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APRIL 2018 OFFICIAL PUBLICATION OF SDCMS

Celebrating 50 Years of

UC San Diego School of Medicine


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APRIL

CONTENTS

VOLUME 105, NUMBER 4

Medical residents train in the Center for the Future of Surgery at UC San Diego School of Medicine Credit: Erik Jepsen/UC San Diego Publications

EDITOR: James Santiago Grisolía, MD 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: Mark W. Sornson, MD, PhD President-elect: David E.J. Bazzo, MD Secretary: James H. Schultz Jr., MD Treasurer: Holly B. Yang, MD Immediate Past President: Mihir Y. Parikh, MD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Sergio R. Flores, MD (Board Representative to Executive Committee) Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Geva E. Mannor, MD, MPH La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Michael A. Lobatz, MD South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Neelima V. Chu, MD South Bay: Paul Manos, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Karrar H. Ali, DO, MPH; #3: Alexexandra E. Page, MD; #4: Nicholas J. Yphantides, MD; #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Erin L. Whitaker, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD

features

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ADDITIONAL VOTING DIRECTORS Communications Chair: J. Steven Poceta, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Meghana Pagadala

Celebrating 50 Years of UC San Diego School of Medicine BY HEATHER BUSCHMAN, PHD

24 Dr. Robert E. Hertzka Teaches Students About Health Policy and Politics in Medicine

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BY SCOTT LAFEE

25 Medical Students Take an Active Role in San Diego County Medical Society BY CECILIA BONADUCE LEGGETT

2018-2019 Board of Directors Candidate Statements

departments

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Three Steps to Becoming the CEO of Your Life

Briefly Noted: Calendar • Giving Back • Public Health Awards

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CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MP AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD (appointed by CMA) At-large AMA Delegate: Robert E. Hertzka, MD (appointed by CMA) At-large AMA Alternate Delegate: Theodore M. Mazer, MD (appointed by CMA)

BY HELANE FRONEK, MD, FACP, FACPh

26 Physician Marketplace: Classifieds

Study Shows Nurse Practitioners and Physicians Face Similar Liability Risks

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BY DAVID B. TROXEL, MD

BY DANIEL J. BRESSLER, MD, FACP

APRIL 2018

ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Heidi M. Meyer, MD Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD\ San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD

Swashbuckling and Attribution

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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GIVING BACK MAY 5: Annual White Coat Gala at Paradise Point Resort Contact: Contact Jen at JOhmstede@ SDCMS.org or at (858) 300-2781 MAY 23: 30th Annual Western States Regional Conference on Physicians’ Well-Being. Being held at UC Riverside. More information: www.rcmanet. org/events. JUNE 22-24: San Diego Academy of Family Physicians 61st Annual Family Medicine Update at Paradise Point Resort. More information: www. sandiegoafp.org. AUG 1-4: Metabolic & Endocrine Disease Summit(MEDS) for NPs and PAs. Physicians welcome. More information: https:// www.globalacademycme. com/ OCT 12-14: UCSD School of Medicine 50th Anniversary Alumni Reunion. More information: medalumni@ucsd.edu

VOLUNTEER OPPORTUNITIES Email Your Volunteer Opportunity Ads to Editor@SDCMS.org PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew. Gonzalez@ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions

POLITICAL ADVOCACY

Help Stop the Dangerous AB 3087 AB 3087 would drastically increase out of pocket patient costs and would create state-sanctioned rationing of healthcare for all Californians. This dangerous legislation would create a government run commission of 9 political appointees who would unilaterally set the price for medical services. This would literally end the commercial health care market in California. Physicians can learn about AB 3087 and contact their legislators directly by going to www.actnow.io/pricefixing.

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for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ ChampionsFH.org, or visit www. ChampionsforHealth.org. SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: We are looking for physicians, mid-level providers and nurses for one-week, primary-care medical clinics in rural Haiti in June and October 2018. This is a rewarding and fun opportunity to work with the people of Haiti and provide care in a rural clinic in a medically under served area. Seattle-King County Disaster Team (a U.S.-based nonprofit) has been operating these clinics since 1998. We coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink.net if you are interested in applying. Visit www.skcdteam.org for further information

QUOTE OF THE MONTH

One looks back with appreciation to the brilliant teachers, but with gratitude to those who touched our human feelings. The curriculum is so much necessary raw material, but warmth is a vital element for the growing plant and for the soul of the child. — Carl Jung


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TrusT A Common sense ApproACh To InformATIon TeChnology

Trust us to be your Technology Business Advisor

SDCMS HOSTS MOVIE SCREENING

On March 27 at UCSD, SDCMS hosted a private reception and exclusive screening of the film Hippocratic: 18 Experiments in Gently Shaking the World featuring Dr. Rajagopal. The film was followed by an in-person Q&A.

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www.soundoffcomputing.com PUBLIC HEALTH AWARDS

Dr. Bob Hertzka and Champions for Health Honored On April 6th, Dr. Bob Hertzka and Champions for Health (CFH) were both honored during the County of San Diego’s annual Live Well San Diego Public Health Champions award ceremony. Both Dr. Hertzka and CFH were acknowledged for their achievements in improving the health and well-being of local residents. Dr. Hertzka was recognized for his “outstanding community service and dedication to the County of San Diego.” Champions for Health was recognized for their efforts to “improve community health and wellness, increase access to care for all, and support for physicians engaged volunteerism.” Congratulations to both for a well-deserved honor.

Endorsed by

SAN DIEGO PHYSICIAN.ORG

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RISK TIP

Study Shows Nurse Practitioners and Physicians Face Similar Liability Risks By David B. Troxel, MD

THE DOCTORS COMPANY analyzed 67 claims — written demands for payment — against nurse practitioners (NPs) that closed over a six-year period from January 2011 through December 2016. These claims arose in family medicine (FM) and internal medicine (IM) practices. To provide context, we compared the NP claims with 1,358 FM and IM claims against physicians that closed during the same time period. If a claim was

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against both the FM or IM physician and the NP, we eliminated it from this study to avoid counting the same claim twice. We included cases that closed within the study’s time frame regardless of how the claim or suit was resolved. This approach helped us to better understand what motivates patients to pursue claims and to gain a broader overview of the system failures and processes that resulted in patient harm.

Our approach to studying these malpractice claims began by reviewing plaintiffs’/ patients’ allegations, giving insights into the perspectives and motivations for filing claims and lawsuits. We then looked at patients’ injuries to understand the full scope of harm. Physician and nurse practitioner experts for both the plaintiffs/patients and the defendants/nurse practitioners/physicians reviewed claims and conducted medical record reviews. Our clinical analysts drew from these sources to gain an accurate and unbiased understanding of the events that lead to actual patient injuries. Nurse practitioner or physician reviewers evaluated each claim to determine whether the standard of care was met. The factors that contributed to claims included clinical judgment, patient factors, communication, clinical systems, clinical environments, and documentation. Our team studied all aspects of the claims and, using benchmarked data, identified risk mitigation strategies that nurse practitioners and their physician partners can use to decrease the risks of injury, thereby improving the quality of care. Limitations: We did not take the following state differences in NP scope of practice (SOP) into consideration because the number of claims in each category would likely lack statistical significance: • In 23 states and Washington, DC, NPs have full authority to practice independently. They can evaluate, diagnose, and manage treatment — including ordering and managing medications. • In 15 states, NPs have reduced practice authority that requires a regulated collaboration agreement with a physician. • In 12 states, NPs have restricted practice authority that necessitates supervision, delegation, or team management by a physician. Most Common Patient Allegations When NPs worked in FM and IM practices, the three most common claim allegations against NPs accounted for 88 percent of their total claim allegations. The top three allegations in claims filed against FMs and IM physicians accounted for 89 percent of their total claim allegations. The diagnosis- and medication-related allegation percentages were similar for both NPs and primary care physicians, while medical-treatment–related allegations were more common for primary care physicians (see FIGURE 1). The small number of NP claims may lack statistical significance.


Discussion The adoption of the electronic health record (EHR) has negatively affected physician satisfaction and practice workflow. As a consequence, physicians are increasingly using medical scribes to untether themselves from their EHRs, enhance efficiency, and reduce burnout. Patient satisfaction also increases with the use of scribes due to improved physician-patient interactions during office visits. A growing body of evidence indicates that NPs provide similar benefits; i.e., they provide high-quality patient care, with patient satisfaction scores similar to those of physicians—which allows physicians to see more patients and focus on those with complex management or diagnostic problems. Increasingly, the growing need for primary care services will be filled by NPs, not primary care physicians. Subject to individual state regulatory guidelines, NPs may take patient histories; conduct physical examinations; order, supervise, perform, and interpret diagnostic and laboratory testing; prescribe pharmacological agents; and render treatment. In 2017, there were more than 248,000 licensed NPs in the United States, with 86.6 percent certified in primary care and 95.8 percent prescribing medications.1 Approximately 8,000 new primary care physicians enter practice each year. By 2020, it is estimated that about 8,500 will retire annually. As the number of primary care physicians declines, their services will increasingly be provided by NPs.2 An estimated 23,000 new NPs completed their academic programs in 2015–2016.3 It is projected that by 2025, physicians will

represent 60 percent of the family practice workforce, and NPs will represent 29 percent (almost one-third).4 For these reasons, it is appropriate to review NP medical malpractice claims and compare them with those of primary care physicians to see if any unique NP risk management issues need to be analyzed. Although this NP claims analysis is statistically limited by the relatively small number of NP claims, it shows that diagnosis-related and medicationrelated allegations are similar for NPs and primary care physicians — as are the final diagnoses in claims with diagnosisrelated allegations. Medical-treatment–related allegations are more frequent for FM and IM physicians, while patient assessment issues, patient injury contributing factors, patient injury–related diagnoses, and injury severity are similar. The key differences are that NPs have lower claims frequency, and their medication-related and medical treatment–related claims have lower indemnity payments. The indemnity payments for diagnosis-related claims are similar for NPs and physicians. An allegation of failure or delay in obtaining a specialty consultation or referral often occurred when an NP managed a complication that was beyond his or her expertise or SOP. The alleged failure to perform an adequate patient assessment often occurred when an NP relied on the medical history or diagnosis in a previous medical record rather than performing a new, comprehensive exam. Many NP malpractice claims can be traced

to clinical and administrative factors: • Failure to adhere to SOP. • nadequate physician supervision. • Absence of written protocols. • Deviation from written protocols. • Failure or delay in seeking physician collaboration or referral. Many of these factors can be remedied if physicians are clear about the nurse practice laws and regulations within their state and they support the NP in providing care within the SOP. The quality program within the practice should monitor the practice of the NP to ensure compliance with the laws and regulations of that particular state. Contributed by The Doctors Company. For more information about the Nurse Practitioner Closed Claims Study, go to www. thedoctors.com/NPstudy. Dr. Troxel is medical director at The Doctors Company. References 1. NP fact sheet. American Association of Nurse Practitioners. www.aanp.org/allabout-nps/np-fact-sheet. Accessed March 26, 2018. 2. Bodenheimer T, Bauer L. Rethinking the primary care workforce—an expanded role for nurses. N Engl J Med. 2016;375(11):10151017. 3. NP fact sheet. American Association of Nurse Practitioners. www.aanp.org/allabout-nps/np-fact-sheet. Accessed March 26, 2018. 4. Bodenheimer T, Bauer L. Rethinking the primary care workforce—an expanded role for nurses. N Engl J Med. 2016;375(11):10151017.

*The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

SAN DIEGO PHYSICIAN.ORG

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SDCMS ELEC TIONS

CANDIDATE STATEMENTS 2018–19 SDCMS Board of Directors

Notes: • (*) After Name = Incumbent • Number in Parentheses (#) After Name = Term Length in Years OFFICERS: Candidate for President-elect: James (Jim) H. Schultz, MD, MBA, FAAFP (1) Jim Schultz is a family physician who practices at Neighborhood Healthcare, a federally qualified community health center serving about 70,000 of the underserved and medically needy. He sees outpatients in Escondido, Pauma Valley, and Temecula, and inpatients as part of the California Emergency Physicians Hospitalist program. He has been chief medical officer of Neighborhood Healthcare since 2001, and is currently the CMO of Integrated Health Partners and of Champions for Health / Project Access San Diego. Prior to his role at Neighborhood Healthcare, Jim was medical director and practicing physician at Graybill Medical Group in Escondido, where he began his professional career in 1988. He is also a volunteer clinical professor at UCSD in the Department of Family and Preventive Medicine and hosts the Family Medicine Residency PGY-1 outpatient gynecology rotation. His goals at SDCMS include helping fashion a strategy for meaningful membership into the future, fairly representing the interests of the physicians of North County, and in bringing in the voice and perspective of those physicians whose practice is predominantly that of the underserved. 

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Candidate for Secretary: Holly B. Yang, MD (1) I have been a member of the San Diego County Medical Society (SDCMS) since I moved to San Diego over 10 years ago. I have been on the board of directors since 2012, and am the current treasurer. At the California Medical Association (CMA) House of Delegates, I have served on two reference committees, and I am currently the vice chair of the Council on Membership, Governance, and Bylaws. I am also an alternate delegate to the American Medical Association from the CMA. With the issues and uncertainty facing medicine, physicians must have an even stronger voice to protect our patients’ ability to access high-quality healthcare and our ability to provide and direct that care. SDCMS serves us well in that role, and is a great resource to physicians of all specialties and practice types in the daily issues we deal with as doctors. Since being elected to the board of directors, I am continually impressed by what we can accomplish when we have a diverse group of physicians come together as a team. I am honored to have the opportunity to give back to my community, and engage with the things that make a difference to our patients and our profession. Thank you for all the work you do to care for the people of our county. Thank you for your trust to represent you. I ask for your continued trust and support for my candidacy for secretary of our SDCMS.   Candidate for Treasurer: Sergio R. Flores, MD (1)  I have served on the SDCMS board of directors as both a Kearny Mesa alternate as well as geographic director.

I am also currently serving on the Executive Committee. I would like to continue serving on the SDCMS board as your treasurer. I’m also on the CMA board of directors since 2012 as well as the current Chairman of the CMA finance committee. I was born and raised in San Diego and graduated from SDSU in 1985. I graduated from the UCSF School of Medicine in 1989 and trained at UC Irvine in internal medicine and gastroenterology from 1989 to 1994, and was board certified in both. I am in private practice and have been a partner at San Diego Digestive Disease Consultants since 1998. I serve on the board of Sharp Community Medical Group for the past 19 years and currently serve on the executive committee as the vice president as well as the Chairman of the finance committee. I served on the Sharp Healthcare board of directors for seven years and continue to serve on their finance committee. I would like to continue to offer my services to you and SDCMS. Thank you. GEOGRAPHIC DIRECTORS: Candidate for Kearny Mesa Geographic Director #1: Jamie M. Jordan, MD (3)  My name is Jamie Jordan and I am a Pediatrician at Children’s Primary Care Medical Group. I have been practicing in San Diego for almost 6 years. I came to San Diego after my training at the University of Arizona for Residency, Boston University for Medical School and UCLA for my undergraduate degree. Although I grew up in the LA area (San Fernando Valley), I have set down roots in San Diego building a new home and starting a family with my husband and baby. I love working in my location because I see the spread of popula-


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tions and a diversity of obstacles in practicing. I also get to use my medical Spanish that I learned while rotating through Panama and Guatemala while in training. I have always jumped in to be involved with every group I join. I became very involved within my company, serving on over 10 some committees as well as becoming a shareholder since joining. I am now hoping to get more involved in the community of San Diego and would love the opportunity to serve as the Kearny Mesa director. Candidate for La Jolla Geographic Director #1: Laura H. Goetz, MD (3) (no statement)   Candidate for North County Geographic Director #1: Patrick A. Tellez, MD, MPH, MHSA* (3)  Dear Colleagues, My name is Patrick Tellez; I currently serve as a clinician in the part-time practice of Pediatric Allergy and as Chief Medical Officer of North County Health Services, a community health center serving over 70,000 residents in San Marcos, Oceanside, Encinitas, Carlsbad and Ramona. It is with keen interest that submit my candidacy to serve our profession through the San Diego County Medical Society Board ofDirectors. My vision is to do whatever I can to assure that physicians maintain a position of leadership as the architects of change in health care in San Diego and throughout California. The foundational ethics that we all embrace in the course of medical practice, include: “First do no harm.” “Beneficence” – always seek to minimize pain and optimize health; “Autonomy” – Empowering and engaging the patient, through education, to enable informed decision making; and, “Justice” – always seek to assure that the resources are available and accessible to deliver an acceptable standard of care.  These very same ethics also apply to the design, leadership and change management of large scale health care systems.  In the absence of physician led initiative, the practice of medicine becomes subject to social, business, economic and other influences which often, whether inten-

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SDCMS ELEC TIONS

tionally or unintentionally, do influence the evolution of medicine, effectiveness of public health and the health status of populations. Today, we live in times of unprecedented change; and yet, it is the current conditions of uncertainty that present us with unprecedented opportunity to make a measurable difference, as a profession, in the future course of health care in our State and country. It is with this vision that I am excited to tender my interest in being considered as a nominee to serve as a member of the team that is the Board of the San Diego County Medical Society.  Candidate for North County Geographic Director #3: Veena A. Prabhakar, DO (3)  I am honored to be nominated as a candidate for North County Director, and it would be my privilege to serve for the first time on the Board for SDCMS. I have been a family physician in North County San Diego for nearly seventeen years, with experience in multiple practice settings. I am presently a full time family physician at Sharp ReesStealy Medical Group in Rancho Bernardo. In my private practice days, I served for many years as treasurer and vice-president for my group. I have also enjoyed serving on various leadership committees throughout my career, including peer review and quality assurance. I am presently a CMA delegate representing the Large Group Practice Forum. I have always been a champion for physician well-being. I found inspiration this past October at the House of Delegates meeting, where physician burnout was addressed with as much vigor as the other critical issues of the day. It was truly empowering to be reminded what physicians can achieve when united. I hope to foster continued conversation about what we can do to support each other in preventing physician burnout, and preserve the joy of what happens when we all enter that exam room. With multiple physician family members in various organizations throughout San Diego, it is clear to me, that despite our subtle differences, we share a common vision in our desire to improve access to high quality cost effective care, while preserving the well-being of those responsible for delivering that care. Despite the daily challenges we all presently

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face, I remain optimistic and passionate about medicine. If elected, I would be extremely proud to represent the voice of my friends and colleagues in North County, and throughout San Diego. On a personal note, I grew up in Bonita, moved back to San Diego shortly after residency and settled in the North County area, where I presently live with my three daughters, and husband David Hattie, also a long-time family physician in North County. I try and find balance with tennis and live music.  Candidate for South Bay Geographic Director #2: Maria T. Carriedo, MD* (3)  I am a family physician from San Ysidro Health Center, a Federally Qualified Community Health Center serving about 94,000 of the medically underserved and culturally diverse population in the South Bay. El Cajon, and Southeast San Diego. I have been the VP and Chief Medical Officer for San Ysidro Health Center since 2012. My goals at SDCMS include not only providing the perspective of a physician working in South County with an underserved and culturally diverse population, but in addition, working together with physicians from throughout the county to build a healthier community. I also look forward to working with a team of physicians to address the important issues of payment reform and physician workforce shortage that we are facing. Throughout my years at San Ysidro Health Center, I have actively been involved with training of students and residents. In addition, working as preceptor with the Scripps Chula Vista Family Residency program, I take great pride in helping in the training of our future Family Medicine physicians. I have been a board member with the San Diego Academy of Family Practice and enjoyed collaborating with physicians from various modes of practice. It has been an honor to have a seat on the board of SDCMS so that I may serve on behalf of all physicians. I ask for your support. AT-LARGE DIRECTORS:  Candidate for Atlarge Director #2: Paul J. Manos, DO (3)  I have had the privilege to practice emergency

medicine over the past twenty years at Paradise Valley Hospital and have served as Medical Director for the past thirteen years. During my tenure at Paradise Valley Hospital, I have served as Chief of Staff and have held numerous other Medical Staff Positions. In 1999, I co-founded eStudysite, which conducts research related studies throughout the county and have conducted more than 150 clinical trials over the past twenty years.  Currently, I am the founder and President of Pacific Paradise Emergency Physician Medical Group, employing 24 physicians and mid-level providers. I am actively involved in teaching Medical Students from Midwestern University, as well as physician assistants and nurse practitioners from various local universities.  My experience as an emergency room physician and primary investigator for clinical research has given me the opportunity to see the many facets and different perspectives of medicine.  Over the years I have had the unique opportunity to work with so many inspiring, dedicated physicians, and community members in San Diego, which sets us apart from all others. Knowing this, I believe we can effect change that will positively impact our patients.  As a practicing physician in an underserved community, I believe that we must advocate for good access to healthcare in this population, as well as advocating for all patients. Having said this, I also believe as physicians we must come together with a unified voice to protect the practice of medicine. I hope to bring to the Board at SDCMS common sense ideas that will help effect change.  Thank you for the opportunity. It’s a privilege to serve our community. Candidate for Atlarge Director #7: Toluwalase (Lase) A. Ajayi, MD* (3)  I have had the honor of serving on the SDCMS board of directors for the past four years and consider it an honor to serve our medical community. I have had the privilege to again ask for your support as I run for at-large director of SDCMS. I have served as an SDCMS at-large director for the past three years, and have recently joined the executive committee. I have been very active bringing the


voice of the community physician and the patients we serve to the California Medical Association. Through my active involvement with SDCMS, I have represented San Diego Physicians at the CMA, serving on the Council of Legislation, the Ethnic Minority section, and just recently completing my term as the chair of the young physician section. I take these responsibilities seriously and work passionately in these roles because I believe that our San Diego County Medical Society provides a vital opportunity for our physician community to be able to speak as a singular “voice” to the public and to the politicians in the city, county, state, and federal government. Recently, we have seen our California Medical Board, the CDC and CMS react to the Opioid Epidemic in ways that may not truly benefit the patients that we are trying to help and place restrictions on the practicing physicians. We have seen and continue to see the cost of medical education increase leading to an increase debt burden on young physicians. EHR interopSOM50th REVISED_02.pdf

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erability and scope of practice continue to place a burden the patient-physician-payer relationships. Given this reality, it will be critical that we as practicing physicians represent, with a unified voice, the medical care interests of our patients. I have worked to help our Medical Society speak with that united voice and continue to work on the ground to help ease these tensions and much more. I would truly appreciate your support as I seek re-election to the SDCMS board of directors. GEOGRAPHIC ALTERNATE DIRECTORS: Candidate for East County Geographic Alternate Director: Heidi M. Meyer, MD (3)  My time so far serving on the SDCMS Board has been a wonderful reminder of the power physicians have to

impact the health of our communities. I look forward to the opportunity to continue to work with the movers and shakers of organized political medicine in the state of California. As a Family Physician, I consider defending the health of the public part of my mission, and the SDCMS Board more than helps me fulfill this mission. My past work on the Arizona and American Academy of Family Physicians boards, as well as my past experience as President of the San Diego Academy of Family Physicians board has been a great compliment to this one. I also enjoy being a voice for the large group practice as I am employed by the Permanente Medical Group.   Candidate for Hillcrest Geographic Alternate Director: Kyle P. Edmonds, MD, FAAHPM* (3)  Dr. Edmonds is an assistant professor of palliative medicine on the

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SDCMS ELEC TIONS

Doris A. Howell Palliative Teams at UC San Diego Health as well as a quality medical director for advanced illness management and care. He has been an SDCMS member since arriving in San Diego for fellowship training in 2012 and has been actively involved in organized medicine since his first year of medical school. In addition to serving on the Board of Directors, he is a member of the CMA Council of Ethical, Legal, and Judicial Affairs and a past president of the CMA Young Physician Section. He is a California delegate to the American Medical Association House of Delegates and a delegate to the AMA YPS from the American Academy of Hospice & Palliative Medicine. He is a resident of Mission Hills where he lives with his wife, daughter, and son. Dr. Edmonds is passionate about health policy and the ways it interacts with our professional lives and the lives of the people we care for every day. He is proud to ask for your support in continuing to be a voice for you, your practice, and your patients.” Candidate for La Jolla Geographic Alternate Director: Wynnshang (Wayne) C. Sun, MD* (3) I have been honored to serve as one of the La Jolla representatives and an at-large alternate director to the San Diego County Medical Society for the past several years. In my time on the board, I have come to realize how important it is that all physicians speak with one voice to work towards what is best for San Diego physicians and their patients. Although my immediate concerns as a general internist in private practice may be different from a specialist in academic medicine or a physician in a large-group practice, the changes that are occurring healthcare affects all of us. I have seen how much can be accomplished when we work together with a united voice, and it is essential that we approach these challenges together so that we can all survive and flourish. I believe my role on the board would be to continue to educate physicians in the importance of being a part of organized medicine, and to help make SDCMS an organization that all physicians would like to join.

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Candidate for North County Geographic Alternate Director: Franklin M. Martin, MD, FACS (3) I am a general surgeon practicing in North County Inland for the past 25 years. I have been a member of the SDCMS, CMA and AMA during that time and would like to give back by serving as an alternate representative. My leadership experience so far has been as a CMA Large Group Delegate for two years, OMSS Delegate from Palomar Medical Center, Chief of Staff at Palomar Medical Center, Past COS for Pomerado Hospital and presently serving as a member of the BOD of SCMG for the past 7 years. I trained at Georgetown University Medical School, residency at Bethesda Naval Hospital, served until 1992 in the Navy and Marines and have been in private practice ever since. The SDCMS and organized medicine as a whole are our best advocates to continue our profession and take care of our patients to the best of our ability. Candidate for South Bay Geographic Alternate Director: Karrar H. Ali, DO, MPH (3)  I am honored to run for the board of the San Diego County Medical Society (SDCMS) again. As an emergency physician at Sharp Chula Vista Medical Center and full partner with Vituity (formerly California Emergency Physicians), I am a physician who seeks to improve medicine at micro and macro levels for our patients, healthcare providers, administrators, and communities. I hold several committee positions at the hospital that focus on efficiency and team-building, as well as being the advocacy lead at Sharp.  I have been a member of SDCMS for nine years and it has been a distinct pleasure to serve on the board over the last six years. I have also enjoyed serving as a delegate and participant in CMA’s annual legislative meetings. Despite the not-always positive trends in the practice of medicine, I believe our best chance to effect desired changes for our profession is to unite on common ground and to advocate through these avenues. I will endeavor to effectively represent all the physicians in my geographic community, as well as my emergency medicine colleagues. I thank you for your continued support.

AT-LARGE ALTERNATE OFFICERS: Candidate for At-large Alternate Officer #3: Susan Kaweski, MD (3) (no statement)

AMA DELEGATE CANDIDATE: Candidate for AMA Delegate #1: James T. Hay, MD* (3) I have had the privilege of serving you in many capacities over the past many years: 2001 president of SDCMS; first president of the SDCMS Foundation; delegate, trustee, speaker, and 2012 president of CMA; and delegate to Our AMA since 2001.  More important than the titles are the accomplishments of your San Diego AMA team. The Hertzka, Hay, Ray, and Mazer team is a major influence within our California delegation. I wrote and introduced a series of resolutions that resulted in the adoption by the AMA HOD of the “Principles of the Patient-centered Medical Home.” I was part of the campaign to elect Bob Hertzka to the AMA’s Council on Medical Services. I was chair of the finance committee of the delegation and helped to reduce expenses for CMA during tight budgetary times. I am a recognized consensusbuilding voice in the AMA House. And with the need to redirect AMA at this time in health system reform, strong leaders like San Diego’s need that voice at AMA.  Locally, I am proud of the tremendous growth of our Medical Society since 2001; of the Foundation, now Champions for Health, an important part of the charitable community in San Diego, and of its Project Access; and of the reorganized governance structure of SDCMS, begun during my president year, that, along with a dynamic CEO and current leadership, has made San Diego the premier county medical society in California.  We need leaders who build consensus and can get things done. Certainly as we face the challenges of healthcare reform and the system reorganization proposals of the administration in Washington, we want people who understand the policy and the politics. I am very grateful that you have believed that I do, and I ask for your support to continue as your delegate to the AMA House of Delegates.


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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

Three Steps to Becoming the CEO of Your Life By Helane Fronek, MD, FACP, FACPh

THE ROAD TO BECOMING a physician is often predetermined — we must excel in college and participate in research, clinical situations, and outside activities to get into medical school. We then follow a prescribed course, culminating in residency or fellowship training. Our personal choices during those years are limited. For this reason, many of us emerge with little sense of our own personal power. Yet, the most important role we play is that of CEO of our life. If we abdicate this role, we arrive at some age (40? 50? Retirement?) feeling disappointed and unfulfilled. Unless we acquired an

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MBA, we may feel unprepared for the role of CEO. What are the important issues? What knowledge must we have to succeed? Kenneth Frazier offered sage advice in a New York Times interview regarding his role as CEO of Merck, outlining his three priorities. The first is a “sense of purpose and direction.” If someone were making a speech about you 20 years from now, what would you want them to say? If you had the opportunity to make one impact on the world or the people you know, what would it be? Considering these questions will uncover the accomplishments and contributions

that would be most meaningful to you. Once you know your purpose, take stock of your actions on a regular basis to insure your alignment with it. Frazier also advised that a CEO must be concerned with asset allocation. We each have limited time, energy, and focus. Are we using these resources appropriately? Do our activities promote our purpose, optimize our physical or emotional state, or sustain our health? If not, perhaps it’s time to withdraw from activities we do for other, less essential reasons. The CEO’s final responsibility is to “make sure you have the right people in the most important jobs.” None of us is an island. Do we have good friends who encourage and support us in living the life we desire? If not, how can we develop those relationships? Are we engaging others to take on certain tasks so we can focus on those that play to our strengths, from which we might learn something important, or that are truly enjoyable? Does our primary relationship provide what we need from it? How might we engage with our partner so we become a source of love, strength and joy for each other? As physicians, we often advocate for our patients, organizing the various participants in their care to achieve the optimal outcome. Taking the time to do the same for ourselves is essential if we want our life to be optimally fulfilling. The good news is that an MBA is not required! A commitment to our own happiness and a bit of time to define our purpose and realign our actions is all that’s needed. It’s what any good CEO must do. 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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UC San Diego School of Medicine

50 Years B Y H E AT H E R B U S C H M A N , P h D

F

rom the beginning, UC San Diego School of Medicine attracted risktakers who welcomed the chance to be a part of a new type of medical education. One of these innovators was Joseph Stokes III, MD, who became the school’s founding dean at the age of 39. In addition to his work in medical education, Stokes led research in preventive medicine, infectious diseases, and cardiovascular disease, particularly as they related to the relatively new field of genetics. Perhaps due to his own varied, interdisciplinary research interests, Stokes and the other founding faculty wanted to build a school that didn’t just have medical students memorize disease symptoms and their treatments from a textbook. They wanted to provide a medical education strongly rooted in the basic sciences and the underlying causes of disease. At the same time, they didn’t want students who did nothing but sit in lectures for their first two years. In a 1964 university press release announcing his appointment, Stokes said he hoped the new medical school would attract a special type of student who is “able and willing to innovate, investigate, and educate … So greatly has scientific investigation advanced medicine that today’s generation of doctors can hardly speak to the doctors of a generation ago. The research output of the medical school is every bit as important as the number of students who are graduated.” But to appeal to those special students, Stokes and team first needed to build a fac-

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ulty of the best and brightest. So they rolled up their sleeves, built bridges with other science departments across the UC San Diego campus and traveled the country to recruit more like-minded educators, clinicians and scientists. One of Stokes’ first recruits was Eugene Braunwald, MD, who served as founding chair of the Department of Medicine. Braunwald left a comfortable academic life at the National Institutes of Health (NIH) to take a chance on a new endeavor — a new school of medicine that was just one building in the middle of a decommissioned Marine Corps base and a newly acquired community hospital a few miles south in Hillcrest. “I was attracted by the concept of a new school starting from scratch, with interesting ideas about education that still had to be fleshed out,” Braunwald said. “The fact that we started with an empty slate attracted me — no students, no buildings and sort of a hospital. Things were primitive. It was really a desert, literally and figuratively. But it was an exhilarating experience.” Others soon followed. Braunwald’s own wife, Nina Starr Braunwald, MD, was among this intrepid group. She was the first woman in the nation to be board certified in cardiac surgery. In 1960, at the age of 32, she had led the surgical team at the NIH that implanted the first successful artificial mitral human heart valve replacement, which she had also designed and built. At UC San Diego School of Medicine, she was acting director of the Division of Cardiac Surgery. The year the school admitted the first class, she was cited

in a publication called “American Men of Science.” There were many more visionaries who came in those early years: Robert Burr Livingston, MD, the first professor and chair of the Department of Neurosciences, is credited with building the first computerized map of the human brain. John S. O’Brien, MD, second chairman of the same department, discovered the genetic cause of Tay-Sachs disease and developed the first tests for the disorder. Daniel Steinberg, MD, PhD, founding head of the Division of Metabolic Diseases, was one of the first to determine that high cholesterol is a major contributing factor in the development of atherosclerosis and coronary heart disease. Elizabeth Barrett-Connor, MD, founded the Rancho Bernardo Heart and Chronic Disease Study in 1972, a landmark project that tracked thousands of participants over more than 40 years.

MORE THAN MEMORIZATION

From the beginning, Stokes and his fellow founders believed the basic science part of the medical school curriculum needn’t to be taught in isolation—they thought it should be taught by other campus departments, such as Biology (now the Division of Biological Sciences). David Bonner, PhD, founding chair of the Department of Biology, once said, “There is no such thing as basic versus applied science; there is only good or bad science.” That philosophy led to what’s known as the “Bonner Plan.” Eventually, UC San Diego medical students would take graduatelevel classes in biochemistry, physiology and pharmacology alongside graduate students devoted to those fields. Second-year medical students took their anatomy and pathology courses with clinical faculty, but could continue working in labs and taking electives in general campus graduate departments. While the Bonner Plan set the stage for an unparalleled intermingling of basic sciences in a medical school, Clifford Grobstein, PhD, the school’s dean when the first class entered in 1968, continued that tradition. Grobstein was a cellular physiologist and it was unusual at that time to have a medical school dean who was not a physician. But it was consistent with the concept of a strong basic science foundation. “We’ve always tried to do things a bit differently,” said John West, MD, PhD, DSc, a pioneer in physiology who has been at the


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School of Medicine almost since the first day — and who still teaches today. “From day one, medical school students are taught by clinical scientists and working researchers. There’s a deep, long-standing, inextricable connection here between the science and the art of medicine. The curriculum has always been about making it real—and about making really good doctors and scientists.” That’s exactly what attracted endocrinologist Gordon Gill, MD, who joined the faculty in July 1969 and is now Emeritus Professor of Medicine at UC San Diego School of Medicine. He was scheduled to become chief resident at Yale University, but a research discovery that changed the direction of his mentor’s lab changed his mind, and the course of his career. “I was very excited about continuing my

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own research, which is why I came to UC San Diego,” Gill said. “I had never been to San Diego before, but I knew I wanted to be my own scientist. It’s hard to describe the thrill of original research discoveries. They are all-consuming. It doesn’t matter if it’s a big discovery or the most important. It’s new and original and if it’s yours, you can’t wait to find answers. In the early years, we worked in an era of great technological advances in biology and cellular sciences — and we took advantage of them. The secret to success in biomedical sciences at UC San Diego has been that entrepreneurial spirit.”

INTERTWINING RESEARCH AND PATIENT CARE

But Stokes, Grobstein and the other founding faculty didn’t stop at research. “One of the problems in American medical education at the time was that medical schools were divided into two years in a classroom, two years in in the clinics,” Braunwald said. “These two had little to do with each other, and yet they are intellectually intertwined. We saw that as an opportunity for making a change.” So the founding faculty integrated both worlds. They introduced students to patients the first week they arrived. And they expected every student to conduct a research project suitable for publication before graduation. When Gill first arrived on the La Jolla campus, there weren’t any buildings. He rented lab space at the nearly Salk Institute to do his research, and did his clinical work down at the newly acquired County Hospital in Hillcrest, now the UC San Diego

CAPTIONS 1. UC San Diego School of Medicine’s first class graduated in 1972. Credit: Health Sciences Communications. Public Relations Materials, Special Collections & Archives, UC San Diego 2. UC San Diego School of Medicine opened in La Jolla in 1968, on land that previously belonged to Camp Matthews, a U.S. Marine Corps rifle range that closed operations in 1964. Aerial view of construction on the new medical school, 1969. Credit: Health Sciences Communications. Public Relations Materials, Special Collections & Archives, UC San Diego 3. Medical students at the UC San Diego Medical Center in Hillcrest, 1980. Credit: Health Sciences Communications. Public Relations Materials, Special Collections & Archives, UC San Diego SAN DIEGO PHYSICIAN.ORG

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CAPTIONS 4.Medical students learn through hands-on experiences in small group in the Simulation Center at UC San Diego School of Medicine. Credit: UC San Diego 5. In the Center for the Future of Surgery at UC San Diego School of Medicine, medical students learn diagnostic skills from high-tech, interactive manikins that mimic disease symptoms. Photo 2017. Credit: Kyle Dykes/UC San Diego Health 6. A graduate student processes samples before sequencing a person’s gut microbiome—revealing the identities of the unique collection of microbes living there. Researchers are just beginning to understand the farreaching effects that a person’s microbiome has on his or her health and UC San Diego School of Medicine is a global leader in this relatively young field. Photo 2016. Credit: Erik Jepsen/UC San Diego Publications

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Medical Center. “We stood the curriculum on its head — we intermingled clinical and science work like nobody else was doing at the time,” Braunwald said. “UC San Diego was a model for what everyone else is doing now.” If standardized exams are a measure of success, the Bonner Plan and the vision of the founding faculty worked: The school’s second class of 48 students ranked No. 1 in the U.S. on the 1971 board exams. That reputation for excellent performance on board exams is part of what drew Charles Nager, MD, class of ’82, to UC San Diego School of Medicine. “I have great memories of going to medical school at UC San Diego,” said Nager,

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who is now chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at UC San Diego Health. “I had truly awesome faculty in my lectures who had a contagious energy. It was invigorating. I was also very close with my classmates. We spent a lot of time together in and out of the classroom.”

TURNING MEDICAL EDUCATION IN ITS HEAD — AGAIN

But the world has grown a lot since then, and the thought of a “career in medicine” has evolved over the decades to mean something much more elaborate to recent UC San Diego medical students. They are trained clinicians, of course, but also stewards of society’s resources: medical economists, efficiency experts, disparity reductionists, big data gurus, and CEOs. “They will enter a world as complex as the diseases they treat,” said David Brenner, MD, current vice chancellor of health sciences and dean of the School of Medicine. Like those before them, Brenner and colleagues are pushing UC San Diego’s medical education to constantly evolve as they prepare students for the ever-changing pressures and opportunities of modern medicine. In 2010, Brenner, Maria Savoia, MD, dean for medical education, and Jess Mandel, MD, associate dean of undergraduate medical education, overhauled the curriculum again, launching what’s known as the Integrated Scientific Curriculum. This move cut the number of lecture hours in half, freeing up the afternoons for students to pursue individual academic


and clinical interests. What’s more, the old pillars of medical school classes — Pathology, Anatomy, Histology and Pharmacology — are no longer standalone courses. Instead, they are woven into new courses organized by organ system. This “tapestry” approach gives students a solid grounding in science as a foundation for clinical practice, and in the important role of genetics and molecular biology in the delivery of highly personalized care. The Integrated Scientific Curriculum also emphasizes problem solving and teambased learning. According to Savoia, who first came to UC San Diego School of Medicine as an intern in 1976, medicine is now a “team sport,” where physicians, nurses, pharmacists, social workers, physical therapists, and others work together to give patients the best possible care. Medical education needs to reflect that, she said. “The days of the ‘solitary genius’ are over,” Mandel agrees. “Students can’t just study subject matter in classrooms and carrels, take a test, and learn how to be a physician. They need to talk as much about what they don’t know as what they do know, ask questions and work with their peers to solve problems. That’s what leads to lifelong learning, and that’s what drives medicine forward.” Though he values his own years in medical school, Nager believes the UC San Di-

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ego School of Medicine experience is even better now. “They have much more clinical exposure than we did,” he said. “There is more of an emphasis on growing the clinical side to meet the needs of outpatient growth in the community.” At the same time, that personal touch and sense of togetherness that attracted Nager and many others haven’t changed. Under the Integrated Scientific Curriculum, incoming classes are divided into six “communities” of students who remain together for their entire academic career. Each community has its own faculty mentor and includes members from each year’s class, giving newcomers built-in mentors and colleagues who can provide support

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guidance as they face the challenges of medical school. “In my mind, the integrated curriculum built a clinical-centered scaffolding that has helped me think and problem-solve like the best diagnosticians, while never failing to emphasize the importance of patient-centered care,” said Darrell Tran, MD, class of 2015, who now serves as chief resident in the Department of Anesthesiology at UC San Diego Health. “I feel especially fortunate to have been an early part of the inspiring changes in our medical school’s curriculum.”

LOOKING AHEAD

While the art and science of medicine have evolved since 1968, the School of Medicine’s goal is constant: Create physicians who are as compassionate as they are brilliant. “We take a lot of things for granted,” Savoia said. “Our collaborative and innovative spirit have become so commonplace that it’s just a part of the landscape. Sometimes you don’t even realize how special the things we do are until you’re out in the world at other places and hear about how a school or researcher is ‘innovating’ by doing something we’ve already been doing without even thinking about it. We just do it. And we have been doing it since the beginning.” Heather Buschman, PhD, is a UC San Diego School of Medicine alumnus and science writer covering biomedical research for UC San Diego Health’s newsletters, magazines and N Equals One podcast. Follow on Twitter at @UCSDMedSchool. SAN DIEGO PHYSICIAN.ORG

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UC SAN DIEGO SCHOOL OF MEDICINE

BY THE NUMBERS

2

seven grad degree programs

professional schools

1,547 FACULTY

2,821

1.9

students, postdocs, residents and fellows

2017 acceptance rate, as a percentage

THIRTEEN Number of SOM deans (1968–2018)

TENTH IN NIH FUNDING FY17

1968

Current median incoming undergraduate grade point average (out of 4.0)

Year of first entering class

3.82

502 Total current student

73

enrollment

659 Faculty research

funding awards, fiscal year 2017, in millions of dollars

MD/PhD students

2

Artists in residence

35 944 Residents and fellows

Current median MCAT score (out of 45)

YEAR FIRST DEGREES WERE CONFERRED

1972

Number of residency and fellowship programs

78

one

National ranking of inaugural class’s score on National Board of Medical Examiners Step 1 exam (1971)

five

NUMBER OF STUDENTRUN FREE CLINIC LOCATIONS

Sources: UC San Diego, U.S. News & World Report, National Institutes of Health, StartClass

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Number of SOM departments

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12 Major Clinical and Research Advances Made at UC San Diego School of Medicine

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Personalized cancer care at Moores Cancer Center, where patients can have their unique tumor genetics reviewed by the Molecular Tumor Board, a multidisciplinary group of physicians and scientists who discuss the best treatment options for each patient, which may include a therapy being studied in one of the 300 clinical trials available on site. UC San Diego researchers were among first to make the connection between inflammation and cancer, and their smoking cessation findings led to changes in public policies regarding tobacco advertising. Cancer therapies and diagnostics based on UC San Diego research include Elmiron (bladder pain), Erbitux (brain tumors), Procysbi (cystinosis), and Lymphoseek (cancer imaging).

Produced the first clear and direct evidence that autism begins during pregnancy, showing that specific genetic dysfunction resulted in disrupted development of prenatal brain tissues (2014).

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Developed pulmonary thromboendarterectomy or PTE, a lifesaving surgical procedure to remove chronic blood clots from major blood vessels in the lung in a condition called chronic thromboembolic pulmonary hypertension (1969).

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Initiated the first human stem cell clinical trials (2014) to test their safety and efficacy in treating three different conditions: spinal cord injury, type 1 diabetes, and leukemia.

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Improved the diagnosis and treatment of Alzheimer’s disease with the creation of the pioneering Shiley-Marcos Alzheimer’s Disease Research Center in 1984, in collaboration with the National Institute on Aging, and the Alzheimer’s Disease Cooperative Study in 1991; the development of volumetric MRIs, coupled with machine learning, to detect patterns of neurodegeneration that distinguish AD from normal aging; the first-in-nation experimental gene therapy surgery to treat Alzheimer’s disease in a 60-year-old woman (2004); the first stem cell-derived, in vitro cellular model of the disease (2012).

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Felipe Medeiros and colleagues at Shiley Eye Institute develop first validated risk calculator to predict glaucoma.

Created a suite of colorful fluorescent probes based on jellyfish bioluminescence that allow researchers to visually track the inner workings of living cells during normal development and disease, and may soon illuminate tumors and nerves in real time during surgery. Earned Roger Tsien the 2008 Nobel Prize in Chemistry.

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Established an international model for HIV and AIDS patient care, known as the Owen Clinic (established 1982), before the infection even had a name, and was part of the team that first demonstrated how HIV can develop resistance to therapeutic drugs (1988).

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Researchers launch the first and ongoing Diagnostic Innovations in Glaucoma Study, the largest observational cohort study of glaucoma patients in the world (1990). Thirteen years later, the groundbreaking African Descent and Glaucoma Evaluation Study begins (2003); it too is ongoing.

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Traced the likely source of Kawasaki disease, the leading cause of acquired heart disease in children, to a windborne agent arising from agricultural activity in China, possibly a yeast (2014).

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Established the region’s first Level I Trauma Center (1976), one of few in the country with a dedicated entrance and staff separate from the emergency department and used as a model for trauma centers around the world, including at the 2014 soccer World Cup and 2016 Olympics in Brazil. UC San Diego Health helped establish the collaborative San Diego Trauma System (1984), which includes six hospitals in the county.

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Determined the role of cholesterol in heart disease after conducting a large, randomized, double-blind study (1984) that was the first to show a statistically significant decrease in heart disease as a result of lowering cholesterol levels through drug therapy, forever changing how physicians treat the condition. SAN DIEGO PHYSICIAN.ORG

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Dr. Robert E. Hertzka Teaches Students About Health Policy and Politics in Medicine BY SCOTT LAFEE

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s the HIV/AIDS crisis emerged and expanded in the 1980s, Robert E. Hertzka watched, appalled. The public health threat was obvious and alarming, but so too was the resulting public discourse, and the declarations and actions of politicians and policy makers who seemed woefully uninformed by modern medical science and practice. As a physician, Hertzka knew better, but he didn’t know what to do. Hertzka had graduated from UC San Diego School of Medicine in 1982, followed by a residency and two years on faculty at UC San Francisco. In 1987, he returned to San Diego to begin a private practice in anesthesiology. He was well-educated and well-trained, but flummoxed by the broad health policy debate. “It was the one thing I didn’t learn anything about in medical school,” he says. So in the summer of 1988, he walked into the office of his former mentor Eric Wahrenbrock, a professor of anesthesiology and associate dean for curriculum and student affairs at UC San Diego School of Medicine, and pitched an idea: “You should have a class on what’s happening in health policy so that students know what’s going on out there.” Wahrenbrock agreed whole-heartedly, then asked Hertzka to launch the class in six weeks. Wahrenbrock would take care of the academic particulars. “He basically bypassed the process. There was no process. I just typed up a syllabus and began.” Thirty years later, Hertzka, who served as president of the San Diego County Medical Society in 1999 and the Califor-

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nia Medical Association in 2004, and who maintains an active practice as an obstetric anesthesiologist, is still teaching his class on health policy and politics in medicine at UC San Diego. It’s among the medical school’s most popular electives — and yet surprisingly novel. “I don’t know of anything similar elsewhere. Other schools don’t do this,” Hertzka says. “From the beginning, students have understood what I’m trying to do. Coming in, most have no experience in the subject. They’ve never met an elected official; never engaged. But they get into it. They meet legislators, learn an enormous amount about healthcare policy and why it’s not as easy to fix as they might think. They come out different people, with a body of knowledge that helps them filter information at a much higher level and share those insights with others.” Several times each year, Hertzka leads field trips with students to Sacramento, where they meet elected officials and staff. In the summers, up to 11 students have served as legislative interns, offering their medicine-focused perspectives (and cheap labor) in exchange for an opportunity to see how policy and laws are made and work. These efforts have been enthusiastically supported by both SDCMS and CMA. And sometimes, students have helped change those policies and laws. On a May night in 2015, a wrong-way drunk driver collided with a car carrying five UC San Diego School of Medicine students. Two students — Elizabeth Cornwell, 23, and Anne Li Baldock, 24 — were killed; the other three students severely injured. The tragedy ripped through campus and

ultimately spawned an effort by Hertzka and students to change the law, requiring that bartenders, among other things, receive mandatory training on how to recognize when customers are too intoxicated to drive. Their bill — AB1221, sponsored by Assemblywoman Lorena Gonzalez Fletcher — became state law in 2017. “AB 1221 would never have been more than ambitious idea without Dr. Hertzka,” says Nicole Herrick, a fourth-year medical student who originated the idea with fellow student Dan Spinosa. “Dan and I went to Dr. Hertzka knowing we had to do something to make our community safer, but were unsure where to begin. Many others would have told us it was a crazy idea and there was no way that two first-year medical students could accomplish any meaningful change. [But] Dr. Hertzka supported us through the entire process, while also allowing us the autonomy to learn that we had the ability and knowledge to draft and pass meaningful legislation.” Cecilia Bonaduce Leggett is a thirdyear medical student at UC San Diego, and among Hertzka’s latest generation of medical activists. She’s interned in Sacramento. Last year she organized a town hall for medical students with Congressman Scott Peters to discuss healthcare policy. She likes to talk about the future of medicine having a say in the future of medicine. “Dr. Hertzka’s classes changed my thinking about what it means to be a physician,” says Bonaduce Leggett. “He teaches us that caring for patients can, and should, extend beyond the exam room. Part of being a compassionate and competent physician is being informed about how our field operates and how patient care is impacted by factors outside of our clinics. His classes, along with the ample support from SDCMS and the CMA, provide us with the tools and knowledge we need to change those factors through advocacy.” Hertzka would be the first to agree. “The experiences these students have in my classes won’t make them better diagnosticians, but I believe they will be better leaders and advocates, not just for themselves or their profession, but for their patients too,” he says. Scott LaFee is a former science journalist and director of media relations for UC San Diego Health.


Medical Students Take an Active Role in San Diego County Medical Society B Y C E C I L I A B O NA D U C E L E G G E T T

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was first introduced to the San Diego County Medical Society (SDCMS) and the role it plays in the San Diego medical community when I signed up for the Introduction to Healthcare Policy class taught by Dr. Bob Hertzka at UC San Diego School of Medicine. During the first few weeks of the course we were introduced to Paul Hegyi, the CEO of SDCMS, who came to our class to teach us about business and finances in medicine. He also accompanies the course’s annual trip to Sacramento to help prepare medical students to lobby their representatives. Dr. Hertzka’s class includes a trip to Sacramento, where the medical students meet with state assembly members and state senators and advocate for policies that we believe will positively impact healthcare in

California. The medical students are supported not only by the School of Medicine, but also by SDCMS. Another example of SDCMS going above and beyond to engage with medical students occurred during my first year of medical school when a couple of my classmates voiced interest in creating a Business in Medicine course. Paul Hegyi was once again there to support the medical students and not only helped us design the curriculum, but also served as one of the continuity lecturers for the course. It was through these experiences that I realized what an important role a county medical society can play in supporting medical schools and medical education. SDCMS also provides opportunities for medical students to get involved with organized medicine at the county level. For example, I am a member of the Communication Committee that puts together SDCMS’s monthly magazines; one of my medical student colleagues is on the Board of Directors as the student representative, and all of the medical students are informed of

opportunities to attend SDCMS events as volunteers so that we have the opportunity to meet local physicians. Being involved with organized medicine helps me stay up to date on policy initiatives that are in the works in Sacramento that will impact not only the way I will practice medicine but also the way my patients will get access to care and healthcare services. Organized medicine isn’t only about policy and advocacy though, it is also about community engagement. SDCMS engages the San Diego medical community by connecting physicians and future physicians who can work together toward shared goals for the future of healthcare in San Diego County. Ms. Leggett is a third-year medical student at UC San Diego School of Medicine. She was born and raised in Los Angeles, attended UC Berkeley and served in Teach For America, teaching seventh-grade science in Washington, DC, before enrolling in medical school.

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CLASSIFIEDS PRACTICE ANNOUNCEMENTS Email Your Practice Announcement Ads to Communications@SDCMS.org NEW CONCIERGE CLINIC IN LA JOLLAKAIZEN BRAIN CENTER: NEW Concierge Clinic in La Jolla - Kaizen Brain Center. With a team of experts, we offer an integrated multidisciplinary approach. We specialize in TBI/Concussion and Cognitive/Memory Disorders. We offer comprehensive exams, transcranial magnetic stimulation treatments, neuronpsychological testing, neurologic PT, medical nutrition consultations, and cognitive rehab therapy. Please call us at 866-2772659 or visit www.kaizenbraincenter.com. CLINICAL TRIAL VOLUNTEERS NEEDED WE ARE LOOKING FOR VOLUNTEERS TO PARTICIPATE IN CLINICAL TRIALS: Currently enrolling volunteers who suffer from rheumatoid arthritis, lupus, psoriasis, and psoriatic arthritis. Qualified volunteers may receive: no-cost investigational study medication, no-cost study-relatedtcare from a study doctor. There is compensation available for time and travel. All study-related care will be at no cost, and volunteers can continue seeing their primary care doctor during the study. Health insurance and doctor referrals are not required to participate. Please email Joy at joy@rheumSD.com for more information. [607] PHYSICIAN POSITIONS AVAILABLE PHYSICIAN POSITION AVAILABLE: We are looking for a passionate physician who believes in putting their patients first and values the patient-physician relationship to help engage them in their health risks, goals, objectives and work collaboratively with the patient to engage them in maintaining or improving their health Position Details: Work Schedule: Monday - Friday 9:00am5:00pm (Flexible), Strong Support Staff, Electronic Health Records, 1 Year Salary Guarantee Benefits: Free Medical/Dental/ Vision, CME Stipend, Malpractice Insurance, Disability, Annual Leave. Requirements: MD with Directly Related Experience in Family Medicine, DEA Certificate, Eligible to Work in the United States, CA Medical Licensure, Exceptional Communication and Interpersonal Skills (POSTED 3/28/2018) Contact: Careview Medical Group, Inc, 292 Euclid Ave, Suite 210 619-262-7523 press#1 PHYSICIAN POSITION AVAILABLE: San Diego area; Out-patient only, Primary Care position; No calls; No hospital and no weekends; Email: sandiegoprimarycare@ yahoo.com (Posted 3/28/2018) PHYSICIAN POSITIONS AVAILABLE: A fulltime position is immediately available for a Primary Care/Long Term Care physician at the Veterans Home of California - Chula Vista. Employment is through the State of California within the California Department of Veterans Affairs (Calvet). Training in primary

care (Internal Medicine or Family Practice) is required and additional experience and/ or training in Long Term Care Medicine or Geriatric Medicine is preferable. Salary range is $17,113.00-$19,969.00/month. Benefits package includes, but is not limited to, vacation, CME, medical, dental, vision and pension. For more information or to apply please use the following URL at http://bit. ly/2BPKDFK (Posted 2/21/2018) MEDICAL CONSULTANT: The County of San Diego, Health and Human Services Agency’s Behavioral Health Division is looking for Board Certified Family Practice or Internal Medicine physicians to provide care for residents at Edgemoor Distinct Part Skilled Nursing Facility (DP/SNF), an award winning, 192-bed rehabilitation and care facility located in the San Diego suburb of Santee. The individual chosen for this vacancy will provide medical care for a younger Medi-Cal population, most of which have brain injuries and significant disabilities, as well as complex physical, social and psychological problems. Visit our website: www.sdcounty.ca.gov/hr for more information on how to apply. FAMILY PRACTICE MD / DO needed for urgent care and family practice office in Carlsbad. Flexible afternoon, evening and weekend shifts available for family practice physician. Exceptional office staff and flexible scheduling options at this busy, wellestablished private practice. Please fax or email CV to (760) 603-7719 or gcwakeman@ sbcglobal.net. PER DIEM PHYSICIAN NEEDED: The County of San Diego Health and Human Services Agency is seeking a physician to work with California Children’s Services (CCS). Applicants (MD or DO) must hold a current California medical license. Board certification in Pediatrics, Child Neurology, Orthopedic Surgery, Physical Medicine and Rehabilitation, Family Medicine or Preventive Medicine is desired, but not required. Applicants must have previous experience in providing medical care for children with disabilities and willing to work a minimum 60 hours per month. If interested, please e-mail your CV to Dr. Marie Green, CCS Medical Director, at Marie.Green@ sdcounty.ca.gov or call (619) 528-4010. FAMILY PRACTICE OR INTERNAL MEDICINE: Spanish-speaking family medicine or internal medicine physician (Board Certified) for Borrero Medical Group located in South San Diego next to Chula Vista. The practice is growing and needs to hire a new physician. Borrero Medical Group is a well-established practice, 22 years in the community, exceptional office staff. Every member of our team plays an important role in improving the health of our patients. We offer an excellent comprehensive benefits package that includes Malpractice Coverage, Health Insurance, Competitive & Attractive Salaries, and Bonus. If interested, please submit inquiry and CV to rosa10borrero@att.net

PART TIME PHYSICIAN: Progressive Medical Specialists is an outpatient medication assisted treatment program located in San Diego, CA. We are currently in need of a parttime Physician to work 1 - 3 days per week. The Program Physician is responsible for providing the day-to-day medical care and treatment for all program patients. The Program Physician performs all duties in compliance with the California Code of Regulations for Narcotic Treatment Programs. Training is provided. Please send your CV to tboylan@pms911.com or call 619-286-4600. 12/5 OB/GYN POSITION AVAILABLE: A MultiSpecialty Group is seeking a full-time OB/GYN must be BC/BE to join a busy OB/GYN and Uro-gynecology practice, group of a physician and a nurse practitioner. Located in Southern California 1 ½ hours East of San Diego and Palm Springs; We offer a Competitive compensation, full benefits and opportunity for partnership. If interested, please e-mail CV to ekmoukarzel@aol.com or fax to : 760-3526221. Visit our website: www.feminacareourogyn.com for additional information on our practice. 11/30 INTERNAL MEDICINE POSITION AVAILABLE: Unique opportunity to practice outpatient internal medicine in beautiful North San Diego County. Practice is part of a well-established internal medicine group with a long history of outstanding care in the community, seeking physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, small group environment, autonomy and very high quality patient care are among the many benefits of this opportunity. Office is located near San Diego coastal communities, 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 619248-2324. 11/2 PRACTICE FOR SALE Email Your Practice for Sale Ads to Communications@SDCMS.org FOR SALE. BUSY FAMILY PRACTICE POTENTIAL URGENT CARE: Established family practice for 27 years located in Chula Vista near H Street at 805 in upscale mall setting. Ideal location with free and easily accessible parking. Spacious 2600 ft. office space with CLIA Certified Lab and X-ray. Practice accepts and experienced in billing: Medicare; Tricare, Immigration Exams, DOT Certification; Workers Comp. Contact: S.J.Anderson (858)736-5818 or Email: marva. winchi.garcia@gmail.com 11/3 PRACTICES WANTED PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call 858-257-7050

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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OFFICE SPACE / REAL ESTATE AVAILABLE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals. Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

SCRIPPS ENCINITAS CAMPUS OFFICE 320 SANTA FE DRIVE, SUITE LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Website: www. eisenhauerobgyn.com. Looking for compatible practice types. (Posted 4/4/2018) MEDICAL OR DENTAL BUSINESS SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located in the center of Hillcrest/ Bankers Hill. Just renovated! The second story of this beautiful two story building is available for lease. A private gated entrance leads to a 1,139 square foot upstairs with 4 to 5 consultation rooms, waiting room with adjoining private deck and full bathroom. Additional security gate and mailbox. Separate address. Wood floors, refinished windows, natural light, quiet street, walkable to restaurants. On-site parking with up to 8 parking spaces available! Asking: $3,000/ month. Terms are negotiable. This will rent fast so hurry! Please contact: hillcrestofficerental@ gmail.com 858.775.5075 OFFICE SPACE FOR RENT: La Jolla — lease — medical or dental related practice or business in a small boutique office space located in the center of beautiful La Jolla, CA. Perfect opportunity for psychiatrist, psychologist, counselor, dentist, physician, surgeon, any dental or medical related occupation welcome. Located in medical dental building. Come join these great practices. 612 sq. feet, classy second floor suite with elevator. Perfect for entrepreneur. Partially equipped for dental practice, surgical practice. Terrific opportunity. $4.90 per sq/ft per month triple net lease contact Kevin Gott : dynamold@aol. com (Posted 3/22/18) OFFICE SPACE/REAL ESTATE AVAILABLE: Furnished office space with licensed surgical center available for full or part time rent. Location 8705 Complex Drive in Kearny Mesa. Call 858-715-1822. (Posted 2/27/2018) SHARED OFFICE SPACE: Very attractive 4 exam room, medical office in Bankers Hill

near Balboa Park. Available 5 days per week. Reasonable rates. Call Claudia at 619-501-4758. (Posted 2/21/2018) SOUTH BAY OFFICE SPACE AVAILABLE: Monthly sublease, 3 exam rooms, medical office, 5 days per week. Reasonable rates. Directly across from Scripps Mercy Hospital, Chula Vista. If interested, please call, 619-4222000. (Posted 2/21/2018) OFFICE SPACE AVAILABLE: Rent by the hour, day, week, month. Reasonable rates. Free parking. Quiet office building. Free Wi-Fi. Perfect for Consultants, Therapists, CPA’s/Bookkeepers, Web Designers, Real Estate, Insurance, Meetings, Etc. Located in central east county. Referral Potential. Please call Marlene at: 619401-1430 or e-mail: saben615@sbcglobal.net (Posted date 2/21/2018) MEDICAL OFFICE IN SOUTH BAY AVAILABLE TO SUBLEASE: Located next to Paradise Valley Hospital, this large, recently renovated office consists of 6 exam rooms and 1 procedure room. The office is currently utilized by Orthopedic Surgeons and a Cardiologist, but can accommodate any practice. Facility provides easy access the PVH Operating Room, Physical Therapist, Imaging Center, Laboratory, and Wound Care Center and has easy freeway access. Opportunity for Orthopedic ER Call at Paradise Valley Hospital and patient referrals. For more information, please contact Jeff Craven: jeff@sdmiortho.com or 858-245-9109 (Posted 2/21/2018) SHARED OFFICE SPACE AVAILABLE: Office space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046 (POSTED 2/14/2018) OFFICE SPACE AVAILABLE –LA JOLLA UTC AREA: Looking for like-minded professionals interested in a small furnished office space a couple of days a week/part-time basis. Modern design. For details and pricing, Contact Newshaw at 866-277-3659 and visit our website www.kaizenbraincenter.com for information about our practice. MEDICAL OFFICE SPACE, SUBLEASE HM POOLE BUILDING SCRIPPS LA JOLLA CAMPUS: Very attractive, comfortable suite with two offices, two exam rooms and two person receptionist area, and beautiful waiting room. Excellent location on the campus of Scripps Memorial Hospital La Jolla. Large windows with open, peaceful garden views, available for full time rental with the option to rent time at the adjacent surgical suite. Rent also includes small kitchenette with sink, electricity, and janitorial service. Call- 858-344-7342 OFFICE SPACE/ REAL ESTATE AVAILABLE IN SOUTH BAY: Available for monthly sublease, 3 exam room, medical office, 5 days per week. Reasonable rates. Directly across from Scripps Mercy Hospital, Chula Vista. If interested, please call 619-422-2000. NONPHYSICIAN POSITIONS AVAILABLE MA OR LVN POSITION AVAILABLE: This patient centered medical practice requires a skilled and professional individual with

exceptional empathy, integrity, maturity and passion for patient care. You must have 5+ years of experience in the field as either an MA or LVN and be comfortable with front and back office work, be able to perform blood draws and injections, understand how to verify insurance, obtain prior authorizations, collect copays and balances. You are driven, diligent, organized, efficient, a clear communicator, honest and constantly wanting to improve. Please submit a detailed resume and 3 references from your last three positions to 92024medical@gmail.com. PART TIME PHYSICIAN ASSISTANT: Looking for a part time Physician Assistant for a rheumatology office in Escondido. 20-30 hrs a week. Spanish desired. To start as soon as possible. Please send resume and references to info@rheumSD.com. 12/5 MEDICAL ASSISTANT IN BUSY RHEUMATOLOGY OFFICE. FULL TIME. Wonderful opportunity for learning and growth. We are looking for someone who is organized, capable of multi tasking, takes instruction well, and has a positive helpful attitude. Tasks include, but are not limited to: Front desk - answering phones, make calls to patients, collect fees, set appointments and filing. Back office: Rooming patients and taking vitals, helping with therapy, keeping things organized and running smoothly, and cleanup. Spanish desired. Salary is based on experience. Please email info@rheumSD. com 11/30 SEEKING A DYNAMIC BUSINESS OFFICE MANAGER for a busy medical practice located on Convoy Street, close proximity to the 163/805 freeway. Responsible for the overall operations of the medical practice and reports directly to the CEO. This position ensures that the medical practice is running smoothly, effectively and efficiently rendering a high standard of quality and customer service. Accountable for operational systems, processes and policies in support of the organization’s mission. Required Education and Experience: Requires at minimum 3 years of significant work related experience in a private or group medical practice setting; supervised at least 10 F.T.E.’s and ability to collaborate with a minimum of 4 physicians in a practice setting. Preferred Education and Experience: AA or higher in Health Management or Business Administration education; Familiarity with health care laws, regulations and standards; Proficient in Excel and Word. We are offering a competitive salary, excellent benefits. Please email resume to businessofficemanager2017@gmail.com. 11/3 PRODUCTS / 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] SAN DIEGO PHYSICIAN.ORG

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POE TRY AN D M EDICIN E

How to Hold a Sword (With apologies to A Dumas and R Sabatini)

Swashbuckling and Attribution By Daniel J. Bressler, MD, FACP

Not so tight to squeeze the breath from Not so loose to fly away Athos taught the young D’Artagnan Still instructs my life today Too much worry chokes the joy out Too sloppy makes your troubles grow Too much work will snuff your flame out Too little you’ll have naught to show Perfection as a goal is tricky Know that it will never be Not too slack and not too picky Find the balance in between Adjust your grip with learned precision With feedback from your life as lived Win and loss both guide decision Allow both outcomes to be gifts When you lose control and drop it Be quick but don’t catastrophize Panic is a bane so stop it Pick up your sword, restart your life Ignore which blade is fancy steel Or whose was handed down to whom Those questions only blunt your feel Leave them in another room So welcome home to you, D’Artagnan You’ve counseled me all of these years A stalwart friend and wise companion We’re both now proudly Musketeers

I SPENT MY ELEMENTARY school years in a suburb of Los Angeles in the 1960s. Among the many neighborhood games played by the little clique of kids I grew up with was Three Musketeers, the term borrowed from Alexandre Dumas’ 1844 swashbuckling classic. I was the youngest among the boys in my neighborhood group, and as such I would play D’Artagnan, the youngest and most inexperienced of our musketeer makebelievers. Stevie, who was stout, strong, and the oldest of the group, would play Athos, the lead musketeer and D’Artagnan’s teacher. Stevie was fond of spouting a proverb given as advice to the upstart-me-D’Artagnan: Hold a sword like you hold a bird. Not too tight or you kill it, not too loose or it flies away. At age 10 these struck me as the most profound words imaginable. I carried this motto with me through my

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education, finding occasions to try to make myself look clever by quoting it in college seminars, medical school classes, or ward rounds. As a practicing primary care doctor, I have used it while counseling patients and colleagues who are wrestling with an issue involving competing goals or desires, such as work-life balance or surgical versus medical intervention. I’ve found it a vividly understandable analogy. A few months ago I began working on the poem included here and thought I’d go back to the source and look up the context in the book where wise Athos shares this insight with brash D’Artagnan. Where indeed! The quote (or a close facsimile) is not from The Three Musketeers at all but is instead from a 1952 film called Scaramouche (based on a 1921 novel by Rafael Sabatini) which has a vaguely musketeer theme. It’s uttered by

Doutreval of Dijon, the fencing teacher: Think of this. A sword is like a bird. If you clutch it too tightly, you choke it — too lightly and it flies away. And so, this favorite and useful quote has an apocryphal source! Unlike science, which relies on credible attribution (partly for its connection to providing the capacity to examine and repeat experiments), literary quips or analogies can serve as tools of instruction whether the source is Beyonce, the Dalai Lama, or the guy working out on the adjacent gym treadmill. Seen this way, inspiration is potentially everywhere. Inspiration is in the ear of the listener. In that light, I give you “How to Hold a Sword” (with apologies to A Dumas and R Sabatini along with thanks to Stevie, wherever he is).


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