May 2017

MAY 2017 OFFICIAL PUBLICATION OF SDCMS

CMA’S 43 ANNUAL Legislative Advocacy Day RD

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Roy Avalos, MD, PhD

Ali R. Hamzei, MD, PhD

Patrick M. McGinty, MD

Founded by the San Diego County Medical Society

MAY

CONTENTS

VOLUME 104, NUMBER 5

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

features

16 Physicians Converge in Sacramento for CMA’s 43rd Annual Legislative Advocacy Day Y ELIZABETH ZIMA B

19 SDCMS Physicians Meet With Legislators

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20

The Importance of Diversity in Clinical Trials

CMA-sponsored Bills for 2017

BY THE CMA FOUNDATION

departments

13 Practice Management Tip of the Month

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BY CMA

Briefly Noted: Calendar • Board Election Results • Bioethics • Public Health • Featured Member • And More …

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6 Medi-Cal Patients Face Hurdles to See Specialists Throughout California

BY CMA

BY ELIZABETH ZIMA

10 Prescribing Opioids Safely: How to Have Difficult Patient Conversations

BY RONEET LEV, MD

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MAY 2017

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 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

Diabetes Prevention Programs: Reducing Costs, Improving Patient Outcomes

26 Physician Marketplace: Classifieds 28 Put Your Own Oxygen Mask on First Y HELANE FRONEK, MD, FACP, FACPh B

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted.

Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org.

All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// ELECTIONS RESULTS

CALENDAR

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

How California Physicians Can Access Free Technical Assistance for MACRA Transition (webinar) MAY 31: 12:15pm–1:15pm SDCMS White Coat Gala (event) JUN 3: 6pm–10:30pm Physician Mixer & Family Pool Party JUN 24: 4pm–8pm

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.

American Liver Foundation’s First “Liver Wellness Forum: Ask the Experts” JUN 10 at the Jacobs Center for Neighborhood Innovation 34th Annual Primary Care Summer Conference AUG 4–6 at the Hilton San Diego Resort & Spa The Future of Medicine: A Conference for Physicians SEP 29 (7:30am–4pm) at Kona Kai Resort & Spa

Congratulations to Our Elected Board Members for 2017–18 Officers: • President-elect: David E.J. Bazzo, MD, FAAFP • Secretary: James “Jim” H. Schultz Jr., MD, MBA, FAAFP, DiMM • Treasurer: Holly B. Yang, MD Geographic Directors: • East County #2: Rakesh R. Patel, MD, FAAFP • East County #3: Jane A. Lyons, MD • Kearny Mesa #1: Sergio R. Flores, MD • Kearny Mesa #2: Alexander K. Quick, MD • La Jolla #2: Marc M. Sedwitz, MD • North County #2: Christopher M. Bergeron, MD, FACS At-large Directors: • #1: Thomas J. Savides, MD • #4: Nicholas “dr. Nick” J. Yphantides, MD • #6: Marcella “Marci” M. Wilson, MD • #8: Robert E. Peters, MD, PhD Geographic Alternate Directors: • Kearny Mesa #2: Eileen R. Quintela, MD At-large Alternate Directors: • #5: Preeti Mehta, MD • #6: Vimal I. Nanavati, MD, FACC, FSCAI • #7: Peter O. Raudaskoski, MD • #8: Kosala Samarasinghe, MD

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BIOETHICS

Nursing and Workplace Violence SDCMS’s Bioethics Commission met on April 26 to discuss “Nursing and Workplace Violence,” with a presentation given by Diana Amaya Rodriquez, PhD, MS, CNS, RN, associate professor at Azusa Pacific University. Workplace violence and its impact were discussed, along with how to identify factors that contribute to workplace violence, the underreporting of workplace violence, understanding its moral and ethical considerations, and exploring strategies to prevent workplace violence.

Starting with a general definition of workplace violence as “incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, wellbeing, or health,” Prof. Rodriguez then went on to quote a few startling statistics, including that between 2002 and 2013, incidents of serious workplace violence were four times more common in healthcare settings than in private industry, and that in 2013, 7.8 out of 10,000 full-time healthcare and social assistance sector employees had cases of serious workplace violence, compared to fewer than 2 out of 10,000 full-time employees in other large sectors such as construction, manufacturing, and retail. Also from 2013, according to the Bureau of Labor Statistics, healthcare worker injuries resulting in days away from work were caused by patients 80% of the time, by “other clients or customers” (i.e., the patient’s friends and family members) 12% of the time, students 3% of the time, coworkers 3% of the time, other persons (not specified) 1% of the time, and an assailant, suspect, or inmate 1% of the time.

SDCMS’s Bioethics Commission will meet again in 2017 on 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 SDCMS@ SDCMS.org.

QUOTE OF THE MONTH

Always forgive your enemies; nothing annoys them so much.

— Oscar Wilde, Irish Playwright, Novelist, Essayist, and Poet (1854–1900)

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/////////////////////////////////////////////////////////////////////////////////////////////////// FEATURED MEMBER

J. KELLOGG PARSONS, MD, MHS, FACS DR. PARSONS, a nine-year member of SDCMS-CMA, is a urologist and professor at UC San Diego’s School of Medicine — and, in his free time, he writes medical thrillers.

San Diego Physician: Talk a little about Under the Knife and the big themes you wanted to investigate with the book.

Dr. Parsons: Under the Knife is the story of a grieving man who stalks the surgeon he holds responsible for his young wife’s untimely death. It incorporates several different themes that have been running around in my head for some time, including the processes by which new surgical devices are developed, how patients become caught up in those processes, and the potential consequences of errors. Much of the novel focuses on a robot that can perform surgery autonomously, analogous to an autopilot on a plane. I use a robot when I perform surgery; many of us do. It’s a device whereby the surgeon sits at a control station and at all times controls the robot. What I imagined

was something a step further: What if you could program the robot to perform surgery on its own? And what if something went horribly wrong with that robot while it was performing surgery?

I also think Under the Knife and my first novel, Doing Harm, are both grounded in the concept that all of us, including myself, are patients. And when we’re patients, we’re vulnerable. We entrust our health and our lives to individuals, systems, and institutions that can make mistakes. Exploring that vulnerability interests me.

San Diego Physician: Do you think writing makes you a better doctor?

Dr. Parsons: Absolutely. I’ve realized that physicians are trained storytellers. We tell each other narratives about our patients every single day. I think writing makes me a better communicator with my peers. I’ve also found that fiction writing keeps me fresh in the day-to-day practice of medicine. I think about medicine all day long. Turning off the medical part of my brain for a while and turning on a completely different part — the creative writing part — intellectually refreshes me. Then I can go back to the medical part of my brain and have renewed energy and vigor in thinking about medicine.

San Diego Physician: You’ve written two books so far. Any immediate plans for a third? Or will you take a break?

Dr. Parsons: I’m currently working on my third. It’s the story of a group of ordinary individuals who, through advanced biomedical technology, are granted extraordinary abilities — but at a terrible price.

LEADERSHIP ACADEMY UC San Diego MS1 medical students with Abraham Verghese, MD, MACP, at CMA’s May 5–7 Western Health Care Leadership Academy. L–R: Dominic Dawkins, Ophelie Lavoie-Gagne, Meghana Pagadala, Dr. Verghese, Ishan Mehta, Lawrence Wang, Alex Marquez, and Tammy Pham. Dr. Verghese, featured speaker at the Academy, is a professor at the Stanford School of Medicine and best-selling author of Cutting for Stone.

He spoke about our strange new era of healthcare, where patients are merely data points, and called for a return to the old-fashioned physical exam, the bedside chat, and the power of informed observation.

SAN DIEGO PHYSICIAN.ORG

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AC C E S S TO C A R E

MEDI-CAL PATIENTS FACE HURDLES TO SEE SPECIALISTS THROUGHOUT CALIFORNIA

by Elizabeth Zima

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MAY 2017

CALIFORNIA’S COMMUNITIES face a severe shortage of physicians, which is expected to get exponentially worse as the population continues to grow and our aging physician workforce moves toward retirement.

Medi-Cal enrollment has surged since 2014, but the percentage of California physicians serving Medi-Cal patients has dropped, a trend that is hampering access to care for enrollees. One in every three Californians (14 million) is dependent on Medi-Cal for healthcare, so this disparity also negatively impacts a patient’s ability to access needed treatment, according to a recent study by the California Health Care Foundation.

There is a fundamental problem with Medi-Cal that is hindering patient access to care, and to specialists in particular: Medi-Cal physician reimbursement is so low that physicians cannot cover the cost of providing care. Currently, California has some of the lowest reimbursement rates for providers ($18 for an office visit), creating an unsustainable disparity between the number of Medi-Cal patients and the physicians who are able to accept them as patients.

“

The challenge that we face is that reimbursement to physicians is the thirdlowest in the country.

So that limits access to specialty care,” says Patrick Tellez, MD, MPH, a pediatric allergy and immunology specialist and chief medical officer for North County Health Services.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” says Mark Dressner, MD, a Long Beach clinic family physician and former president of the California Academy of Family Physicians. “We’re really disappointed and concerned with what it’s going to do for patient access.”

The volume of poor and uninsured patients who need to see specialists has overwhelmed the healthcare system in Los Angeles, causing appointment delays.

Dr. Dressner says he is extremely frustrated with the problem. “If I have patients that need a rheumatology consultation, it can take two years for them to get an appointment,” he explains. Some of his patients have to travel more than 50 miles to see specialists who will take Medi-Cal because none of the specialists in the immediate area will.

Not only are physicians frustrated with the lack of access to care, the patients themselves are frustrated with their treatment.

Barbara Appling, a 56-year-old patient with diabetes, was referred to an orthopedist in the Los Angeles area near her home.

“I called the office repeatedly for an appointment,” she says. “It took four months to get one. Then, when I went to the office, I was there for 40 minutes waiting to be seen — until the office manager told me they could not see me.” Appling has both Medi-Cal and Medicare insurance. The office staff member told her the doctor didn’t take either.

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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AC C E S S TO C A R E

“I’m very frustrated that I cannot see a doctor when I need to. People have refused to take Medi-Cal since I got it,” she says.

Due to low Medi-Cal reimbursement rates, physicians who see Medi-Cal patients often do so at a financial loss to their practices. In order to maintain viable practices that can continue to serve their communities, physicians who take Medi-Cal often need to limit the number of Medi-Cal patients that can be treated in their practice.

Because they do not have ready access to physicians, Medi-Cal patients are more likely to postpone needed care due to long appointment wait times. They are also twice as likely to use emergency room visits to access specialty care (compared to individuals with private insurance or Medicare).

In areas where the numbers of specialists are low, physicians are more likely to report difficulty obtaining referrals for Medi-Cal patients than for privately insured patients.

Debra Lupeika, MD, a family physician providing care through the Shasta Community Health Center in Redding, says some of the most difficult issues she faces are getting her sickest patients referrals to specialty providers.

The frustration of not being able to refer wears on her, like the time her patient suffered without an appointment. “She had complicated medical problems, and she was homeless,” Dr. Lupeika says. “She had a cancer on her face that had been partly removed, but it came back. We couldn’t get a biopsy. It is really hard to get our patients into a specialist due to insurance issues.”

Lack of access to specialists also plagues San Diego County. “The challenge that we face is that reimbursement to physicians is the third-lowest in the country. So that limits access to specialty care,” says Patrick Tellez, MD, MPH, a pediatric allergy and immunology specialist and chief medical officer for North County Health Services, which provides healthcare to a diverse community of low-income patients at 13 health centers in North San Diego and Riverside counties.

“Our mission, as a primary medical, dental, and behavioral health practice attending to over 65,000 patients annually, is to assure that our patients are able to access and receive needed primary and specialty care that meets the high standards that everyone expects of us when we

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MAY 2017

Governor Jerry Brown’s $120 billion budget proposal for the 2017–18 fiscal year appropriates $1.2 billion of the Prop. 56 tobacco tax money to cover cost increases for the Medi-Cal program. are the patient,” Dr. Tellez says. “However, when the reimbursement for specialty care is so low, specialists can only afford to accept a small percentage of patients that truly need and deserve the care.

“So, while in an average month we as primary care providers may make about 2,500 or more referrals to specialty care, due to affordability, wait times and constrained access, less than half are able to be seen,” Dr. Tellez says. “As a result, this has the long-term adverse impact of increasing the cost of care for everyone. Improving access to specialty care has been shown to help prevent preventable complications of chronic disease, which lowers the longterm cost of care … it acts like a rising tide that floats all boats.”

Of California’s 58 counties, Merced County has the 43rd worst physician-topatient-ratio, with just 45.4 family physicians per 100,000 residents. That’s far less than California’s statewide ratio of 77.3 doctors per 100,000 residents. According to the Merced County 2016 Community Health Assessment, the entire county is considered a health-professional shortage area.

Eduardo T. Villarama, MD, family physician and regional medical director of Golden Valley Health Centers in Merced, says he is aware of many instances when patients who needed to see a specialist were turned away. “We have more than 70% Medi-Cal patient population, and specialty care providers regularly turn them away or are not able to accommodate the demand because the specialists are not reimbursed appropriately.”

He says a few of his patients, “one with

seizure disorder and the other we suspect to have multiple sclerosis,” have had to wait at least six months to be seen by a specialist in neurology. “I know for a fact that the patients being insured by MediCal played a role in our abilities to get them in sooner.”

Ample research demonstrates that the Medi-Cal system is struggling from persistent underfunding. Last year, CMA co-sponsored the Proposition 56 tobacco tax to raise money to improve access to and quality of medical services for all Californians, especially our most vulnerable communities who rely on Medi-Cal. Governor Jerry Brown’s $120 billion budget proposal for the 2017–18 fiscal year appropriates $1.2 billion of the Prop. 56 tobacco tax money to cover cost increases for the Medi-Cal program. Although the measure was written to explicitly prohibit the use of the new tobacco tax revenue to offset general fund obligations, Governor Brown’s budget does exactly that — rather than using those funds to improve California’s dismal provider reimbursement rates, as the voters intended.

With more than 14 million Californians relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high. Californians voted for the tobacco tax to remove these barriers to reliable and quality care. California cannot afford to continue starving this program by diverting Prop. 56 revenues to cover the state’s general fund obligations.

“The language of Prop. 56 was clear: The people voted overwhelmingly in support of improving payments for programs and providers to ensure that patients can see a doctor when and where they need one,” says CMA President Ruth Haskins, MD. “We must honor the will of the voters and use the estimated $1 billion in new healthcare revenue for its intended purpose, instead of writing a blank check to the general fund.”

CMA is working with the Legislature and the Brown administration to develop a solution that doesn’t supplant the will of California voters or put low-income families and communities at risk.

Ms. Zima is a staff writer with CMA. If you have a story to tell about how low Medi-Cal reimbursements have adversely affected your ability to care for patients, contact CMA at communications@cmanet.org.

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

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Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid prescriptions and reduce risks that could lead to malpractice suits.

PRESCRIBING OPIOIDS SAFELY

”

•

How to Have Difficult Patient Conversations

by Roneet Lev, MD •

DRUG OVERDOSE is the leading cause of accidental death in the United States, and opioids account for more than 60% of those deaths (1). While opioids are effective pain medications when used in the proper setting, concerns arise when the patient’s condition lasts longer than three months, and prescribing more medication does not necessarily result in better pain control.

Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid prescriptions and reduce risks that could lead to malpractice suits. The Doctors Company reviewed 1,770 claims that closed between 2007 and 2015 in which patient harm involved medication factors (2). In 272 of these claims (15%), the medications were narcotic analgesics. 64% of these claims were in the outpatient setting, including: • physicians’ offices and hospital clinics (78%) • ambulatory and day surgery (10%) • emergency room (9%) • patient’s home (3%) The admitting diagnoses for these outpatient narcotic-related claims were

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MAY 2017

pain not otherwise specified (NOS) (24%), spine-related pain (22%), joint/extremityrelated pain (9%), mental health issues (6%), and drug abuse/dependence (4%).

Patient allegations for these claims included improper medication management or treatment (70%), wrong dose (9%), and wrong medication (3%). Final diagnoses in these claims included poisoning by methadone, heroin, and opiates/narcotics NOS (76%) and drug dependence (8%).

Communication problems are among the patient-contributing factors that lead to injury, appearing in 40% of claims (3).

Incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns.

These tips can help when dealing with opioid requests and prescriptions: • Don’t make the mistake of jumping to conclusions that the patient is a drug seeker because the patient is there repeatedly for the same pain complaint. It could instead be a situation of missed di-

•

•

agnosis. Treat this patient like any other patient. Take a good history, including a very detailed medication history. Do a thorough physical examination. See if something was missed on previous visits.

Your prescription drug monitoring program (PDMP) is a valuable tool, like checking allergies and old records. Use the PDMP to learn about your patient’s prescription patterns, not just to check for doctor shopping.

Medication refills for chronic conditions should have a medication agreement.

ONE doctor and ONE pharmacy should prescribe controlled medication given for three months or more. This is true for dental pain, fractures, fibromyalgia, cancer, anxiety, and ADHD. If you see a patient for the third month of a controlled medication, start a medication agreement if you plan on continuing this therapy.

Opioid withdrawal is uncomfortable but not life-threatening. New patients who present to a new pain specialist should not immediately be given the pain medications they state they need. A pain specialist typically completes thorough research before making medication recommendations, and it could be two weeks before the patient is placed on a regular regimen. You may find it necessary to send a patient home without a pain prescription if that patient has already received one in the past month from a different provider.

When patients say that their medication is not working, ask the patient, “How are you taking the medication?” You’ll be surprised how many patients used 400mg of ibuprofen twice a day and it was not enough. Taking a detailed medi-

PATIENT

DOCTOR ANSWER

“Can I have something for pain?”

“Yes, let me check your medical record for the best choice.”

“The medicines don’t work.”

“Can you please tell me how you take the prescription?”

“My prescription was stolen.”

“Did you file a police report?”

“I have chronic pain.”

“For your safety, you need your medications c oordinated by one doctor and one pharmacy.”

“I received extra pain medications elsewhere.”

• “Let’s do a drug specimen today.”

• “I see you received 20 pills from the emergency department; what happened?”

• “OK, to stay on the same schedule, this month I will write 100 tablets (120 minus 20).”

A case of clear doctor shopping

“I am concerned because your medications can be addicting. I am going to refer you to someone who can help with this.”

A case of need to stop an opioid prescription

“The medication no longer appears to be as beneficial as it once was. As the benefits of the opioids no longer outweigh the risks, we need to discontinue this approach and together find a safer and more effective means of dealing with your pain.”

cation history and providing patient education about the right dosage, right timing, and side effects to be aware of is essential to medication safety.

• When you hand a patient a prescription for a controlled medication, add a few words to let the patient know that these are serious medications: “I will give you a prescription for Norco. Please realize that this is a medication that can be abused.

Keep it secure, take it only as prescribed, and do not drive if not fully alert.”

• Be aware of the level of health literacy of the individual patient, and adjust your language appropriately. Ask patients to repeat back the information you gave to ensure they properly understand.

• Communicate the risk of medication theft to patients. Patients who are on a chronic treatment plan should know to watch their medication as closely as they would their money.

Above is a helpful chart on good answers for specific patient questions and situations: Get more safe prescribing resources at www.SanDiegoSafePrescribing.org, and learn more about effective doctor-patient communication at www.thedoctors.com/ askme3.

Dr. Lev, a 24-year member of SDCMS-CMA, is chief of Scripps Mercy Emergency Department, chair of the Prescription Drug Abuse Medical Task Force, and president of the Independent Emergency Physicians Consortium.

References: 1. Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. Centers for Disease Control and Prevention. Dec. 30, 2016. https:// www.cdc.gov/mmwr/volumes/65/wr/ mm655051e1.htm. Accessed Jan. 26, 2017.

2. Analysis of medication-related claims from The Doctors Company. The Doctors Company. http://www.thedoctors. com/KnowledgeCenter/Publications/ TheDoctorsAdvocate/Analysis-ofMedication-Related-Claims-from-TheDoctors-Company. Accessed April 17, 2017.

3. Patient-centered communications: Building patient rapport. The Doctors Company. http://www.thedoctors. com/KnowledgeCenter/PatientSafety/ articles/Patient-Centered-Communications-Building-Patient-Rapport.

Accessed Jan. 9, 2017.

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MEDICAL RESEARCH

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Some studies show less than 5% participation among minorities and especially among African Americans.

THE IMPORTANCE OF DIVERSITY IN CLINICAL TRIALS

by The CMA Foundation

The CMA Foundation, through its cornerstone program, the Network of Ethnic Physician Organizations (NEPO), has launched its “Encouraging Diversity in Clinical Trials” campaign to increase clinical trial participation among California’s multi-ethic patient populations. The campaign is part of the CMA Foundation’s ongoing commitment to raising awareness about critical health disparities and their impact on California’s underserved communities.

”

“An unrepresentative ethnic population in clinical trials can hinder progress in the development of safe, efficient, and cost-effective therapies for diseases most prevalent among these patient populations,” says Margaret Juarez, MD, NEPO chair. “Some studies show less than 5% participation among minorities and especially among African Americans. This is significant in that when scientists create treatments, the ethnic makeup is a factor in how medications respond to the body based on dosage, drug, or another factor altogether.”

The two-pronged campaign launch entails the distribution

of more than 350 posters to 25 ethnic physician organizations and medical specialty societies across the state, as well as the launch of a 30-second public service announcement in key markets across the state.

“Innovations in treatment are bringing about a revolution in patient care, and no individual or groups of Californians should be left behind,” Dr. Juarez adds. “Participation in clinical trials by diverse communities will help improve health outcomes for patients of color and their families.”

Patients interested in participating in clinical trials should discuss the topic with their healthcare provider and visit www.clinicaltrials.gov.

For more information about the “Encouraging Diversity in Clinical Trials” campaign or the CMA Foundation, visit www. thecmafoundation.org.

For more than 50 years, the CMA Foundation has sought to improve individual and community health by providing a vital link between physicians and their communities. Originally established as the charitable arm of CMA, the Foundation eventually grew into one of California’s leading advocates for community health. By launching groundbreaking efforts, such as tobacco education in the mid-1990s, and partnering with health professionals such as pharmacists, nurses, and medical assistants, the CMA Foundation has cemented itself as a leader in improving the health of California’s residents.

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MAY 2017

CALIFORNIA MEDICAL ASSOCIATION

PRACTICE MANAGEMENT:

TIP OF THE MONTH

MAY

Take charge of your online reputation.

In today’s digital world, monitoring and managing a physician’s online presence is essential to avoiding potential harm to their reputation that could negatively affecting their practice. While it might not be feasible for physicians to prevent every negative comment, establishing a process to monitor their digital presence and taking control of information about the practice online will significantly reduce the potential impact of a bad review. For more information, see http://cal.md/apr-2017-tip.

CMA’s online health law library contains thousands of pages of On-Call documents in hundreds of chapters containing valuable information for physicians and their staff. Access to the library is free to members in the resource library at www.cmanet.org/cma-on-call or by calling CMA’s member help center, (800) 786-4262. Nonmembers can purchase documents for $2 per page.

TROUBLE GETTING PAID? WE CAN HELP! CMA’s team of practice management experts has a combined experience of over 125 years in medical practice operations. Our goal is to empower physician practices by providing resources and guidance to improve the success of your practice.

Access to CMA experts is a FREE, members-only benefit.

Call (800) 786-4262 or email memberservice@cmanet.org.

Meet Your Advocate: Lisa Matsubara Lisa serves as Legal Counsel in CMA’s Center for Legal Affairs, advocating on behalf of California physicians on issues of privacy and security, digital health, scope of practice, reproductive health and public health.

She manages CMA’s legal educational resources, including the California Physician’s Legal Handbook, the state’s most comprehensive publication on health law and the practice of medicine, and CMA’s legal information line, which provides information about California and federal laws to CMA members.

In the constantly changing legal landscape affecting the practice of medicine, I am proud to be part of the CMA team of experts, helping California physicians stay updated on the law and advocating every day to protect our physicians and their patients.”

Lisa Matsubara, CMA Legal Counsel TO OPT OUT OF FUTURE NOTICES, EMAIL MEMBERSERVICE@CMANET.ORG OR FAX (916) 551-2036. BE SURE TO INCLUDE THE FAX NUMBER YOU WANT REMOVED.

P U B L I C H E A LT H

DIABETES PREVENTION PROGRAMS Reducing Costs, Improving Patient Outcomes by The California Medical Association

SUGAR. IT’S THE SWEET, grainy staple surging through the foods so many of your patients love but can’t entirely kick. Yet the effect of these seemingly innocuous treats has become as deeply rooted as a cavity in the lives of sick patients and the U.S. healthcare system, according to a recent study on prediabetes and medical expenditures (www.ncbi.nlm.nih.gov/ pubmed/28192030).

Published in Population Health Management, the study demonstrates how preventing the onset of type 2 diabetes can reduce annual healthcare costs by thousands of dollars per patient and generate large positive returns on investment (ROI) for health systems, insurers, and employers.

Researchers in the study used individual-level claims data from more than 8,000

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MAY 2017

commercially insured adults to estimate medical expenditures among individuals with prediabetes. Data on expenditures were combined with findings from previous studies to estimate net savings and ROI if they were to participate in a CDC-recognized diabetes prevention program (DPP).

Based on an analysis of the data, researchers found that: • Patients who develop diabetes are very costly. Expenditures during the oneto-three-year period following HbA1c screening are one-third higher for those who develop diabetes. That amounts to an annual average of $2,671 per patient.

• Preventing diabetes is more than a vital public health solution — it’s an effective financial strategy. Because the annual cost differential for patients who devel-

op diabetes is significant, “The threeyear ROI for a national DPP is estimated to be as high as 42%,” wrote the study’s authors, Tamkeen Khan, PhD, Stavros Tsipas, and Gregory Wozniak, PhD, all of the AMA. • Diabetes prevention programs are still one of the best solutions for improving health outcomes and reducing burdensome medical expenditures. In fact, patient participation in a CDC-recognized DPP (nccd.cdc.gov/DDT_DPRP/ Programs.aspx) in a community-based or primary care setting costs between $400 and $500 per person — far less than the average annual medical care expenditure savings. Not to mention previous research confirms that the impact of these programs extends

beyond dollar signs: People who complete DPPs are one-third less likely to develop type 2 diabetes after 10 years.

Using results from this analysis and findings in previous studies, the study authors estimated just 14% of patients who complete a DPP will be diagnosed with diabetes within three years, compared with 29% of those who do not participate.

DPPs in California: CMA’s Plan to Prevent Diabetes These recent findings underscore precisely why AMA and CMA have partnered to advance patient participation in DPPs throughout our state and galvanize support for community-based interventions.

More than 86 million Americans are living with prediabetes, but most of them are unaware. In California alone, an estimated 13 million adults have the condition, putting them at high risk of developing type 2 diabetes without intervention.

“The diabetes epidemic is out of control

and getting worse. In California, diabetes rates have increased by 35% since 2001,” says CMA President Ruth Haskins, MD. “In partnership with AMA, we are working hands-on with California’s physicians to implement meaningful diabetes prevention efforts to improve the health of Californian’s and ultimately improve the health of people across the country.”

The partnership is part of Prevent Diabetes STAT (preventdiabetesstat.org), a strategic effort launched by AMA in collaboration with the CDC in 2015 to engage more Americans with prediabetes and slow the progression of type 2 diabetes.

“The goal of this partnership is to get patients with prediabetes into proven lifestyle change programs that have been shown to cut the risk in half of progressing to type 2 diabetes,” said AMA President Andrew W. Gurman, MD. “By working with a variety of practices and health systems within California, we are learning the best ways to implement processes for screen-

ing, testing, and referring across different clinical settings. We will use these models in the future to support other states as they adopt a similar process — helping even more Americans stave off or delay type 2 diabetes to improve health outcomes.”

Calculate DPP Savings for Your Patient Population An online tool (ama-roi-calculator.appspot. com) from AMA helps employers, insurers, health systems, and others to calculate net savings and ROI for their sample populations. Play with this calculator to see how upping the share of your patients who enroll in a DPP can have a sizeable effect on the number who develop diabetes and how much money can be saved through prevention.

To find a CDC-recognized program near you or online, visit https://nccd.cdc.gov/ DDT_DPRP/Programs.aspx. For more diabetes prevention resources from AMA and CMA, visit www.cmanet.org/diabetesprevention.

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POLITICAL ADVOCACY

PHYSICIANS CONVERGE IN SACRAMENTO RD FOR CMA’S 43 ANNUAL Legislative Advocacy Day

BY ELIZABETH ZIMA, STAFF WRITER, CMA 16

MAY 2017

More than 500 physicians, medical students, and stakeholders gathered in Sacramento on April 18 to bring the voice of medicine to legislators for the 43rd annual CMA Legislative Advocacy Day. ¶ Wearing white coats, physicians converged on the Capitol to educate legislators about critical healthcare issues, including the negative impact Governor Brown’s proposed budget would have on healthcare in our state. ¶ “It’s a day-in and day-out grind to make sure that healthcare rises to the top in the Capitol,” CMA CEO Dustin Corcoran told attendees before they headed out to meet with their legislators. “But when the legislators see you in your white coat, [they] will remember your face and remember the stories you tell about how bills will impact you and your patients.”

And the physicians and medical students who took time out of their busy schedules to be there indeed felt that they made a difference.

“I was really impressed by how interested the legislators are in listening to what we have to say, and how much they respect our opinion as practicing physicians,” said Jessica Deas, MD, a pediatric resident at UC San Francisco’s Children’s Hospital. “They’re interested in hearing our stories, and I really felt like in a single day, we had some impact, which is very cool.”

California Attorney General Xavier Becerra spoke to attendees and reinforced how much weight the physician voice carries with lawmakers.

“You were a force in D.C., and you have always been a force in Sacramento,” said Becerra, encouraging California physicians to remain engaged as the healthcare reform debate continues.

“We’ll move forward with health reform; it’s a work in progress,” he said, pointing

out that California has served like a lab for the rest of the country, testing and improving the process of providing care to large numbers of people. “We’ll figure out how to make this better,” he said, calling the current proposals on health reform in the nation’s capital “frightening.”

Becerra, whose wife is an OB/GYN physician, said he sees firsthand the challenges faced by physicians.

“I know you work hard and spend plenty of time in the evening checking boxes,” he said. “I understand what you do, and the closer we get to universal healthcare for all, the easier it will be for you to practice. I’ve got your back on this.”

Attendees also heard from California Health and Human Services Secretary Diana Dooley, who got right to the point.

“I know we don’t pay enough,” said Dooley. “I know what it means to be a MediCal provider. There aren’t enough resources. So we work together to stretch what we have as far as it will go. And in California, we’ve stretched it much further than anywhere in the country.”

Dooley noted that the quest for universal coverage in California has been going on for close to 40 years.

“We’ve been searching for a way to find a level of cost that is manageable,” she said.

“We do have very good quality healthcare in this country.

We provide care to a lot of people, but we provide it at a very high cost. We have to be looking at ways we can reduce that cost, or at least mitigate its growth.”

The reason California has

SAN DIEGO PHYSICIAN.ORG

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POLITICAL ADVOCACY

been as successful as it has in the implementation of the Affordable Care Act (ACA), according to Dooley, is because we haven’t had the partisan rancor.

“I’m very proud of the work that we’ve done to make it work as well as it has,” she said. “It’s a work in progress and there’s more we need to do but at the moment, I’m deeply committed to preserving the gains that we’ve made and doing everything we can to assure that we can move forward in California.”

“What we’ve heard over the past six or seven years as we’ve worked to implement the law is what’s wrong with it,” said Dooley.

One of the side effects of the challenge to the ACA has been the recognition of what we actually have done right, she said.

“What we’ve done in the past three or four months is coalesce around the actual language of the law and what it has done. And I think the political system has actually worked very well.”

“There have been a lot of voices about what’s wrong with it, and those voices have been across the spectrum,” said Dooley. “From consumers who want more. From plans that want more flexibility. From physicians who want higher pay. All of the challenges in the healthcare system have now been given a name: Obamacare. But many of those challenges existed precedent to the law. And, in fact, the law was trying to address some of them.”

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“

It’s a day-in and day-out grind to make sure that healthcare rises to the top in the Capitol.

”

Photo Captions — Clockwise From Top: Janus Norman, Senior Vice President, CMA Centers for Government Relations and Political Operations (L–R) Assemblymember Jim Wood, DDS, Health Committee Chair, With SDCMS CEO Paul Hegyi Ted Mazer, MD, CMA President-elect, at the Podium (L–R) CMA Lobbyists Amy Durbin and Michelle Baca With Bob Wailes, MD, CMA Board of Trustees Vice Chair

Dooley believes that California can lead the way as we continue to work to address the challenges of our marketdriven healthcare system.

“It’s a patchwork of add-ons that has very much encumbered our ability to function in an efficient way,” she said. “The first order of business for me is to illustrate in every way that I know the gains that we’ve made, the success that we’ve had and the willingness to reach across lines — whether they’re partisan or professional — and find solutions to the real problems that get beyond the rhetoric of the left and the right.”

Attention employees of

Healthcare Professionals

SDCMS PHYSICIANS MEET WITH LEGISLATORS On Tuesday, April 18, Drs. Karrar Ali, Stuart Cohen, Sergio Flores, Bob Hertzka, Ted Mazer, Vimal Nanavati, Bing Pao, Alex Quick, Al Ray, Will Tseng, Bob Wailes, and Holly Yang, along with UC San Diego first-year medical students Emily Mannix and Meghana Pagadala, joined over 500 other physicians, medical students, and stakeholders who attended the California Medical Association’s 43rd annual Legislative Advocacy Day held in Sacramento.

Accompanied by SDCMS’s CEO, Paul Hegyi, and Senior Director of Governance & Operations, Jen Ohmstede, they spent the day meeting with Senator Ben Hueso, Assemblymembers Shirley Weber, Lorena GonzalezFletcher, Todd Gloria, Rocky Chavez, Brian Maienschein, Randy Voepel, and legislative staff members from the offices of Senator Toni Atkins, Senator Joel Anderson, and Assemblymember Marie Waldron, advocating on behalf of California’s physicians and patients.

Key legislative issues that were discussed included AB 1048 (Arambula), which would reduce pressure on physicians in prescribing opioids; SB 641 (Lara), which would clarify privacy related to CURES; Proposition 56 and tobacco tax fund allocations; and graduate medical education (GME).

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POLITICAL ADVOCACY

CMA-SPONSORED BILLS FOR 2017 CMA’s powerful government relations team works tirelessly to support the development of valuable healthcare policy that protects and enhances the practice of medicine in California and to ensure physicians are able to deliver highquality care to the patients of our state. Below are details of the bills CMA is sponsoring this session.

CURES Privacy (SB 641): The Controlled Substance Utilization Review Evaluation System (CURES), the California Department of Justice prescription drug monitoring program, allows authorized users, including physicians, pharmacists, law enforcement and regulatory boards, to access information about a patient’s controlled substance prescription history. This bill will clarify how law enforcement can access the data, prohibiting the release of CURES data to a law enforcement agency without a valid warrant based on probable cause for an active investigation involving prescription drug abuse or diversion. This bill will help align the privacy protections for prescription information in CURES with that which is provided for patients’ medical records.

20

MAY 2017

“

I know we don’t pay enough,” said Dooley. “I know what it means to be a Medi-Cal provider. There aren’t enough resources. So we work together to stretch what we have as far as it will go. And in California, we’ve stretched it much further than anywhere in the country.

”

Photo Captions — Clockwise From Top: Ruth E. Haskins, MD, CMA President (L–R) Kevin de Leon, California Senate President Pro Tempore, Nuriel Moghaven, MD, Ted Mazer, MD, CMA President-elect, and Rodney Borger, MD (L–R) David Aizuss, MD, CMA Board of Trustees Chair, Bob Wailes, MD, CMA Board of Trustees Vice Chair, Dustin Corcoran, CMA CEO, Lee Snook, MD, Speaker of CMA’s House of Delegates, and Ted Mazer, MD, CMA President-elect

Pain Management and Schedule II Prescriptions (AB 1048): Currently, hospitals and health facilities are required to assess a patient’s pain every time vital signs are checked, which can create unintentional pressure to prescribe medications for pain. This bill would remove the requirement that pain be assessed at every vital sign check and instead would require health facilities to ensure that pain assessment is performed in a consistent manner that is appropriate to the patient, and that the results are noted in the patient’s chart. The bill also allows prescriptions for Schedule II controlled substances to be partially filled if requested by the patient or prescriber. This will allow the patient to get appropriate care while reducing the amount of unused medications. Approximately 70 percent of people who use opioids nonmedically got them from a friend or relative, or on the street.

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Restoring Trust in Medical Board Probation (AB 505): This measure prohibits the Medical Board of California from entering into a settlement for probation in cases that allege serious offenses that put patients at risk, including (1) a felony conviction resulting in direct patient harm; (2) alcohol or drug abuse resulting in direct patient harm; and (3) sexual acts or sexual exploitation.

Instead, these allegations would go through a full hearing process so that the medical board has a finding of fact based on evidence before deciding upon disciplinary actions. This bill enhances the integrity of the medical board’s disciplinary office,

(L–R) Dustin Corcoran, CMA CEO, and Francisco J. Silva, CMA General Counsel and Senior Vice President

improves patient safety and privacy, and preserves physicians’ due process rights.

Pharmacy Benefit Manager Transparency (AB 315): This measure would, for the first time, regulate pharmacy benefit managers (PBMs) operating in California, requiring them to be licensed by the California State Board of Pharmacy. PBMs have evolved from basic claims administrators to more complex organizations offering a wide range of prescription drug managed tools, like drug utilization review, disease management and consultative services. PBMs have not, however, been subject to state oversight or regula-

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tion. This bill would not only require licensure, but would also require PBMs to report aggregate data related to rebates, discounts and price concessions from drug manufacturers, as well as the savings that are passed on to consumers.

Responsible Beverage Service Training (AB 1221): This bill aims to reduce drunk driving by requiring restaurant and bar servers be trained to identify when a customer has had too much alcohol to drink. The bill was spurred by a tragic drunk-driving accident that took the lives of two UC San Diego medical students and injured three others, who were struck

“

It’s a patchwork of add-ons that has very much encumbered our ability to function in an efficient way.

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by a drunk driver going the wrong way. This bill is a reintroduction of last session’s AB 2121, and responds to technical fixes requested by Governor Brown.

Out-of-Hospital Births (SB 457): Recognizing the increased risks associated with births that occur outside of a hospital setting, this bill establishes uniform standards for any births that are attended outside of a hospital or hospital-based birthing center by physicians, certified nurse midwives and licensed midwives. Healthcare providers attending an out-of-hospital birth would be required to provide parents with information on the

limits of the care that can be provided outside of a hospital setting. The bill would also require practitioners attending out-of-hospital births to make hospital transfer arrangements and communicate with a hospital’s medical team, if necessary. Additionally, it would require data collection on these births. CMA is sponsoring this bill with the American College of Obstetricians and Gynecologists.

Workers’ Compensation (SB 189): Currently, the officers and directors of quasipublic or private corporations who own at least 15 percent of the issued stock are excluded from the definition of “employee” for purposes of

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California Attorney General Xavier Becerra

workers’ compensation insurance. This bill would expand this exclusion to officers or directors who own at least 10 percent of issued stock.

It would also expand the exclusion to apply to owners of professional corporations who are practitioners rendering the professional services for which the professional corporation is organized, as long as they sign written waivers stating under penalty of perjury that they are covered by a health insurance policy or a healthcare service plan.

Consumer Complaint Reporting (SB 647): This bill would require the Department of Managed Health

Care and the Department of Insurance to submit to the Legislature, and post online, a yearly record of all complaints received regarding employee welfare benefit plans as defined under the federal Employee Retirement Income Security Act of 1974.

For more information on these and other bills of interest to physicians, members can see CMA’s Legislative Hot List, published regularly during the legislative session.

The Hot List provides a summary and the current status of CMA-sponsored bills, as well as the progress of other significant legislation. To subscribe, visit www.cmanet. org/newsletters.

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CLASSIFIEDS PHYSICIAN POSITIONS AVAILABLE DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a fulltime/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. Please call practice administrator at (858) 761-7362 or email jmaas12@hotmail.com for more information. [612] 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) 248-2324. [611] 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.

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Please submit inquiry and CV to Garcia.Leanne-Sarah@scrippshealth.org. [610] FAMILY PRACTICE MD/DO WANTED for urgent care and family practice office in Carlsbad. Flexible morning, afternoon, evening, and weekend shifts available for family practice physician. Exceptional office staff and flexible scheduling options at this busy, well-established private practice. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [609] LOOKING FOR A FAMILY PRACTITIONER: Well-established solo family practitioner located in suburban San Diego wishing to transition into retirement and looking for a fellow family practitioner to assume fully operational practice. This practice is part of a 15-member incorporated family practice medical group with lab, X-ray, and MRI facilities. All interested candidates will be considered. Please email CV with contact information to Editor@SDCMS.org.

[607]

SEEKING PART-TIME PHYSICIAN: Anderson Medical Center is a busy primary care, sports, and occupational medicine practice housed in a state-of-the-art urgent care facility in Pacific Beach. We’re seeking a part-time physician. Experience in a busy practice, emergency department, or urgent care; with musculoskeletal medicine, X-ray, and sutures/wound care required; and ability to provide compassionate care in a fast-paced environment necessary. We seek someone who values: integrity and quality medical care; with impeccable bedside manner, emotional / professional maturity, ability to work well with patients / team members, easily manages multiple priorities / patients; detail-oriented and team-focused. We’re open 8:00am–8:00pm, Monday–Friday, 8:00am–4:00pm weekends.

Providers share day, night, and weekend coverage. Contact Anderson Medical Center at (858) 224-7977. CVs may be emailed to jhardyman@andersonmedicalcenter.com. [606] SEEKING PART-TIME CARDIOLOGIST: Seeking a cardiologist to work part-time in an outpatient cardiology practice in North San Diego County. Practice opportunities from Monday through Saturday. Hours are from 8am to 5pm. There is no night call or holiday workdays. The contracted cardiologists would decide from the days available which days to work. Please fax resume to (760) 510-1811 or email to evelynochoa2013@yahoo.com. [596] SHARPCARE MEDICAL FOUNDATION CHIEF MEDICAL OFFICER: Full-time CMO for new primary care Foundation model.

Adult primary care physician, 80% clinical / 20% administrative with practice in La Mesa area: Current unrestricted license to practice medicine in the State of California; board certified in primary care or related sub-specialty area; minimum five years of medical administration experience; excellent communication skills; demonstrated clinical practice leadership experience; knowledge of managed healthcare systems, medical quality assurance, quality improvement and risk management; demonstrated leadership, management, organizational, and interpersonal skills; ability to work collaboratively internally and externally; demonstrated ability to assess business needs, design and implement programs, and evaluate results; demonstrated commitment to group practice and healthcare system values. Job type: Full-time. Contact Glenn Chong at glenn.chong@sharp.com or call (858) 499-4557. [594] SEEKING FAMILY MEDICINE AND INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time or half time (job share) BC/BE family medicine and internal medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 2334730. Email: lori.miller@sharp.com. [590] SEEKING EMERGENCY MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE emergency medicine physicians to join our urgent care department. We offer a first-year competitive compensation and an excellent benefits package. Please send CV to

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

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SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [591] FAMILY MEDICINE / INTERNAL MEDICINE PHYSICIANS NEEDED: Graybill Medical Group is one of North San Diego County’s largest independent multi-specialty groups with over 80+ physicians and midlevel practitioners.

We currently have full-time openings in our San Marcos, Ramona (solo practice), and Temecula locations. Current CA and DEA licenses required. Must be BC/BE. We offer a competitive compensation and benefit package, including malpractice coverage and shareholder opportunity. Check out a full list of our benefits under Careers at www.graybill.org. Send CVs to ssnodgrass@graybill.org, apply online, or fax (760) 738-7101. [592] 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 julie@sandiegomobiledoctor.com.

We are very anxious to fill this position, and we look forward to hearing from YOU! No agencies please. [584] 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] 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] OFFICE SPACE AVAILABLE / REAL ESTATE OPPORTUNITY TO OWN A MEDICAL OFFICE BUILDING IN BEAUTIFUL ESCONDIDO: Why rent when you can own and have other medical professionals (building tenants) help pay your mortgage?! For about the price of a nice southern California home, you can own a seventenant office building. For more information, call or text Ralph Hemphill (CA BRE licensee 01238305) at (760) 613-9791. [608] NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista 92083. Large office space is located in an upscale medical office. Finishings, décor, and atmosphere are upscale and inviting, a great place to build your business and clientele following. Few blocks from Tri-City Medical Center. X-ray suite is included. Included with multiple exam rooms, procedure / dressing room, is access to a kitchenette / break room,

two bathrooms, and spacious reception areas all located on the property. Wifi is included as well.

Ample free parking. Contact Harish Hosalkar, MD, at hhorthomd@gmail.com or on cell at (858) 243-6883. [605]

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 SOUTH COUNTY MEDICAL SPACE AVAILABLE: 2323 E. 8th St., Wellness Center Suite 103, National City 91950. Large office space available for lease/rent. Finishings, décor, and atmosphere are upscale and inviting, a great place to build your business and clientele following. X-ray suite is included. Lots of free parking space. Included with multiple exam rooms, procedure / dressing room, is access to a kitchenette / break room, two bathrooms and spacious reception areas all located on the property. Wifi is included as well. Contact Harish Hosalkar, MD, at hhorthomd@gmail.com or on cell at (858) 243-6883. [604] OPEN TO ALL MEDICAL PROFESSIONALS: Lease an office from San Diego Psychological Center in Poway or work as a licensed contractor. First floor, bathroom, receptionist area, waiting room, playroom, kitchen, handicap access, separate entrance / exit. By Pomerado Hospital. Contact Sam at (760) 607-6463. [603] MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE / SHARE IN UTC / LA JOLLA AREA: Established orthopedic surgeon seeks tenant to share office space. 4675ft2 in Chancellor Park, near Scripps Memorial Hospital. Completely rebuilt in 2009. Six exam rooms, digital X-ray onsite. Beautiful finishings, spacious waiting room, conference room, break room. Ample space for support staff and a private office for physician. Available immediately, full or part time. Ideal for primary or satellite office. Excellent freeway access (1-5 and 805), first-floor suite located off lobby near main building entrance. For further information, please contact Georgana Bradley at (858) 4570050 or at gbradley@jpbamc.com. [602] MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 1729 Palm Avenue is an approximately 2,433ft2, freestanding, professional medical office building conveniently located in San Diego. 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. Sale Price: $519,000. Lease Rate: $1.35/sf + Utilities. Please contact Chris Baumgart with Cushman & Wakefield for more information at (760) 431-3847 or at chris.baumgart@cushwake.com. [600] EAST COUNTY SINGLE-STORY HOME FOR SALE: East county single-story home on cul-desac, 4,800+ square feet, Hidden Mesa Estates, custom built 1990, on 0.8 acres, 5 bedrooms, 3.5 baths, 2 family rooms, plus den, pool, spa,

deck with cabana, original owner. To contact agent, email ranchhouse21@gmail.com. [597] 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. [585] 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 Wi-Fi. Kitchen available. Central workroom.

Wheelchair accessible. Perfect for therapists, consultants, etc. Call Marlene at (619) 401-1430 or email saben615@sbcglobal.net. [582] 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 Editor@SDCMS.org for more information. [867]

NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 9925330 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] MEDICAL EQUIPMENT WAITING ROOM KIOSK WITH TABLETOP STAND: (eClinicalWorks Compatible) Decrease wait times, increase collections, and improve financial performance. 17-inch touchscreen with swipe magnetic credit card reader. Copays and accounts receivable payable upon check-in.

Software included. Original cost new $5,199.

Sell for only $1,299. Email Editor@SDCMS.org.

[587] 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) 3002780. [559]

PLACE YOUR AD HERE

NONPHYSICIAN POSITIONS AVAILABLE FAMILY MEDICINE NURSE PRACTITIONER: Needed at the Sycuan Medical Dental Center, a tribal health center on the Sycuan Reservation in El Cajon. Full-time position includes part-time patient care / part-time administrative duties.

Mon.–Fri., 8am–4pm. Apply online at www.sycuan.com. [595] SEEKING PER DIEM PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Graybill Medical Group is one of North San Diego County’s largest independent multi-specialty groups with over 80+ physicians and midlevel practitioners.

We are currently looking for a per diem PA or NP to provide direct patient care in an urgent care / extended family practice setting in Escondido; to work three weekend shifts per month (8am–4pm) with a possibility of additional shifts as needed. Must have a current CA (PA or NP) license, and be ACLS and CPR certified. Two years’ prior experience in an urgent care or ER required. Bilingual in English/Spanish helpful. Send CV to ssnodgrass@graybill.org, apply at www.graybill.org, or fax to (760) 738-7101. [593]

Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org SAN DIEGO PHYSICIAN.ORG

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P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

PUT YOUR OWN OXYGEN MASK ON FIRST

by Helane Fronek, MD, FACP, FACPh

IN HIS COURAGEOUS ARTICLE in The New England Journal of Medicine, “Breaking the Stigma: A Physician’s Perspective on Self-care and Recovery,” Adam B. Hill, MD, explains his road to recovery after suffering from alcoholism, depression, and suicidal ideation. He describes a period in his career when he felt “abused, overworked, neglected, and underappreciated.” Dr. Hill states, “I felt I had lost my identity.”

As a physician coach, I speak with many physicians who feel this way. Physicians are often not given the same sense of respect as in the past. We are no longer “doctors” but “providers” — as if our years of study and training aren’t considered important or meaningful. We worry about making the correct diagnosis and implementing the best treatment, and now also worry how our patients will rate us. When a patient or staff member complains, it is often the doctor who is asked to adjust his behavior to accommodate the other party.

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“

I rearranged the hierarchy of my needs to reflect the fact that I am a human being, a husband, a father, and then a physician.

I learned that I must take care of myself before I can care for anyone else.

”

And finally, we now devote unpaid hours to entering data, satisfying regulations or insurance requirements. This leaves less time for meaningful patient interactions or a life that can balance the stress at work.

Dr. Hill found that taking charge of his own life was the key. “I rearranged the hierarchy of my needs to reflect the fact that I am a human being, a husband, a father, and then a physician. I learned that I must take care of myself before I can care for anyone else.” As we hear on every flight, “Put your own oxygen mask on first.” And yet, many of us put ourselves, and our own mental health, last.

What might it look like if you put yourself first? What priorities would you establish? What boundaries would you create?

What would you say “no” to?

Dr. Hill then discusses the tragedy of stereotyping physicians who are struggling and the stigma that comes with acknowledging a mental health issue. Studies show depression affects 27% of medical students; unfortunately, only 15.7% seek treatment. It takes courage to admit we have a problem, and yet we brand anyone with a problem as damaged, weak, or incapable. So we quietly keep our imperfect thoughts and feelings to ourselves.

We compare our internal insecurities with the seemingly perfect external composure of others. Being brave enough to show our vulnerabilities to our colleagues can let them know they are not alone and can establish a therapeutic, supportive relationship for us all. If we could change this perspective, perhaps we wouldn’t lose 300–400 physicians to suicide each year.

The conclusion to Dr. Hill’s article focuses on building supportive networks, the “bedrock” of his recovery. From reminding you of your strength and resilience to holding you accountable to your commitment to your own wellbeing, family, friends, colleagues, counselors, and coaches can be invaluable in your pursuit of a more balanced life and healthier life. Let’s all take a stand for our own health and our own lives.

A healthy doctor is the best kind of doctor for any patient to have.

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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At CAP, we salute your dedication and support you in every way we can — with protection to reduce the worry of professional liability lawsuits, but also with a host of value-added services to help manage your practice so you can focus on the highest quality professional care. Ask for a no-obligation quote and more information on CAP membership.

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