MARCH 2017 OFFICIAL PUBLICATION OF SDCMS
Are Your Patients Food Insecure? PAGE 20
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SAN DIEGO PHYSICIAN.ORG
VOLUME 104, NUMBER 3
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) 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 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
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
“ Yes or No? Within the Past 12 Months …” Food Insecurity in San Diego — An Interview With Dr. Patricia Cantrell BY SAN DIEGO PHYSICIAN
Briefly Noted: Calendar • Healthcare Reform • Medical Students • Physician Socials • In Memoriam • Public Health • And More …
2016 SDCMS Annual Report
# HeartToHeart: Families Working Together to Prevent Heart Disease BY CECILIA BONADUCE, MSII
ut Your SDCMS-CMA P Membership to Work!
Up for Review: Five Keys to Managing Online Criticism
BY KEVIN PHO, MD
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
18 Finding a Good Nursing Home BY GREG DILL
Physician Marketplace: Classifieds
Are You Playing to Win, or Playing Not to Lose?
BY HELANE FRONEK, MD, FACP, FACPh
Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]
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SAN DIEGO PHYSICIAN.ORG
/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// HEALTHCARE REFORM
Trump Won (??!!): Now What?
SDCMS-CMA CALENDAR For further information or to register for the following events, contact Jen at (858) 300-2781 or at JOhmstede@SDCMS.org.
On Feb. 23, Dr. Robert E. Hertzka, former president both of SDCMS and CMA, immediate past chair of AMA’s Council on Medical Service, “Health Policy and Politics” instructor at the UC San Diego School of Medicine, and 36-year member of SDCMS-CMA, presented his “Trump Won (??!!): Now What?” talk to more than 75 medical students, physicians, and guests at the UC San Diego SOM. Watch Dr. Hertzka’s hour-long talk in its entirety at YouTube.com/SDCMSPhysicians.
Implementing Strategies to Enhance Advance Care Planning (webinar) APR 12: 12:15pm–1:15pm Aligning Clinical Practice With Diabetes Prevention (webinar) APR 26: 12:15pm–1:15pm SDCMS Physician Social (event) APR 28: 5:30pm–8pm Western Health Care Leadership Academy (conference) MAY 5–7 at the Marriott Marquis San Diego Marina SDCMS White Coat Gala (event) JUN 3: 6pm–10:30pm
HEALTHCARE CONFERENCES 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. New Treatments in Chronic Liver Disease MAR 31–APR 2 at the Estancia La Jolla Hotel Clinical Advances in Heart Failure and Arrhythmias APR 28–30 at the Loews Coronado Bay Resort in Coronado
(L–R): Meghana S. Pagadala, Ishan Mehta, Anna E. Buehler, Alex M. Li, Kelsey A. Perry, Ben Tsuda, Katie Young, Karen A. Keniston, Albert S. Song, Scarlett M. Chen, Alexander Beletsky, Milli Desai, and Thejas P. Kamath
Students Meet Legislators in Sacramento, Feb. 14–15 Each year, SDCMS sends groups of first-year UC San Diego medical students to Sacramento to meet with state legislators. This past February 14–15, Jason Adams, Shubham Agrawal, Alexander Beletsky, Anna Elise Buehler, Gabrielle Cahill, Scarlett M. Chen, Milli Desai, Anna M. Dornisch, Rushikesh Joshi, Thejas P. Kamath, Karen A. Keniston, Soumya Kurnool, Alex M. Li, Emily Mannix, Ishan Mehta, Meghana S. Pagadala, Saatchi Patell, Kelsey A. Perry, Kate Pool, Elischa J. Sanders, Albert S. Song, Ben Tsuda, and Katie Young made the trip, accompanied by Drs. Robert Hertzka and Mihir Parikh, and SDCMS CEO Paul Hegyi. The students met with Senator Joel Anderson, Assemblymember Dr. Joaquin Arambula, Senator Toni Atkins, Assemblymember Rocky Chávez, Assemblymember Todd Gloria, Assemblymember Lorena Gonzalez, Assemblymember Brian Maienschein, Senator Dr. Richard Pan, and Assemblymember Shirley Weber.
JOIN US ON APRIL 28! Please join your physician colleagues on Friday, April 28 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.
/////////////////////////////////////////////////////////////////////////////////////////////////// PUBLIC HEALTH HEART HEALTH
Love Your Heart
QUOTE OF THE MONTH
(L–R) Nicholas “dr. Nick” Yphantides, MD, MPH, chief medical officer for the County of San Diego, Kristi Koenig, MD, the County of San Diego’s new EMS medical director, James T. Hay, MD, past president, Champions for Health, and Paul Hegyi, SDCMS CEO.
Love Your Heart, a program under the Live Well San Diego vision, is an annual event that takes place on Feb. 14, during which the County of San Diego and its partners, including SDCMS and Champions for Health, provide free blood pressure screenings to the public at select sites throughout the San Diego region and Mexico. The goal of Love Your Heart is to activate residents to “know their numbers” and take charge of their own heart health. To learn more about Love Your Heart and Live Well San Diego, visit www.livewellsd.org.
Gerald B. Farrow, MD, 38-year member of SDCMS-CMA, was discovered to have passed away on Dec. 22, 2016.
Gregory M. Gullahorn, MD, 22-year member of SDCMS-CMA, was discovered to have passed away on March 9, 2016.
Our deepest sympathies to the family and friends of Drs. Farrow and Gullahorn.
If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance.
— Orville Wright, Printer/Publisher, Bicycle Retailer/ Manufacturer, Airplane Inventor/ Manufacturer, Pilot Trainer (1871–1948)
HEPATITIS B VIRUS SCREENING RECOMMENDATIONS FOR PROVIDERS Serologic testing with Hepatitis B surface antigen (HBsAg) is the primary way to identify chronic HBV infection. Testing with HBsAg now is recommended for*: • persons born in geographic regions with HBsAg prevalence of ≥2% (Latin America partially, Africa, Asia, Australia) • U.S. born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of ≥8% (West Africa) • Injection drug users • men who have sex with men • persons with elevated ALT/AST of unknown etiology • persons with selected medical conditions who require immunosuppressive therapy • pregnant women • infants born to HBsAgpositive mothers • household contacts and sex partners of HBVinfected persons • persons who are the source of blood or body fluid exposures that might warrant post exposure prophylaxis (e.g., needlestick injury to a healthcare worker) • persons infected with HIV *Reference: Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection, MMWR 2008;57(RR-8) SAN DIEGO PHYSICIAN.ORG
SDCMS ANNUAL REPORT
2016 2016 GENERAL ELECTION CMA won all of its statewide ballot measure endorsements in 2016. Your CMA successfully fought to … • Invest in Medi-Cal — Yes on 52, 55, and 56! • Provide more essential services like medical checkups, immunizations, and prescriptions for 13 million lowincome Californians, including 7 million children — Yes on 52! • Ensure critical infrastructure projects, including hospitals and medical facilities, aren’t subject to delays or loss of local control — No on 53! • Improve access to healthcare services, including Medi-Cal, for lowincome children and their families — Yes on 55! • Save lives, reduce smoking rates, and prevent thousands of children from starting smoking in the first place — Yes on 56! • Break down barriers and remove outdated bilingual education mandates to better reflect California’s diverse society — Yes on 58! • Prevent an increase in state prescription drug costs and preserve patient access to medications — No on 61! • Strengthen California’s ability to prevent gun violence — Yes on 63! • Protect public health and clarify the role of physicians in controlling and regulating the adult use of cannabis — Yes on 64!
California ranks 48th in the nation for payments to physicians. Medi-Cal visits reimburse 36% less than Medicare visits. 40% of California’s physicians provide 80% of Medi-Cal visits. 14 million Californians (1 in 3) depend on Medi-Cal for healthcare. 56% of Medi-Cal enrollees report difficulty finding a specialist. Medi-Cal patients are more likely to postpone needed care due to long appointment wait times, and they’re twice as likely to use emergency room visits to access specialty care (compared to private insurance and/or Medicare). Bottom line: CMA will fight to ensure we honor the will of Prop. 56 voters and invest the estimated $1.2 billion in new healthcare revenue for its intended purpose: to improve payments for providers to ensure that patients can see a doctor when and where they need one!
CMA MACRA Resources in 2016: • MACRA Resources Center (www. cmanet.org/macra) • Chart Comparing MACRA to Current Law (Payments, Bonuses, Penalties) • New MACRA Checklist: “What Should I Do Now to Prepare?” • Seven Webinars on Various MACRA Topics, Available On-demand • CMA Tip Sheet on Medicare Quality Reporting Programs CMA responded to the final MACRA implementation rule, reviewing and assessing the impact of the complex rule, while remaining committed to ensuring that MACRA allows more innovative, physician-led alternative payment models, and lessens the reporting burdens on everyone. After CMA, AMA, and other physician stakeholders urged CMS to ease the burdens and delay the first MACRA reporting period to give physicians more time to prepare, CMS allowed physicians to choose the level and pace at which they comply with the new MACRA Medicare payment reforms.
SDCMS ANNUAL REPORT 2016
STOPPING UNSAFE SCOPE EXPANSIONS • CMA killed AB 1306, which would have deleted the statutory requirement that certified nurse midwives perform certain medical procedures only under standardized procedures developed and implemented under the supervision of a physician and surgeon. • CMA killed SB 538, which would have allowed naturopathic doctors to independently prescribe all Schedule V controlled substances, as well as any drug approved by the FDA and labeled “for prescription only” or words of similar effect, except for chemotherapeutics. • CMA killed SB 323, which would have allowed nurse practitioners to practice in specialties such as primary care, pain management, and cardiology without physician supervision. • CMA killed SB 622, which would have allowed optometrists to perform delicate scalpel and laser eye surgeries, administer immunizations, and perform or order appropriate laboratory and diagnostic imaging tests.
SDCMS Medical Students at the Capitol
SDCMS Physicians and Medical Students Meeting With Senator Toni Atkins
CMA House of Delegates
The California Supreme Court reversed an appellate court opinion that would have thwarted MICRA’s longstanding definition of “professional negligence.” The ruling could have been misused to undermine the goals of MICRA and adversely affect the entirety of the healthcare system and safety net in California. CMA filed an amicus brief in the case, Flores vs. Presbyterian Intercommunity Hospital, arguing that the rule the plaintiff proposed — that MICRA should be limited to conduct requiring specialized medical skills — was contrary to statutory intent as evidenced by the statutory language, longstanding decisional authority, and legislative history.
SDCMS’s Legislative Advocacy Trips in 2016: • On April 13, 2016, six SDCMS physicians and four UC San Diego medical students joined more than 400 others from across California for CMA’s 42nd annual Legislative Advocacy Day in Sacramento to speak with legislators and their senior staff about healthcare issues that affect the practice and future of medicine. • SDCMS took one group of medical students to Sacramento in 2016 to meet with legislators, and joined the San Diego Regional Chamber of Commerce during its legislative trip to Sacramento. More than 500 physicians from across California, including 27 from SDCMS, convened in Sacramento Oct. 15–16 for CMA’s annual House of Delegates (HOD) meeting. The HOD now meets to establish broad policy on current major issues affecting physician members, the association, and the practice of medicine. The major issues discussed at the Oct. meeting were MACRA, maintenance of certification, opioids, physician burnout, ACA changes, and public health.
PROTECTING THE EMERGENCY MEDICAL SERVICES SB 867, co-sponsored by CMA and signed by the governor, extends the Maddy Emergency Medical Services Fund, which provides reimbursement to physicians who treat uninsured patients, for at least another 10 years.
PUBLIC HEALTH • CMA-sponsored AB 2121, a life-saving measure requiring alcohol servers and managers to complete a training course on responsible beverage service, made it to the governor’s desk in 2016. CMA is introducing similar legislation in 2017. • SDCMS worked with the County and other organizations to aggressively distribute Zika virus resources to San Diego County’s physicians and residents, and to inform physicians of the spread of mumps, hepatitis A, Zika virus, influenza, vector-borne diseases, Shigella flexneri, IMD, HPAI, and Elizabethkingia anophelis. • SDCMS worked with the County of San Diego to promote its 15-minute Vector-borne Diseases Survey.
SAN DIEGO PHYSICIAN.ORG
CMA published new resources and updated existing resources to aid physicians and the public in complying with California’s mandatory school vaccination requirement, which began July 1, 2016. These resources include information on when children must be vaccinated, which vaccinations are required, what information physicians must provide to parents or guardians regarding the risks, benefits, and adverse reactions to a specific vaccine, and more.
WORKERS’ COMPENSATION CMA-supported SB 563, which was amended into SB 1160 and signed by the governor, will increase transparency and accountability in the workers’ compensation utilization review process.
AB 72 Often, when a controversial bill passes, it is the lesser of two evils, and this is what happened with the passage of AB 72 over its more sinister twin, AB 533. Both bills, labeled as “Surprise Billing” legislation, were a byproduct of insurance companies’ narrow and inadequate physician networks. When AB 72 — offered as an alternative to AB 533 — was being vetted by CMA, it received input from a broad representation of physicians from every mode of practice. CMA’s various forums had spokespeople at each CMA board of trustees meeting. By ensuring stakeholder participation in the AB 72 development process, CMA was able to secure improvements in AB 72 that made it better than AB 533. CMA was able to get the Legislature’s support for these changes in the bill by switching its position from “opposed” to “neutral.” This was CMA’s only option: to seek the support of allies in pushing for AB 72 over AB 533. Many of CMA’s struggles are invisible to members, and sometimes a bill’s passage appears to occur because of neglect by CMA; nothing could be further from the truth. CMA’s AB 72 resources include an FAQ on the controversial new law and a webinar on how it works, who it impacts, and how to avoid it.
official publication of SDcMS june 2016
San Diego County Physician Workforce & Compensation
PRESCRIPTION DRUG ABUSE • CMA published a members-only resource page to provide physicians with the most current information and resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction, and overdose: www.cmanet.org/safe-prescribing. • March 16 CMA Webinar: CURES 2.0: Navigating the State’s New Prescription Drug Monitoring Database • SDCMS continues to host www.sandiegosafeprescribing.org, with provider guidelines for anyone who prescribes controlled substances, information on what you need to know about CURES, patient medication agreements, information on safe pain medication prescribing in EDs and urgent cares, educational materials, and more.
PHYSICIAN WELLNESS • CMA-sponsored SB 1177, signed by the governor, authorizes the MBC to contract with an independent third party to administer a physician Health and Wellness Program as a means of rehabilitating physicians and surgeons dealing with substance abuse conditions. • CMA continued to provide confidential doctor-to-doctor assistance to those trying to live with depression, anxiety, anger, alcoholism, drug abuse, and severe stress through its Physicians’ and Dentists’ Confidential Assistance Line at (213) 383-2691. • CMA killed SB 1033, which would have denied physicians their right to due process in the event of a medical board investigation by requiring they notify patients if their licenses were placed in probationary status.
“Physicians United for a healthy san diego”
SDCMS ANNUAL REPORT 2016
• SDCMS Published the Report of Its 2015 San Diego County’s Physician Workforce and Compensation Survey in 2016 • CMA led a coalition of healthcare groups that secured $100 million to support and expand primary care GME in medically underserved areas. Under the budget agreement, the state would spend $100 million over three years to fund the Song-Brown Program, an existing grant program that supports primary care residency programs in medically underserved areas. CMA is fighting Gov. Brown’s 2017 budget proposal to eliminate $33.4 million in healthcare workforce funding.
BIOETHICS SDCMS’s Bioethics Commission has been meeting quarterly since 2007 to discuss bioethics issues, share ideas, and explore standards of practice. In 2016 the commission met to discuss ethical challenges in pediatric hospice and palliative care, distributive justice in the context of medical rationing, patients’ right to treatment of pain and physician and institutional response in the opioid epidemic era, and patients’ rights and dementia.
STOPPING HEALTH PLAN ABUSES • CMA prevailed in Nov. when the California Supreme Court ruled in the case of Centinela Freeman Emergency Medical Assocs. v. Health Net et al. that health plans cannot irresponsibly delegate risk and leave physicians unpaid for services provided in good faith to enrollees. • From day one, CMA opposed the Anthem-Cigna and Aetna-Humana mega-mergers because they would hurt patients and increase healthcare costs. With CMA’s long-held concerns over reduced competition and increased health plan market power, early in 2016 it conducted a survey to determine California physicians’ perspective on the Anthem-Cigna and Aetna-Humana mergers and found that 85% of California’s physicians opposed the mergers. • CMA continued to remind its members that they do not have to accept substandard contracts that are not beneficial to their practice. To help physicians understand their rights when a health plan has sent notice of a material change to a contract, CMA published “Contract Amendments: An Action Guide for Physicians,” which includes a discussion of options available to physicians when presented with a material contract change, as well as a financial impact worksheet that will help physicians calculate the net impact of fee schedule changes on their practice.
SUPPORTING HOSPITAL MEDICAL STAFFS CMA filed an amicus brief in support of the medical staff at Tulare Regional Medical Center in its lawsuit against the hospital alleging violations of state laws when the hospital terminated the entire medical staff and its duly elected officers. December 2016 official publication of SDcMS
HIPAA • SDCMS conducted a “HIPAA Compliance: Key Risks All Physicians Should Know” webinar in June. • CMA hosted an “Is Your Practice at Risk for a HIPAA Security Breach?” webinar in November.
Medical Missions to the himalayas, Nigeria, aNd Fiji
HELP WITH MEANINGFUL USE • CMA Repeatedly Called on CMS to Delay Meaningful Use Stage 3 and Reform Stage 2 • SDCMS and CMA urged members to preemptively file for a 2015 hardship exception to avoid penalties in 2016. • CMA published “Meaningful Use Hardship Exception FAQs” to help physicians navigate the hardship exemptions process.
CAL MEDICONNECT CMA created a new resource — “Ask the Expert: Billing Medi-Medi Patients” — to help members collect the 20% that Medicare does not cover when they aren’t Medi-Cal providers but provide services to Cal MediConnect (MediMedi) patients.
COMMUNICATING TO, FOR, AND FROM PHYSICIANS
• SDCMS hosted an End of Life Option Act (which took effect June 9) workshop in October. • CMA published an ON-CALL FAQ document titled, “The California End of Life Option Act.”
SDCMS ANNUAL REPORT 2016
END-OF-LIFE OPTION ACT
• CMA killed SB 932, which would have dramatically changed the balance of power and given payers the upper hand when negotiating physician contracts. • CMA Webinar: Contract Renegotiations: How to Get Past ‘No’ With a Payer • CMA Guide: “Contract Renegotiations: Making Your Business Case” • SB 137 took effect July 1, 2016, requiring health plans to ensure physician directories are accurate and up to date. In April, CMA hosted a webinar about the new law and a directory accuracy pilot program, providing an overview of the pilot program and the requirements of SB 137. In addition, CMA published a guide on the new law.
• San Diego Physician delivers SDCMS’s message to more than 9,000 physicians in the county every month, and to more than 400 legislators, journalists, hospitals, libraries, and others. • SDCMS published 15 issues of our “News You Can Use” e-newsletter, reaching 9,000+ recipients every two or three weeks. • SDCMS President Dr. Mihir Parikh recorded eight brief video updates for members on a variety of topics, including a new program SDCMS and others will launch in early 2017 to help patients in San Diego fight food insecurity, MACRA, MOC, AB 72 confusion and resources, medical missions, and more!
SAN DIEGO PHYSICIAN.ORG
SDCMS ANNUAL REPORT 2016
Dr. Ray (center)
MEMBERS IN THE NEWS
• Dr. Ted Mazer Elected CMA President-elect • Dec. 16 Union-Tribune: “Dr. Ted Mazer Becomes State Leader Amid Changing Healthcare Landscape” • Nov. 23 KPBS: “Dr. Butcher Defied Discrimination, and San Diego Reaped the Benefits” • Dr. Al Ray was awarded the Gary F. Krieger Speaker’s Recognition Award for distinguishing himself with his contributions to patients, to the profession, to CMA, and to the CMA House of Delegates. • Dr. Bob Wailes received the Joseph Boyle, MD, Young at Heart Award from CMA’s Young Physician Section, given to a CMA member for supporting and mentoring California’s young physicians. • Dr. Lase Ajayi was inducted as CMA Young Physician Section chair. • Dr. Susan Kaweski was elected vice chair of CALPAC, CMA’s political action committee. • Dr. Nick Yphantides Was Named County of San Diego HHSA CMO • Dr. Robert Smith was named VASDHS director. • After five-plus years with CMA, finally as its vice president of membership, marketing, and communications, Paul Hegyi took over as CEO of SDCMS on Jan. 1, 2016.
RESIDENTS & MEDICAL STUDENTS • SDCMS partnered with former SDCMS CEO Tom Gehring and UC San Diego to once again offer the “Life After Residency” workshop for resident and young physicians. • Under the direction of Dr. Bob Hertzka, UC San Diego medical students in 2016 had the opportunity to take a course on healthcare policy, which included two trips to the Capitol to lobby legislators on healthcare issues, as well as summer internships with Speaker Emeritus Toni Atkins, Assemblymembers Shirley Weber and Brian Maienschein, State Senators Joel Anderson and Dr. Richard Pan, and others. • Dr. Mihir Parikh, SDCMS president, led the processions of both the UC San Diego School of Medicine White Coat Ceremony and Commencement Ceremony processions. • SDCMS’s CEO and several SDCMS physician leaders assisted Dr. Bob Hertzka in instructing the UC San Diego School of Medicine’s “Business of Medicine” course.
SDCMS and CMA worked to ensure our members were kept abreast of and ready for the end of the ICD-10 grace period, the deadline to dispute 2015 PQRS and QRUR findings, the need to verify CHPI data, new chronic pain/opioid treatment guidelines for injured workers, CMS’s Meaningful Use hardship exception deadline, the end of the vaccination personal belief exemption, the need to work with payers to ensure their physician directories are accurate, the need to register for CURES, UHC’s clinical data submission protocol expansion, Covered CA changes, new health laws, the need for business associates agreements, the requirement to post nondiscrimination statements, the need to respond to BetterDoctor requests, new payer-required prior authorizations, updated disease reporting requirements, new drug testing codes, and more.
NEW MEMBER BENEFIT SDCMS’s new member benefit through San Diego Private Bank helps member physicians save on their SBA-guaranteed loans — San Diego Private Bank will pay 1% out of the total SBA guarantee fee percentage.
Let us help you grow
In partnership with CMA, SDCMS held 28 webinars and seminars in 2016 on a broad range of topics, including MACRA, HIPAA, closing a medical practice, CURES 2.0, lobbying 101, how to reduce overhead expenses and increase profitability, contract renegotiations, reimbursement 101, how to increase workers’ compensation revenue, Medicare provider enrollment, pain management and safe prescribing, nondiscrimination statements compliance, and more!
SUPPORTING OFFICE MANAGERS • Congratulations, Doris Castillo, SDCMS’s 2016 Office Manager of the Year —nominated by Karen Hanna, MD, of Minimally Invasive Surgeons of North County. • Since 2012, SDCMS has welcomed member physician office managers and practice administrators to participate in its private SDCMS Office Manager Forum, enabling office managers to build a community of mutual support.
SDCMS ANNUAL REPORT 2016
SEMINARS AND WEBINARS
SOCIAL MEDIA Follow SDCMS and CMA on Social Media: • YouTube.com/SDCMSPhysicians • YouTube.com/CMAPhysicians • Twitter.com/SDCMS • Twitter.com/ cmaphysicians • Facebook.com/SanDiegoCountyMedicalSociety • Facebook.com/ cmaphysicians • Medium.com/@SDCMS • Medium. com/@CMAPhysicians
Thank you to all San Diego County physicians who continue to champion the work of the San Diego County Medical Society and California Medical Association! Bipartisan support of organized medicine has never been more important than it is now, with Democrats holding super-majorities in both houses in Sacramento and Republicans controlling both houses in Congress. We need every physician’s voice to protect the practice of medicine and our patients’ health and wellbeing. • • • • •
Regular Physician Members: 2,819 Resident Physician Members: 1,237 Medical Student Members: 363 Retired Physician Members: 749 Grand Total SDCMS Membership for 2016: 5,168
For the first time in CMA’s 160-year history, membership surpassed 43,000 in 2016 — your CMA is bigger and stronger that it has ever been!
EVENTS AND SOCIALS
• SDCMS hosted four physician socials at locations around San Diego County in 2016, including our most successful social to date, held at the Reuben H. Fleet Science Center with more than 250 in attendance. • More than 200 physicians and honored guests attended our 2016 SDCMS and Champions for Health White Coat Gala in June, including Representative Scott Peters, Senator Toni Atkins, Senator Marty Block, Assemblymember Lorena Gonzalez, and keynote speakers Dustin Corcoran, CMA CEO, and James Floros, San Diego Foodbank CEO. SDCMS celebrated 146 years of healing, while welcoming Dr. Mihir Parikh as president for 2016–17 and thanking Dr. William Tseng for his service as immediate past president. More than 400 physicians and guests attended the Oct. 29 Top Doctors Gala.
SDCMS Physician Social at the Reuben H. Fleet Science Center
Senator Marty Block and Assemblymember Lorena Gonzalez Recognizing Dr. Will Tseng.
SAN DIEGO PHYSICIAN.ORG
SDCMS ANNUAL REPORT 2016
REVENUE AND EXPENSES
Champions for Health
Champions for Health
Dr. Kamshad Raiszadeh
Dr. Ramin Raiszadeh
Spine Institute of San Diego Six years ago, two local physicians, who are also brothers and partners, began volunteering with Project Access San Diego. Through this flagship program of Champions for Health, the pro bono work of Ramin Raiszadeh, MD, and Kamshad Raiszadeh, MD, has had a significant impact on improving community health. On several occasions, both physicians have dedicated their time and talents, pro bono, to help uninsured San Diegans receive spinal surgeries needed to regain their health, return to work, and continue taking care of their families. Without the support of these two physicians, this extensive and life-changing medical care would not be available to Project Access patients. Champions for Health is tremendously grateful for and reliant on physicians like Dr. Ramin Raiszadeh and Dr. Kamshad Raiszadeh, who volunteer their expertise and skills to heal our community’s most vulnerable patients.
To join our team of champion physicians, please contact: 858-300-2780 I Barbara.Mandel@ChampionsFH.org or visit: www.ChampionsForHealth.org.
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P U B L I C H E A LT H
#HEARTTOHEART Families Working Together to Prevent Heart Disease by Cecilia (“CC”) Bonaduce, MSII
DEAR DAD, An American has a heart attack every 42 seconds. Twenty-seven years ago, just before I was born, you were that statistic. I grew up hearing about the time you felt “off” and drove yourself to the hospital — only to find out you were in the midst of a life-threatening heart attack. You didn’t know the signs of “myocardial infarctions” at the time, likely because only 27% of people in the United States are aware of all of the major symptoms of a heart attack. But we know the symptoms now: you from experience and me as a medical student.
I know you didn’t think much about heart health before the episode. You were feeling great, living life, and confidently approaching your 40s. But this heart attack made it inescapably clear that you needed to learn about heart disease and take steps to reduce your risk for future problems. It’s now been nearly 30 years without any heart problems! I’m grateful that you recognized something “wasn’t right” and got yourself to a hospital. That decision enabled you to be present and healthy for my birth a few months later. And you were there when I won my first debate tournament in high school. You were there when I was accepted
into UC Berkeley. And you were there to help carry furniture and boxes into my first dorm room (up seven flights of stairs with no elevator access!). You were there two years ago for my first day of medical school. And you’ll be there in six months to walk me down the aisle at my wedding. We weren’t guaranteed to share any of these moments, and my heart is filled with so much gratitude and joy knowing you’re doing what it takes to protect your heart. Because I didn’t fully understand heart disease and the importance of preventive care until I started medical school. Heart disease is the number one cause of death among men and women in the United States. We learned about the risk factors on the first day of cardiology class. Why day one? Because many of the risks are preventable and reversible. In fact, 80% of heart disease and stroke events can be avoided with lifestyle changes and education. After our family’s experience, I now understand the importance of discussing risks, symptoms, and prevention with my patients, family, and friends. High blood pressure and high cholesterol are two big risk factors for heart disease. I may know the names of the drugs used to address those risks, their mechanisms of action, and potential adverse effects — but Dad, you’re the one who figured out a system to take them every day and renew prescriptions before they run out. Another risk factor? Physical inactivity. Dad, thank you for walking every day to stay active, and I love that you even walk to the gym to get extra cardio. I’m also grateful that you quit smoking cigarettes nearly 30 years ago — and never went back. Thank you for taking these steps to reduce your risk of heart disease. And thank you for letting me share our story with other dads and daughters — perhaps our #HeartToHeart story will help ensure others get to enjoy a lifetime of happy memories with their loved ones.
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UP FOR REVIEW Five Keys to Managing Online Criticism by Kevin Pho, MD, Founder and Editor, KevinMD.com
No matter how professional and caring you may be as a doctor, eventually you will face criticism on the web. Here are five keys to managing that criticism. Note: For more tips on social media and online issues, visit The Doctors Company social media resource center at www. thedoctors.com/socialmedia.
Listen to the Criticism: Patients may leave online reviews because they feel this is the only way they can have a voice. By listening to online criticism, you can identify and fix easily correctable situations and improve patients’ satisfaction scores.
Take Critical Conversations Offline: Whenever you see criticism on the web, there’s a strong temptation to respond to it immediately. You want to set the record straight and clear the air. Instead, take the conversation offline. An online argument is unlikely to result in anything productive. Post a standard reply thanking the patient for the comment and asking him or her to call the clinic. Be careful not to reveal any private patient information.
Read the Fine Print: If you believe any online comments are suspicious, contact the rating site to see if the comments violate the terms of service agreement.
Many doctors dislike being rated at all, but to succeed in the online world you shouldn’t ignore reviews.
Ask More Patients to Rate You Online. Most patients generally like their doctors, and dozens of studies show that a majority of online ratings are positive. By asking more patients to rate you online, you can make negative ratings look more like outliers. Ask your patients to post a review if there’s something they like about you or what your practice is doing, or if they have any suggestions for your practice. Don’t cherrypick patients or pressure them to say something positive about your practice, but ask for a rating from every single patient in a low-key and low-pressure way.
Resist the Urge to Sue. Only rarely have doctors successfully sued rating sites, which may argue that removing negative ratings is an infringement of a patient’s right to free speech. By suing patients over criticism, you will only bring more attention to it and highlight the negative reviews. We now live in a world where doctors are rated like professionals in many other industries, a trend that will continue to grow. Many doctors dislike being rated at all, but to succeed in the online world you shouldn’t ignore reviews. Instead, approach online ratings proactively. You’ll find yourself better able to influence the online conversation about you, fix any shortcomings in your practice, and engage critical patients in a positive, constructive way.
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FINDING A GOOD NURSING HOME by Greg Dill
ONE RECENT SUNDAY MORNING, I woke up to a text message from a coworker saying she’d been up all night with her mother in the ER. Her mom had fallen, broken her hip, and was getting admitted to the hospital for surgery. As you can imagine, my colleague was exhausted, worried, and facing some important decisions. Even as her mom was being prepped for surgery, the hospital’s care coordinator was asking which rehabilitation facility she should be sent to afterward.
As a fellow official of CMS, my associate has a better-than-average understanding of the healthcare system. But she’d never had to find a rehabilitation facility for a loved one. So she turned to an online tool CMS developed to help people find a suitable nursing home when they need one. The tool is called Nursing Home Compare, and you can find it on our www. Medicare.gov website. Just click on the button that says, “Find nursing homes.” Enter your ZIP code or city and you can
begin your search. Nursing Home Compare assigns from one to five stars to every nursing facility that participates in Medicare or Medicaid, with five stars being the highest rating. These star ratings give you and your family an easy-to-understand summary of three important dimensions of nursing home quality: health inspection results, staffing information, and quality of care. The goal of our Five-Star Quality Rating System is to help people distinguish between higher- and lower-performing nursing homes. CMS also wants to help nursing homes identify problem areas and to improve their quality. Nursing facilities receive an overall star rating based on three types of performance indicators, each of which has its own star rating: • Health inspections: Nursing homes that participate in Medicare or Medicaid undergo unannounced, comprehensive inspections about once a year. CMS bases health inspection ratings on the number, scope, and severity of deficiencies found during the three most recent inspections, as well as on results of complaint investigations during the most recent 36 months. • Staffing levels: CMS bases staffing ratings on two components: (1) Registered nurse hours per resident day; and (2) total staffing hours (registered nurse plus licensed practical nurse plus nurse aide hours) per resident day. The staffing measures are adjusted for different levels of resident care needs.
Maximizing the bottom line, one office at a time. • Quality measures: These ratings are based on how a nursing home performs on 16 of the 24 quality-of-care measures currently posted on Nursing Home Compare. The measures reflect whether residents got flu shots, are in pain, or are losing weight. We also look at how well the facility controls pressure ulcers (bed sores), whether it overuses antipsychotic medications, and other indicators of how residents are treated. A facility’s overall star rating is a composite of the ratings on the measures above. The core of the overall rating is the health inspection rating, which is adjusted up if the facility receives high staffing or quality-of-care ratings, or down if those ratings are low. You can compare multiple facilities on Nursing Home Compare, as my colleague did when looking for the best spot for her mother. But keep in mind that star ratings are intended to be combined with other sources of information (such as a doctor’s recommendation) and shouldn’t substitute for visiting the nursing home in person. Indeed, after my coworker identified two possible facilities, she visited the one that had an available room and was pleased to learn it had high ratings for food service, something very important to her mother. At www.Medicare.gov, you’ll also find “compare” websites for hospitals, home health services, dialysis facilities, medical equipment suppliers, and Medicare-approved health and prescription drug plans. Choosing a nursing home for yourself or a loved one is a complex, personal, and often emotionally draining decision. With that in mind, we developed a detailed brochure, “Your Guide to Choosing a Nursing Home or Other Long-Term Care,” which you can find online at www.medicare.gov/ Pubs/pdf/02174.pdf. Among other things, the brochure provides a checklist of questions to ask nursing home managers, alternatives to nursing home care, and the legal rights and protections of nursing home residents. I’m glad to report my colleague’s mother is on the mend! Mr. Dill is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1 (800) MEDICARE (1-800-633-4227).
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Note: This interview was recorded Feb. 21, 2017. Patricia E. Cantrell, MD, SDCMSCMA member for 19 years and board-certified in pediatrics, is the current president of the San Diego and Imperial counties chapter of the American Academy of Pediatrics.
SDP: What is food insecurity and how does it differ from hunger?
“ Yes or No? Within the Past 12 Months …” Food Insecurity in San Diego — An Interview With Dr. Patricia Cantrell BY SAN DI EG O PHYSICIAN
Dr. Patricia Cantrell: Many people have trouble understanding the difference between the two. Food insecurity is a household-level economic and social condition of limited or uncertain access to adequate food. Hunger, on the other hand, is an individual-level physiological condition that may or may not result from food insecurity. For example, you can be hungry right before lunch but have the money to buy food and satisfy your hunger. If you’re food insecure, you might not have the resources to satisfy that hunger. SDP: Are those American Academy of Pediatrics definitions? Dr. Cantrell: In fact they’re from the USDA. In 2006 they introduced new language to describe ranges of the severity of food insecurity. You can be low food security or very low food security. Low food security is defined as reports of reduced quality, variety, or desirability of diet, with little or no indication of reduced food intake. So maybe you’re not able to buy that wonderful salmon or fresh salad or things like that, and instead you’re buying the Top Ramen, which
What’s the Difference Between Food Insecurity and Hunger? Food insecurity is a household-level economic and social condition of limited or uncertain access to adequate food. Hunger, on the other hand, is an individual-level physiological condition that may result from food insecurity.
What’s the Difference Between a Food Bank and a Food Pantry? According to Wikipedia, a food bank is a nonprofit, charitable organization that distributes food to those who have difficulty purchasing enough food to avoid hunger. Food banks usually operate on the “warehouse” model, acting as food storage and distribution depots for smaller frontline agencies — food banks usually do not themselves give out food directly to the hungry. After the food is collected, sorted, and reviewed for quality, these food banks then distribute it to nonprofit community or government agencies, including food pantries, food closets, soup kitchens, homeless shelters, orphanages, schools, etc.
What Is a Food Desert? According to the USDA: Limited access to supermarkets, supercenters, grocery stores, or other sources of healthy and affordable food may make it harder for some Americans to eat a healthy diet. There are many ways to measure food store access for individuals and for neighborhoods, and many ways to define which areas are food deserts — neighborhoods that lack healthy food sources. Most measures and definitions take into account at least some of the following indicators of access: • Accessibility to sources of healthy food, as measured by distance to a store or by the number of stores in an area. • Individual-level resources that may affect accessibility, such as family income or vehicle availability. • Neighborhood-level indicators of resources, such as the average income of the neighborhood and the availability of public transportation. According to the 2008 Farm Bill: A food desert as an “area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower income neighborhoods and communities.”
is a lot cheaper; it might not be as healthy, and you may not be going hungry, but it’s not necessarily nutritious or good for you. Very low food security, on the other hand, is defined as reports of multiple indications of disrupted eating patterns and reduced food intake. So you’ll often see parents, especially moms, go without eating as much in order to make sure that their children get enough food; they’ll actually decrease their food intake in order to take care of their children — that’s the very low food security. SDP: But we’re not talking about people who eat too much fast food? DR. CANTRELL: If you’re talking about the low food security group, many times they end up eating fast food, low nutrient-dense food because it’s cheaper; they don’t eat that nutritious, varied diet. And then there’s something called “food deserts” [see www.ers. usda.gov/data-products/foodaccess-research-atlas]; many people who are food insecure live in areas where they don’t have health food stores or grocery stores on every corner. Instead, there are a lot more fast food places or corner minimarts that don’t often have nutritious food. It’s a vicious cycle because that’s what they get used to eating, they like it, and then they buy more of it. A lot of studies have shown that if you get satisfied with high-calorie foods, you end up not eating as much of the other foods. SDP: Asking your patients where they live might help you determine whether or not they’re at risk for food insecurity. DR. CANTRELL: It’s possible, and that does help, but many times doctors don’t know exact areas very well. Personally, I find it hard to look at a patient and try to decide whether
they’re food insecure or not. I have some patients I’m pretty sure are food insecure, but I’ve been shocked when I’ve asked food insecurity questions to certain patients and they’ve said yes, yes we are food insecure. I just assumed they were hooked up with SNAP, the Supplemental Nutrition Assistance Program, but they didn’t even know about it. So you can’t just look at a person and assume, yes, they’re food insecure or not. And I think, as doctors, we think we can. That’s why screening for food insecurity for everyone is so important, so that you don’t let your personal biases and judgments get in the way. SDP: Are there screens out there doctors can access? DR. CANTRELL: Yes, there is a screen for food insecurity; it’s a two-question screening that has been validated and used by many physicians and is now being recommended by the American Academy of Pediatrics (AAP). They have a policy statement on screening for food insecurity, and they’re recommending that all pediatricians ask their families these two screening questions, and to do it in a standardized way so that you’re not missing those people that are food insecure. 21% of children live in food insecure households in the United States, and San Diego is about that same number; that’s about one in five families, and, I have to tell you, I think we’re missing them. So by having this standardized and validated screening, and teaching physicians how important it is to use it, we’ll be able to pick up a lot more families. SDP: You’re recommending it for all pediatricians, but your cardiologist or surgeon, for example, probably isn’t going to screen for food insecurity, correct? DR. CANTRELL: We may eventually go there. The SAN DIEGO PHYSICIAN.ORG
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policy statement did indeed come out of the American Academy of Pediatrics, but what we’re trying to do with our San Diego Food Insecurity Coalition is to get all primary care physicians involved. We also want to get the hospitals asking these questions because hospitalized patients are often food insecure at higher rates than non-hospitalized patients. On discharge we’re looking at asking those two questions, and if they screen positive — and a positive screen is a yes on either of the two questions — then it’s recommended that you refer them to services. SDP: Can you talk about food insecurity in San Diego beyond the 21% of children in food insecure households? Are we pretty reflective of the country as a whole?
LOW FOOD SECURITY IS DEFINED AS REPORTS OF REDUCED QUALITY, VARIETY, OR DESIRABILITY OF DIET, WITH LITTLE OR NO INDICATION OF REDUCED FOOD INTAKE. DR. CANTRELL: Well, we’re close to the border, and we have a big migrant population from Mexico, but we also have a lot of refugee populations here. I have many patients from Somalia [and] Iraq that are food insecure because they come over here with nothing. Maybe they’re getting some help, but it’s usually not enough to feed everybody. SDP: Do you find that people are food insecure over long periods of time or that it’s more an episodic problem?
DR. CANTRELL: It often is episodic. When you have a big life change such as the loss of a job or a divorce, then all of a sudden a family who was food secure can become food insecure. You can flow in and out of food security. SDP: So these are questions you should be asking your patients every time you see them? DR. CANTRELL: Yes, that’s what we recommend. Kind of like when the doctor asks, “Do you smoke? Do you exercise? How much do you exercise?” We actually want this to be a part of that routine questioning because we feel that it’s that important. SDP: Is there any data that looks at long-term effects of being food insecure as a child? DR. CANTRELL: We know that children who come from food insecure households have higher rates of obesity, higher rates of depression, poorer school performance, and many other chronic illnesses, like asthma, in the future. Some of that makes sense, like obesity, for example, because if you’re going to be eating those junkier foods, the fast foods, the high-calorie-dense foods, they’re addictive and then you end up eating more of it, and that ends up being a part of your diet. As well, when you’re in a food insecure household, there’s just often a lot more stress. Parents are stressed. Maybe they’re working two jobs to make ends meet, and they can’t be there for the child. Luckily, if you’re under a certain income threshold, you can have breakfast and lunch provided during the school year, and then the family just has to worry about taking care of dinner. The weekends, those can
What Is CalFresh, SNAP?
CalFresh (federally known as the Supplemental Nutrition Assistance Program or SNAP, itself formerly known as the Food Stamp Program) is a federally mandated, state-supervised, and county-operated government entitlement program that provides monthly food benefits to assist low-income households in purchasing the food they need to maintain adequate nutritional levels.
be tough. There are certain situations where the kid’s main meal is Friday lunch, and then they really don’t get another good meal until breakfast on Monday. The summers can be a problem too. SDP: Do you ever suspect that your patients are too ashamed to tell you? DR. CANTRELL: Yes, I think so. Many are proud. I recently had one family where the father was diagnosed with cancer and he couldn’t work, and the mother was also not working so that she could help take care of him; they were having trouble making ends meet. They admitted it to me, and I told them how to get hooked up with CalFresh, and they said, “But we’ve never needed that before, we’ve always worked.” I think they didn’t want to have that stigma. I tried to explain it to them, that things happen in life, and that we didn’t expect your husband to have cancer right now, but what we need to do is make sure that you have — even if it’s just a little extra help here and there — that you have maybe a little more money to go toward buying very nutritious food because your family needs to eat very well right now. When I explained it to her like that, that I don’t want you to just buy the cheapest food right now, I want you to eat as healthy as you can, she understood it. But I think it was still hard for her because she and her husband always worked — they didn’t just live off of the government. SDP: That should be an easy discussion for doctors to have with their patients because it’s about doing everything they can to get better, starting with getting the right nutrition. Is there anything else physicians can do? DR. CANTRELL: Physicians can, first of all, refer their patients to services. I think sometimes that might be very daunting for physicians because, to be honest with you, I don’t think we’re taught to do that. I think they might think that that’s a job for a social worker, but most physician offices don’t have social workers. Once doctors realize the connection of health and food security, they’ll understand that by
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PUBLIC HEALTH making sure that their patients are food secure, they’re taking care of their health. Doctors are burdened with a lot to do already, so we want to make it as easy as possible. Trying to have physicians keep up with where the food pantries are, what area of town their patients live in, it’s overwhelming, and I think it’s very difficult for everyday physicians to feel that they are on top of that. So what we are trying to do is take away that burden and just make it as easy as possible. Just refer your patients to 2-1-1, and they’ll take it from there. 2-1-1 will screen your patients, they’ll see if they qualify, they’ll get them hooked up in their neighborhoods, and they can help them apply for CalFresh. It’s wonderful because 2-1-1 will do all the work for the physician. The main thing is that the
physician just has to screen the patients and then refer them to 2-1-1. The nice thing about this screening process is that the physicians actually don’t even have to be involved. They can have their nurse or medical assistant screen when the patient checks in, and if they screen positive, they can just refer right there, say hey, we see that you tested positive, why don’t you call 2-1-1 and they can help? If the physician wants to deal with it and talk about it, absolutely, the physician can do that, but it could be an automatic referral, or the physician could be notified, either way. We created a food prescription pad so that all the physician or medical assistant or nurse has to do is just tear off a piece of paper, give it to the patient, one side’s English, one side’s Spanish, and just let them know that because you screened
positive here, why don’t you give these guys a call? It’s free, it’s safe, just call 2-1-1, and they can help. SDP: Talk about the San Diego Food Insecurity Coalition a little bit. DR. CANTRELL: When the American Academy of Pediatrics policy statement came out recommending that all pediatricians screen for food insecurity, I realized, as the president of the local chapter, that we were in a unique position to rally all of the pediatricians in San Diego around this issue because we transcend all medical groups. We’re not just a single medical group, and this isn’t just a single medical group issue; we can help every single medical group, whether you’re Sharp, or UCSD, Scripps, Kaiser, all of our
patients will benefit from it, so it’s a win-win in my mind. The AAP in San Diego has gone out to different pediatric offices in the county and taught providers about, for example, WIC, so we thought why not do this with food insecurity as well? And then we started thinking, who could help us with this? Who knows about food insecurity? Initially we met with the Food Bank and the Hunger Coalition, and they were excellent. And then we thought, why don’t we move this out to all physicians, which is how SDCMS became involved. The more physicians we can teach about the connection between health and food insecurity, the better for all our patients. SDP: Are you thinking something long-term with the coalition?
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Two-question Screening Tool Identifies 97% of Food Insecurity DR. CANTRELL: I envision this growing. I think initially we’re doing a passive referral, which is just handing the information to the patient, but what has been shown to be more effective is an active referral where you take the patient right then and there and actively sign them up for CalFresh before they even leave the office. We know that when they leave the office, they might not call. I think this is a very new topic for physicians. Many don’t understand that connection between food insecurity and health, and I don’t think they feel it’s their responsibility. I think in order for them to have their patients be the healthiest they can be, if they understand that connection, they’ll help their food insecure patients become food secure.
According to AAP’s “Promoting Food Security for All Children” policy statement (http://pediatrics.aappublications. org/content/136/5/e1431), answering yes to either of the following two statements indicates that a family is struggling with food insecurity: 1. “Within the past 12 months, we worried whether our food would run out before we got money to buy more.” 2. “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.”
USDA Definitions Food Security • High food security = no reported indications of foodaccess problems or limitations. • Marginal food security = one or two reported indications — typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake. Food Insecurity • Low food security = reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake. • Very low food security = reports of multiple indications of disrupted eating patterns and reduced food intake.
In the future we might actually ask health plans, if this grows, to do a more active referral, then we’ll get even more people hooked up. SDP: But right now, two questions for the screening, 2-1-1, the prescription pad, it’s all pretty simple. DR. CANTRELL: It is pretty simple, but unless physicians have that prompt with the two questions, they’re not going to ask. They’ve got their busy day. The doctor might know what to do if the patient said, hey, I’m having trouble with food, but even then, honestly, I think some physicians would have no idea. At least now we can tell them, have your patient call 2-1-1; it makes it really simple. SDP: Thank you for your time, Dr. Cantrell.
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CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PLAQUE PSORIASIS RESEARCH STUDY: Clarify Medical is looking for adults aged 18 years or older to participate in a 10-week medical research study to determine how well a new investigational device works in the treatment of plaque psoriasis. The device is a new handheld, connected phototherapy (light) device that is designed to be used at home. The device is connected to your smartphone, which is connected to Clarify Medical support personnel and your prescriber. The study involves five in-clinic visits, photographs, and your feedback interacting with the system. For more information, please contact Charlene Kakimoto, MD, at firstname.lastname@example.org or at (619) 540-9705.  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) 5810400 or email email@example.com.  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.  PHYSICIAN POSITIONS AVAILABLE GENERAL, FAMILY, OR INTERNAL MEDICINE PHYSICIAN NEEDED IMMEDIATELY: This opening is an independent contractor position. We are a house-call practice located in beautiful North San Diego County. We will also provide paid training on our EMR. 8–5, Monday–Friday, 10–12 patients per day, and on-call pager one week every three weeks, telephone call only. No rounds or hospital duties. If interested, please email your CV to firstname.lastname@example.org. We are very anxious to fill this position, and we look forward to hearing from YOU! No agencies please.  PART-TIME ORTHOPAEDIC PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks an orthopaedic physician to see patients in our office one afternoon per week. If interested, please call Jeff Dill at (619) 456-2453 or send CV to email@example.com.  FULL-TIME PRIMARY CARE PEDIATRIC POSITION AVAILABLE in beautiful San Diego, California, to provide coverage for newborn care in Maternal Child Health Unit and community outpatient pediatric clinic. Job duty includes supervision and teaching of
residents and medical students. Average 20–25 patients daily. No evening or weekend calls or attendance of deliveries. Centrally located in San Diego with easy access to gorgeous beaches, parks, hiking trails, San Diego Zoo, and fine dining. Opening available now. Must be certified for PALS and NRP. BC or BE. An additional part-time position is also available. Please submit inquiry and CV to Garcia.Leanne-Sarah@scrippshealth.org.  SEEKING PEDIATRIC HOSPITALIST: UCSD’s Department of Pediatrics and Rady Children’s Hospital of San Diego seeking applicants for Division of Pediatric Hospital Medicine. Candidates must be MDs and completed PHM fellowship, or have at least five years of active experience in PHM, including consistent trainee teaching, California medical license/eligibility, BC in pediatrics, and active PHM work history. Interested applicants must submit a CV, cover letter, and a statement summarizing past or potential contributions to diversity. Applications must be submitted through the UCSD’s Academic Personnel RECRUIT system. To read the entire posting and to apply, visit http://apptrkr.com/956661. EOO/AAE  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 firstname.lastname@example.org or call (619) 248-2324.  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) 5810400 or email email@example.com.  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 fulltime. POC is Dr. Jake Hollingsworth: (858) 261-4622; firstname.lastname@example.org; www.kflpsychiatry.com and www.ketamineforlife.com.  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
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and part-time physicians. Current CA and DEA licenses required. Malpractice coverage provided. Full benefits packet. Email resume to email@example.com or fax to (760) 414 3702. Visit our website at www.vistacommuntyclinic.org. EEO Employer/ Vet/Disabled/AA  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 firstname.lastname@example.org.  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 email@example.com.  OPPORTUNITY FOR INTERVENTIONAL PHYSIATRY / PHYSICAL MEDICINE SPECIALIST: Practice opportunity for parttime 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 firstname.lastname@example.org.  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 email@example.com. Visit www.thehousecalldocs.com.  OFFICE SPACE AVAILABLE / REAL ESTATE
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 | firstname.lastname@example.org HILLCREST OFFICE TO SHARE: Fourth floor suite at 4033 Third Avenue, a short walk to Mercy Hospital. Two exam rooms, private office, and break room. All days available. Please call Jack Yang at (619) 548 0450.  EL CAJON OFFICE SPACE FOR RENT: Centrally located in East County in El Cajon. Rent by the hour, day, week, or month.
Reasonable rates. Free parking. Quiet office building. Free parking. Free Wi-Fi. Kitchen available. Central workroom. Wheelchair accessible. Perfect for therapists, consultants, etc. Call Marlene at (619) 401-1430 or email email@example.com. 
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.
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 firstname.lastname@example.org.  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.  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.  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 email@example.com.  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.  POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to firstname.lastname@example.org. 
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 email@example.com or (619) 504-5830.  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.  OFFICE SPACE WANTED
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.  NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 9925330 or email firstname.lastname@example.org. Visit www.thehousecalldocs.com.  PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com.  SERVICES OFFERED
SUBLEASE WANTED IN HILLCREST, NORTH PARK, UNIVERSITY HEIGHTS, MISSION HILLS, BANKERS HILL, OR SOUTH PARK: 1/2 day to start. Need office, one exam and receptionist spot. Boarded in PM&R / pain subspecialist. UCSD / Scripps-Green trained. Have consulting practice elsewhere. (619) 210-9291 or email@example.com.  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 firstname.lastname@example.org. 
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) 3002780. 
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P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T
ARE YOU PLAYING TO WIN, OR PLAYING NOT TO LOSE? by Helane Fronek, MD, FACP, FACPh
on a leadership role, we are playing not to lose. When we want to join a group but hold back, afraid we might not be welcome, we are playing not to lose. Our reward for this behavior is a lot of regret, resentment, and a life that feels like it’s a black-and-white version of the full-color life we dreamed we would have. How much more colorful could our life be if, instead, we played to win? Sure, we might stumble through that uncomfortable conversation or suffer some embarrassment if we don’t perform perfectly in a new role. Or we could feel humiliated if our overture to join a group is rebuffed. But as we leave our comfort zone, we might discover we are more
“When one door of happiness closes, another opens; but often we look so long at the closed door that we do not see the one which has been opened for us.”
WHEN I MET MY HUSBAND, an avid skier, I realized that I better learn to ski and like it if I wanted the relationship to work. Fortunately, I did. Skiing became a fun family activity and afforded me a great way to enjoy being in nature in winter. Yet, between my relative clumsiness, lack of confidence, and the recognition that I’m aging, I know my skills will never compare to my husband’s. So, as I was negotiating my way down a black diamond run in fresh powder, trying to keep up with him, my focus was solely on trying not to fall. In that moment, I became aware that my fear was holding me back from enjoying the exhilaration of
gliding through the snow and the breathtaking beauty that surrounded me. I was playing not to lose. Now, one can argue that the risk of falling was significant, as were the consequences. But this idea of playing not to lose is something that each of us regularly encounters in our professional and personal lives. When we are upset by something but avoid having an honest conversation about it for fear of creating an uncomfortable confrontation, we are playing not to lose. When we allow our fears or lack of confidence to prevent us from volunteering to work on a project that interests us or take
resilient than we gave ourselves credit for. We might learn some skills as we honestly discuss a difficult subject or take on new roles. And if our attempt doesn’t work out, we can stop spending time hoping that it will and find a new opportunity that might be even more interesting or fit us better. As Helen Keller once remarked, “When one door of happiness closes, another opens; but often we look so long at the closed door that we do not see the one which has been opened for us.” Consider where in your life you’re playing not to lose. What is it you’re afraid of losing? Is that really more exciting, important, or fulfilling than what you might gain if you won? What would you do differently if, instead, you played to win? 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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