical Director, at dmarquardtmd@roadrunner. com or call (619) 321-2614. [487] PART-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a part-time physician. Flexible hours, strong staff, and good compensation (based on experience). Please send CV to jeff@eastcountyurgentcare.com. [474] SEEKING A FOOT/ANKLE SPECIALIST: Well-established, highly respected, four-physician group, private practice in San Diego seeking a foot/ankle specialist. Our group is expanding to meet high volume of cases and planned expansion. Potential opportunity for any established subspecialist looking for a permanent practice location. We have a broad-based primary care referral base, mature EHR, digital X-ray, ultrasound, and DME program. Interested parties, please email your CV in confidence to lisas@sdsm.net. [461] SEEKING EMERGENCY MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 500+ physician multispecialty group in San Diego, is seeking full-time BC/BE emergency medicine physicians to join our urgent care staff. We offer a competitive compensation package, excellent benefits, and shareholder opportunity after two years.

Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax (619) 2334730. Email lori.miller@sharp.com. [459] SEEKING FAMILY MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 500+ physician multi-specialty group in San Diego, is seeking full-time BC/BE family medicine physicians for the South Bay. We offer a competitive compensation package, excellent benefits, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax (619) 233-4730. Email lori. miller@sharp.com. [458] SEEKING INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 500+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians for the South Bay. We offer a competitive compensation package, excellent benefits, and shareholder

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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opportunity after two years. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax (619) 233-4730. Email lori. miller@sharp.com. [457] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 9925330 or email CV to drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [037] PHYSICIANS NEEDED: Family medicine and pediatric physician positions currently available.

Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County, Riverside County, and Orange County. We have openings for full-time and part-time physicians. Current CA and DEA licenses required. Malpractice coverage provided.

Full benefits packet. Forward resume to hr@vistacommuntyclinic.org or fax to (760) 414 3702. Visit our website at www.vistacommuntyclinic.org. EEO Employer / Vet / Disabled /AA [912] OFFICE SPACE AVAILABLE BEAUTIFUL DOCTOR’S OFFICE FOR RENT IN BANKER’S HILL: Ocean view office, two exam rooms, can share staff or bring your own. Furnished, lab on site. Office multi-specialty group and bilingual front office staff. Please call Diana, office manager, for more details at (619) 233-4044. [500] 2,000FT2 MEDICAL OFFICE SPACE AVAILABLE TO SHARE IN POWAY: Office space available to share with orthopedic surgeon in Poway at professional medical building. Approximately 2,000ft2, separate reception, four exam rooms, part time on Thursdays and Fridays or schedule to discuss. Utilities included, separate desk work area for one employee with separate phone line and internet. Rates will depend on usage, short- or longterm lease available. Newly remodeled, upbeat staff and environment, walking distance to Pomerado Hospital and other medical facilities nearby. For more information, email Anna at anna@pomeradoortho.com or call (858) 487-6440. [464] OFFICE SPACE FOR RENT WITH WELL-ESTABLISHED ORTHOPAEDIC PRACTICE: Located near Alvarado Hospital. Onsite digital X-ray. Ideal for specialties such as pain management, rheumatology, foot/ankle, spine. Interested parties, please email lisas@sdsm.net. [493] MEDICAL OFFICE SPACE FOR RENT IN ENCINITAS: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway.

Features include two spacious exam rooms, private consultation / doctor’s office, lunchroom, private bathroom, and a spacious waiting room shared with one other doctor. Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (858) 756-3021 or email ktagdiri@gmail.com for more information. [489] 3998 VISTA WAY, IN OCEANSIDE: Three medical office spaces approximately 2,000–2,500 square feet 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. [480] MEDICAL OFFICE SPACE FOR SUBLEASE WITHIN 4,000FT2 ESTABLISHED FAMILY PRACTICE IN UTC / LA JOLLA AREA: Ideal location between I-5 and I-805. Only a few blocks from UCSD and Scripps. Spacious ground floor space with ample parking within a professional medical complex. Up to two modern, private exam

/ treatment rooms available, nurses station, shared or own receptionist. Clean, contemporary design, ADA compliant, built-in laboratory. Excellent, inhouse referral base from four busy and respected practitioners. Ideal for OB/GYN, dermatology, aesthetic medicine, neurology, ENT, or other complimentary specialty. Please email thbdesigninc@ gmail.com or call (858) 999-5153. [453] 1,701FT2 MEDICAL OFFICE SPACE AVAILABLE TO SHARE IN CLASS A MEDICAL OFFICE BUILDING: Turnkey, recently remodeled, first floor in Sorrento Valley with excellent highway access and easy, free parking. Flexible schedule options. Four exam rooms. Two entrances. Reasonable rates. Email or call for more information: (619) 218-8980, mobyrne61@gmail.com. [444] 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] 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 PART-TIME NURSE PRACTITIONER POSITION: Beautiful Banker Hills, office with multi-specialty group, adult medicine, travel, HIV medicine, and friendly environment. Please call Diana, office manager, for more details at (619) 233-4044 and fax (619) 233-4144. [501] MEDICAL OFFICE ADMINISTRATOR: We are a one-doctor private practice looking to hire a front office with previous office experience. Must have warm caring demeanor, excellent interpersonal and customer service skills. Must have good computer skills and experience with electronic medical records. Experience with Athena net is especially helpful. Other important experiences are front office administrative tasks such as operational and customer service issues, coordinating employee resources and patient flow. Familiarity with back office task is a plus. Forward your resume and cover letter to ktagdiri@gmail.com. [490] 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] ACCOUNTING MANAGER: The accounting manager is responsible for general accounting functions, including general ledger, month end reconciliation’s, close, and financial preparation, cash management, and oversight of accounts payable

and payroll functions. The accounting manager will manage and provide guidance to the accounts payable, staff accountants, and payroll. Qualifications: Bachelor’s degree in finance / accounting; 7+ years in senior-level accounting, with three years management experience; Strong knowledge base of finance, accounting, budgeting, payroll regulations, and cost analysis in accordance with GAAP required; Preferred knowledge base within healthcare and/or grants management accounting; Preferred database experience within Great Plains and ADP. Contact Joyce Nagel at (760) 736-8737 or at joyce.nagel@nchs-health.org. [483] RAMONA HEALTH CENTER MANAGER: The Ramona health center manager is responsible for the management and operation of the day-to-day activities of the health center, including employment.

The manager will maintain the mission of NCHS to improve the health status of our diverse communities by providing quality healthcare that is comprehensive, affordable, and culturally sensitive.

Qualifications: Bachelor’s degree or equivalent work experience in health services administration, public health, or related field; Knowledge of medical terminology, legal and technical aspects of a medical records system, and ICD9 and CPT codes; 3-5 years’ experience in a medical, health, or social services setting; 3+ years’ management experience. Contact Joyce Nagel at (760) 736-8737 or at joyce.nagel@nchs-health.org. [484] LVN NURSE MANAGER: The LVN nurse manager is responsible for day-to-day activities of the health center. You will participate as a member of the leadership team to ensure effective quality medical services to patients. Health center manager assures that health center procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients. Responsible for assisting in scheduling clinicians for optimal medical coverage. Able to maintain a high standard of confidentiality. Qualifications: High school diploma, GED or foreign equivalent; Graduate of an accredited LVN/LPN program; Current California state licensure LVN/LPN; Current IV cert required; Current CPR/BLS American Heart Association; Two years’ experience supervising staff in a healthcare setting. Contact Joyce Nagel at (760) 736-8737 or at joyce.nagel@nchs-health.org. [485] RN — BILINGUAL WHS: The Women’s Health Services registered nurse (RN), under the direction of the director of nurses, follows medical protocols and administrative procedures. WHS RN will run a NSt/AFI clinic, doing patient education and conducting triages for the department. Will also assist in preparing patients, perform laboratory procedures, and dispense and administer medication.

You will be responsible for case management, and maintain the confidentiality. Qualifications: ASN, prefer BSN; Current California state registered nurse license; CPR/BLS American Heart Association, current; Two years’ nursing experience prefer in WHS; Required bilingual in English and Spanish. Contact Joyce Nagel at (760) 736-8737 or at joyce.nagel@nchs-health.org. [486] PHYSICIAN ASSISTANT NEEDED FOR BUSY MULTI-DISCIPLINARY MEDICAL PRACTICE TO START IMMEDIATELY: Requirements: Must be CA licensed; Have high ability to work in a fast-paced environment and handle stressful situations; Must be compassionate and have great bedside manner.

Please email or fax resume with salary requirements to jeannielanderos@yahoo.com or (858) 202-1548. To learn more about our company, visit us at www.paincarerehab.com. [481] 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]

TIONER: 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] Legal Services

When the BMQA calls …

Your best friend is competent counsel Call the Law Offices of Richard B. Rodriguez 33 years of experience Reasonable Rates (619) 427-7622 Email:lawrichrod@aol.com MEDICAL EQUIPMENT / FURNITURE FOR SALE CLEARWAVE OFFICE WAITING ROOM CHECKIN KIOSK WITH TABLETOP STAND: (eClinicalWorks Compatible) Decrease wait times, increase collections, and improve financial performance.

Liberty Tabletop Kiosk with 17-inch, built-in, all-inone touchscreen computer with privacy filter. Intel Celeron Dual Core, E1500, 202 GHz processor, 2GB RAM, 160GB hard-drive, ID Tech swipe magnetic credit card reader mounted on right side of the screen. Copays and accounts receivable payable upon check-in. Windows 7 OS, LogMeIn Pro2, IE 9, and McAfee. eClinicalWorks kiosk software included. Original cost new $5,199. Sell for only $1,899. Email KLewis@SDCMS.org. [443] EXAM PROCEDURE LIGHT IN EXCELLENT CONDITION (GENTLY USED): Works well, with 12V halogen bulb. Bought new for $225.00, asking $50. Color is white with chrome. Has flexible goose neck. Base with 4 wheels for easy mobility and long cord. Plug-in is 3 prong. Perfect for medical procedures or skin care. If interested, please call (858) 272-2021. Located in a medical center near Interstate 5. [482] MEDICAL EQUIPMENT: Two Midmark 404 exam tables (excellent condition), including extra tabletop (brand new) $400.00 each. Two TAB file cabinets (3’x5’) at $200.00 each. X-ray file cabinet (3’x6.5’) at $200.00. X-ray view box $100.00.

Finger Reduction system at $200.00. Cast cutting saw at $100.00. Health O Meter Mechanical Pediatric scale (nearly new) at $100.00. All offers can be best priced. Please call (619) 298-9938 if interested. [479]

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

PHYSICIAN ASSISTANT OR NURSE PRACTI-

SAN DIEGO PHYSICIAN.org

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P e r s o n a l & P r o f e s s i o n a l D e v e lo p m e n t

Our mind has hijacked our attention, and we’ve moved out of our present experience; however, as we become more capable of remaining mindful, we recognize the thought and let it pass by, returning our attention to the activity of the moment.

Finding Peace and More Power Beyond our Stress

by Helane Fronek, MD, FACP, FACPh

A client who left her medical position and is looking for a new medical endeavor lay awake at night, concerned about her future. She ruminated that she might never work as a physician again. She imagined losing her sense of identity and becoming depressed, that her husband would leave her, and her family would fall apart.

She tried, unsuccessfully, to “think happy thoughts.” She then realized it was these types of thoughts, and not the imagined events, that were at risk of undermining her life. She had become the observer of her thoughts. That awareness separated her from the negative thoughts and weakened their grip on her. Exhausted but more peaceful, she fell asleep.

Years ago, after learning that my mammogram showed suspicious calcifications, my thoughts rocketed into a frightening

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future in which I died, and my husband and children were suffering. If I had the skill of mindfulness that my client used, I might have avoided this frightening experience.

The power of mindfulness to relieve us of unnecessary suffering was demonstrated today during a medical school session on the long-term effects of adverse childhood experiences. A woman shared her history of abuse and how she used mindfulness to find relief from the flashbacks. When frightening thoughts arose, she was able to recognize their source in the past and bring herself back to the healthier reality she was now living. While those events had happened, they were not happening now, and she no longer needed to be afraid.

How does one practice “mindfulness”?

It’s simple — although not always easy.

Meditation and yoga focus on one aspect

of our experience: breathing or movement.

As we focus, we notice that thoughts divert our attention from the breathing or movement. Often, our minds seize these thoughts and create a compelling story about them.

Recalling a patient encounter, we might worry we said the wrong thing or missed a diagnosis. We then worry we aren’t as skilled as we “should” be and imagine dire consequences or list what we “need” to do to improve. Our mind has hijacked our attention, and we’ve moved out of our present experience; however, as we become more capable of remaining mindful, we recognize the thought and let it pass by, returning our attention to the activity of the moment: breathing or movement. This improves our ability to do this routinely during the day when similarly distressing but irrelevant thoughts come into our awareness.

The next time you notice yourself worrying, ask two simple questions: Is this concern real in the present moment? Is there something I can do about it now? If not, bring yourself back to what is true for you in this moment. Where are you?

What is there to appreciate? What needs to be done right now? While physicians encounter many stressors each day, we also have the ability to step over imagined worries and put our focus on what is real in our lives — where we actually have the power to make a difference.

Dr. Fronek, SDCMSCMA 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.com.

Success.

It’s what California’s finest physicians strive for... and what CAP can help you achieve.

Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

Prepare for Value-Based Compensation with CAP’s Free Guide As payers move toward a more value-focused model of reimbursement, your practice’s revenue stream may soon be tied entirely to clinical outcomes and patient experience.

CAP’s Physician’s Action Guide to Value-Based Compensation is replete with valuable information and tips to help you stay ahead of the VBC curve and attain fair and prompt reimbursement from public and private payers.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/Value SAN DIEGO PHYSICIAN.org

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$5.95 | www.SANDIEGOPHYSICIAN.org

PRSRT STD U.S. POSTAGE

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca 92123

PAID DENVER, CO PERMIT NO. 5377

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UNMATCHED

WE ARE UNMATCHED IN REWARDING OUR MEMBERS FOR PRACTICING GOOD MEDICINE

As a company founded by doctors for doctors, we believe that doctors deserve more than a little gratitude for an outstanding career. That’s why we created the Tribute® Plan—to reward our members for their loyalty and commitment to superior patient care with a significant financial award at retirement. How significant?

The highest distribution to date is $138,599. This is just one example of our unwavering dedication to rewarding doctors.

Join your colleagues—become a member of The Doctors Company.

CALL OUR LOS ANGELES OFFICE AT 888.536.5346 OR VISIT WWW.THEDOCTORS.COM

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts.

For additional details, see www.thedoctors.com/tribute.

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