February 2025

FEBRUARY 2025

Official Publication of SDCMS

How America Lost Control of the Bird Flu

SETTING THE STAGE FOR ANOTHER PANDEMIC

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FEBRUARY 2025

Contents FEBRUARY

Editor: William T–C Tseng, MD, MPH Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; William T-C Tseng, MD; Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder

VOLUME 112, NUMBER 2

OFFICERS President: Steve H. Koh, MD President–Elect: Preeti S. Mehta, MD Immediate Past President: Nicholas (dr. Nick) J. Yphantides, MD, MPH Secretary: Maria T. Carriedo-Ceniceros, MD Treasurer: Karrar H. Ali, DO, MPH GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rachel Van Hollebeke, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Dustin H. Wailes, MD La Jolla #1: Toluwalasé (Lasé) A. Ajayi, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Arlene J. Morales, MD (Board Representative to the Executive Committee) North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Latisa S. Carson, MD AT–LARGE DIRECTORS #1: Rakesh R. Patel, MD, FAAFP, MBA (Board Representative to the Executive Committee) #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Daniel D. Klaristenfeld, MD #6: Alexander K. Quick, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician: Emily A. Nagler, MD Retired Physician: Mitsuo Tomita, MD Medical Student: Kenya Ochoa CMA OFFICERS AND TRUSTEES Trustee: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM Trustee: Sergio R. Flores, MD Trustee: Timothy A. Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: William T–C Tseng, MD, MPH At–Large: Albert Ray, MD At–Large: Robert E. Hertzka, MD At–Large: Theodore M. Mazer, MD At–Large: Kyle P. Edmonds, MD At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At–Large: David E.J. Bazzo, MD, FAAFP At–Large Alternate: Sergio R. Flores, MD CMA DELEGATES District I: Steven L.W. Chen, MD, FACS, MBA District I: Vikant Gulati, MD District I: Eric L. Rafla-Yuan, MD District I: Ran Regev, MD District I: Quinn Lippmann, MD District I: Kosala Samarasinghe, MD District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH District I: Randy J. Young, MD

FEATURE

4

How America Lost Control of the Bird Flu, Setting the Stage for Another Pandemic

By Amy Maxmen

DEPARTMENTS

2

Briefly Noted: Advocacy • PHC Wildfire Relief

10

DEA Proposes a Special Registry for Telehealth Providers of Controlled Substances

By Joyce Frieden

12

Better Engaging Our Older Patients

By James Santiago Grisolia, MD

14

The Healthcare Landscape in 2025 – The Keynote Address for the Riverside County Medical Society Installation

By Toluwalasé “Lasé” A. Ajayi, MD

16

Autism Prevalence Is Climbing, but It’s Not Due to Vaccines

By Judy George

18

Angle of Repose

By Daniel J. Bressler, MD, FACP

19

What if This Isn’t True?

By Helane Fronek, MD, FACP, FASVLM, FAMWA 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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SANDIEGOPHYSICIAN.ORG

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ADVOCACY

AMA Holds State Advocacy Summit in Carlsbad CARLSBAD’S OMNI LA COSTA HOSTED the American Medical Association’s (AMA) annual State Advocacy Summit in early January, bringing together more than 300 physician leaders and medical society staff. Will Flanary, MD, better known by his social media persona Dr. Glaucomflecken, opened the program.

A survivor of two orchiectomies by 30 and cardiac arrest at 34, Flanary highlighted how he uses humor to cope with the challenges he’s faced, both as a patient and physician. He spoke about the importance of recognizing “co-survivors” such as his wife, Kristin, and the need to understand the family experience.

You can learn more about Dr. Glaucomflecken and link to his often hilarious social media from his website glaucomflecken.com.

San Diego’s newest State Senator, Akilah Weber Pierson, MD, participated in a panel of state legislators who discussed the challenges of legislating in these complicated times, the importance of relationship building between constituents and policymakers, and how physicians and medical societies can most effectively advocate to them on our priority issues. Dr. Weber highlighted how critically important it is to have physicians serve in legislative office so their expertise can be brought to bear when considering complicated

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FEBRUARY 2025

healthcare issues, and the need for physicians to support their colleagues when running for office. If you’re interested in running for office, consider attending AMA’s campaign school, which you find more about at ampaconline. org under “Political Education”. You can also contact the California Medical Association’s political advocacy team at cmadocs.org/calpac.

SDCMS Past-President and Secretary of AMA’s Board of Trustees Toluwalasé Ajayi, MD, introduced a panel of staff from three state attorney general offices on “Strategies to Protect Access to Reproductive Health Care Services.” The panel included Erica Connolly, JD, deputy attorney general of California. They highlighted the important ways they support physicians and other healthcare professionals with guidance on challenging legal issues, programs that link physicians with legal support, and collaborations with healthcare professionals. You can find the Reproductive Health Legal Assistance Project at ACOG.org and the Reproductive Health Law Hub at americanhealthlaw.org.

In what was probably the most maddening of topics, a panel addressed “Reforming Payer Practices to Improve Access to Care,” including Ron Howrigon, a self-proclaimed reformed healthcare executive who now works with

providers dealing with payers. Panelists explored systemic barriers to care that patients and physicians are facing and discussed how to build on the growing awareness and momentum with constructive advocacy to enact change. You can directly engage in CMA’s efforts to stop healthcare delays at cmadocs. org/priorauth.

Past CMA President and Chair-elect of AMA’s Board of Trustees, David Aizuss, MD, moderated a presentation on private equity (PE) and the corporatization of healthcare. As physicians express concerns about how they might retain clinical autonomy and provide high-quality patient care within a PE arrangement, medical associations and physician advocates are left asking what can be done. The presentation included policy solutions that can help address the corporatization of medicine at the state level.

Dr. Ajayi was joined at the summit by SDCMS members Steven Chen, MD, a member of AMA’s Council on Medical Service, Al Ray, MD, and Karl Steinberg, MD. We’re all really appreciative of the AMA umbrella that came with the meeting materials. The next State Advocacy Summit will be held in Los Angeles in January 2026 and return to Carlsbad in January 2027.

SUPPORT PHC

Disaster Relief THE ACTIVE WILDFIRES IN SOUTHERN CALIFORNIA HAVE destroyed thousands of homes, structures, and medical practices, and displaced thousands of residents and your physician colleagues.

In response, the California Medical Association (CMA) and Physicians for a Healthy California (PHC) have launched a donation page to support impacted physicians and their practices.

Donations to the Disaster Relief Fund will be used to reestablish the delivery of medical care to areas of California affected by disasters by providing physicians who are victims of disasters with financial assistance to help restore their medical practices. Please visit https://phcdocs.org/relief to make a tax-deductible donation.

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INFECTIOUS DISEASES

How America Lost Control of the Bird Flu, Setting the Stage for Another Pandemic

By Amy Maxmen

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FEBRUARY 2025

KEITH POULSEN’S JAW DROPPED when farmers showed him images on their cellphones at the World Dairy Expo in Wisconsin in October. A livestock veterinarian at the University of Wisconsin, Poulsen had seen sick cows before, with their noses dripping and udders slack.

But the scale of the farmers’ efforts to treat the sick cows stunned him. They showed videos of systems they built to hydrate hundreds of cattle at once. In 14-hour shifts, dairy workers pumped gallons of electrolyte-rich fluids into ailing cows through metal tubes inserted into the esophagus.

“It was like watching a field hospital on an active battlefront treating hundreds of wounded soldiers,” he said.

Nearly a year into the first outbreak of the bird flu among cattle, the virus

“

Over the past 30 years, half of around 900 people diagnosed with bird flu around the world have died.

Even if the case fatality rate is much lower for this strain of the bird flu, COVID showed how devastating a 1% death rate can be when a virus spreads easily.”

shows no sign of slowing. The U.S. government failed to eliminate the virus on dairy farms when it was confined to a handful of states, by quickly identifying infected cows and taking measures to keep their infections from spreading.

Now at least 875 herds across 16 states have tested positive.

Experts say they have lost faith in the government’s ability to contain the outbreak.

“We are in a terrible situation and going into a worse situation,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “I don’t know if the bird flu will become a pandemic, but if it does, we are screwed.”

To understand how the bird flu got out of hand, KFF Health News interviewed nearly 70 government officials, farmers and farmworkers, and research-

ers with expertise in virology, pandemics, veterinary medicine, and more.

Together with emails obtained from local health departments through public records requests, this investigation revealed key problems, including deference to the farm industry, eroded public health budgets, neglect for the safety of agriculture workers, and the sluggish pace of federal interventions.

Case in point: The U.S. Department of Agriculture in December announced a federal order to test milk nationwide.

Researchers welcomed the news but said it should have happened months ago — before the virus was so entrenched.

“It’s disheartening to see so many of the same failures that emerged during the COVID-19 crisis reemerge,” said Tom Bollyky, director of the Global Health Program at the Council on Foreign Relations.

Far more bird flu damage is inevitable, but the extent of it will be left to the Trump administration and Mother Nature. Already, the USDA has funneled more than $1.7 billion into tamping down the bird flu on poultry farms since 2022, which includes reimbursing farmers who’ve had to cull their flocks, and more than $430 million into combating the bird flu on dairy farms. In coming years, the bird flu may cost billions of dollars more in expenses and losses.

Dairy industry experts say the virus kills roughly 2% to 5% of infected dairy cows and reduces a herd’s milk production by about 20%.

The runny nose of a dairy cow on a farm with a bird flu outbreak.

Worse, the outbreak poses the threat of a pandemic. More than 60 people in the U.S. have been infected, mainly by cows or poultry, but cases could skyrocket if the virus evolves to spread efficiently from person to person. And the recent news of a person critically ill in Louisiana with the bird flu shows that the virus can be dangerous.

Just a few mutations could allow the bird flu to spread between people.

Because viruses mutate within human and animal bodies, each infection is like a pull of a slot machine lever.

“Even if there’s only a 5% chance of a bird flu pandemic happening, we’re talking about a pandemic that probably looks like 2020 or worse,” said Tom Peacock, a bird flu researcher at the Pirbright Institute in the United Kingdom,

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INFECTIOUS DISEASES

A photograph of the eyes of an infected dairy worker in Texas, with ruptured blood vessels and bleeding conjunctiva.

referring to COVID. “The U.S. knows the risk but hasn’t done anything to slow this down,” he added.

Beyond the bird flu, the federal government’s handling of the outbreak reveals cracks in the U.S. health security system that would allow other risky new pathogens to take root. “This virus may not be the one that takes off,” said Maria Van Kerkhove, director of the emerging diseases group at the World Health Organization. “But this is a real fire exercise right now, and it demonstrates what needs to be improved.”

A Slow Start It may have been a grackle, a goose, or some other wild bird that infected a cow in northern Texas. Last February, the state’s dairy farmers took note when cows stopped making milk. They worked alongside veterinarians to figure out why. In less than two months, veterinary researchers identified the highly pathogenic H5N1 bird flu virus as the culprit.

Long listed among pathogens with pandemic potential, the bird flu’s unprecedented spread among cows marked a worrying shift. It had evolved to thrive in animals that are more like people biologically than birds.

After the USDA announced the dairy outbreak on March 25, control shifted from farmers, veterinarians, and local

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“

It does not look pleasant.

Apparently, the conjunctivitis that this is causing is not a mild one, but rather ruptured blood vessels and bleeding conjunctiva.”

– SEAN ROBERTS, EMERGENCY SERVICES SPECIALIST AT THE TULARE COUNTY HEALTH DEPARTMENT

officials to state and federal agencies.

Collaboration disintegrated almost immediately.

Farmers worried the government might block their milk sales or even demand sick cows be killed, as poultry are, said Kay Russo, a livestock veterinarian in Fort Collins, Colorado.

Instead, Russo and other veterinarians said, they were dismayed by inaction. The USDA didn’t respond to their urgent requests to support studies on dairy farms — and for money and confidentiality policies to protect farmers from financial loss if they agreed to test animals.

The USDA announced that it would conduct studies itself. But researchers grew anxious as weeks passed without

results. “Probably the biggest mistake from the USDA was not involving the boots-on-the-ground veterinarians,” Russo said.

Will Clement, a USDA senior adviser for communications, said in an email: “Since first learning of H5N1 in dairy cattle in late March 2024, USDA has worked swiftly and diligently to assess the prevalence of the virus in U.S. dairy herds.” The agency provided research funds to state and national animal health labs beginning in April, he added.

The USDA didn’t require lactating cows to be tested before interstate travel until April 29. By then, the outbreak had spread to eight other states.

Farmers often move cattle across great distances, for calving in one place, raising in warm, dry climates, and milking in cooler ones. Analyses of the virus’s genes implied that it spread between cows rather than repeatedly jumping from birds into herds.

Milking equipment was a likely source of infection, and there were hints of other possibilities, such as through the air as cows coughed or in droplets on objects, like work boots. But not enough data had been collected to know how exactly it was happening. Many farmers declined to test their herds, despite an announcement of funds to compensate them for lost milk production in May. “There is a fear within the dairy farmer community that if they become officially listed as an affected farm, they may lose their milk market,” said Jamie Jonker, chief science officer at the National Milk Producers Federation, an organization that represents dairy farmers. To his knowledge, he added, this hasn’t happened.

Speculation filled knowledge gaps.

Zach Riley, head of the Colorado Livestock Association, said he suspected that wild birds may be spreading the virus to herds across the country, despite scientific data suggesting otherwise.

Riley said farmers were considering whether to install “floppy inflatable men you see outside of car dealerships” to ward off the birds.

Advisories from agriculture departments to farmers were somewhat speculative, too. Officials recommended biosecurity measures such as disinfecting equipment and limiting visitors. As the virus kept spreading throughout the summer, USDA senior official Eric Deeble said at a press briefing, “The response is adequate.”

The USDA, the Centers for Disease Control and Prevention, and the Food and Drug Administration presented a united front at these briefings, calling it a “One Health” approach. In reality, agriculture agencies took the lead.

This was explicit in an email from a local health department in Colorado to the county’s commissioners. “The State is treating this primarily as an agriculture issue (rightly so) and the public health part is secondary,” wrote Jason Chessher, public health director in Weld County, Colorado. The state’s leading agriculture county, Weld’s livestock and poultry industry produces about $1.9 billion in sales each year.

Patchy Surveillance In July, the bird flu spread from dairies in Colorado to poultry farms. To contain it, two poultry operations employed about 650 temporary workers — Spanish-speaking immigrants as young as 15 — to cull flocks. Inside hot barns, they caught infected birds, gassed them with carbon dioxide, and disposed of the carcasses. Many did the hazardous job without goggles, face masks, and gloves.

By the time Colorado’s health department asked if workers felt sick, five women and four men had been infected.

They all had red, swollen eyes — conjunctivitis — and several had such symptoms as fevers, body aches, and nausea.

State health departments posted online notices offering farms protective gear, but dairy workers in several states told KFF Health News that they had none. They also hadn’t heard about the bird flu, never mind tests for it.

Studies in Colorado, Michigan, and Texas would later show that bird flu

cases had gone under the radar. In one analysis, eight dairy workers who hadn’t been tested — 7% of those studied — had antibodies against the virus, a sign that they had been infected.

Missed cases made it impossible to determine how the virus jumped into people and whether it was growing more infectious or dangerous. “I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, an executive director at the international organization the Coalition for Epidemic Preparedness Innovations, who served as assistant secretary for preparedness and response in the Obama administration.

Citing “insufficient data,” the British government raised its assessment of the risk posed by the U.S. dairy outbreak in July from three to four on a six-tier scale.

Virologists around the world said they were flabbergasted by how poorly the United States was tracking the situation. “You are surrounded by highly pathogenic viruses in the wild and in farm animals,” said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands. “If three months from now we are at the start of the pandemic, it is nobody’s surprise.”

Although the bird flu is not yet spreading swiftly between people, a shift in that direction could cause immense suffering. The CDC has repeatedly described the cases among farmworkers this year as mild — they weren’t hospitalized. But that doesn’t mean symptoms are a breeze, or that the virus can’t cause worse.

“It does not look pleasant,” wrote Sean Roberts, an emergency services specialist at the Tulare County, California, health department in an email to colleagues in May. He described photographs of an infected dairy worker in another state: “Apparently, the conjunctivitis that this is causing is not a mild one, but rather ruptured blood vessels and bleeding conjunctiva.”

Over the past 30 years, half of around

A photograph of a note found in a break room at a dairy farm saying “cows with flu in Pen 56” in Spanish.

900 people diagnosed with bird flu around the world have died. Even if the case fatality rate is much lower for this strain of the bird flu, COVID showed how devastating a 1% death rate can be when a virus spreads easily.

Like other cases around the world, the person now hospitalized with the bird flu in Louisiana appears to have gotten the virus directly from birds. After the case was announced, the CDC released a statement saying, “A sporadic case of severe H5N1 bird flu illness in a person is not unexpected.”

‘The Cows Are More Valuable Than Us’ Local health officials were trying hard to track infections, according to hundreds of emails from county health departments in five states. But their efforts were stymied. Even if farmers reported infected herds to the USDA and agriculture agencies told health departments where the infected cows were, health officials had to rely on farm owners for access.

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INFECTIOUS DISEASES

A researcher draws blood from a farmworker to analyze it for signs of a previous, undetected bird flu infection.

“The agriculture community has dictated the rules of engagement from the start,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That was a big mistake.”

Some farmers told health officials not to visit and declined to monitor their employees for signs of sickness. Sending workers to clinics for testing could leave them shorthanded when cattle needed care. “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too,” said an email from the Weld, Colorado, health department.

“We know of 386 persons exposed — but we know this is far from the

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total,” said an email from a public health specialist to officials at Tulare’s health department recounting a call with state health officials. “Employers do not want to run this through worker’s compensation. Workers are hesitant to get tested due to cost,” she wrote.

Jennifer Morse, medical director of the Mid-Michigan District Health Department, said local health officials have been hesitant to apply pressure after the backlash many faced at the peak of COVID. Describing the 19 rural counties she serves as “very minimal-government-minded,” she said, “if you try to work against them, it will not go well.”

Rural health departments are also stretched thin. Organizations that

specialize in outreach to farmworkers offered to assist health officials early in the outbreak, but months passed without contracts or funding. During the first years of COVID, lagging government funds for outreach to farmworkers and other historically marginalized groups led to a disproportionate toll of the disease among people of color.

Kevin Griffis, director of communications at the CDC, said the agency worked with the National Center for Farmworker Health throughout the summer “to reach every farmworker impacted by H5N1.” But Bethany Boggess Alcauter, the center’s director of public health programs, said it didn’t receive a CDC grant for bird flu outreach until October, to the tune of $4 million. Before then, she said, the group had very limited funds for the task. “We are certainly not reaching ‘every farmworker,’” she added.

Farmworker advocates also pressed the CDC for money to offset workers’ financial concerns about testing, including paying for medical care, sick leave, and the risk of being fired. This amounted to an offer of $75 each. “Outreach is clearly not a huge priority,” Boggess said.

“I hear over and over from workers, ‘The cows are more valuable than us.’”

The USDA has so far put more than $2.1 billion into reimbursing poultry and dairy farmers for losses due to the bird flu and other measures to control the spread on farms. Federal agencies have also put $292 million into developing and stockpiling bird flu vaccines for animals and people. In a controversial decision, the CDC has advised against offering the ones on hand to farmworkers.

“If you want to keep this from becoming a human pandemic, you focus on protecting farmworkers, since that’s the most likely way that this will enter the human population,” said Peg Seminario, an occupational health researcher in Bethesda, Maryland. “The fact that this isn’t happening drives me crazy.”

Nirav Shah, principal deputy director of the CDC, said the agency aims to keep workers safe. “Widespread awareness does take time,” he said. “And that’s the

work we’re committed to doing.”

With President Donald Trump in office, farmworkers may be even less protected. Trump’s pledge of mass deportations will have repercussions whether they happen or not, said Tania PachecoWerner, director of the Central Valley Health Policy Institute in California.

Many dairy and poultry workers are living in the U.S. without authorization or on temporary visas linked to their employers. Such precarity made people less willing to see doctors about COVID symptoms or complain about unsafe working conditions in 2020. “Mass deportation is an astronomical challenge for public health,” Pacheco-Werner said.

Not ‘Immaculate Conception’ A switch flipped in September among experts who study pandemics as national security threats. A patient in Missouri had the bird flu, and no one knew why.

“Evidence points to this being a one-off case,” Shah said at a briefing with journalists. About a month later, the agency revealed it was not.

Antibody tests found that a person who lived with the patient had been infected, too. The CDC didn’t know how the two had gotten the virus, and the possibility of human transmission couldn’t be ruled out.

Nonetheless, at an October briefing, Shah said the public risk remained low and the USDA’s Deeble said he was optimistic that the dairy outbreak could be eliminated.

Experts were perturbed by such confident statements in the face of uncertainty, especially as California’s outbreak spiked and a child was mysteriously infected by the same strain of virus found on dairy farms.

“This wasn’t just immaculate conception,” said Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “It came from somewhere and we don’t know where, but that hasn’t triggered any kind of reset in approach — just the same kind of complacency and low energy.”

Sam Scarpino, a disease surveillance specialist in the Boston area, wondered how many other mysterious infections had gone undetected. Surveillance outside of farms was even patchier than on them, and bird flu tests have been hard to get.

Although pandemic experts had identified the CDC’s singular hold on testing for new viruses as a key explanation for why America was hit so hard by COVID in 2020, the system remained the same. Bird flu tests could be run only by the CDC and public health labs until this month, even though commercial and academic diagnostic laboratories had inquired about running tests since April. The CDC and FDA should have tried to help them along months ago, said Ali Khan, a former top CDC official who now leads the University of Nebraska Medical Center College of Public Health.

As winter sets in, the bird flu becomes harder to spot because patient symptoms may be mistaken for the seasonal flu. Flu season also raises a risk that the two flu viruses could swap genes if they infect a person simultaneously.

That could form a hybrid bird flu that spreads swiftly through coughs and sneezes.

A sluggish response to emerging outbreaks may simply be a new, unfortunate norm for America, said Bollyky, at the Council on Foreign Relations. If so, the nation has gotten lucky that the bird flu still can’t spread easily between people. Controlling the virus will be much harder and costlier than it would have been when the outbreak was small.

But it’s possible.

Agriculture officials could start testing every silo of bulk milk, in every state, monthly, said Poulsen, the livestock veterinarian. “Not one and done,” he added. If they detect the virus, they’d need to determine the affected farm in time to stop sick cows from spreading infections to the rest of the herd — or at least to other farms. Cows can spread the bird flu before they’re sick, he said, so speed is crucial.

Curtailing the virus on farms is the best way to prevent human infections, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, but human surveillance must be stepped up, too. Every clinic serving communities where farmworkers live should have easy access to bird flu tests — and be encouraged to use them. Funds for farmworker outreach must be boosted.

And, she added, the CDC should change its position and offer farmworkers bird flu vaccines to protect them and ward off the chance of a hybrid bird flu that spreads quickly.

The rising number of cases not linked to farms signals a need for more testing in general. When patients are positive on a general flu test — a common diagnostic that indicates human, swine, or bird flu — clinics should probe more deeply, Nuzzo said.

The alternative is a wait-and-see approach in which the nation responds only after enormous damage to lives or businesses. This tack tends to rely on mass vaccination. But an effort analogous to Trump’s Operation Warp Speed is not assured, and neither is rollout like that for the first COVID shots, given a rise in vaccine skepticism among Republican lawmakers.

Change may instead need to start from the bottom up — on dairy farms, still the most common source of human infections, said Poulsen. He noticed a shift in attitudes among farmers at the Dairy Expo: “They’re starting to say, ‘How do I save my dairy for the next generation?’ They recognize how severe this is, and that it’s not just going away.”

Amy Maxmen is a correspondent for KFF Health News, which produced this report.

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PRACTICE MANAGEMENT

DEA Proposes a Special Registry for Telehealth Providers of Controlled Substances Agency Also Issues Final Rule for 6-month Buprenorphine Prescriptions Issued Over the Phone By Joyce Frieden PHYSICIANS WOULD HAVE TO register with the Drug Enforcement Administration (DEA) for telehealth prescribing of certain controlled substances under a proposed rule issued recently by the agency.

“DEA’s goal is to provide telehealth access for needed medications while ensuring patient safety and preventing the diversion of medications into the illicit drug market,” DEA Administrator Anne Milgram said in a press release.

“We understand the difficulties some patients have accessing medical providers in person, and we want to ease this burden while also providing safeguards to keep patients safe.”

Under the rule, providers who prescribe Schedule III–V controlled substances would need to apply for a special registration; substances in Schedule III–V include alprazolam (Xanax), ketamine, and diazepam (Valium). The special registration will also be available to Schedule II providers who are board-certified in psychiatry, hospice care, pediatrics, or long-term care; that registration would apply to medications “identified as the most addictive and prone to diversion to the illegal drug market,” according to the press release; however, Schedule II prescribers would have to be located in the same state as

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the patient. Schedule II drugs include codeine and amphetamine-dextroamphetamine (Adderall).

In addition, online platforms that allow for telehealth prescribing would have to register with the DEA for the first time. “This is critical, as DEA has found some unscrupulous medical providers on online platforms have used flexible telemedicine rules to put profit ahead of the wellbeing of patients,” the release noted.

The DEA also issued a final rule on Wednesday allowing for opioid use disorder patients to receive a six-month supply of buprenorphine through a telephone consultation with a provider; further prescriptions of buprenorphine will require an in-person visit to a medical provider, the DEA said.

Interest groups responded cautiously to the rules’ release. “While we are still digesting the DEA’s Special Registration framework ... it is clear that these updates carry significant implications for the telehealth community,” Kyle Zebley, executive director at the American Telemedicine Association’s ATA Action organization. “Early indications suggest the proposed rule includes elements that represent significant operational challenges. All stakeholders need time to carefully review this important

proposal, which appears to incorporate valuable elements and other potentially unworkable restrictions that focus on maintaining compliance with patient verification, electronic recordkeeping, and ongoing monitoring.”

As to the buprenorphine final rule, “upon initial review, we are hopeful that this will allow for the continued delivery of care for those vulnerable Americans receiving buprenorphine treatment via telehealth,” Zebley said. “Like the special registration proposed rule, more analysis will be forthcoming.”

The Alliance for Connected Care, which represents telemedicine providers, gave a mixed review. “We are pleased to see the DEA propose a special registration, as required by statute, to allow comprehensive medical care through telemedicine, including Schedule II medications,” the group said

“

The alliance is very concerned to see language in the proposed rulemaking mandating what portion of patient care can be offered through telemedicine, as this is not an appropriate guardrail for a telehealth service.”

– THE ALLIANCE FOR CONNECTED CARE

in a statement. “These treatments are important in providing mental health, end-of-life care, substance use treatment, and many other services.”

“However, the alliance is very concerned to see language in the proposed rulemaking mandating what portion of patient care can be offered through telemedicine, as this is not an appropriate guardrail for a telehealth service,” the statement continued. “Similarly, restricting the geography in which telemedicine can be offered undermines the value of creating virtual access for those patients who need it most. Restricting access to telemedicine will lead to harsh consequences for many Americans relying on telehealth for mental health, substance use disorder, sleep disorders, terminal illness, and many other medical issues.”

Marika Miller, JD, an associate at the Chicago office of Foley & Lardner

who advises telehealth companies and healthcare providers, wasn’t surprised by the announcement. “I was not expecting the DEA to dust off their highly criticized rules from March 2023 and release revised versions, but I am not surprised they did,” she said in an email. “Had the rules not been published before Jan. 20, they were likely to have been abandoned by the incoming Trump administration.”

“We have been waiting for a special registration process for more than 15 years, but what has been proposed does not live up to stakeholders’ expectations,” she continued. “We anticipate the industry will urge the DEA for a rewrite,

which will take some time.”

She noted that the final buprenorphine rule introduces restrictions for prescribing buprenorphine via telemedicine, including a nationwide prescription drug monitoring program review and the six-month initial supply.

“With the proposed special registration process unlikely to be finalized this year, maintaining DEA telemedicine flexibilities will be crucial for continued buprenorphine prescriptions via telemedicine,” she said. “There is too much uncertainty about what the Trump administration will prioritize over the next four years to know if the final buprenorphine rule will stick.”

Joyce Frieden oversees Washington coverage for MedPage Today, where this article first appeared. She writes about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy.

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11

PATIENT ENGAGEMENT/MANAGEMENT

Better Engaging Our Older Patients

By James Santiago Grisolia, MD

RECENTLY, A DAUGHTER TOLD the story of her aging father, once a whiz at Photoshop, who lost his computer and social media abilities from cognitive decline due to Alzheimer’s.1 She pointed out the constantly changing webpages and icons for apps, and how nothing felt familiar to him when he came back after a few months. This was an important loss for him, and perhaps accelerated his decline. She worries that many Alzheimer’s patients are losing stimulation and social contacts as they lose the ability to work Instagram, TikTok and X. My patients are different. Once adept at paying bills and other aspects of fi-

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“

While scientific evidence so far only supports short-term benefits, most neurologists and families agree that cognitive stimulation slows or prevents cognitive decline, whereas mental inactivity accelerates it.”

nance, they cannot keep up as the world moves from paper checks to online banking and internet-based records, passwords, etc. As Alzheimer’s increasingly hits baby boomers, I’m sure we’ll see more and more patients actually losing computer and social media skills, but that’s not the major problem yet.

Underlying both scenarios, the problem remains gradual loss of flexibility and engagement with the world.

While scientific evidence so far only supports short-term benefits, most neurologists and families agree that cognitive stimulation slows or prevents cognitive decline, whereas mental inactivity accelerates it. Isolation during the pandemic triggered a tidal wave of cognitive decline2, which continues washing patients and families into physician offices today. Mental stimulation is not the same as “brain training,” of which there’s a profusion of programs, each promising help with memory, attention or verbal skills, often with short-term support but no proven long-term benefit. On a practical basis, mental stimulation should include some combination of learning new things and social stimulation. Learning new motor skills doesn’t seem to help, but “book learning” such as puzzles, Bible study, language or history seems helpful.

In my experience, passive reading or watching TV or movies can result in a superficial, repetitive experience with little actual comprehension or brain stimulation. As my father declined in Spain during the pandemic, he was still reading the same book about Eleanor of Aquitaine every time I called, perhaps the same page over and over.

His caregivers were limited, but if I could have been at his side, we could have read the same book aloud to each other (sharpening my Spanish would stimulate my brain, too!), discussed what happened and what it meant. In San Diego, I’ve advised many families to sit with their affected relative while

watching TV or a movie, breaking the hypnosis by discussing what they see and using the news or other shows as a tool of engagement, rather than noncomprehension.

To families or to patients who are just beginning their decline, I encourage social groups, volunteer work, book clubs, or Bible study groups through their church or synagogue. Engagement in the patient’s first language provides more stimulation and connection with prior experience. For monolingual Spanish speakers, a social or senior group conducted in English usually only intensifies frustration and isolation.

While more social engagement, preferably on novel topics, seems helpful at any stage, there’s also excellent

support for the importance of physical activity, whether formal classes or just walking. The Mediterranean or MIND diets have proven consistently helpful, whether for prevention or slowing the course of cognitive loss. Alcohol should be restricted, although fresh controversy has arisen over whether a single drink a day helps or hurts cognition. For younger family members, I also mention blood pressure control, as even modest hypertension seems to corrode brain vessels and contribute to dementia.3

References 1. “Americans With Dementia Are Grieving Social Media,” Talia Barrington, The Atlantic, Jan 7, 2025.

2. “Alzheimer’s: The Second Epidemic,” James Grisolia, MedPage Today, Oct 3, 2020.

3. “Effect of intensive vs standard blood pressure control on probable dementia: a randomized clinical trial. JD Williamson et al, JAMA 2019; 321:553-561.

Dr. Grisolia is a neurologist, former editor of San Diego Physician magazine, and former chief of staff at Scripps Mercy Hospital.

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OUTLOOK FOR HEALTHCARE

The Healthcare Landscape in 2025 The Keynote Address for the Riverside County Medical Society Installation

By Toluwalasé “Lasé” A. Ajayi, MD

Introduction Good evening, esteemed colleagues, members of the Riverside County Medical Society, and honored guests. It is truly an honor to join you tonight to celebrate this significant occasion. As the Secretary of the American Medical Association’s Board of Trustees, I bring greetings from the AMA and deep gratitude for your unwavering commitment to advancing healthcare in Riverside County and beyond.

Tonight, as we install new leaders and reflect on the road ahead, I want to recognize the profound impact each of you has on the health and wellbeing of your patients and communities. In these challenging times, your dedication inspires not only your colleagues here in Riverside but physicians across the country.

Celebrating Leadership: Dr. Anoop Maheshwari Before discussing broader topics, I would like to acknowledge Dr. Anoop Maheshwari, who begins his term as the 132nd president of the Riverside County

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Medical Association. Dr. Maheshwari’s career exemplifies service, leadership, and dedication. He is more than a physician — he’s a family man, a musician who finds joy in playing the flute, and a traveler with an unyielding appreciation for a good cup of coffee. Under his leadership, I have no doubt that RCMA will continue to flourish. Congratulations, Dr. Maheshwari, on this well-deserved honor.

The Healthcare Landscape in 2025 We gather tonight amid a pivotal moment in healthcare. Across the nation, physicians are navigating a perfect storm of challenges: declining reimbursement rates, skyrocketing administrative burdens, and mounting workforce shortages. Practices — whether independent, group, or health-system-

based — are struggling to keep their doors open. For many of us, the system feels unsustainable, and our patients are bearing the brunt.

Barriers to accessing care remain unacceptably high, particularly for our most vulnerable populations. Families are waiting too long to see specialists, rural and underserved communities lack sufficient medical resources, and outdated payment structures fail to support the complexity of modern medicine. Physicians are feeling the weight of these challenges, leading to alarming rates of burnout and, in some cases, decisions to leave the profession altogether.

Yet, challenges also provide opportunities — to advocate for systemic change, innovate in care delivery, and reaffirm our collective commitment to improving the lives of our patients.

AMA’s Advocacy: Medicare, AI, and Value-Based Care As we face these challenges, the AMA stands firmly alongside you. Our advocacy priorities reflect a commitment to supporting physicians and improving the healthcare system for all.

Medicare Reimbursement Reform: Declining reimbursement rates threaten the viability of medical practices. The AMA is aggressively pursuing reforms to ensure a sustainable and predictable payment system. We understand that practices cannot thrive under declining reimbursement rates and short-term fixes. This remains a fight we will not relent on.

AI Regulation and Innovation: Artificial intelligence is transforming medicine, presenting both opportunities and risks. The AMA is leading efforts to ensure AI is used responsibly, emphasizing equity, transparency, and patient safety. Here in Riverside, where a Healthcare AI Conference is hosted annually, we see how local innovation aligns with national efforts. The AMA’s AI Collaborative fosters partnerships among stakeholders, ensuring that this technology enhances, rather than hinders, patient care.

Value-Based Care and Population Health: Transitioning to value-based care models requires robust support.

The AMA is equipping physicians with the resources and knowledge to adapt successfully. A key example of that is Dr. Sea Chen, the AMA’s Physician Director of Practice Sustainability, recently participating in RCMA’s Strategic Planning Retreat, offering valuable insights to help physicians navigate these changes.

New Leadership in Washington, DC Now, the recent leadership changes in Washington bring both uncertainty and opportunity. As policymakers consider reforms to healthcare delivery, the AMA

remains a steadfast advocate for physicians and patients. We are closely monitoring potential shifts in federal policies, including Medicare payment structures, public health funding, and regulatory frameworks for emerging technologies like AI. Together, we must ensure that new policies prioritize access, equity, and sustainability in healthcare.

RCMA: A Model for Growth and Engagement We can also learn from what you are doing here. The Riverside County Medical Society exemplifies what’s possible when physicians unite for a common purpose. With more than 3,600 members, including residents and students, RCMA is now the fifth-largest county medical society in California. Doubling membership over the past year is a remarkable achievement and a testament to RCMA’s leadership and commitment to its members.

Your success highlights the importance of engagement — whether through advocacy, mentorship, or education. By fostering collaboration among physicians, advocating for resources, and prioritizing equitable care, RCMA has set a powerful example for medical societies nationwide.

Call to Action As we look ahead, I urge you to remain engaged — with RCMA, CMA, AMA, and each other. Your voices, expertise, and experiences are invaluable. Whether through advocacy, mentorship, or innovation, each of you has the power to shape the future of medicine.

Consider how you can make your mark in addressing the challenges we face. How can we work together to ensure fair reimbursement, reduce administrative burdens, and close the gaps in access to care? These are not easy questions, but they are the questions that will define our profession and our legacy.

Closing To the new leaders of RCMA, I commend you for stepping up to serve at such a critical time. Leadership is not about having all the answers; it’s about bringing people together to find solutions.

And to every physician here tonight, know that your work matters. The care you provide, the lives you touch, and the advocacy you champion all contribute to a stronger, healthier future.

As we leave here tonight, let us carry forward a shared vision — a vision of a healthcare system where physicians are empowered, patients are cared for with dignity, and equity is at the heart of every decision we make.

Thank you for the opportunity to speak with you tonight and for all that you do to advance our noble profession.

Together, we can overcome the challenge.

Dr. Ajayi is a pediatrician, a palliative care physician, and a researcher. She is secretary of the board of the American Medical Association and was the first Black woman to be president of the San Diego County Medical Society.

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15

NEUROLOGY

Autism Prevalence Is Climbing, but It’s Not Due to Vaccines Many Factors Contribute to the Rise in Diagnoses, but What Causes Autism Remains Elusive

By Judy George PRESIDENT TRUMP HAS SAID that Robert F. Kennedy Jr., his nominee to run HHS, would investigate why autism spectrum disorder (ASD) diagnoses are rising.

Since at least 2014, Trump has floated a theory that vaccines are behind the rise, but no evidence indicates this is true.

“There have been extensive studies researching potential links to routine childhood vaccinations and autism diagnoses, and the results have shown that no such link exists,” said Eric Burnett, MD, of Columbia University Irving Medical Center in New York City.

“The rise in autism diagnoses is largely due to greater awareness, better diagnosis, and broader diagnostic criteria,” Dr. Burnett said. “Correlation does not imply causation; just because two trends occur together doesn’t mean one caused the other.”

Do More People Have Autism?

In the past two decades, ASD diagnoses among children in the U.S. have jumped fourfold, according to CDC data. The agency’s Autism and Developmental Disabilities Monitoring network, which tracks the number and characteristics of children with ASD in 11 communities, showed that prevalence from 2000 to 2020 climbed from 6.7 to 27.6 cases per 1,000.

This means an estimated 2.8% of 8-year-old children were identified with autism in 2020, the CDC said. A recent analysis of medical records suggested that ASD diagnoses also rose

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substantially in young adults from 2011 through 2022.

There’s no single cause of autism, but several factors may have fueled the rising prevalence numbers, said Alison Singer, president of the Autism Science Foundation, a nonprofit group that funds autism research.

“The first is that the definition of autism changed in 2013 when we went from DSM-IV to DSM-V,” Singer said.

“The five subtypes of autism in DSMIV, which included classic autism and Asperger’s syndrome, collapsed into one overly broad category of autism spectrum disorder.” That led to higherfunctioning individuals being diagnosed with autism, she observed.

Better awareness and ascertainment accounted for a portion of the increase in prevalence, she said. Societal changes came into play, too.

“Parents are having children later in life and we know that higher maternal and paternal age leads to higher rates of autism,” Singer noted. Infants born prematurely are more likely to survive now, and those children are more likely to be diagnosed with ASD and developmental delays.

Why Are We Screening More?

Screening and surveillance for ASD have increased over the years, said Susan Hyman, MD, of the University of Rochester Medical Center in New York, who co-authored the most recent American Academy of Pediatrics (AAP) report on identifying and managing ASD. The imperative to screen for ASD

was recognized by parents and groups like the AAP when research showed that early intervention could improve functional skills in several developmental domains. “If improved functional outcomes were possible, identifying children who might benefit from them became an important movement,” Dr. Hyman said.

Screening is now done during wellchild visits in most primary care pediatric practices when children are ages 18 months and 24 months, Dr. Hyman noted. There’s also been “a catch-up in diagnoses” among medically underserved populations, she pointed out.

“While there continues to be inequity in services provided, gains have been made in recognizing the diagnosis,” she said. “Increased rates of diagnosis among females, older youth and adults, and underserved populations have all contributed to the reported increase in prevalence of diagnosis.”

Why Were Vaccines Blamed?

In 1998, Andrew Wakefield, MBBS, formerly of the Royal Free Hospital and School of Medicine in London, published a now-retracted paper in The Lancet

“ stating that 12 children had intestinal abnormalities after receiving the measles, mumps, and rubella (MMR) vaccination. In eight of the 12 children, parents associated the vaccine with the onset of behavioral symptoms.

Wakefield and co-authors hypothesized that intestinal inflammation after the MMR vaccine released gut proteins that eventually migrated to the brain, causing damage that was reflected in autism symptoms.

“The Wakefield study was flawed because nothing was studied,” said Paul Offit, MD, of Children’s Hospital of Philadelphia.

“It was merely a report of eight children who had developed signs and symptoms of autism within a month of receiving the MMR vaccine. There was not a control group,” he emphasized.

“Therefore, there was no way of knowing whether autism was occurring at a level greater than would be expected by chance alone.”

An investigative reporter later demonstrated that “Wakefield had misrepresented both clinical and biological data, causing the journal to withdraw the paper,” Dr. Offit said.

According to The Times of London, Dr. Wakefield was accused of altering the clinical findings for eight of 12 children in the study.”

According to The Times of London, Dr. Wakefield was accused of altering the clinical findings for eight of 12 children in the study. Five of the eight children reportedly had psychosocial problems before they received the vaccine, though the paper described them as developmentally normal. Hospital pathology reports showed no findings of intestinal inflammation in the children. Only one child allegedly had new-onset behavioral symptoms days after receiving the vaccine.

In January 2010, the U.K. General Medical Council ruled that Dr. Wakefield acted dishonestly and irresponsibly.

Several days later, The Lancet retracted his paper.

What Have Other Studies Shown?

In 1999, another group of London-based researchers reported in The Lancet there was no epidemiological evidence for a causal association between autism and the MMR vaccine. That conclusion was played out repeatedly in studies published in subsequent years.

One of the largest was a retrospective analysis of more than 537,000 children in Denmark published in the New England Journal of Medicine, which showed the risk of autism diagnoses was similar whether a child had the MMR vaccine or not. In the U.S., a study published in JAMA showed no harmful association between the MMR vaccine and autism, even in children at high risk for ASD. “These were studies that were well done, with appropriate controls,” Dr. Offit said.

Other hypotheses linking autism and vaccines that have been debunked centered around thimerosal, a preservative containing low levels of ethylmercury used in some multidose vials of vaccines, and arguments claiming that administering multiple vaccines at once may weaken the immune system.

(All vaccines routinely recommended in the U.S. for children ages 6 years and younger are available in formulations that do not contain thimerosal.)

Yet, what causes autism remains unknown. There’s been rapid progress in translational research integrating genetics, neurobiology, and clinical presentation, and that needs to continue, Dr. Hyman stressed.

“It is possible that environmental factors — other than vaccines, which have extensive data indicating they are not responsible — may interact with genetic predisposition to increase an individual’s risk for autism,” she said.

Judy George covers neurology and neuroscience news for MedPage Today, where this article first appeared, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and other subjects.

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17

POETRY AND MEDICINE

Angle of Repose

By Daniel J. Bressler, MD, FACP

Angle of Repose These lives which sometimes seem to be so stable Our job, our health, our loves, our face, our clothes Are always balanced halfway off the table Dangling at the angle of repose All the acts of fate that nearly knock us All the curtains ducked before they close The Do Not Enter signs that do not block us Help maintain the angle of repose Recall the times we planned and almost acted Yet stopped before things really came to blows Compared to other agents who in fact did And got crushed beneath the angle of repose From knowing when to stay and when to scatter Escaping out of range when others froze To pluck essential truth from idle chatter Is to navigate the angle of repose

DEFINITION: THE “angle of repose” describes the maximum slope at which a mound of loose particles, such as sand or soil, can maintain its structure without collapsing. This angle represents the boundary between stability and slide, measured from the horizontal.

In physiology, the concept akin to this is homeostasis, a delicate balance of numerous factors that enable life to flourish. We, along with all of life, exist within an interlocking mesh of “Goldilocks phenomena”— conditions that are just right, not too extreme in any direction, which underpin the dynamic nature of biological adaptation.

In the narrative of our lives, our “granular material” is composed of our genetic and epigenetic inheritance, and our experiences

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up to the present moment.

Eventually, this process reaches a critical point, where stability gives way to disorder—be it through disease or accident.

The poignant reality that frames the longitudinal practice of medicine is this: We all tread a precarious path over an abyss that will, in time, claim us. The acknowledgment of our inherent fragility and mortality casts a shadow over our lives, but in this shadow, we find the potential for profound experiences. When we are fortunate and intentional, this backdrop allows for moments and even years of love, art, joy, and service.

Do we tolerate an easy shallow answer While cynicism roots and slowly grows?

Do we strive to extirpate such cancer Or surrender to this angle of repose?

You aimed to live a life of quiet service But your eyes have seen the darkness and it shows So instead of getting peace you just get nervous Clutching at the angle of repose If you’re convinced the world conspires to stress you, You’ll always end up bloodied from its blows.

Yet if you hold its twists and turns might bless you, You strengthen your own angle of repose.

A continuum of carnival and prison And all the consequences these suppose Suspended at each fragile station risen Balanced at the angle of repose

Dr. Bressler has been practicing internal medicine in San Diego since 1984. During his career he has taught medical students and residents, and also chaired various hospital committees. He is currently affiliated with Scripps Mercy Hospital and Mission Hills Post Acute Care.

PERSONAL AND PROFESSIONAL DEVELOPMENT

What if This Isn’t True?

By Helane Fronek, MD, FACP, FASVLM, FAMWA YEARS AGO, A BUMPER STICKER caught my eye. “Don’t believe everything you think,” it read. Funny on the surface, and deeply meaningful. We are very protective of our thoughts. As physicians, we often believe our abilities to think and reason are our most important skills. Yet, as intelligent people, we can think ourselves into or out of almost any thought. And if we pay attention to our thoughts, we’ll notice many contradictions within a short period of time.

Truly, our thoughts are not as unassailable as we believe them to be.

As a coach, I often encourage my clients to gain greater balance in their lives by adopting new hobbies, developing a specialty within their practice, or fostering new relationships. While some accept these suggestions with enthusiasm, most encounter resistance, even when they realize the potential benefits.

Used to feeling competent at what we have been doing for years, beginning something new often feels clumsy and confusing. While we may pick up a new hobby just for fun, once we decide to intentionally improve, we notice the ways in which we aren’t as capable as we feel about our other, long-practiced activities. We have entered the painful realm of “conscious incompetence.” If we compare ourselves to others who have been honing their skills over many years, our sense of inferiority feels even starker.

I watched this dynamic at a recent music workshop. An experienced academic arrived, excited to use her newly developing drum skills and play with

other amateur musicians. However, she soon backed out of the performance, defeated by her own thoughts that she just “wasn’t good enough.”

It was sad to see her stand in her own way, and it reminded me of the times I have done the same to myself.

One approach is to recall the challenges we experienced in learning anything — from tying our shoes as children to performing medical procedures. We should expect to go through a period of relative “incompetence” on our way to becoming competent. But if those defeating thoughts continue to create obstacles, the writer Byron Katie (the work.com) offers questions that have helped her, and thousands of other people, move past their untrue thoughts and find greater peace. She suggests we

begin by asking, can I be certain this is true? How do I feel when I believe this?

Who would I be without this thought?

And simply posing the question, “What if this isn’t true?” opens new perspectives. The jarring nature of the question helps us move it out of the center of our awareness. There is now room for other beliefs. And, if this isn’t true, what does it make possible for us and our lives? How much richer, more interesting, and more fun would our lives be if we allowed ourselves the joy and satisfaction of exploring all that life has to offer? To do that, we may first need to recall that bumper sticker and learn to not believe everything we think.

Dr. Fronek is a Certified Physician Development Coach, CPCC, PCC, and an assistant clinical professor of medicine at the UC San Diego School of Medicine.

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Ideal candidates may also consider a locum or locum–to–hire arrangement. Join us in making a difference in our patients’ lives while enjoying your dream location! Email cv to jobs@ljvascular.com. [2875-1030] PART–TIME PRIMARY CARE PHYSICIAN: Primary Care Clinic in San Diego searching for part–time physician for 1 to 2 days a week, no afterhours calls. Please send CV to medclinic1@yahoo.com.

[2872-0909] OB/GYN POSITION AVAILABE | EL CENTRO: A successful Private OBGYN practice in El Centro, CA seeking a board eligible/certified OB/GYN. Competitive salary and benefits package is available with a tract of partnership. J-1 Visa applicants are welcome. Send CV to feminacareo@gmail.com or call Katia M. at 760-352-4103 for more information. [2865-0809] COUNTY OF SAN DIEGO DEPUTY CHIEF ADMINISTRATIVE OFFICER: Salary: $280,000-$300,000 Annually. The County of San Diego is thrilled to announce unique openings for Deputy Chief Administrative Officers (DCAOs) across our four County Groups: Finance and General Government Group (FGG), Health & Human Services Agency (HHSA), Land Use and Environment Group (LUEG), and the Public Safety Group (PSG). With a new Chief Administrative Officer (CAO) at the helm, the County is in an extraordinary period of transformation and opportunity. The DCAOs will direct, organize and oversee all activities within their designated Group. Additionally, the DCAOs aid the CAO in the coordination of county operations, program planning, development, and implementation. The DCAOs must demonstrate strong leadership and model our core values of integrity, belonging, equity, excellence, access, and sustainability. How To Apply: Take this opportunity to make a significant impact and drive positive change in our community. Apply now by submitting your application here: Deputy Chief Administrative Officer-24210407U. COUNTY OF SAN DIEGO PROBATION DEPT. MEDICAL DIRECTOR: The County of San Diego is seeking dynamic physician leaders with a passion for building healthy communities. This is an exceptional opportunity for a California licensed, Board-certified physician to help transform our continuum of care and lead essential medical initiatives within the County’s Probation Department. Anticipated Hiring Range: Depends on Qualifications Full Salary Range: $181,417.60 - $297,960.00 Annually COUNTY OF SAN DIEGO As part of the Probation Administrative team, the Medical Director is responsible for the clinical oversight and leadership of daily operations amongst Probation facilities’ correctional healthcare programs and services. As the Medical Director, you will have significant responsibilities for formulating and implementing medical policies, protocols, and procedures for the Probation Department. Medical Director.

PART–TIME CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part–time cardiologist. Please send resume to Dr. Keith Brady at uabresearchdoc@yahoo.com. [2873-0713] INTERNAL MEDICINE PHYSICIAN: Federally Qualified Health Center located in San Diego County has an opening for an Internal Medicine Physician. This position reports to the chief medical officer and provides the full scope of primary care services, including diagnosis, treatment, and coordination of care to its patients. The candidate should be board eligible and working toward certification in Internal Medicine. Competitive base salary, CME education, Four weeks paid vacation, year one, 401K plan, No evenings and weekends, Monday through Friday 8:00am to 5:00pm. For more information or to apply, please contact Dr. Keith Brady at: uabresearchdoc@yahoo. com. [2874-0713]

MEDICAL OFFICE FOR SUBLEASE OR SHARE: A newly remodeled and fully built–out medical clinic in Torrey Hills. The office is approximately 2,700 sq ft with 5 fully equipped exam rooms, 1 lab, 1 office, spacious and welcoming waiting room, spacious reception area, large breakroom, and ADA–accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please get in touch with Charlie at (714) 2710476 or cmescher1@gmail.com. Available immediately. [2871-0906] LA JOLLA/XIMED OFFICE TO SUBLEASE: Modern upscale office on the campus of Scripps Hospital — part or full time. Can accommodate any specialty. Multiple days per week and full use of the office is available. If interested please email kochariann@yahoo.com or call (818) 319-5139. [2866-0904] SUBLEASE AVAILABLE: Sublease available in modern, upscale Medical Office Building equidistant from Scripps and Sharp CV. Ample free parking. Class A+ office space/medical use with high-end updates. A unique opportunity for Specialist to expand reach into the South Bay area without breaking the bank. Specialists can be accommodated in this first floor high-end turnkey office consisting of 1670 sq ft. Located in South Bay near Interstate 805. Half day or full day/week available. South Bay is the fastest growing area of San Diego. Successful sublease candidates will qualify to participate in ongoing exclusive quarterly networking events in the area. Call Alicia, 619-585-0476.

OFFICE SPACE FOR SUBLEASE | SOUTHEAST SAN DIEGO: 3 patient exam rooms, nurse’s station, large reception area and waiting room. Large parking lot with valet on-site, and nearby bus stop. 286 Euclid Ave - Suite 205, San Diego, CA 92104. Please contact Dr. Kofi D. Sefa-Boakye’s office manager: Agnes Loonie at (619) 435-0041 or ams66000@aol.com. [2869-0801] MEDICAL OFFICE FOR SALE OR SUBLEASE: A newly remodeled and fully built-out primary care clinic in a highly visible Medical Mall on Mira Mesa Blvd. at corner of Camino Ruiz. The office is approximately 1000 sq ft with 2 fully equipped exam rooms, 1 office, 1 nurse station, spacious and welcoming waiting room, spacious reception area, and ADA accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please contact Nox at 619-776-5295 or noxwins@ hotmail.com. Available immediately.

RENOVATED MEDICAL OFFICE AVAILABLE | EL CAJON: Recently renovated, turn-key medical office in freestanding single-story unit available in El Cajon. Seven exam rooms, spacious waiting area with floor-to-ceiling windows, staff break room, doctor’s private office, multiple admin areas, manager’s office all in lovely, drought-resistant garden setting. Ample free patient parking with close access to freeways and Sharp Grossmont and Alvarado Hospitals. Safe and secure with round-the-clock monitored property, patrol, and cameras.

Available March 1st. Call 24/7 on-call property manager Michelle at the Avocado Professional Center (619) 916-8393 or email help@ avocadoprofessionalcenter.com.

OPERATING ROOM FOR RENT: State of the Art AAAASF Certified Operating Rooms for Rent at Outpatient Surgery of Sorrento. 5445 Oberlin Drive, San Diego 92121. Ideally located and newly built 5 star facility located with easy freeway access in the heart of San Diego in Sorrento Mesa. Facility includes two operating rooms and two recovery bays, waiting area, State of the Art UPC02 Lasér, Endoscopic Equipment with easy parking. Ideal for cosmetic surgery. Competitive Rates. Call Cyndy for more information 858.658.0595 or email Cyndy@ roydavidmd.com.

PRIME LOCATION | MEDICAL BUILDING LEASE OR OWN OPPORTUNITY IN LA MESA: Extraordinary opportunity to lease or lease-to-own a highly visible, freeway-oriented medical building in La Mesa, on Interstate 8 at the 70th Street on-ramp. Immaculate 2-story, 7.5k square foot property with elevator and ample free on-site parking (45 spaces). Already built out and equipped with MRI/CAT machine.

Easy access to both Alvarado and Sharp Grossmont Hospitals, SDSU, restaurants, and walking distance to 70th St Trolley Station. Perfect for owner-user or investor. Please contact Tracy Giordano [Coldwell Banker West, DRE# 02052571] for more information at (619) 987-5498.

POWAY MEDICAL OFFICE SPACE FOR LEASE: Fully built out, turnkey 1257 sq ft ADA-compliant suite for lease. Great location in Pomerado Medical/Dental Building, next to Palomar Med Center Poway campus. Building restricted to medical/allied health/dental practices, currently houses ~26 suites. Ideal for small health practice as primary or satellite location. Lease includes front lobby, reception area, restrooms, large treatment area, private treatment/exam rooms.

Located on second floor, elevator/stair access. Bright, natural lighting; unobstructed views of foothills. On-site parking; nearby bus service.

Flexible lease terms available from 3-5 years at fair market rate.

Contact Debbie Summers at debjsummers3@gmail.com or (858) 382-8127. [2856-1101] KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643 Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems. Ample free parking. Newly constructed Class A+ medical office space/medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for use (including splint/cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam room doubles as a minor procedure room. Ample waiting room area. In office x-ray with additional waiting area outside of the x-ray room. Orthopedic surgery centric office space. Includes access to a kitchenette/indoor break room, exterior break room and private physician workspace.

Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and scurry@ ortho1.com for more information. Available for immediate occupancy.

LA JOLLA/UTC OFFICE TO SUBLEASE OR SHARE: Modern upscale office near Scripps Memorial, UCSD hospital, and the UTC mall. One large exam/procedure room and one regular-sized exam room. Large physician office for consults as well. Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available. If interested please email drphilipw@gmail.com.

ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and reception. Large parking lot with free parking for patients. Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista CA 92082. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, decor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from TriCity Medical Center and across from the urgent care. Includes: multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is not included. For inquiries contact hosalkarofficeassist@gmail.com or call/ text (858)740-1928.

MEDICAL EQUIPMENT / FURNITURE FOR SALE UROLOGY OFFICE CLOSING 6/2023 | EQUIPMENT AVAILABLE: Six fully furnished exam rooms including tables (2 bench, 3 power chair/table, 1 knee stirrup), rolling stools, lights, step stools, patient chairs. Waiting room chairs, tables, magazine rack. Specialty items—Shimadzu ultrasound, SciCan sterilizer, Dyonics camera with Sharp monitor, Medtronic Duet urodynamics with T-DOC catheters, Bard prostate biopsy gun with needles, Cooper Surgical urodynamics, Elmed ESU cautery, AO 4 lens microscope. RICOH MP-3054 printer with low print count. For more information contact: r.pua@cox.net.

NON–PHYSICIAN POSITIONS AVAILABLE NURSE PRACTITIONER | PHYSICIAN ASSISTANT: Open position for Nurse Practitioner/Physician Assistant for an outpatient adult medicine clinic in Chula Vista. Low volume of patients. No call or weekends.

Please send resumes to medclinic1@yahoo.com. [2876-1121] POSTDOCTORAL SCHOLARS: The Office of Research Affairs, at the University of California, San Diego, in support of the campus, multidisciplinary Organized Research Units (ORUs) https://research.ucsd. edu/ORU/index.html is conducting an open search for Postdoctoral Scholars in various academic disciplines. View this position online: https://apol-recruit.ucsd.edu/JPF03803. The postdoctoral experience emphasizes scholarship and continued research training. UC’s postdoctoral scholars bring expertise and creativity that enrich the research environment for all members of the UC community, including graduate and undergraduate students. Postdocs are often expected to complete research objectives, publishing results, and may support and/or contribute expertise to writing grant applications https://apol-recruit. ucsd.edu/JPF03803/apply. [2864-0808] RESEARCH SCIENTISTS (NON–TENURED, ASSISTANT, ASSOCIATE OR FULL LEVEL): The University of California, San Diego campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search for Research Scientists (non–tenured, assistant, associate or full level). Research Scientists are extramurally funded, academic researchers who develop and lead independent research and creative programs similar to Ladder Rank Professors. They are expected to serve as Principal Investigators on extramural grants, generate high caliber publications and research products, engage in university and public service, continuously demonstrate independent, high quality, significant research activity and scholarly reputation. Appointments and duration vary depending on the length of the research project and availability of funding. Apply now at https://apol-recruit.ucsd.edu/ JPF03711. [2867-0904] PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research and Innovation https://research.ucsd.edu/, in support of the Campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding: https://apol-recruit.ucsd.edu/ JPF03712/apply. [2868-0904]

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Invite you to the installation of the 155th SDCMS President at our

United In Wellness Gala

Saturday, June 14, 2025 • 5-9 pm Eve at RaDD • 975 Waterfront Place, Suite 400, San Diego, CA 92101 Barnard family Foundation

Unitedinwellnessgala.org For sponsorship information, please contact Gabriela Stichler at gabriela.stichler@championsfh.org or at 858-300-2789