February 2017

FEBRUARY 2017 OFFICIAL PUBLICATION OF SDCMS

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FEBRUARY

CONTENTS

VOLUME 104, NUMBER 2

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: Mihir Y. Parikh, MD President-elect: Mark W. Sornson, MD Secretary: David E. J. Bazzo, MD Treasurer: James H. Schultz Jr., MD Immediate Past President: William T-C Tseng, MD, MPH (CMA Trustee)

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AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali, DO, MPH • Steven L-W Chen, MD, MBA (Alt) • Stephen R. Hayden, MD • Vimal I. Nanavati, MD (Alt) • Alexexandra E. Page, MD • Robert E. Peters, MD, PhD (Alt) • Carl A. Powell, DO (Alt) • Peter O. Raudaskoski, MD • Albert Ray, MD (Alt) • Thomas J. Savides, MD • Karl E. Steinberg, MD (Alt) • Erin L. Whitaker, MD (Alt) • Marcella (Marci) M. Wilson, MD (Alt) • Holly B. Yang, MD (Board Rep) • Nicholas J. Yphantides, MD

feature

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OTHER VOTING MEMBERS Communications Chair: J. Steven Poceta, MD Delegation Chair: Robert E. Peters, MD, PhD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: David Li

2-1-1 San Diego: An Interview With John Ohanian, CEO

(centerfold)

2-1-1 San Diego Poster for Your Waiting / Exam Room

departments 4

Briefly Noted: Calendar • Office Manager Advocacy • Bioethics • Welcome New and Returning Members • Featured Members • Physician Socials • And More …

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MA Federal Update: Healthcare C Reform and MACRA

BY ELIZABETH MCNEIL

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The Doctor’s Dilemma

BY HOWARD MARCUS, MD, FACP

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erspectives on the Future of P Medicine: A Conversation With Dr. Wachter

BY RICHARD E. ANDERSON, MD, FACP

OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Zachary T. Berman, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (Delegation Vice Chair) (At-large AMA Delegate, Appointed by CMA) Delegation Chair: Robert E. Peters, MD, PhD CMA President-elect: Theodore M. Mazer, MD (At-large AMA Delegate, Appointed by CMA) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate, Appointed by CMA) • Ralph R. Ocampo, MD CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

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Put Your SDCMS-CMA Membership to Work: Get Involved!

26 Physician Marketplace: Classifieds

19 What a Lender Looks for When Reviewing a Loan Request

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BY MICHAEL T. VALENTI

BY HELANE FRONEK, MD, FACP, FACPh

FEBRUARY 2017

GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt) • Jay P. Mongiardo, MD • Venu Prabaker, MD • Kosala Samarasinghe, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD (Board Rep) • 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 • Wayne C. Sun, MD (Alt) North County: Neelima V. Chu, MD (Alt) • Michael A. Lobatz, MD • Patrick A. Tellez, MD South Bay: Maria Carriedo, MD (Alt) • Reno D. Tiangco, MD

The Masculine and Feminine of Delivering Healthcare

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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OFFICE MANAGER ADVOCACY

Encourage Your Office Manager to Sign Up! SDCMS’s online Office Manager Forum enables our members’ office managers and practice administrators to build a community of mutual support in order to, for example, get answers to their practice management questions, share best practices, stay abreast of upcoming deadlines, and much more! This is a private, invitation-only forum for the office managers and practice administrators of current SDCMS member physicians, giving them access to a shared calendar, discussion forums, member profiles, photo gallery, file storage, and more. To join, go to sdcmsofficemanagerforum.groupsite.com. If you have any questions, email Editor@SDCMS.org.

HEALTHCARE CONFERENCES

SDCMS-CMA CALENDAR

To submit a community healthcare event for possible publication, email Editor@SDCMS. org. Events should be physician-focused and should take place in or near San Diego County.

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

Coalition for Compassionate Care of California Annual Summit MAR 13–14 in Sacramento

Physician Networking Opportunity & Mixer (social) APR 14, 5:30pm–8pm, at Casa Machado Restaurant (Overlooking Montgomery Field Airport)

Ocular Diseases Drug Discovery MAR 20–21 at the Hilton San Diego Resort & Spa

CMA Legislative Advocacy Day (conference) APR 18 at the Sheraton Grand in Sacramento Western Health Care Leadership Academy (conference) MAY 5–7 at the Marriott Marquis San Diego Marina

Biomarker Summit 2017 MAR 20–22 at the Hilton San Diego Resort & Spa New Treatments in Chronic Liver Disease MAR 31–APR 2 at the Estancia La Jolla Hotel ASLMS 2017, the 37th Annual Conference of the American Society for Laser Medicine and Surgery APR 5–9 at the San Diego Convention Center & Hilton San Diego Bayfront Hotel — aslms.org Clinical Advances in Heart Failure and Arrhythmias APR 28–30 at the Loews Coronado Bay Resort in Coronado

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FEBRUARY 2017

BIOETHICS

When Families Coerce SDCMS’s Bioethics Commission met on Jan. 25 to discuss “Relational Autonomy or Coercion?” with a presentation given by Lynette Cederquist, MD, and Paula Goodman-Crews, LCSW. When does family support become autonomy-diminishing pressure? When does family pressure become autonomy-defeating coercion? And what culturally sensitive standards should physicians use to discern and identify patients under the undue influence of someone else? These questions and others, along with two heartrending case studies of local patients, one a 48-year-old male with Bulbar ALS whose parents did not believe he had ALS, and the other a 55-year-old man with heart and lung failure whose wife aggressively opposed his decision to be taken off life support, guided a lively hour-long discussion.

SDCMS’s Bioethics Commission will meet again in 2017 on April 26, July 26, and Oct. 25. Our 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. Meetings begin at 6 p.m. and end at 8 p.m., and are held 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.

SDCMS has a number of committees and commissions and various other opportunities for member physicians to become involved and get engaged. To learn more about how you can support your physician colleagues, fight for your patients, and be a part of the solution, email SDCMS@SDCMS.org. Thank you for your membership!

/////////////////////////////////////////////////////////////////////////////////////////////////// MEMBERSHIP

Welcome New and Returning Members!

NEW MEMBERS Hatem A. Abou-Sayed, MD Plastic Surgery San Diego (858) 247-2933 Samuel A. Amukele, MD Urology San Diego (619) 662-5458 Neil A. Aranha, MD Anesthesiology San Diego (858) 673-6100 Robert J. Belsher, MD Family Medicine Carlsbad (619) 528-5000 Timothy A. Bemiller, MD Gastroenterology San Diego (619) 532-6460 Joseph A. Blatt, MD Clinical Cardiac Electrophysiology La Jolla (619) 528-5000 Eduardo A. Borquez, MD Emergency Medicine San Diego (619) 528-5000 Andres F. Bustamante, MD Internal Medicine Bonita (619) 528-5000 Gayle Cabalbag, MD Internal Medicine San Diego (619) 528-5000 Juan S. Calderon Molina, MD Nephrology La Jolla (619) 475-4900 Yeukkei Cheung, MD Orthopaedic Surgery San Diego (619) 528-5000 David P. Cork, MD Cardiovascular Disease San Diego (858) 534-8930 Said T. Daneshmand, MD Reproductive Endocrinology/Infertility San Diego (858) 794-6363

Shawnjit S. Dhesi, MD Anesthesiology San Diego (858) 565-9666 Eric S. Eikermann, MD Anesthesiology Vista (858) 565-9666 Erick R. Elchico, MD Anesthesiology San Diego (858) 565-9666 Dasia E. Esener, MD Emergency Medicine San Diego (619) 528-5000 Janice L. Fernandez, MD Anesthesiology San Diego (858) 565-9666 Nilofar Firooznia, MD Diagnostic Radiology Poway (858) 487-9729 Andrei Fodoreanu, MD Pediatrics San Diego (619) 528-5000 Cainan H. Foltz, MD Gastroenterology San Diego (858) 292-7527 Mark A. Franke, MD Diagnostic Radiology San Diego (530) 808-1630 James W. Gaudet, MD Psychiatry San Diego (619) 662-5661 Nareg A. Gharibjanians, MD Anesthesiology San Diego (858) 565-9666 Reshma Gokaldas, MD Neurology Carlsbad (760) 631-3000 John L. Grimwood, MD Dermatopathology San Diego (619) 532-6400 Gary C. Gualberto, MD Neurology Solana Beach (760) 631-3000

Margaret S. Hsu Taghavi, MD Diagnostic Radiology La Mesa (619) 460-2770

Rachit Patel, MD Psychiatry Carlsbad (760) 631-3000

Gary S. Zane, MD Anesthesiology San Diego (858) 565-9666

Mohamed S. Ibrahim, MD Anesthesiology San Diego (858) 673-6100

Leonard E. Philo, MD Gastroenterology Rancho Santa Fe (619) 532-6400

Shiyin S. Zhu, MD Anesthesiology San Diego (858) 565-9666

James S. Kim, MD Anesthesiology San Diego (858) 565-9666

Tara A. Quesnell, MD Clinical Neurophysiology Carlsbad (760) 631-3000

RETURNING MEMBERS

Yogita Lakhera, MD Nephrology San Marcos (909) 558-4000

Andrew N. Robbins, MD Diagnostic Radiology San Diego (714) 871-5577

Valentin A. Lance, MD Radiology La Mesa (619) 460-2770

Christopher Rodarte, MD Ophthalmology San Diego (619) 528-5000

Kathryn Langham, MD Child and Adolescent Psychiatry San Diego (858) 534-2757

Jeffrey K. Rowe, MD Psychiatry San Diego (858) 694-4695

Sinjin Lee, MD Clinical Cardiac Electrophysiology San Diego (619) 528-5000 Kristine H. Lethert, MD Hematology San Diego (619) 528-5000 Yan Li, MD Anesthesiology San Diego (858) 673-6100 Amreesh Mahil, MD Anesthesiology San Diego (858) 565-9666 Yolanda Marzan, MD Anesthesiology San Diego (858) 565-9666 Brian J. Minnillo, MD Urology La Jolla (858) 453-5944 Andrew Mohr, MD Anesthesiology San Diego (619) 543-5897 William P. Neil, MD Vascular Neurology San Diego (619) 528-5000 Elisa S. W. Ng, MD Internal Medicine San Diego (858) 573-5281 Tuan-Anh T. Nguyen, MD Psychiatry San Diego (619) 528-5000

Pamila K. Brar, MD Internal Medicine San Diego (858) 864-1027

Ariel Shuckett, MD Obstetrics and Gynecology San Diego (858) 277-9378 Jan P. Sliwa, MD Anesthesiology San Diego (858) 565-9666 Christine C. Sterling, MD Obstetrics and Gynecology San Diego (858) 277-9378 Dhwanil Vyas, MD Nephrology San Diego (858) 810-8000

Helen A. Harvey, MD Pediatrics San Diego (858) 966-5863 Kelley D. Hodgkiss- Harlow, MD Vascular Surgery San Diego (619) 528-5000 Matthew H. Hom, MD Hospitalist La Jolla (619) 507-0909 Saad Juma, MD Urology Encinitas (760) 753-8373 Allan N. Kremp, MD Pathology San Diego (619) 297-4900 Steven A. La Fond, MD Family Medicine San Diego (858) 514-3700

Aaron D. Wallace, MD Anesthesiology San Diego (858) 565-9666 Sierra L. Washington, MD Obstetrics and Gynecology San Diego (619) 881-4500 David B. Winn, MD Internal Medicine San Diego (619) 528-5000 Donald P. Woodmansee, MD Allergy and Immunology San Marcos (619) 528-5000 Chao-Hsiung E. Yang, MD Internal Medicine San Diego (619) 528-5000 Randall J. Young, MD Emergency Medicine San Diego (619) 528-5000

Bernard A. Feigenbaum, MD Allergy and Immunology San Diego (619) 291-5800

Alan C. Y. Lin, MD Internal Medicine San Diego (619) 686-3935 Ryan W. Matson, MD Internal Medicine San Diego (619) 686-3935 Jared D. Nieman, MD Anesthesiology San Diego (619) 528-5000 Jeffrey S. Rakoff, MD Obstetrics and Gynecology San Diego (858) 794-6363 Angela N. Smith, MD Anesthesiology Encinitas (858) 565-9666

SAN DIEGO PHYSICIAN.ORG

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PHYSICIAN SOCIALS

Dr. Walker Named Medical Director for Scripps Clinic Medical Group

Richard (Dick) H. Walker, MD, 12-year member of SDCMS-CMA, attended medical school at the University of Chicago and then completed two years of general surgery residency at UCLA and his orthopedic surgery residency at Stanford University.

He is board-certified by the American Board of Orthopedic Surgery.

Since 1983, Dr. Walker has devoted his career at Scripps Clinic to maintaining a combination of clinical, teaching, research, and leadership roles, including performing thousands of total hip and total knee replacement procedures. In addition to his clinical practice, he conducts research on total hip and knee replacement outcomes, biomechanics and techniques, and thromboembolic disease prevention after total hip and knee replacement. He has presented his research on joint replacement at scientific meetings across the United States, as well as in Canada, South America, Europe, and Asia. He has also served as an editorial reviewer for internationally prominent orthopedic journals for more than two decades, including The Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, and the Journal of Orthopaedic Research.

As an educator, Dr. Walker has served for more than 30 years as a faculty mem-

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ber guiding young orthopedists through post-residency fellowships focused on joint replacement surgery. His leadership roles have included serving on the board of directors of Scripps Clinic Medical Group (SCMG) for more than 25 years, as chairman of the Department of Surgery for SCMG for nearly 20 years, and as vice president of surgery, gynecology, and radiology for Scripps Clinic for more than 10 years, as well as chief of staff and chairman of surgery for Scripps Green Hospital and president of the Western Orthopaedic Association/San Diego Chapter (now the San Diego Orthopaedic Society).

Dr. Walker has been named numerous times to San Diego Magazine’s Top Doctors, Best Doctors in America, Who’s Who in Medicine and Healthcare, Who’s Who in America, and Who’s Who in the World. He is a fellow of the American College of Surgeons and the American Academy of Orthopaedic Surgeons, and a member of numerous professional societies, including the Western Orthopaedic Association and the American Association of Hip and Knee Surgeons, as well as international societies, including the Association of Bone and Joint Surgeons, the International Society for Technology in Arthroplasty, and Computer Assisted Orthopaedic Surgery — International.

One of his favorite avocations outside of medicine has been baseball. He played college and semi-professional baseball before going to medical school. Later, he returned to baseball to coach youth baseball and softball at multiple levels; to watch his son also play college and semi-professional baseball; and to play himself in adult baseball leagues for more than 15 years (including multiple trips to the National Senior Baseball League annual World Series in Phoenix, reaching the World Series Final Four twice, and finally winning a World Series national championship in 2010). He was able to combine his passions for orthopedics and baseball by serving as a team physician for the San Diego Padres for more than 15 years, including the 1984 and 1998 National League pennant seasons.

Please join your physician colleagues on Friday, April 14, for SDCMS’s next physician networking opportunity and mixer from 5:30 p.m. to 8 p.m. at Casa Machado Restaurant, 3750 John J. Montgomery Dr., San Diego 92123 — overlooking Montgomery Field Airport.

Come mingle, socialize, and network with your colleagues, and be sure to bring your spouse/significant other — complimentary hors d’oeuvres and drinks will be provided. RSVPs are required, so register soon at SDCMS.org — and do spread the word by letting your colleagues know to join us as well. If you have any questions, contact Jen at JOhmstede@SDCMS.org or at (858) 300-2781.

“

There can be no deep disappointment where there is not deep love.

”

— Martin Luther King Jr. (1929–1968)

/////////////////////////////////////////////////////////////////////////////////////////////////// Michael J. Lalich, MD, eight-year member of SDCMS-CMA, has practiced medicine with the Southern California Permanente Medical Group (SCPMG) since 1997. As area medical director for Kaiser Permanente in San Diego, Dr. Lalich leads and inspires more than 1,300 physicians and their staff who help 600,000 San Diego Kaiser Permanente members and the community at large to thrive. As director of San Diego’s largest medical group, he also guides physician communications and encourages wellness and work-life balance among physicians.

Dr. Lalich is ABFM-certified and was named Kaiser Permanente San Diego’s 2012–13 Family Medicine Physician of the Year. He has been named a San Diego Magazine Top Doc since 2010, and was the KP San Diego Leadership Development Institute Physician Top Performer in 2013.

Prior to his role as area medical director, Dr. Lalich was chief of family medicine for KP San Diego, where he led more than 300 primary care physicians at 14 medical office buildings across San Diego County,

FEATURED MEMBER

Dr. Lalich Takes Over as Area Medical Director of SCPMG

including managing multiple projects and interdepartmental agreements between primary care, specialty care, surgical services, and hospital medicine. From 2009 to 2016, he hired 148 family medicine physicians. He also co-led KP San Diego’s efforts to secure 15 Guinness World Records in healthcare and worked closely with the family medicine residency director to found the Kaiser Permanente San Diego Family Medicine Residency Program.

A graduate of Gustavus Adolphus College in St. Peter, Minn., and alumnus of the University of Minnesota Graduate School, Dr. Lalich received his medical degree from University of Minnesota Medical School. He conducted his family medicine residency at UC San Diego.

Dr. Lalich is passionate about community service, including the Challenged Athletes Foundation and the Special Olympics World Games, and helps to ensure a healthy start for future athletes by volunteering at KP San Diego’s free high school sports physicals program.

Dr. Lalich lives in East County with his wife and daughter.

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L E G I S L AT I V E A DVO C AC Y

CMA FEDERAL UPDATE Healthcare Reform and MACRA

by Elizabeth McNeil, Vice President, Federal Government Relations, California

Note: This Update Was Written January 16, 2017

I. HEALTHCARE REFORM With the election of Donald Trump to the U.S. presidency and Republicans in control of both the U.S. House of Representatives and the Senate, Republican leaders are moving swiftly to fulfill a cornerstone campaign promise to repeal the Affordable Care Act (ACA).

A. ACA Repeal On Friday, Jan. 13, the House followed the Senate in passing a nonbinding budget resolution (S Con Res 3) that sets 2017 spending targets and provides instructions

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to the Congressional Policy Committees to: 1. Develop a majority-vote budget reconciliation bill that repeals the ACA by late February; 2. Achieve savings from the ACA repeal legislation; and 3. Develop an ACA replacement plan.

The budget reconciliation bill would repeal the ACA, but it would not take effect for 2–3 years, while Congress works on a replacement plan. Under House and Senate rules, budget reconciliation bills can only include budgetary items and can be adopted by a simple majority vote (rather than the usual 60 votes required for passage in the Senate), thereby circumventing a Senate Democratic-led filibuster.

CMA’s overriding goal will be to ensure that Californians who have coverage today do not lose coverage or access to care.

B. ACA Replacement Plan Previous bills introduced by House Speaker Paul Ryan, U.S. Department of Health and Human Services (HHS) Secretary Nominee Tom Price, MD, and Senate Finance Committee Chairman Orrin Hatch provide insight into the potential healthcare reform legislation that will replace the ACA. As previously written, none of these proposals provides as much coverage as the ACA. Instead, the proposals only repeal the ACA insurance provisions, individual mandate, and Medicaid expansion for lowincome adults. They replace the ACA with a private, voluntary health insurance marketplace where insurers may sell insurance across state lines.

It is unclear how the individual market would successfully operate. Some bills allow states to establish high-risk pools and expand health savings accounts. Most provide tax credits, and some provide subsidies to help low-income families afford coverage. Several bills allow individuals to deduct the cost of health insurance premiums while eliminating such deductions for employer-sponsored coverage. Most bills repeal the ACA insurance reforms, such as the requirements for insurers to dedicate 85% of revenues to patient care and to provide coverage to those with preexisting conditions. All of the bills eliminate the Medicaid expansion and cap federal funding for Medicaid either through block grants or per capita cap funding in exchange for greater state flexibility. Speaker Ryan’s bill replaces the Medicare defined benefit program with Medicare premium support that provides vouchers to seniors to purchase private health insurance coverage. And finally, several proposals include MICRA-like medical liability reform.

Regardless of previous healthcare reform proposals, the Republican leadership recognizes that a more comprehensive approach is warranted, and they plan to take more time to develop a replacement plan. They have also reached out to state governors and insurance commissioners for their input on the ACA, Medicaid expansion, and exchanges. Sixteen Republican governors and fourteen Democratic governors expanded their Medicaid programs, and the majority of these governors are asking Congress to maintain the Medicaid funding.

Finally, the ACA replacement legislation will require 60 votes in the Senate.

Therefore, Republican leaders will need to compromise with at least a handful of Democrats to gain final passage.

C. CMA Advocacy CMA is actively involved in shaping the future of healthcare reform at the national level and has extensive policy on healthcare reform issues. Based on that policy, CMA’s overriding goal will be to ensure that Californians who have coverage today do not lose coverage or access to care.

CMA will also work to protect current state and federal healthcare funding, including the Proposition 55 and 56 tobacco taxes. Current CMA policy opposes Medicaid block grants. Moreover, CMA will continue to work to ensure that lowand moderate-income families can afford coverage. We have promoted responsible healthcare financing, including the use of the tax code to help Californians purchase insurance and subsidies to help low-income families afford coverage.

An underfunded healthcare system places unsustainable burdens and unfunded mandates on physicians. It also creates access-to-care problems, healthcare delays, and economic hardship for patients. CMA will be a voice for patient choice in the new healthcare system. CMA physicians are committed to the health and well-being of our patients.

And finally, CMA will fight to maintain the hard-fought insurance reforms that require insurers to dedicate 85% of their revenues to direct medical care, community rate, and submit premium increases to regulators, as well as prohibit insurers from placing lifetime or annual limits on benefits, blocking coverage for preexisting conditions, or rescinding coverage when a patient becomes ill. CMA has fought health plan mergers over the years to promote an open, competitive healthcare marketplace in California.

CMA also recognizes that the ACA has serious shortcomings that need to be addressed. More than one in three Californians are now enrolled in the state’s Medi-Cal program, yet few have true access to a doctor. Because the Medi-Cal reimbursement rates are among the lowest in the nation, most physicians cannot afford to participate. Moreover, the payment rates and physician networks in the Covered California exchange are inadequate, and many families continue to express concerns about the affordability of insurance in the exchanges. The individual market needs more stability, and while the ACA significantly expanded coverage, it did not expand access to care for many Californians.

Based on CMA policy, we have developed SAN DIEGO PHYSICIAN.ORG

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overarching healthcare reform principles to guide CMA’s advocacy through the debate.

CMA’s overriding goal is to ensure that Californians maintain access to quality, meaningful, affordable coverage.

CMA’s core priorities for the future of federal healthcare reform: 1. Ensure Californians do not lose coverage or access to care.

2. Improve access to care.

3. Protect state and federal healthcare funding for Californians. Support appropriate and broad-based healthcare financing.

4. Continue tax policies and subsidies that help low- to moderate-income patients afford coverage.

5. Advocate for broad patient choice of physicians, plans, and coverage through health savings accounts, private contracting, private insurers, and health plans, as well as government programs.

6. Maintain the important insurance reforms that protect physicians and their patients, such as coverage for preexisting conditions.

7. Stabilize the individual insurance market.

8. Provide access to affordable prescription drugs.

9. Medical liability reform that does not undermine California’s MICRA law.

II. MEDICARE MACRA UPDATE Background In 2015, Congress passed the Medicare Access and Children’s Health Reauthorization Act (MACRA), which eliminated the Medicare SGR formula and established two Medicare payment tracks physicians can choose from to participate.

The first track allows physicians to participate in alternative payment models (APMs) with a 5% bonus for meeting certain EHR and quality standards. APMs must also assume some downside financial risk, except primary care medical homes.

The legislation also allows innovative, alternative physician-focused payment models to be approved through another regulatory process. The second track is the traditional Medicare fee-for-service payment track with four performancereporting programs: 1. Quality (formerly known as the Physician Quality Reporting System or PQRS); 2. EHR Advancing Care Information (ACI) (formerly known as the Meaningful Use Program);

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3. Cost (formerly known as the Value Modifier Program); 4. New category called Improvement Activities (comprised of activities most physicians are already doing).

These fee-for-service reporting programs have been consolidated and simplified under a new program: the Merit-based Incentive Payment System (MIPS). For the MIPS reporting categories, Congress reinstated substantial bonuses and reduced the penalties from current law. The Centers for Medicare and Medicaid Services (CMS) issued the final MACRA implementing rule in October 2016. The new MACRA law and the final rule represent a significant improvement over the previous system. Moreover, CMS is providing a longer transition path for practices to get ready for MACRA. CMA and AMA successfully advocated for a Medicare program that is less burdensome than existing law. Improvements include: • Exempts 30% of Medicare physicians.

• Longer transition path, i.e., physicians can start reporting on Jan. 1 or Oct. 1, 2017.

• No penalties in 2017 if physicians report on one quality measure.

• Reduces penalties after 2017.

• Reinstates bonus payments.

• Eliminates all duplicative quality measures.

• Reduces the number of measures by half.

• Report on six quality measures, five

EHR measures, and 2–4 improvement activities.

• Fewer requirements for small/rural practices, and provides a transition path.

• Only need to report on 50% of patients for quality.

• Eliminates pass/fail: Proportional credit given for measures that are met.

• More ways to report (claims, EHR, web, QCDR).

• Greater selection of applicable national specialty society measure sets.

• Funding to help small and rural practices transition.

• Allows alternative models with reduced financial risk.

• Greater enforcement on EHR vendors who are not interoperable.

CMA will continue advocacy efforts to relieve physicians from Medicare reporting burdens and for greater accountability and penalties on the EHR vendors that do not meet MACRA requirements.

Congress is not likely to take major action on the bipartisan MACRA law in 2017 because CMS delayed MACRA in 2017 and made significant improvements. However, CMA and AMA will continue to be actively engaged with Congress and the administration to reduce the regulatory burdens on physicians. CMA will also continue to offer programs to educate and assist our members so they can successfully participate. Please see the CMA MACRA Resource Center at www.cmanet.org/MACRA.

Dear Fellow Physician: These are uncertain times for all of us. But one thing is certain. Care for those most vulnerable patients in need of the skills and concern of their physician is paramount. That is why Project Access San Diego was initiated in 2008, and why it remains just as relevant – if not more – today.

MediCal expansion, feasible through the implementation of the Afford able Care Act, meant that adults without minor children could receive care for chronic and urgent health needs. Young adults could remain on their parents’ health plans until age 26. And that many immigr ants and refugees, struggling to make a living in their new home country, did not need to wait five years for eligibility to health services.

Despite those advances, not every uninsured adult is able to receive access to affordable healthcare coverage. In San Diego County, approximately 170,000 are uninsured for a variety of reasons. Project Access San Diego is the safety net for those without other resources for specialty healthcare services.

Because of the dedication of the physician community, we are able to navigate and coordinate care that gets men and women back to health, back to work and caring for their families, and back to being a productive and contributing member of our community.

Health care has always been a “safe zone”. Physicians and hospitals have never participated in immigration issues. Regardless of political views, one uniting opinion shared in the medical community is that patients’ health needs come first.

We stand with our physician partners. Project Access will continue to serve our low-income and majority-immigrant patient population. We ask that the healthcare commu nity continue to stand with Project Access. We need your support more than ever before, as both physician volunteers and as donors. Our average cost per patient is $720. That amount enables us to coordinate care and remove barriers like transportation, translation, medication, and other items critical to physicians efficiently providing healthcare services to those in need. Project Access relies on a mix of contributors, and we need YOUR support.

At this critical time, many are looking for a way to DO SOMETHING . You can do something that makes a life-changing, and quite possibly life-saving, difference for someon e. Please consider making a contribution NOW and give the gift of health.

Albert Ray, MD President of the Board Champions for Health

Make a contribution today at www.ChampionsForHealth.org

Founded by San Diego County Medical Society SAN DIEGO PHYSICIAN.ORG

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R I S K M A N AG E M E N T

THE DOCTOR’S DILEMMA

by Howard Marcus, MD, FACP

THE DOCTORS COMPANY Internal Medicine Closed Claims Study (www.thedoctors. com/KnowledgeCenter/PatientSafety/ articles/Internal-Medicine-Closed-ClaimsStudy) analyzed 1,180 claims that closed from 2007 to 2014. The study found that the top allegation, representing 39% of claims against internists, was diagnosis related and resulted from a delay or failure to diagnose. This finding is consistent with data published in Improving Diagnosis in Health Care (National Academies of Sciences, Engineering, and Medicine), which found that 34% of nonsurgical specialty claims are diagnosis related.

Physicians fail to diagnose accurately for

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many reasons. The dilemma can be understood best in the context of the complexity of clinical medicine. Illnesses present with an infinite number of variations, illustrated by the 68,000 ICD-10 diagnostic codes and 8,000 recognized diseases and syndromes — many of which are uncommon. The average primary care physician diagnoses about 400 different diseases a year and, every now and then, encounters a rare medical condition that he or she may have never seen before.

It is in this context that failure to diagnose may be viewed as an error or lapse in reasoning rather than just a failure of clinical skill.

Therefore, diagnostic accuracy can be improved with a better understanding of how to

avoid pitfalls in medical decision-making.

The monograph Improving Diagnosis in Health Care characterizes failure to diagnose in terms of two types of thinking processes — rapid and slow — and the effects of psychological biases on medical decisionmaking.

Type I, or rapid decision-making, involves pattern recognition (heuristics) that allows the clinician to successfully diagnose and treat most patients efficiently. For example, a female patient with dysuria and frequency will most often have an uncomplicated urinary tract infection.

Type II, or slow decision-making, requires recognition by the clinician of the possibility of a complex medical problem and the need for careful thought, a differential diagnosis, lab and imaging studies, reference resources (such as UpToDate), and/or consultation with a specialist. Recognition of risk factors is essential.

Psychological biases may undermine accurate diagnosis and treatment. Some common examples include the following: • Anchoring bias: The tendency to rely too heavily on, or “anchor” to, one trait or piece of information when making decisions — usually the first piece of information or diagnosis that is acquired.

• Premature closure: The tendency to apply premature closure to the decisionmaking process by accepting a diagnosis or treatment before it has been fully verified.

• Overconfidence bias: A universal tendency to believe we know more than we do.

• Optimism bias: The tendency to be overly optimistic by overestimating favorable and pleasing outcomes. This can also be considered a form of denial.

The following illustrations are taken from The Doctors Company Internal Medicine Closed Claims Study.

Case One A 53-year-old male presented to the hospital with acute chest, epigastric, and back pain. Risk factors included hypertension, diabetes, tobacco use, and a family history of coronary artery disease. An EKG was negative for acute changes. Lab studies included a normal CPK and minimally borderline troponin. The lipase was 1,455, and a diagnosis of acute pancreatitis was made. The epigastric pain improved, but the patient continued to report lower chest pain associated with chest palpation. Two weeks after discharge, he presented with an acute myocardial infarction.

The physician correctly diagnosed pancreatitis but, in retrospect, missed subtle suggestions of myocardial ischemia, including a slightly elevated troponin and persistent, although atypical, chest pain in the setting of multiple risk factors. The physician anchored on the single diagnosis of pancreatitis, which led to premature closure of the diagnostic process.

Case Two A 60-year-old female presented to the internist with abdominal pain and rectal bleeding. She was referred to a gynecologist, who diagnosed a likely uterine fibroid on ultrasound. An endometrial biopsy was benign.

Symptoms persisted, and several months later the internist ordered an abdominal CT scan that revealed a malignant rectal mass displacing the uterus.

The internist appears to have been reassured by the gynecologist’s finding of benign pelvic disease. This is an example of premature closure, demonstrating that when the referral was made, the thinking stopped.

Both patient and physician want pleasing outcomes, but a differential diagnosis — in this case, focusing on the common causes of rectal bleeding — would have probably led to a more timely diagnosis of rectal cancer.

Case Three A 65-year-old female presented with nausea, fever, and a dark area in the visual field of the right eye. She was diagnosed with a viral infection. Four days later, she presented to an ophthalmologist with the loss of central vision in the right eye and was diagnosed with a retinal detachment, resulting in permanent loss of vision.

Primary care physicians see many patients with nonspecific symptoms of nausea and fever. Most of these patients have an acute and self-limited viral illness. However, complaints of acute visual loss are relatively uncommon in a general practice, and most primary care physicians do not have the training or equipment to properly evaluate those patients. This case illustrates overconfidence bias in which the physician appears to have failed to recognize the potential significance of an unusual visual complaint, concentrating instead on the more common viral illness.

Case Four A 45-year-old male, febrile, with poorly controlled diabetes, was admitted to the hospital with vomiting and weight loss. Blood cultures revealed gram-positive cocci in chains.

The patient was discharged on antibiotics

before the final culture and sensitivity report was available, but he was readmitted a week later with hemodynamic decompensation and fever, and diagnosed with mitral and aortic valve endocarditis. The results of the prior culture demonstrated Streptococcus viridans. He underwent valve replacement, developed severe left ventricular decompensation, and died from end-stage congestive heart failure before a heart transplant could be performed.

This patient’s initial improvement appears to have led to another example of premature closure and optimism bias. It is, of course, essential to review final blood culture results and not make the assumption that the patient’s initial improvement is a predictor of a successful outcome.

Case Five A 59-year-old male admitted with abdominal pain was diagnosed with acute diverticulitis and treated with Garamycin, Avelox, and Flagyl. The patient was discharged on the same three antibiotics without an order to monitor serum gentamicin levels. Subsequent symptoms of vertigo were ultimately diagnosed as gentamicin vestibular toxicity.

Traditional physician education has emphasized memorization and “thinking on your feet.” Stopping to consult with a reliable reference in the middle of rounds has not been part of that tradition. No clinician can possibly know all of the information required to practice medicine. There should be a low threshold for reviewing references to help with diagnosis and treatment — even for relatively common conditions such as diverticulitis. This case provides another example of overconfidence bias.

Accurate diagnosis and treatment are often challenging — particularly in the context of time limitations and multitasking required in today’s practice environment.

Having a better understanding of current theories on how to improve the diagnostic process may help clinicians reduce errors and improve outcomes.

Read the full study, including expanded case examples and risk mitigation strategies, at www.thedoctors.com/internalmedicinestudy.

Dr. Marcus is a board-certified internal medicine physician who practices in Austin, Texas. He is chair of the Texas Alliance for Patient Access (a tort reform organization) and a member of and consultant to The Doctors Company Texas Advisory Board. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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ACCE SS TO CAR E

Poster for Your Exam / Waiting Room

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2-1-1 SAN DIEGO AN INTERVIEW WITH JOHN OHANIAN, CEO

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//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////

Note: Interview conducted Jan. 25, 2017.

San Diego Physician: What’s the biggest takeaway you’d like doctors to leave with after reading this interview?

John Ohanian: Doctors know that food security, adequate housing, financial and social supports, and other social factors impact their patients’ health, but they may be hesitant to discuss these issues with their patients because they may not know where to start to offer solutions. That’s where we come in; 2-1-1 is a connector to all of our community’s social programs and services that are critical to the overall health of patients. Our staff help our callers navigate the complex healthcare system and connect to the resources they need.

We want doctors to know that 2-1-1 is here for their

patients 24 hours a day, 365 days a year, and that we offer services in more than 200 languages. If doctors, nurses, or their support staff think their patient might be in need of supportive services, they can refer that patient to 2-1-1.

When it’s more of an emergent situation, the doctor’s support staff can pick up the phone and call one of our specialists. As well, our searchable database of more than 6,000 resources is available to the public on our website at www.211sandiego.org.

I think number one is just getting the word out — most doctors don’t even know that help is one phone call away.

And when a trusted, helping professional shares information about 2-1-1, patients are more likely to reach out.

SDP: Do you come across many doctors who have no idea you’re out there doing what you do?

John: Yes, unfortunately too many. We connect with about 500,000 callers each year, but there are still multitudes of people who could benefit from our services who don’t know anything about us or the depth of service we offer.

I think it’s also challenging because we’ve evolved in the past decade. We used to serve mostly very low-income people — people who were getting county services or who were homeless — but now we have programs that benefit all people of all ages and socioeconomic situations. An adult living in Rancho Santa Fe caring for an aging parent with dementia can call and find out which programs and services are available.

We also play a role during disasters. We provide realtime information about road closures, shelters, evacuation orders … that’s when the general community hears the most about 2-1-1 because we’re promoted all over the place.

SDP: What role do you actually play during disasters?

John: We work with our partners in times of disaster to make sure the general public has necessary and validated non-emergency information. We work closely with the County’s Office of Emergency Services, CalFire, and cities across our region.

We’re the place where people get real-time information when, for example, there’s an evacuation notice and you get a call to your house

advising you to evacuate your home. At the end of that message it says to call 2-1-1 for more information. When that happens, we ramp up with staff and volunteers and answer tens of thousands of calls a day.

We also play a role when there’s a public health crisis.

During the spread of H1N1, we were the number that the County Public Health Department advertised to let people know what to do to prevent the spread of the disease and where to get more information. People were scared and they wanted to talk to a live person. We’re that place for people when they’re in a difficult situation and they don’t know what to do or where to begin.

SDP: How many people do you have manning the phones on an average day?

John: Overall in the organization we have about 130 staff, but because it’s 24/7/365, it gets spread out depending on the hour.

People need to know that we’re free and that we’re 24/7. We support more than 200 languages, so anyone can call us. That’s kind of the big picture of 2-1-1 for the clients that are out there.

We also want doctors to know that we play a strong role in getting people actually enrolled in programs. We’re not just giving information and telling people where to call. We submit applications to enroll people in Medi-Cal, Covered California, CalSAN DIEGO PHYSICIAN.ORG

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We want doctors to know that 2-1-1 IS HERE for their patients 24 HOURS A DAY, 365 DAYS A YEAR, and that

we offer services in more than 200 LANGUAGES.

////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Fresh, prescription assistance programs and utility assistance programs directly to the agencies who administer the programs. We’ll do it right over the phone, saving our callers time and energy.

We’re also now collecting that person’s record, so if they call back three weeks or three months later, we’ll get an update on how the interaction with the referred organization went. When EMS picks someone up at their house and they notice, for example, that they have no food or there are no grab bars for an aging person, the first responder will actually get the client’s permission for us to reach out to them with an outbound call shortly after their EMS visit to try to help them.

We’re also working with Sharp Grossmont Hospital and scaling out to several other hospitals. 2-1-1’s Health Navigation team receives discharge information from the hospital, and our team proactively reaches out to the patient to make sure they have access to needed resources like a medical home, transportation, housing, adequate food.

Our overall goal is to provide ongoing care coordination to avoid unnecessary hospital readmission. The initial pilot has been very successful in decreasing risks and vulnerabilities, increasing patient satisfaction, and decreasing readmission rates for at-risk populations.

Another facet that most folks are unaware of is how we utilize our technology

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to share client records. By creating a single client record that multiple social and health providers have access to, we’ve reduced emergency room transports by 30%, and we’ve reduced people falling into homelessness by about 40%, just by developing tools. It’s not only us looking at your record when you call in, but it’s sharing that information with a communitybased program. Our new 360° Community Coordination allows helping professionals to use technology to improve efficiencies and provide seamless care. We see it as a tool not just for our clients but for nonprofits as well.

SDP: How does it work?

John: Right now we have about 14 community-based organizations (CBOs) participating. When a client comes in to the CBO, the staff are able to ping the 360° Community Coordination system to see if there is more information about this client from other CBOs than just what is in their own system. Where has this client been before and who else is working with this client? The clients are giving permission for these agencies to share their information with each other in order to help coordinate their care.

SDP: So a doctor would have access to that too if they set up an account?

John: Right, if they joined as a participating provider.

SDP: How would you set up somebody with Medi-Cal through the telephone?

John: We have a unique partnership with the County of San Diego where we’ve established a way that we can actually do telephonic signatures and verifications. We have an enrollment department, and people can go straight onto our website, schedule an appointment, we’ll call them at their appointment time, and we take all of their information over the phone. What’s nice is with one interview, if they’re eligible for Medi-Cal, they’re likely eligible for CalFresh (aka food stamps), and we can do both applications in one call.

SDP: You don’t see people physically in your offices?

John: Nope. It’s all virtual.

They don’t have to travel anywhere.

SDP: What if they don’t have access to the internet?

John: They can just call us — it’s free.

SDP: Talk about your Health Navigation Program.

John: Health Navigation started out because we found that many of our callers had an issue related to their healthcare situation; people that are newly covered under Covered California or MediCal didn’t know how to use their benefits, for example,

so we educate them on how to use their benefits, we link them up with prescription drug programs, discount programs, we book them an appointment at the community clinics so they can find a medical home, we relay them to a medical clinic, we partner with City of San Diego EMS or the discharge plan at Sharp Grossmont — we have a specialty team that is focused on managing a certain core number of clients through their journey.

SDP: If a doctor wanted to call in as opposed to going onto your website to try to figure out what you do, they could just call in and get a couple-minute rundown on what 2-1-1 can do for their patients?

John: Yup. Just call 2-1-1 anytime — it’s a free phone call.

SDP: How do you want the doctors to use the poster included in this issue?

John: We thought they could put it up in their offices, in their staff rooms, in their lobby or waiting rooms, so when a patient is sitting in the waiting room or exam room who has never heard of 2-1-1, the poster might trigger a discussion around what 2-1-1 can do for the patient. We also have a specially designed prescription pad that doctors can give out to patients, encouraging healthcare providers to begin having the conversation

Maximizing the bottom line, one office at a time.

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////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// about addressing the social determinants of health.

SDP: If doctors wanted other literature, one-pagers to hand out, wallet cards …

John: They can go to our website, 211sandiego.org, and there’s an order form they can fill out (211sandiego. org/contacts).

$

SDP: 28 Days of Awareness … what’s that about?

John: February 11 is National Awareness Day for 2-1-1.

Typically, we’ve done a luncheon where we’ve had 1,200 people together — community leaders, ambassadors — celebrating what 2-1-1’s been able to accomplish, thanking the community because 2-1-1 is nothing without community partners. But this year, we’re pretty focused for the next six months on building out our robust 360° Community Coordination, so putting on a luncheon for 1,200 people just wasn’t in the cards.

One of the biggest issues we face is that not enough San Diegans know about us.

So we thought, why not take the entire month of February and launch a campaign to get the word out across multiple sectors so that the people who need to know about us get to know about us? So that’s what we’re doing. We’re working with community partners, like the Medical Society, schools, and businesses, to let people know that we exist. Our hope

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SAN DIEGO PHYSICIAN.ORG

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We’re a nonprofit that CONNECTS INDIVIDUALS

to social programs and services that are CRITICAL

TO THEIR OVERALL HEALTH.

////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// is that it’s going to turn into a year-long campaign so we’re constantly out there — depending on the day or month, or what’s going on in the community — we’re always playing a role, whether it’s talking about homelessness, veterans, or women’s health.

I’m also launching a Facebook Live show. It’s going to be a weekly show from 9 to 10 a.m. on Wednesdays.

We’re going to have partners and guests sharing their stories. It’s an opportunity for us to tell client stories and share with the community on a regular basis in a different medium what it is to experience something like needing help or what’s going on in the community.

It’s all under the umbrella of a Live Well San Diego agenda.

SDP: Where is 2-1-1 in five or 10 years?

John: Ten years ago, when I started, I never imagined where we’d be today. I think our predecessors are pretty impressed. I think we definitely are seen as pioneers across the country in this space, because a lot of 2-1-1s are still in the space of basic information referral, in other words, “What’s your issue? OK, let me give you the phone number.”

I co-organize TEDxSanDiego, so we’re big on TEDx talks like Simon Sinek, who asks, “Why do you exist?” We came together five years ago and

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said we exist to help people live healthier, happier lives, and then we started thinking, well, what do we really need to be, what do we want to do, because if we didn’t exist, couldn’t people just Google the information?

When we said no, it goes a lot deeper than that, we thought, well, it is deeper, but are we doing deeper work? We never wanted to step on nonprofits’ or case managers’ toes, to do their work, but what we’ve seen is that coordination is actually what we need in this day and age. We don’t need people taking buses all over the place when we can actually solve their problems virtually, or at least get them started.

So I think what we’re going to have is just like in the health information exchange world, I think we’re going to have better, deeper client records. I think we’re going to have data on service gaps, on unmet needs, on trends in the community so that we can actually go to stakeholders and say, “You’re concerned about elderly staying at home? Well, here’s what our data states,” and we can pinpoint it to certain areas in the county. We can sit with City Council and say, “Hey, in your district, here’s what’s going on.” People are so hungry for data, and we have a wealth of data and are working to make it understandable, digestible, and actionable. What I love about it is we can change

our program one day and start seeing interesting data trends happen the next.

SDP: Are you working with San Diego Health Connect?

John: Yes. Dan Chavez, the executive director, is on our board of directors, and we are looking for ways to allow doctors who want to find out about someone’s social services not to have to log in to our network. Obviously, everyone’s concerned about privacy and security, and we’re going to follow HIPAA, but we’re not going to hide behind it.

SDP: Where does 2-1-1 get its money?

John: We contract for services. About 10 years ago, we had a $1 million budget that was grant-funded.

Now we have an $11 million budget. We still raise about $1 million from grants and donations, but about 90% of our budget comes from fee-for-service contracts.

We’re an efficiency tool for the government. When the USDA does work in CalFresh trying to get people to know about the program, educated, demystified, and then enrolled, that work we do through a contract.

The County has a number of programs we refer to in order to determine eligibility; we try to be that front door for the County to make it more efficient as someone goes through County services. Whether it’s the

Public Health Department, Emergency Services, or other work we do through Covered California or SDG&E’s utility assistance program, for example, we do work on their behalf. If we can become a front door for a lot of people, it takes a very small cost to them individually, but together it adds up.

SDP: Any final thoughts you want doctors to know that we didn’t touch on?

John: People trust their doctors, and because of that trusted relationship, if their doctors tell them to call 2-1-1, that would go a long way toward helping patients get the services they need. And I think the other piece is demystifying the fact that we’re not a government organization.

It’s not like 9-1-1, or 4-1-1 where you pay a dollar to call. We’re a nonprofit that connects individuals to social programs and services that are critical to their overall health.

SDP: You want to be known as the doctor’s partner, as a member of the healthcare team …

John: Absolutely. We’re actually hiring a chief medical officer, part-time, so that they can make sure that everything we’re doing falls in line with what a doctor would expect.

SDP: Thank you, John.

////////

MEMBER BENEFITS

THE SBA’S 7(A) GUARANTEED LOAN PROGRAM What a Lender Looks for When Reviewing a Loan Request

by Michael T. Valenti, Senior Vice President, San Diego Private Bank

WHEN APPLYING for an SBA-guaranteed loan, the borrower applies to a lending institution, not the SBA (the lender applies to the SBA for a loan guaranty). Guarantees are up to $3,750,000 (75%) of each loan made by participant lenders. These loans typically range from $100,000 to $5 million and are repaid in monthly installments.

They can be used for a variety of business purposes, including working capital, equipment acquisition, and real estate purchases. Maturities depend on the use of loan proceeds but typically range from seven to 25 years.

DISTINCTLY DIFFERENT

What a Lender Looks for When Reviewing a Loan Request … … for New Business: • Describe in detail the type of business to be established.

• Describe your experience and management credentials.

• Prepare a detailed estimate of how much capital will be needed to start.

State how much you have and how much you will need to borrow.

• Prepare a current personal financial statement, listing all personal assets and liabilities.

• Prepare a month-by-month projection of revenues, expenses, and profit for the first 12 months. Also do a companion cash-flow projection for the same period. Explain your major assumptions in an accompanying narrative.

• List the collateral to be offered as security with estimates of the market value of each item.

• Take this material to your banker. If the bank wants an SBA guaranty for your loan, they will make application to us. You deal with the bank; the bank deals with the SBA.

et us help you grow

… for Established Business: • Current business financial information: Prepare a current balance sheet and an income (profit and loss) statement for current year up to the date of the balance sheet (dated within the last 60 days). At least three years of tax returns for the business and personal (for each person owning 20% or more of the company).

• Historical business financial information: Prepare income statements and balance sheets for the past three full years. Do not include personal items on the statements. Reconcile the equity balances between each year.

• Prepare a current personal financial statement for each owner, partner, or stockholder owning at least 20% of the business.

• List the collateral to be offered as security, with estimates of the market value of each item.

• State the amount and intended uses of the loan.

• Take this material to your banker. If the bank wants an SBA guaranty for your loan, they will apply to the SBA. You deal with the bank; the bank deals with the SBA.

For SDCMS member physicians, San Diego Private Bank will pay 1% out of the total SBA guarantee fee percentage.

SDCMS Member-exclusive Benefit For SDCMS member physicians, San Diego Private Bank will pay 1% out of the total SBA guarantee fee percentage. For example, if an SDCMS member physician takes out an SBA-guaranteed loan for $500,000 with San Diego Private Bank, and the SBA guarantees 75% of that, or $375,000, the guarantee fee will be $11,250 (3% of $375,000).

San Diego Private Bank will then pay 1% out of the 3% guarantee fee, or $3,750 of the $11,250. In other words, in this example, this SDCMS member physician would save $3,750 by banking with San Diego Private Bank! For more information, contact Michael T. Valenti, Senior Vice President, at San Diego Private Bank: Direct: (760) 759-1709; Cell: (714) 746-9323; Email: mvalenti@sandiegoprivatebank.net.

SAN DIEGO PHYSICIAN.ORG

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FUTURE OF MEDICINE

PERSPECTIVES ON THE FUTURE OF MEDICINE A Conversation With Dr. Wachter, Author of The Digital Doctor by Richard E. Anderson, MD, FACP, Chairman and CEO, The Doctors Company

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FEBRUARY 2017

IN JUST THE PAST FEW YEARS, the healthcare system has undergone a remarkable transformation from a paper-based system to a digital one. On top of that, healthcare organizations and physicians are under intense pressure to improve value — measured as safety, access, efficiency, cost, and patient experience.

Robert M. Wachter, MD, professor and chair of the Department of Medicine at the University of California, San Francisco, and bestselling author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, discussed this unprecedented change in the healthcare environment — and how it will affect both doctors and patients — during his keynote speech at The Doctors Company’s 2016 Executive Advisory Board. In the following

The idea that a patient would have to take off a day from work and drive to a hospital or to a doctor’s office, park, and then see a doctor for a 20-minute visit — people will look back at that and say, “You did that 15 years ago?”

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conversation with Dr. Wachter, I asked him to share his thoughts on the challenges and opportunities ahead.

Question: Health technology, including mobile apps and wearables, has led to a large increase in the amount of patient data that doctors have to deal with. How will this new data play a role in healthcare?

Dr. Wachter: In the future, our healthcare system will be primarily digital, and there will be a far more fluid flow of information than there is today. The patient’s information will be available to the patient, to the family, and to the clinicians, whether the patient is at home or in a clinic or being seen in a hospital. Patients will have the information that they need to manage themselves.

And clinicians will have the information they need. And so will the system; in fact, ours will truly become a learning healthcare system, one that makes itself iteratively better as it takes advantage of the experience of prior patients. Up until now, most of the investments have been in enterprise systems like EHRs in hospitals. I think the next big wave in healthcare investment is in consumer-facing technologies that allow patients to monitor their own health.

Question: Startups in big cities have attempted to bring back house calls, although there is concern that this will not scale for large populations of patients, particularly in rural areas. Telemedicine has also exploded in use and popularity, although reimbursement and liability issues have not been resolved. How do you see these alternate avenues of care evolving in the future?

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Corporate ID: HCVRT_ZZZ Call Sprint Sales: 866-639-8354 Visit a local Sprint Store: sprint.com/storelocator Existing customers add your discount at sprint.com/verify Activ. Fee: Up to $30/line. Credit approval req. SDP Discount: Avail. for eligible agency/company employees or org. members (ongoing verification). Discount subj. to change according to the agency’s/ company’s/org.’s agmt. with Sprint & is avail. upon request for sel. mo. data svc. charges. Discount only applies to data svc. for Better Choice Plans. Not avail. with no credit check offers. Limit one SDP discount per account. Other Terms: Offers/coverage not avail. everywhere or for all devices/networks. Restrictions apply. See store or sprint.com for details. © 2017 Sprint. All rights reserved. Sprint & logo are trademarks N155651CA of Sprint. Other marks are property of their respective owners.

CMA MEMBER HELP LINE! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262

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FUTURE OF MEDICINE

Today’s versions of EHRs are not very good, because they were built to serve too many masters.

Dr. Wachter: If we can resolve these issues about telemedicine, I see patients getting most of their care from home, managing their chronic conditions like diabetes, high blood pressure, and heart failure through information provided by the computer through a series of smart algorithms. And when they need to see clinicians, it will be largely through televisits. The idea that a patient would have to take off a day from work and drive to a hospital or to a doctor’s office, park, and then see a doctor for a 20-minute visit — people will look back at that and say, “You did that 15 years ago?” I think this vision is quite inspiring. I think that when we get to that place, we will be providing care that’s better and safer and cheaper and more patient centric than what we do today.

of a separate ICU will go away. Patients will have single rooms. When I walk into the patient’s room, the patient will see on their screen who I am, along with my background and bio. The nature of consultation will also change. Right now, when I see a patient in the hospital, if the patient needs the help of a cardiologist or a nephrologist, I’ll call them for a consult, and they may come and see the patient later in the day, and then they’ll leave a note for me and I’ll read it and go back and see the patient. In the future, I’ll go in and see the patient and if I need a nephrology consult, I’ll pull him or her up on the screen in the patient’s room and we’ll have a threeway conversation. That ability to integrate our care and talk to one another facilitated by technology will make things much better and more efficient than they are today.

Question: What do you think a hospital visit will look like in the future?

Dr. Wachter: First of all, just in terms of the national marketplace, there will be far fewer hospitals, and those that exist will be fairly large, will be bristling with technology, and will really be one big ICU. The notion

Question: The idea of patient engagement — encouraging patients to be actively involved in their healthcare — has become a common discussion in medicine. This concept, including ideas such as giving patients open access to doctors’ notes, nudges patients to be involved, but it also means

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REGISTRY

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PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Seeking Family Medicine, Pediatrics and Obstetrics and Gynecology Physicians in San Diego, Riverside and Orange Counties Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic.

Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred.

Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

www.vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled

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Locum Tenens Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

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that patients will be expected to live up to a different level of responsibility for their health. How do you see the patient role in future years?

Dr. Wachter: The role of the patient in their own healthcare is going to be utterly transformed. Patients have been passive in the healthcare system up to now. Technology democratizes everything, and it will elevate the role of the patient by giving them new tools and access to information.

The doctor will no longer be the only expert in the room. We’ll see patients who are able to partner with their doctors in ways that they’re not able to today — through computer tools, smart algorithms, and linkage to online communities where they meet other patients with similar problems.

But we have to be careful because patients also may try to take care of themselves and be their own doctors. We have to figure out how to get this right — how to allow technology to permit our patients to manage themselves better on their own or with the assistance of the healthcare system, but also to recognize that there are times where

patients really need to see a doctor or someone that’s part of the healthcare system.

Question: While EHRs have brought many positives, they have also created new risks and frustrations for doctors and patients.

The Doctors Company did a study of our closed malpractice claims in which EHRs were a contributing factor, finding that 64% of these claims were caused by system factors like lack of alerts or clinical decision support, and 42% of claims were caused by user factors like inputting incorrect information. What are your thoughts on current EHR issues?

Dr. Wachter: EHRs are really important because we can’t possibly take care of patients using paper and pencil and fax machines. But today’s versions of EHRs are not very good, because they were built to serve too many masters. If they were built simply to help the doctor take care of his or her patients, they would look one way. But they weren’t. They were also built to make billing more efficient. They were built for malpractice prevention, to meet

regulatory requirements, and for quality measurement. And the problem is that when you build a digital system for 10 different masters, you come up with something that isn’t very good for any of those goals. We’ll have to do three main things to make the EHR the vehicle that we want it to be. First is promoting for more use of user-centered design. The second is dealing with too many alerts — alert fatigue is overwhelming and dangerous, and we simply have to figure out how to prevent it. And the third is interoperability, to ensure that patient medical records can be shared easily between doctors, hospitals, and other healthcare providers at any time. Technology has brought great things to healthcare, but it always brings unanticipated consequences. It’s dangerous to believe that technology will solve all problems — we must instead view it as just another tool to help us improve how we care for patients.

Reprinted with permission. ©2016 The Doctors Company (www.thedoctors.com).

This article originally appeared in The Doctor’s Advocate, fourth quarter 2016.

SAN DIEGO PHYSICIAN.ORG

23

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FEBRUARY 2017

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25

CLASSIFIEDS PRACTICE FOR SALE INTERNAL / PULMONARY/ SLEEP PHYSICIAN LOOKING TO RETIRE Looking for CA-licensed physician in any of these specialties to join and take over practice.

Call (858) 581-0400 or email jrvevaina@yahoo.com. [574] SOUTHERN CALIFORNIA’S LARGEST MEDICAL SPA OFFERED FOR SALE: Injectable and laser services offered throughout San Diego and southern Orange counties.

Virtually inexhaustible supply of new patients.

Owned by a single physician who wishes to retire. Ideal for single physician who wants to step into a growing and lucrative esthetics practice in one of the nicest locations in the United States or for a San Diego or Orange County surgical group looking for a steady stream of procedure referrals in addition to the already lucrative cosmetics practice.

Physician seller works 30 hours per week to net approximately 32% of current $1.15M gross income. Call (619) 994-8701. [564] PHYSICIAN POSITIONS WANTED PLASTIC SURGERY OR DERMATOLOGY PRACTICE: Semi-retired plastic surgeon seeking profit-sharing arrangement with ethical plastic surgery or dermatology practice to provide ThermiVa, ThermiTight and ThermiSmooth with my devices. Contact: tsdpsinfo@gmail.com. [572] PHYSICIAN POSITIONS AVAILABLE PRIVATE PRACTICE INTERNAL MEDICINE OPPORTUNITY IN BEAUTIFUL NORTH SAN DIEGO COUNTY: Unique opportunity to practice outpatient internal medicine in a private practice setting. Practice is part of a well-established internal medicine group with a 30+ year history of outstanding care in the community, seeking physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, flexible scheduling options, small group environment, autonomy, and very high quality patient care are among the many benefits of this opportunity. Office is easily accessible from all parts of San Diego County, as well as Orange County. Seeking BC/BE applicants. Please send CV to portofino3@aol.com or call (619) 2482324. [577] DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a full-time/part-time BC- or BE-eligible dermatologist. Existing practice taking over another busy practice and looking to add dermatologist. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two energetic dermatologists and a highly trained staff in a positive environment. We care about our patients and treat our staff like family. Opportunity to do medical, cosmetic, and surgical dermatology. May 2017 start preferred. Please call practice administrator at (858) 761-7362 or email jmaas12@hotmail.com for more information. [575]

INTERNAL / PULMONARY/ SLEEP PHYSICIAN LOOKING TO RETIRE: Looking for CA-licensed physician in any of these specialties to join and take over practice.

Call (858) 581-0400 or email jrvevaina@yahoo.com. [574]

time or full-time interventional physiatry / physical medicine specialist with wellestablished orthopaedic practice. Office located near Alvarado Hospital. Onsite digital X-ray and EMR. Interested parties, please email lisas@sdsm.net. [554]

SEEKING INVASIVE CARDIOLOGIST: A busy private practice in North County seeks an invasive cardiologist for full-time work.

New graduates welcome. Be busy from Day 1.

Must be BC/BE in general cardiology, nuclear cardiology, and echocardiography. Email bccjobcenter@gmail.com. [571]

PUBLIC HEALTH MEDICAL OFFICER, TUBERCULOSIS CONTROL & REFUGEE HEALTH: HHSA. Anticipated range $145,000– $155,000. Excellent benefits package. For details, go to www.sandiegocounty.gov/content/ dam/sdc/hr/jobs/HHSA_TB_Control.pdf. [548]

PSYCHIATRIST WANTED TO JOIN GROWING PSYCHIATRIC PRACTICE: I have billing, credentialing, and admin support in place, as well as telepsychiatry service and EHR (drchrono). My clinic takes most major insurances, but not Medicare/Medi-Cal. The clinic will likely move to a larger space in North San Diego County soon. I’m open to the person working as a contractor for a split of their revenue, or for a flat fee for a portion of the overhead. Clinic also provides IV ketamine infusions. Open to part-time and full-time. POC is Dr. Jake Hollingsworth: (858) 261-4622; doctorjake@kflpsychiatry.com; www.kflpsychiatry.com and www.ketamineforlife.com. [567] FAMILY MEDICINE / PEDIATRIC 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. Email resume to hr@vistacommuntyclinic.org or fax to (760) 414 3702. Visit our website at www.vistacommuntyclinic.org. EEO Employer/ Vet/Disabled/AA [566] SEEKING HOSPITALISTS: UC San Diego, Dept. of Pediatrics, is seeking hospitalists to provide direct patient care in the Level I/ III Newborn Intensive Care Unit, Division of Neonatology, at UCSD Hillcrest and UCSD Jacobs Medical Center, both in the San Diego area. Candidates must have California medical licensing/eligibility, board certification in pediatrics, and experience in pediatric hospital medicine, preferably, with experience in the care of patients in a NICU or completion of a hospital medicine fellowship, and certification in neonatal resuscitation. The Division of Neonatology has a strong commitment to clinical care, teaching and research. Interested persons should email Erika Fernandez, MD, at erfernandez@ucsd.edu. [565] LOOKING FOR PRIMARY CARE PHYSICIAN: Well-established primary care group in San Diego is looking for a full- or part-time primary care physician. Out-patient only, with no calls or weekends. Please submit your CV with letterhead to infoclinic1@yahoo.com. [562] OPPORTUNITY FOR INTERVENTIONAL PHYSIATRY / PHYSICAL MEDICINE SPECIALIST: Practice opportunity for part-

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

26

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SEEKING URGENT CARE CLINICIANS: UC San Diego, Department of Pediatrics (wwwpediatrics.ucsd.edu), and Rady Children’s Hospital of San Diego (www.rchsd.org) is seeking clinicians for our urgent care clinics, Division of Emergency Medicine & Urgent Care.

Clinicians should be BC/BE pediatricians, with experience in general pediatrics and urgent care. Our main campus EM has a census of over 85,000 visits per year; the division also has four community pediatric urgent care centers with a combined census of about 54,000 visits per year. Salary will be commensurate with experience. Interested persons should contact Dr. Katherine Konzen, Director of Pediatric Urgent Care, at kkonzen@rchsd.org. [531] SEEKING FAMILY MEDICINE PHYSICIANS: Sharp Rees-Stealy Medical Group is seeking full-time or half-time (job share) BC/BE family medicine physicians to join our staff. Openings available in La Mesa, Downtown San Diego, Otay Ranch, and Kearny Mesa. 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, or email lori.miller@sharp.com. [529] SEEKING INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE Internal Medicine physicians to join our staff. Openings available in La Mesa, Otay Ranch, Downtown San Diego and Kearny Mesa. 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, or email lori.miller@sharp.com. [528] SEEKING OCCUPATIONAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE Occupational 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) 2334730, or email lori.miller@sharp.com. [527] SEEKING OB/GYN NOCTURNIST PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time and part-time BC/BE ob-gyn nocturnists to join our staff working at Sharp Mary Birch Hospital. 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, or email lori.miller@sharp.com. [526] DERMATOLOGIST NEEDED: Dermatologist, with California license, needed for a well established, well respected dermatology practice in Encinitas, CA. Part-time or full-time position available immediately. Competitive salary. Training in Mohs micrographic surgery

a plus. Exceptional new graduates are considered for the position. Please email CV to dermmd10@gmail.com or call (760) 612-7171.

[523] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($200–$250+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]

SHARE OFFICE SPACE IN SAN DIEGO: Near Alvarado Hospital. Beautiful office with two exam rooms and one procedure room.

Available up to three days per week. Reasonable monthly rent with no contract required. Email Pat at patbutina@sbcglobal.net. [563] OFFICE SPACE TO SUBLET ON CAMPUS OF SHARP CHULA VISTA MEDICAL CENTER HOSPITAL: Located at 752 Medical Center Court. Half days to share available.

Completely furnished, turnkey operation, pleasant environment. For additional details, please email Connie Espinoza, Business Office Manager, at conniee4@gmail.com. [561]

OFFICE SPACE AVAILABLE / REAL ESTATE

MISSION VALLEY AMBULATORY SURGICAL CENTER FOR LEASE Centrally located in Mission Valley, AAAHC Accredited with two fully equipped operating rooms, recovery department, nicely appointed patient waiting area and doctor’s lounge.

Highly qualified surgical staff is provided. The center is leasable by the day, week or month.

Please contact Matthew Rifat for further information at 619-708-3675.

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp & Rady Children’s. Ready-to-occupy suites ranging from 1,300-5,000 SF with mix of exam rooms and offices. Will consider short-term & long-term leases.

For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org”

LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE FOR 2–3 DAYS PER WEEK: In the 4520 Executive Drive bldg. Excellent location between I-5 and I-805. Beautiful, renovated office space with two exam rooms and large physicians office for consultations. Ideal for primary care, pain management, physical therapy, rheumatology, infectious disease, dermatology, orthopedics. Interested parties, please email missyphilip@gmail.com. [573] SOUTH BAY OFFICE SPACE AVAILABLE: Looking to grow your practice? If you’re an orthopedic specialist, ENT, urologist, neurologist, or geriatrics, we have an opportunity to enter a turn-key office. Medicare patients and stable income. Location: South Bay. Please call (619) 585-0476. Ask for Dr. N. [570] LA JOLLA (NEAR UTC) MEDICAL OFFICE FOR SUBLEASE OR SHARE: Genesee Plaza medical office building. 9339 Genesee Ave. Great location between I-5 and I-805. Up to four exam rooms and private or shared consult office available. 1,500-square-foot beautiful office. Additional 1,800 square feet available to build out. Reasonable rent. Please call (858) 6257979 and ask for Alicia. [568]

MEDICAL OFFICE BUILDING FOR SALE: 1729 Palm Avenue is an approximately 2,433-square-foot, freestanding, professional medical office building conveniently located in San Diego. The property can be occupied by an individual owner or as a two-tenant building, which would offer new owner flexibility in occupancy while receiving additional rental income. The property offers excellent exposure and visibility along Palm Avenue with approximately 38,000 ADT (Costar) and is minutes away from Imperial Beach and the Pacific Ocean. Please contact Chris Baumgart with Cushman & Wakefield for more information at (760) 431-3847 or at chris.baumgart@cushwake.com. [558] 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. [530] 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 $5,000 for 4–5 year lease, rent $1,800 per month net ($400 NNN). 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 PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for busy pediatrics office with three doctors in Chula Vista. Part time, flexible days/hours. Fluent in English and Spanish. Call (619) 454-0457 or email condorsoul@aol.com. [576] MEDICAL BILLERS NEEDED: Medical billers with greater than two years of experience needed. Part-time or full-time available. Fulltime available with full benefits. Please send resume to FootMD@FootMD.org. [569] ADMINISTRATIVE ASSISTANT NEEDED for busy family practice solo office in La Mesa.

Knowledge of medical billing and coding a must. Front office experience a must! Full time with great benefits. Please email resume to p.fortuna@efpmg.com. [557] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary.

Call (619) 992-5330 or email drhunt@ thehousecalldocs.com. Visit WWW.THEHOUSECALLDOCS.COM. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 9925330 or email drhunt@thehousecalldocs.com.

Visit www.thehousecalldocs.com. [038] SERVICES OFFERED PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

PLACE YOUR AD HERE Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org

SAN DIEGO PHYSICIAN.ORG

27

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

THE MASCULINE AND FEMININE OF DELIVERING HEALTHCARE

by Helane Fronek, MD, FACP, FACPh

RECENTLY, A MEDICAL STUDENT told me she was criticized for “spending too much time” with patients during a primary care rotation. In stunned silence, I wondered how this comment could even cross a preceptor’s mind. A student must learn about the patient’s experience, and doesn’t yet have the knowledge to know what can be left out of an evaluation. What are we teaching our students? What kind of doctors are we developing?

And yet, I understand the preceptor’s concern. The modern practice of medicine requires that we curtail discussions with patients, lest we run late. I know many of

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FEBRUARY 2017

us worry we’ll miss important information our patients might share if we demonstrated greater interest and openness. We won’t develop the trust needed for our patients to follow our recommendations. And we’ll deprive ourselves of the joy we derive from those closer relationships. In a study by the Center for Health Futures, more than 80% of physicians cited “relationships with patients” as “highly important” to their own sense of personal satisfaction.

Just as we’re adjusting to this more rapid way of seeing patients, a recent article in JAMA reported that patients cared for by women physicians had lower mortality and

readmission rates. The authors state that women physicians tend to follow clinical guidelines and evidence-based protocols more than men, but did this create the difference? The real question we need to ask is, what are the specific traits associated with these improved outcomes?

There are many ways in which women and men tend to differ, and it’s possible that some of these features created this impact. Feminine traits such as receptivity, empathy, nurturing, tenderness, patience, and loving can contribute to lower morbidity and mortality. Logic, focus, passion, discipline, confidence, and strength, considered masculine traits, might assist us in dealing with the more demanding schedule we are asked to keep. We all embody both feminine and masculine characteristics.

I’m sure you can identify traits in both lists that come naturally to you and that you use daily in your work as a physician. How can each of us hone the skills that will result in the best outcomes and those required for the modern practice of medicine?

As seasoned physicians, what traits and practices will serve us well in straddling this new reality of seeing more patients, while still providing compassionate, patient-centered care? I struggle to keep patient interactions focused on what’s most important. When I put my more masculine abilities of discipline and focus into action, I’m better able to manage the encounter. In the brilliant movie, The Doctor, we watch the surgeon miss many opportunities to respond with kindness toward his patients. After he becomes a patient, he becomes more present, understanding, and empathic. We each have skills in both arenas. The opportunity is to intentionally use those that are required to achieve this challenging balance of efficiency and presence that the modern practice of medicine and our patients require.

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

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