March 2025

MARCH 2025

Official Publication of SDCMS

Staying Grateful in Terrifying Times Karl Steinberg, MD

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988: TRANSFORMING MENTAL HEALTH CRISIS RESPONSE IN SAN DIEGO AND BEYOND Eric Rafla-Yuan, MD

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Contents MARCH

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 3

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 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: Christina Noravian 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 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

FEATURES

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DEPARTMENTS

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Staying Grateful in Terrifying Times

By Karl Steinberg, MD

988: Transforming Mental Health Crisis Response in San Diego and Beyond

By Eric Rafla-Yuan, MD

California Children’s Services: Transitioning Youth and Young Adults With Complex Healthcare Needs to Adult Planning

By Rebecca Conrad, MPH

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Briefly Noted: Advocacy • Workers’ Compensation Fees • Health Equity Leadership

12 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.]

Telehealth Companies Boost Ad Spending While Taking on More Complex Medicine

By Darius Tahir

Study Challenges Schizophrenia Guidelines

By Paul Smyth, MD

Obesity in Lung Cancer Patients Linked to Longer Survival

By Mike Bassett

New State Law Requires TB Screening in Adult Primary Care; CDPH Hosting Best Practices Webinar

By California Medical Association Staff

So-Called ‘DEI’ and So-Called ‘Meritocracy’

By James Santiago Grisolia, MD

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Sharing Memories Now

By Adama Dyoniziak

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Classifieds SANDIEGOPHYSICIAN.ORG

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California Medical Association Launches ‘Your Care Is At Our Core’ Advocacy Campaign THE CALIFORNIA MEDICAL ASSOCIATION (CMA) is proud to launch the Your Care Is At Our Core Campaign in partnership with the American Medical Association (AMA) to strengthen the patient-physician relationship during a time of eroding trust in science and medical institutions.

In recent years, mis- and disinformation, as well as battles over the COVID-19 pandemic, science, and evidence-based care, have created challenges for physicians and healthcare workers. These factors have chipped away at the patient-physician relationship, which forms the foundation of providing quality care.

“Caring for our patients is at the heart of why so many physicians choose medicine,” said CMA President Shannon Udovic-Constant, MD. “We deeply value the trust our patients place in us, knowing that earning and maintaining that trust is essential to delivering high-quality care. That’s why it’s critical to address the growing challenges to medicine — from declining trust in science to administrative bureaucracy that pulls us away from patient care — so we can continue to provide the best possible treatment.”

“Physicians are drawn to medicine to heal and to change lives for the better,” said AMA President Bruce A. Scott, MD. “Too often these days administrative burdens, red tape, and obstacles like prior authorization eat into our time with patients and create barriers in the patient-physician relationship. Building and maintaining this relationship is critical for establishing trust and achieving positive health outcomes in our communities, and we must make that our focal point.”

The data bear this out – 89% of patients say that the doctor-patient relationship is central to healthcare, and 79% of patients say that bureaucratic red tape hinders physicians’ efforts to provide the best care to patients.1 Despite patients’ desire for more attention and access, third-party actors in the healthcare system, including health insurance companies, pharmacy benefit managers, hospitals, and

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others, are severely limiting the amount of time physicians can spend with their patients, as well as curtailing access to treatments physicians can provide to treat and comfort their patients. Patients who need care can often feel vulnerable, and establishing a meaningful patient-physician relationship is necessary to building trust and providing them with the most effective care and treatment.

Physicians across the country are advocating for less bureaucracy and more time with their patients. CMA will continue to highlight and amplify these efforts through the Your Care Is At Our Core campaign.

1 Results from a National Online Survey of 1,000 voters conducted March 8-10, 2023 on behalf of the AMA.

DWC Updates Workers’ Compensation Physician Fee Schedule

PHC Now Accepting Nominations for 2025 Health Equity Leadership Awards PHYSICIANS FOR A HEALTHY CALIFORNIA (PHC) is now accepting nominations for its annual Health Equity Leadership Awards, which will be presented at the Health Equity Leadership Awards Reception on July 10, 2025, during the Health Equity Leadership Summit.

All nomination forms and accompanying materials must be submitted

by April 4, 2025, at 11:59 p.m., to healthequitysummit@phcdocs.org.

Honorees will be notified of the selection decision by the end of May. Honorees or a representative must be present at the Health Equity Leadership Summit Leadership Awards Reception in Pasadena to receive the award.

For more information or to submit a nomination, please visit https:// phcdocs.org/awards.

• Sparks Leadership Award honoring those dedicated to improving community health • Mahal Access to Health Care and Disparities Award recognizing efforts to improve healthcare access or reduce disparities • Staggers Outstanding Ethnic Physician Organization Award celebrating ethnic physician organizations improving community health • Diverse Physician Leadership Award recognizing diverse physicians for leadership benefiting their communities • Medical Student Health Equity Leadership Award honoring medical students working to advance health equity • Resident Health Equity Leadership Award acknowledging a resident advancing health equity and leadership in medicine • Young Physician Health Equity Leadership Award celebrating young physicians improving access, cultural competency, and patient advocacy For more information, please visit https//phcdocs.org/news

THE CALIFORNIA DIVISION OF WORKERS’ COMPENSATION (DWC) recently updated its Official Medical Fee Schedule for Physician Services/Non-Physician Practitioner Services to conform to relevant 2025 changes in the Medicare payment system. The update is effective for dates of service on or after Feb. 1, 2025.

The new fee schedule includes the following adjustments: • Updated relative value units • Updated CPT coding • Updated conversion factors • Updated National Correct Coding Initiative Edits • Updated Table A — anesthesia conversion factors adjusted for Geographic Practice Cost Index localities • Updated telehealth list For more information, see the detailed explanation of the changes from DWC at www.dir.ca.gov/dwc.

Questions can be directed to DWC at DWCFeeSchedule@dir.ca.gov.

The order and related documents can be found on the DWC OMFS physician fee schedule webpage.

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PRACTICE OF MEDICINE

Staying Grateful in Terrifying Times

By Karl Steinberg, MD

THIS YEAR MARKS 30 YEARS THAT I’ve been a long-term care geriatrician and a hospice and skilled nursing facility medical director, and I love my work. Perhaps paradoxically, there’s nothing like caring for folks who are frail, vulnerable, functionally dependent, and nearing death to make you feel grateful on a visceral and organic level.

Yes, when I do simple tasks — put on my own socks, walk up a flight of stairs, drive my car to work, interpret lab results — I feel genuinely blessed every day. I may not always be able to do all of those things, although my 91-year-old psychiatrist dad, who lives with me in Oceanside, is still able to do all of those (yes, he’s still working — and he pays

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rent!), so I hope I too will have quite a few more years of both good cognition and functional independence.

In January I had the opportunity to attend the AMA’s State Advocacy Summit and CMA’s Board of Trustees meeting and retreat, both conveniently here in San Diego County. In these truly terrifying times on so many levels, it was great to commune with dedicated, idealistic leaders who mostly share common values and goals — which include providing compassionate, accessible medical care to the most vulnerable members of our communities.

But the attacks on science and public health are alarming, and the threat of further erosion of public trust in the

medical profession and in our public health efforts like vaccines looms ominously and depressingly. Respected institutions like the Centers for Disease Control and Prevention (CDC) have been silenced, and efforts to support equity have been discouraged if not completely banned—and who would have ever predicted that “equity” would become a dangerous word to say in our country?

Unqualified people in power with dangerously unscientific beliefs threaten to claw back many of the gains we’ve made through public health and medicine over the last century, and it doesn’t look to me like our resistance is likely to succeed, at least in the short run. But we’ll keep trying.

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There is talk in the current administration of capping Medicaid funding per beneficiary per annum — which would likely reduce the compensation available to nursing homes for Medi-Cal residents (who constitute a substantial majority of long-term nursing home residents across the U.S.).

The current administration appears to be committed to substantial tax cuts, especially for the wealthy, and that unfortunately is going to mean cuts in spending that will have inevitably destructive impacts. Federal assistance in the Medicaid program currently constitutes fully 50% of our state’s Medicaid (we call it Medi-Cal) funding. Several proposed cuts would constitute no less than a disaster for our most vulnerable residents, including children, older adults, nursing home residents, lowincome families, and pregnant women.

There is talk in the current administration of capping Medicaid funding per beneficiary per annum — which would likely reduce the compensation available

to nursing homes for Medi-Cal residents (who constitute a substantial majority of long-term nursing home residents across the U.S.). The average per diem Medi-Cal rate for a semi-private nursing home room is around $275, and skilled nursing facility operators tell me that this is already not enough to even meet their overhead. These facilities rely on other payer sources, especially Medicare, to allow them to stay above water, including making payroll and keeping their exorbitant liability insurance premiums current.

Skilled nursing facilities across the country have already been dwindling, with more than 750 nursing homes, many in rural and underserved areas, shuttering in 2024 alone. This has resulted in the displacement of tens of thousands of residents, some of whom are now an hour’s drive or more away from their local families. This trend is likely to continue, and ultimately the criteria for nursing home Medicaid eligibility may have to tighten up.

Sadly, this means a lot of frail, medically complex, functionally dependent elders will either wind up in unsafe situations in private homes in the community with family or friends — or will literally land on the street. I don’t think anyone, no matter what their political and social beliefs, wants to see unhoused 95-year-olds sleeping outdoors under a tree. But unfortunately, we probably will. Will the sight of a helpless, wizened nonagenarian with a shopping cart in the park touch the public’s (and legislators’) heartstrings enough to turn the tides on Medicaid cuts, and maybe even

give us an appetite for addressing the larger homelessness crisis? I hope so, and I’m really just trying to make some lemonade here.

There are other potential positive consequences we could see moving forward under the current administration, some of which even have pretty broad bipartisan support. Legislation has again been introduced (HR 879, “The Patient Access and Practice Stabilization Act”) that would create at least another short-term Medicare physician payment fix after five consecutive years of Medicare reimbursement cuts and the cost-adjusted net 33% payment reduction we’ve seen in the last 20 years.

Expansion of telemedicine coverage is also a popular potential gain that has bipartisan support, as do notions like reducing abuse by pharmacy benefit managers (PBMs), and addressing the prior authorization hassles that many of us face every day from insurers.

So, how do we try to remain sunny in this decidedly inhospitable climate?

My strategy has been to try to spread compassion and love, not negativity, in my own circles, including my seriously ill and older patients, my coworkers and colleagues, and my family and friends.

My day-to-day life is full of small victories, meaningful interactions, activities I enjoy, and so much more to be grateful for, especially my partner, my family, and our poodles (I’ve made it a practice to take my dogs with me to the nursing homes since the ’90s) — truthfully, not that different from the way it was a year ago, or 10 years ago. I try to focus on those positive aspects of life and stay in

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a place of gratitude.

Also, back in 2022, I decided that watching “news” — which these days is mostly talking heads telling you what you should believe and why you should be angry about it — was doing me a lot more harm than good. So I stopped watching it, period. My dad tells me it’s important to know what’s going on, but I’m not sure I agree when it comes to the mountain of things I cannot change (which I suppose means I must accept them). I figure if there are things I really need to know, someone I know and love will tell me what they are.

I still get a news feed on my phone and will open a select few sites, mostly those that are relevant to my clinical and policy interests. I spend very little time on social media, although I miss it a little (unlike the news). And I have to say: Next to getting clean and sober in 1991, and buying a cabin in the San Ber-

nardino mountains in 2014, my decision to delete the news media from my life has had the most enduringly positive impact on the quality of my day-to-day existence. That may not be a solution for everyone, but it has been a godsend for me.

We are headed for some stormy seas in the months and years ahead, but I hope and pray that we will get through them, and that some good will come of the turmoil. I hope not too many

disadvantaged people (especially elders) will have to suffer. We will learn some lessons and perhaps get back on track. I hope progressive organizations (including organized medicine) will help resist some of the insanity and try to keep the train on the rails. In the meantime, as physicians, we get to wake up every morning, look in the mirror, and know we are going to do something that is in service to others today. And that is a lot to be grateful for.

Dr. Steinberg is a geriatrician and hospice/palliative medicine specialist in Oceanside. He is a member of the SDCMS Board of Directors, chairs the CMA Council on Ethical, Legal and Judicial Affairs, chairs the CMA Administrative Medicine Forum delegation, and is a delegate to the AMA House of Delegates on behalf of the Post-Acute and Long-Term Care Medical Association (PALTmed, formerly AMDA).

He has been a hospice and skilled nursing facility medical director in North County since 1995.

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MENTAL HEALTH

988: Transforming Mental Health Crisis Response in San Diego and Beyond

By Eric Rafla-Yuan, MD Introduction In recent years, suicide and other mental health crises have surged, placing immense pressure on emergency services, law enforcement, and healthcare systems. The launch of the 988 Suicide & Crisis Lifeline represents a transformative shift in how we respond to mental health emergencies, designed to provide immediate access to crisis support, connecting individuals in distress with trained mental health professionals instead of police or emergency medical responders.

As physicians in San Diego County, it is imperative to understand how 988 functions, its implications for our practices, and how we can integrate it into patient care. This article explores the history, functionality, benefits, and challenges of 988, as well as its impact on California’s mental health landscape.

The Evolution of 988: A Necessary Reform Fifty years ago, if you experienced a medical emergency, your best option was to call a local emergency number — one that likely routed your call to the police. More often than not, officers would transport you to the hospital in the back of a police car. There were no ambulances, no EMTs, and no specialized emergency medical response teams. In fact, the American College of Emergency Physicians (ACEP) was only founded in 1968, and emergency medicine wasn’t officially recognized as a specialty by the American Medical Association (AMA) until 1972.

Since then, emergency medical services (EMS) have evolved dramatically, with sophisticated ambulance systems, paramedic teams, and trauma centers becoming standard across the country. Yet, despite these advancements, crisis response for mental health emergencies has remained largely unchanged. Too often, when a patient in psychiatric distress needs urgent help, the best available option is still to call 911 — leading to a response from law enforcement and a ride to the hospital in the back of a police car. How is that ethical? How is that reasonable?

Recognizing the urgent need for reform, state and national advocacy efforts have driven the creation of 988, ushering in a new era for psychiatric emergency services. In 2020, Congress passed the National Suicide Hotline Designation Act, officially establishing 988 as the national mental health crisis line. The 988 Implementation Act of 2022 provided essential funding and infrastructure support, ensuring its rollout at the state and local levels.

When 988 went live nationwide on July 16, 2022, managed by the Substance Abuse and Mental Health Services Administration (SAMHSA), it fundamentally changed the landscape of mental health crisis response.

Since its launch, 988 has exponentially increased access to life-saving support, handling millions of calls, texts, and chats from individuals in distress. Callers are now connected directly with trained crisis counselors at one of more than 250 crisis centers across the country, providing immediate, compassionate, and specialized care — without the need for police intervention.

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Too often, when a patient in psychiatric distress needs urgent help, the best available option is still to call 911 — leading to a response from law enforcement and a ride to the hospital in the back of a police car. How is that ethical? How is that reasonable?

IMAGE CREDIT: THE MILES HALL FOUNDATION

988 represents a long-overdue transformation in how we approach psychiatric emergencies. Just as emergency medicine evolved over the past five decades, we are now witnessing a revolution in mental health crisis care — one that prioritizes treatment over punishment and care over criminalization.

The Story of Miles Hall and AB 988 In June 2019, 23-year-old Miles Hall, a young Black man experiencing a mental health crisis, was fatally shot by police in Walnut Creek, Calif. His mother had called 911, seeking help getting her son, who had schizoaffective disorder, to the hospital. Instead of receiving compassionate care, Miles was shot within seconds of their arrival.

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of the support from the 988 Implementation Act and AB 988, California has had great success with responding to calls in a timely fashion. In fact, despite handling more 988 calls than any other state, calls are responded to in approximately 30–40 seconds.

Specialized Services • Veterans Crisis Line: Callers can press “1” to connect with counselors specializing in veteran and military mental health.

• Spanish Language Line: Pressing “2” provides access to bilingual Spanish-speaking counselors.

• LGBTQ+ Services: Press “3” for support tailored to LGBTQ+ youth.

IMAGE CREDIT: WELL BEING TRUST

His tragic death underscored the urgent need for a crisis response system that safeguards the health and lives of patients with mental illness, rather than criminalize them. The advocacy efforts of Miles Hall’s family led to the passage of AB 988—the Miles Hall Lifeline and Suicide Prevention Act — which established a statewide plan for 988 implementation in California.

AB 988, signed into law in 2022, ensures that 988 is more than just a crisis hotline — it is the foundation for a comprehensive mental health crisis response system. The legislation is designed to build a network of trained professionals, crisis intervention teams, and crisis stabilization services, reducing the reliance on law enforcement in mental health emergencies and ensuring that individuals with mental illness receive the timely and quality emergency services, just as we would expect for any other kind of medical emergency.

Key Provisions of AB 988 1. Requires all of California’s 58 counties to have a full crisis continuum of care in place, including 988 directed mobile crisis teams and (non-emergency room) crisis facilities. These services are statutorily required to be respon-

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sive in real time and available 24/7 2. Insurance requirements: insurance companies are not allowed to require pre-authorization or other restrictive criteria on crisis services 3. Sustainable funding: obtained via a small-cent phone fee, in the same way that 911 is funded 4. Continuing oversight of the 988 system by a technical advisory board How 988 Works in California: A Closer Look Support via Phone Call, Text, or Online Chat Anyone experiencing emotional distress or suicidal thoughts can call or text 988 or chat online at 988lifeline. org. The service is free, confidential, and available 24/7 in all 50 states, tribal areas, and US territories.

Immediate Connection to Trained Crisis Counselors Calls are routed based on area code to the nearest 988 crisis center, where trained counselors assess the situation, provide support, and determine appropriate next steps. (Note: The FCC has taken the necessary steps to route calls based on geographic proximity which will likely begin later this year). Because

Coordination With Local Crisis Teams If and when further support beyond just a phone intervention is needed, 988 counselors work with local crisis teams to dispatch mobile crisis units or connect individuals with outpatient services — which leads to less unnecessary hospitalizations or police involvement.

Future Challenges and Considerations Workforce and Funding Shortages As with other mental health workforce shortages, 988 centers nationwide are continuing efforts to hire and retain enough trained counselors to meet rising call volumes. Long wait times could undermine trust in the system, leading some individuals to

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In fact, despite handling more 988 calls than any other state, calls are responded to in approximately 30–40 seconds.

If you or someone you know is struggling or in crisis, confidential help is available.

Call or text 988 or chat online at 988lifeline.org You’ll be able to speak with a trained crisis counselor any time of day or night.

resort to 911 instead. Additionally, while 988 aims to dispatch mobile crisis teams instead of law enforcement, some regions may lack sufficient mobile crisis units. Without adequate community-based support, some calls may still result in police involvement or emergency department referrals.

These concerns are greater outside of California, and especially for those that live in states that have not supported 988 and crisis service implementation.

Awareness and Public Education Many Americans remain unaware of 988 or misunderstand its purpose.

Physicians can play a crucial role in educating patients, families, and communities about 988 as an essential resource for psychiatric emergencies.

What Physicians in San Diego Can Do Educate Patients and Families Inform patients with mental health concerns about 988 and how it can help.

Encourage families and caregivers to utilize 988 during mental health crises.

Advocate for Better Crisis Services Support local and state funding initiatives to expand 988 services and mobile crisis response teams.

Incorporate 988 Into Clinical Practice Include 988 information on discharge paperwork for patients at risk of crisis.

Ensure that all paperwork is updated and no longer references the prior national suicide prevention lifeline (i.e.

1-800-273-TALK) Train clinic staff on the appropriate process for utilizing 988 should an incident arise for a patient or staff member on site.

The Future of 988 in San Diego County While 988 is still in its early stages, it holds immense promise for transforming mental health crisis response. San Diego is already home to one of California’s thirteen 988 call centers. We are

IMAGE CREDIT: ERIC RAFLA-YUAN

already seeing 988 signs in San Diego shopping centers, on student IDs, and on billboards around the county. As 988 continues to become more integrated and accessible, it will require ongoing investment in staffing, crisis infrastructure, and public education. With continued support from physicians, patients and families, and policymakers — 988 will increasingly be a lifesaving resource for our community.

Further Resources “Decoupling Crisis Response from Policing — A Step Toward Equitable Psychiatric Emergency Services” (The New England Journal of Medicine) https://www.nejm.org/doi/full/10.1056/ NEJMms2035710

988 Suicide & Crisis Lifeline 988lifeline.org 988 FAQ https://www.samhsa.gov/mentalhealth/988/faqs CalOES 988 Technical Advisory Board https://www.caloes.ca.gov/office-of-thedirector/operations/logistics-management/public-safety-communications/ ca-9-1-1-emergency-communicationsbranch/ca-9-8-8-information/ California 5-year 988 & Crisis Services Implementation Plan https://www.chhs.ca.gov/wp-content/ uploads/2025/01/AB-988-Five-YearImplementation-Plan-Final-ADA-Compliant.pdf

Dr. Rafla-Yuan serves on the SDCMS board and as a delegate to CMA’s House of Delegates. In 2022 he served as senior staff director for a bipartisan 988 and Crisis Services Congressional Task Force, and in 2023 was appointed by Gov. Gavin Newsom to the California 988 Technical Advisory Board, where he serves as equity and accessibility working group chair. He is chief financial officer for the Social Determinants of Health Network and is vice president of AGLP: The Association of LGBTQ+ Psychiatrists, the oldest LGBT professional organization in the United States.

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CHILDREN’S HEALTH

California Children’s Services: Transitioning Youth and Young Adults With Complex Healthcare Needs to Adult Planning

By Rebecca Conrad, MPH THE STATEWIDE CALIFORNIA Children’s Services (CCS) program provides medical case management services for eligible children and youth with specific physical, complex and/or chronic health conditions or diseases.

The medical case management services include helping children and youth get linked to special doctors, including outof-county and out-of-state specialists, and providing referrals to other agencies, such as public health nursing and regional centers. CCS case managers also ensure clients have all the medical supplies, equipment, and rehabilitation care prescribed by their specialists.

The CCS program, as part of receiving federal Title V Maternal and Child Health funds, is required to report annually on several critical performance measures and periodically survey families of children and youth with special healthcare needs on their priorities and unmet needs. One of the performance measures requires that “all youth with special healthcare needs will receive the services necessary to make transitions to all aspects of adult life, including adult healthcare, work, and independence.” This is stated in the background of the Department of Health Care Services (DHCS) statewide guidelines for healthcare transition planning for children with special healthcare needs (CCS Information Notice: No.: 10-02, 2010).

Since CCS support ends when a client turns 21, the California Department of Health Care Services mandates Transition to Adulthood Planning (TP) begin when clients turn 14 so they have plenty

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Vista TP Workshop, 2023

of time to prepare for their future after CCS services end.

Locally, the County of San Diego CCS program strives to assist caregivers by providing planning tools to make the transition into adulthood easier.

The County of San Diego CCS Program aims to have over 90% of our clients, aged 14 and over, whose medical record indicates a condition that requires a transition plan, have documentation of a transition planning assessment.

This early intervention and assessment help to provide a smooth transition of services for young adults who may need specialty medical services after their 21st birthday. Ensuring CCS clients have an established primary care provider for their adult care can mitigate gaps in service. Early transition planning intervention and assessment also allows necessary medical referrals and services to continue, without gaps, once the CCS client is no longer under CCS medical case management.

The County of San Diego CCS pro-

gram’s best practices for transition planning includes having CCS public health nurses, occupational therapists, and physical therapists review cases, and documenting whether transition planning is needed for clients aged 14, 16, 18, and 20. If they determine TP is needed, they will provide initial information to families. During the early stages of transition planning, occupational and physical therapists develop therapeutic objectives based on the life and vocational goals that CCS youth and their families seek to achieve as they transition to adulthood. CCS social workers then contact all clients turning 18 and 20 to offer individualized TP resource assessments. The assessments determine key action items to consider, and from these items a checklist is created to work on with the client before transitioning out of CCS services. CCS social workers, case managers, and therapists also provide additional resources and referrals to outside services that CCS families and clients can utilize once

they transition out of CCS medical case management. Social workers also meet with families to review the transition planning assessment and checklist to ensure all documentation for the CCS client’s transition planning is completed prior to their 21st birthday.

Each CCS staff involved in the client’s case management has roles and responsibilities to help aid in transition planning. This ensures CCS clients are more prepared when transitioning out of CCS care. However, medical providers and community partners who support children and youth with special healthcare needs also play a critical role in ensuring these youth transition smoothly. In San Diego County, a committee of CCS case management staff and community partners hold TP workshops, in-person or virtually, twice a year for clients who have a medical condition that will not resolve prior to age 21 and are age 17 and older. These workshops are a collaboration between the CCS program and community partners such as MediCal Managed Care Plans, San Diego Regional Center, Exceptional Family Resource Center, In-Home Supportive Services, Legal Aid Society, San Ysidro Health-Waiver Program, and various other vendors who serve youth and adults with disabilities. They can provide information on adult health insurance, community resources, legal conservatorship, durable medical equipment, and other transition to adulthood resources.

How can medical healthcare providers assist CCS clients with transition planning? Kathy Griffee, a CCS public health nurse supervisor, suggests that a best practice is to begin discussing with the client at age 18 about the possible transfer to a new adult specialist who will accept their primary insurance. If primary care providers can prepare CCS clients and assist with transition planning, there will be a smooth shift in care when the client turns 21 years old. Griffee adds that if the CCS-eligible condition is chronic and/or debilitating, community resources may be needed. Medical providers can help by advising families

to call the local CCS office and ask to speak with the assigned social worker to assist the client and family. Additionally, when the client is authorized for a Special Care Center (i.e., Endocrine, Hematology/Oncology, Rehabilitation), the primary care physician, the client, or the family can request transition planning assistance from the Special Care Center Team. It is always best to address transition planning needs early to avoid abrupt changes to new providers.

Jahari Weir, a CCS Health Services social worker, states that social, educational, or career goals will also need to be assessed when beginning transition planning. A client’s goals will determine what support resources they may need as they become an adult, so asking specific questions is key to understanding their needs. Community resources that can assist in this area include the Legal Aid Society of San Diego (to discuss the possibility of a conservatorship), In-Home Supportive Services (IHSS), Supplemental Security Income (SSI), and Aging and Independent Services (AIS).

Weir also mentions that a best practice is to have a conversation with caregivers before a CCS client’s 18th birthday to explain how transition planning begins.

This can help caregivers better understand transferring medical care after their 21st birthday.

While CCS assists patients and caregivers with transition planning, having everyone on the care team be proactive in the process will help ensure clients have linkages to all the care providers they need after they turn 21.

As medical care providers, it is essential to fully understand the needs of the CCS clients and their expectations. CCS

“

If primary care providers can prepare CCS clients and assist with transition planning, there will be a smooth shift in care when the client turns 21 years old.

aims to make transition planning easier for clients and caregivers by providing them with the tools to thrive. The CCS medical case management team promotes the use of transition planning questionnaires, guides, workshops, and meetings with CCS clients. CCS clients and caregivers will need to understand the use of referrals, how to access managed care plans, what services they will need, and how to work with new medical care providers once they transition into adult managed care. Medical care providers could ask key questions about conservatorships, release of information (ROIs), and request CCS staff to review a client’s case to ensure their transition planning needs are met. By creating an inclusive approach and personal support for CCS clients and caregivers, it can bridge the gap between the medical components of their needs and provide a holistic approach.

Rebecca Conrad received her Master of Public Health with a concentration of health promotion and health education from California State University San Marcos. She currently works with California Children’s Services (CCS) as a community health promotion specialist II. She strives to bring accessible resources to CCS clients and families. Her passion for networking helps builds connections within the County of San Diego.

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11

TELEHEALTH

Telehealth Companies Boost Ad Spending While Taking on More Complex Medicine

By Darius Tahir SHANNON SHARPE WAS HAVING one of those 15-minutes-of-internetinfamy moments. Social media blew up in September after the retired Denver Broncos tight end — accidentally, he later said — broadcast some of his intimate activities online.

One of his sponsors took advantage of the moment: the telehealth company Ro, which sells a variety of prescription medicines for erectile dysfunction and hair and weight loss. The company revved up a social media campaign on the social platform X for an ad in which Sharpe boasted about his experience with the company’s erectile dysfunction medications, a company spokesperson confirmed.

The ads were more than just a passing attempt to hitch a corporate caboose to a runaway social media locomotive. A group of direct-to-consumer telehealth companies have become omnipresent across just about all media formats, seeking patients interested in their low-stigma, low-fuss, low-touch, highconvenience health products.

They’re on your favorite podcasts and in the background on the cable TV in your gym. Thirteen telehealth entities spent a combined $111 million in 2023 on television ads, more than double the sum in 2019, according to an analysis from iSpot.tv, a television ad-tracking company, provided to KFF Health News.

The ads feature high-wattage celebri-

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ties such as Jennifer Lopez as well as lesser-known influencers who are paid four figures to post a snapshot or short video to Instagram, according to interviews with marketers. Three publicly traded telehealth companies spent a total of more than $1.4 billion on advertising, sales, and marketing in 2023, according to financial reports filed with the Securities and Exchange Commission, categories that reflect the extent of their online efforts.

The companies’ advertising typically emphasizes convenience in a healthcare system that’s often just the opposite. They promise judgment-free birth control or care for conditions like erectile dysfunction and hair loss that have traditionally been stigmatized. As the companies expand, they’re venturing into more complex kinds of medicine, such as care for mental health conditions and obesity.

Services that telehealth companies offer, critics warn, may shortchange patients in need of close, sensitive attention. Researchers differ on telehealth services’ quality, with some saying telehealth companies offer little follow-up and inconsistent care from a revolving cast of doctors.

Still, they agree the care is fundamentally different from the traditional style.

A company’s model can “kind of flip what you’re taught at medical school on its head,” said Ateev Mehrotra, a Brown

University professor of public health who studies telehealth.

Typically, he said, a patient goes to the doctor with a complaint; there, the parties figure out a diagnosis and, if appropriate, a medication. By contrast, he said, telehealth companies’ advertising invites patients to make their own diagnoses, while pairing them with clinicians who, if they confirm their conditions, prescribe medicines the patients already think they want.

Under this style of medicine, the clinician is “now a screener, and you just want to make sure that that medication is safe for that patient,” Mehrotra said.

The model may work for certain kinds of care, Mehrotra said, such as birth control. He and some colleagues conducted a study in which they recruited patients with standardized backstories to patronize startups offer-

ing contraceptive medicines over the internet. Generally, the study found, the services performed well.

Harley Diamond, a patient at Nurx, a startup offering birth control prescriptions and other services, offers an example of how these companies can work well in some circumstances. After she saw an Instagram ad, she signed up to get birth control. She lives in Tennessee, a red state where it can be difficult to access contraception: Local clinics have closed and an arsonist burned down a Planned Parenthood. (The facility recently reopened.)

But when she turned to Nurx for her mental health, she found the service confounding and its convenience lacking.

The company’s app sends her frequent questionnaires about symptoms and reactions to drugs, she said. “There is no comforting face to validate you,” she

wrote in an email to KFF Health News.

The questions were the same each time, and she said she spoke with a new doctor in every interaction.

“It can feel like you’re having to start from scratch explaining yourself to someone new every month,” she said.

When she expressed concerns — for example, about side effects of an antidepressant she was taking — it would take “days, generally,” to hear back, with no change in her protocol, she said. Often, she said, her messages would get no response at all.

Rajani Rao, senior vice president at Nurx, said the company is “constantly working” to improve response times, “especially as we experience a high volume of patient care requests.” In mental health, the majority of Nurx’s patients experience elimination of symptoms after six months of treatment, she said.

Rao also referred to Nurx as providing an “integrated care team,” using language echoed across the industry.

Ro, for example, says its care is available in the time and format of its patient’s preference and that it audits the quality of its services.

Continuous care is crucial to make sure mental health patients are on the right doses of medications and that they’re not experiencing side effects, said Reshma Ramachandran, an assistant professor of medicine at Yale who has conducted her own secret-shopper study of telehealth sites.

What’s more, research shows many mental health medications are best paired with therapy, Ramachandran said.

Ramachandran thinks frustrations like Diamond’s might be widespread, based on her team’s research. She said she’s frustrated at the “very groovy, glossy” picture painted by telehealth ads.

Ramachandran said her study is still under consideration for publication in medical journals. But she provided preliminary results to congressional offices examining the telehealth sector.

Last year, Sen. Dick Durbin, an Illinois Democrat, and former Sen. Mike Braun, an Indiana Republican, introduced legislation to regulate some telehealth advertising practices. A spokesperson for Durbin said he intends to reintroduce the bill this year.

Darius Tahir is a correspondent for KFF Health News, where this article first appeared, and is based in Washington, DC. He reports on health technology with an eye toward how it helps (or doesn’t) underserved populations; how it can be used (or not) to help government’s public health efforts; and whether or not it’s as innovative as it’s cracked up to be.

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PSYCHIATRY

Study Challenges Schizophrenia Guidelines Lower Risk of Second Relapse After Switching to Clozapine, Cohort Study Shows By Paul Smyth, MD

SWITCHING TO CLOZAPINE AFTER a first schizophrenia relapse was associated with a lower risk of second relapse compared with other strategies, a population-based cohort study in Finland found.

The risk of a second relapse was lower with a switch to clozapine compared with continuing any non-clozapine oral antipsychotic monotherapy (57.1% vs 73.2%, adjusted HR 0.66, 95% CI 0.49–0.89), reported Heidi Taipale, PhD, of the University of Eastern Finland in Kuopio, and co-authors.

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Switching to another non-clozapine oral antipsychotic monotherapy (adjusted HR 0.99, 95% CI 0.76–1.28) was just as ineffective as not using an antipsychotic (adjusted HR 1.07, 95% CI 0.80–1.42), the researchers wrote in Lancet Psychiatry.

The findings challenge current guidelines recommending clozapine as a third-line treatment, which can lead to long delays in starting the drug, Taipale and colleagues observed.

“When a person with first-episode schizophrenia has a first psychosis

relapse despite the use of non-clozapine oral antipsychotics, continuation with the same antipsychotic or a switch to another non-clozapine oral antipsychotic is not beneficial in relapse prevention,” they wrote. “Instead, clozapine initiation should be considered as part of shared decision-making with the person with schizophrenia and carers.”

Clozapine is recommended for the third of people with schizophrenia who have not responded to two or more conventional antipsychotics, noted Sameer Jauhar, MBChB, PhD, of King’s College in London, England, and co-authors in an accompanying editorial.

The current study “questions that orthodoxy and asks whether clozapine should be offered after first-line antipsychotic treatment failure,” setting the scene for a randomized controlled trial of clozapine after an initial antipsychotic has failed, they wrote.

Although clozapine has been available since the 1950s, and despite being the only licensed treatment for treatment-resistant schizophrenia, it continues to be underused for a variety of reasons, Dr. Jubal and colleagues suggested, including a need for close blood monitoring and a side-effect profile of constipation, hypersalivation, and weight gain. In the U.S., possible barriers include a risk evaluation and mitigation strategy (REMS) program designed around clozapine’s risk for severe neutropenia.

If clinical trials show benefit, “the issue for the field will be implementation, addressing legitimate concerns about side effects through better monitoring and adjunctive treatment, and how benefits and risks of clozapine are conveyed to clinicians, patients, and their families,” the editorialists observed. “The question will therefore not be should we offer clozapine, but how do we offer clozapine?”

Guidelines from the American Psychiatric Association (APA) recommend clozapine for treatment-resistant schizophrenia or when the risk for

suicide attempts or suicide remains substantial despite other schizophrenia treatments. The APA guidelines also suggest clozapine when the risk for aggressive behavior remains substantial despite other treatments.

Taipale and colleagues evaluated 3,000 people ages 45 or younger who had first-episode schizophrenia and were hospitalized with a first relapse from 1996 through 2014. All were included in the Finnish hospital discharge register. None had been taking antipsychotics in the year preceding initial diagnosis or hospitalization, and all had a relapse within five years of discharge from their initial hospitalization.

The mean age was 30 years and 35.6% were women. Before the first relapse, most participants were either not using antipsychotics (45.5%) or were using

non-clozapine oral antipsychotic monotherapy (32.4%). Of the 3,000 patients in the overall cohort, 71.7% had a second relapse within two years.

Treatments were assessed during the 30 days before hospitalization for the first relapse and 30 days after discharge, and were classified as long-acting injectable antipsychotics, clozapine, non-clozapine oral antipsychotic monotherapy, non-clozapine oral antipsychotic polypharmacy, or nonantipsychotics.

Long-acting injectables have shown benefits in patients with first-episode schizophrenia and this study extends these findings, Taipale and co-authors noted. In this cohort, initiating a longacting injectable in antipsychotic nonusers was associated with a decreased risk of a second relapse relative to non-

use (adjusted HR 0.67, 95% CI 0.53-0.84).

Taipale and colleagues acknowledged that treatment changes later than 30 days after discharge and before a second relapse were not included in the study. It was likely that non-clozapine oral antipsychotic treatments were discontinued by patients, resulting in high relapse rates, they noted.

Finland’s healthcare system provides reimbursed medications and access to healthcare services with very low cost, and findings may not be generalizable to other settings. The study also did not include all schizophrenia-spectrum disorders.

Dr. Smyth is a contributing writer to MedPage Today, where this article first appeared.

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15

ONCOLOGY/HEMATOLOGY

Obesity in Lung Cancer Patients Linked to Longer Survival Association Driven by Patients Who Did Not Have Low Skeletal Muscle Mass or Myosteatosis

By Mike Bassett OBESITY WAS ASSOCIATED WITH improved overall survival (OS) after curative resection in patients with nonsmall cell lung cancer (NSCLC), particularly those who did not have low skeletal muscle mass (LSMM) or myosteatosis, according to a retrospective study from South Korea.

Among more than 7,000 patients, those who were categorized as having obesity (body mass index [BMI] ≥25) had a 21% reduced risk of death compared with patients without obesity (HR 0.79, 95% CI 0.71–0.88, P<0.001) — an association driven by patients who did not have LSMM or myosteatosis (HR 0.77, 95% CI 0.66–0.90, P=0.001), reported Juhee Cho, MA, PhD, of Sungkyunkwan University and Samsung Medical Center in Seoul, and colleagues.

The associations between obesity and lower mortality were observed only in male patients (HR 0.72, 95% CI 0.60– 0.85, P<0.001) and patients who had ever smoked (HR 0.71, 95% CI 0.60–0.85, P<0.001) who did not have LSMM and myosteatosis, they noted in Radiology.

Cho and colleagues also evaluated recurrence-free survival and found that patients with obesity had a 13% lower risk of recurrence or death versus those without obesity (HR 0.87, 95% CI 0.78–0.98, P=0.02). However, when classified according to skeletal muscle status, the difference in the risk of recurrence or death between patients with or without obesity did not reach statistical significance, regardless of LSMM and/or myosteatosis status.

The authors noted that the results align with those of previous studies that emphasized the role played by skeletal

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muscle mass in the “obesity paradox,” in which patients with cancer and obesity seem to have better survival than their counterparts without obesity.

“Based on the findings of this study, it is proposed that patients with obesity whose skeletal muscle quality and quantity are preserved may drive the obesity paradox, emphasizing the essential contribution of skeletal muscle to this phenomenon,” they wrote.

“Although BMI is a useful and practical tool for initial assessment, it should be complemented by detailed body composition measurements to better understand the obesity paradox in nonsmall cell lung cancer,” they added.

In an editorial accompanying the study, Michael W. Vannier, MD, of the University of Chicago, observed that the association between obesity and lung cancer is “complex,” and that one of the takeaways of the study is that the use of BMI to measure adiposity is limited, and the method of measuring sarcopenia in NSCLC “is crucial.”

Thus, BMI as a measuring stick should be augmented with sarcopenia metrics, Vannier noted. “Deep learning tools to extract these metrics such as sarcopenia are already available, and further development of predictive models using probabilistic models is promising to unravel the fundamental basis of the obesity paradox in cancer.”

For this study, Cho and colleagues included 7,076 Korean patients with NSCLC who underwent curative resection between January 2008 and December 2019. PET/CT scans were evaluated using commercial deep learning software and the results were used

to estimate OS and recurrence-free survival and multivariable-adjusted hazard ratios for subgroups based on BMI and muscle mass.

Mean age of the patients was 62.5 years, and 61% were men. About 80% had adenocarcinoma, and 72% had stage I disease. Median follow-up was 60.9 months.

Of these patients, 64.5% did not have obesity, including 3.2% who were underweight (BMI <18.5); 52.9% had standard weight (BMI range 18.5-22.9); and 43.8% were categorized as overweight (BMI range 23-24.9). A total of 2,512 patients (35.5%) had obesity, with 8.4% having a BMI of ≥30.

Of the patients in the obesity group, 5.1% were identified as having LSMM and 41.4% were found to have myosteatosis.

The authors acknowledged that their study had several limitations, including the fact that it consisted only of Korean patients with a low prevalence of morbid obesity and who mostly had early-stage disease.

“Future research is warranted to determine if these associations persist in other populations,” they wrote.

Mike Bassett is a staff writer for MedPage Today, where this article first appeared.

NEW STATE LEGAL REQUIREMENTS

New State Law Requires TB Screening in Adult Primary Care; CDPH Hosting Best Practices Webinar

By California Medical Association Staff WHAT YOU NEED TO KNOW: A new state law requires adult patients receiving primary care services to be offered a TB screening test if risk factors are identified. CDPH is offering a free webinar on April 24 that will cover best practices for latent TB screening and treatment.

On Jan. 1, 2025, a new law took effect to address the preventable suffering and death caused by tuberculosis in California. An estimated 2 million Californians are infected with tuberculosis (TB). AB 2132, authored by Assemblymember Evan Low (D-Silicon Valley), requires adult patients receiving primary care services to be offered a TB screening test if risk factors are identi-

fied, and if the patient’s health insurance covers it, followed by provision or referral for appropriate follow-up care.

Before the onset of the COVID-19 pandemic, TB was the top infectious disease killer worldwide, claiming more than 1.5 million lives every year.

Californians are disproportionately affected by the disease, with about 2,000 Californians diagnosed with active TB disease every year and over 2 million Californians infected with the bacteria but not yet sick. California’s tuberculosis incidence is nearly double that of the national incidence rate.

Of the more than 2 million Californians with latent TB infection, only 20% are aware of their diagnosis and

only 12% have been treated. TB disproportionately impacts subgroups defined by race, ethnicity, and place of birth in California and urgently needs addressing from a health equity lens.

The Important Role of Physicians Primary care providers serve a critical role in identifying patients with risk factors for TB infection. Because there is not an effective vaccine, the most promising tool in the fight against TB is diagnosing and treating latent TB infection, as recommended by the California Department of Public Health (CDPH), the Centers for Disease Control and Prevention, and the U.S. Preventive Services Task Force.

The CDPH Tuberculosis Control Branch is hosting a free webinar for physicians on April 24 from 12 to 1:30 p.m. that will cover best practices for latent TB screening and treatment. Registration is open now for this webinar.

Please contact CDPH TB Control Branch at TBFreeCATraining@cdph. ca.gov with any questions.

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17

OPINION

So-Called ‘DEI’ and So-Called ‘Meritocracy’

By James Santiago Grisolia, MD

SINCE HIS FIRST DAY, INCOMING President Donald Trump has issued a torrent of executive orders, among them to expunge all DEI (Diversity, Equity and Inclusion) programs in any federal department or agency, forbidding even the mention of the DEI words, while encouraging whistleblowers to snitch on any colleagues who persist in espousing diversity in any of its forbidden forms. Programs are axed, employees are furloughed, snitch hotlines are being set up.

Apart from his likely longstanding personal animus against diversity, Trump’s war against DEI initially seems calibrated to appeal to his electoral base. We in healthcare know the value of diversity and view it differently.

We take care of patients from all genders, all ethnicities, all income levels, and know that special needs require special accommodations. We know that Latino docs can take better care of Latino patients, that Black docs can take

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better care of Black patients, and that each patient needs attention to his, her, or their particular, individual needs.

We know that social determinants of health make a huge difference in health outcomes, sometimes bigger than our own personal efforts as clinicians. We know the difference between “equality” and “equity”: folks with poor access to food, to shelter, or to medical care need access issues addressed to even the playing field.

So where comes this animus against DEI, even to forbid the words, or the concepts under another name? Many White Americans say they’re tired of talking about race, tired of quotas, and suspicious that unqualified people get hired or accepted to school, sometimes over themselves or their children. During the presidential campaign, many Trump supporters called Kamala Harris a “DEI hire,” also using this term against other people of color, LGBTQ, or even people with

a disability. Oddly, President Trump tried to blame the recent American Airlines-military helicopter crash over Washington, DC on “DEI hiring.” This irrational comment was meant to underscore the pervasive and insidious nature of hiring people with disabilities, of suspicious genders or ethnicities, even in an arena where technical competence already dominates.

Mainstream American culture believes in meritocracy and the importance of the individual. Our shared American values emphasize individual achievement, trusting that a talented, hardworking individual will rise economically and professionally despite prejudice, despite economic odds, despite it all. Horatio Alger is tattooed on our brains, our bones. Any attempt at affirmative action, of trying to correct prior inequities by encouraging racial or other diversity, raises suspicions that, somehow, less qualified candidates get accepted to school, to jobs, to life through “DEI hires” while more deserving, usually White male, candidates get passed over.

Trump’s Executive Order of Jan. 21 was even titled “Ending Illegal Discrimination and Restoring Merit-Based Opportunity,” explicitly contrasting hiring for diversity with allowing technical merit as the only criterion. However, Trump’s overall program clearly turns “meritocracy” on its head.1 Trump’s actions before and during this second term clearly show that the new meritocracy has nothing to do with actual merit, in the sense that better test scores, higher training, or even relevant experience might determine who is the best appointee. His appointees vary wildly, as highlighted by their Senate confirmation hearings, rarely with relevant work experience to their proposed positions. Their only unifying characteristic: unwavering loyalty to Trump and to his program.

Multiple authors collaborated in writing Project 2025 for The Heritage Foundation. Many of the authors served in the first Trump administration and are serving again in the second. While

Trump repeatedly distanced himself from Project 2025 during the election campaign, in fact his initial actions faithfully follow its playbook.2 In particular, this conservative manifesto advocates for reducing the number of civil service employees and making it easier to fire them. Indeed, Trump’s new spate of executive orders include restoring his prior Schedule F, where civil servants may be fired for “failing to implement administration policies.” Famously, he’s also encouraged civil service employees to take a resignation package he calls “Fork in the Road,” but he and others have told multiple departments to prepare for layoffs.

In addition to a commitment to downsize the federal government, it’s clear that the new meaning of “meritocracy” will be personal loyalty to President Trump. Eliminating DEI, while perhaps arising from white

fragility3 and a desire by the authors of Project 2025 to reduce Black and Latino influence in government, at this point is being used by the Trump administration as a pretext for firing individuals and entire sections within departments that might obstruct his agenda. The impacts on healthcare, public health, and biomedical research are only beginning to be felt.

Editor’s Note: San Diego Physician magazine welcomes differing opinions on this topic from readers. Please contact kevinjspillane@gmail.com for information on submitting an opposing view for our magazine.

References 1. Jason Stanley. “We are witnessing the rise of a new Republican ‘Southern Strategy’ How to make sense of the Trump administration’s attacks on Diversity, Equity and Inclusion,” The Guardian, Mon 10 Feb 2025 2. Melissa Quinn. “Where Trump Policies and Project 2025 Proposals Match Up,” CBSNews.com, February 3, 2025 3. Robin Diangelo. White Fragility, Beacon Press, Boston. 2018

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

PLACE YOUR AD HERE FEBRUARY 2020

Official Publication of SDCMS

MARCH 2020

Official Publication of SDCMS

Celebrating 150 Years

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

Artificial Intelligence and Medicine THE DEBATE

PREVENTION DIABETES Reversing the Risks

DEMENTIA Reducing the Burden How to Engaging Patients GUN SAFETY

BUILD TRUST

BREAST CANCER Preventing Deaths

in 15-Minute Office Visits

Contact Jennifer Rohr 858.437.3476 • Jennifer.Rohr@SDCMS.org

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19

CHAMPIONS FOR HEALTH

Axel and his family

Sharing Memories Now

By Adama Dyoniziak “WE WERE ABLE TO BE HONEST about what we were feeling,” says Axel.

“We discovered things about ourselves as a family and we were vulnerable.”

The 18-year-old spoke of the rarity of conversations with family members about loving and caring for each other while they are still alive, instead of in memories when they pass away. “The time together helped me with my stress,” he continues. Not only was he practicing skills to manage stress, but the conversations and time with his family made him feel less stressed.

Champions for Health received a grant from The Conrad Prebys Foundation in 2024, which expanded Project Access San Diego (PASD) to address the identified emotional support needs of youth involved in caregiving for adults

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receiving specialty care consultations and surgeries. The new program, “Supporting the Emotional Well-Being of Youth Caregivers and their Families,” provides in-home services to overburdened youth and their family members.

Using sensory and cultural activities, family members relearn how to connect with each other over nine sessions.

Youth and parents discuss their needs, strengths, and concerns as a family. Each session consists of a sensory activity, psychoeducation, and time for connection and discussion. Youth identify what sensory activities may soothe them and how to access that information for grounding and self-care during stressful situations.

Axel is the oldest child in his family, which includes his father, mother, and

16-year-old sister. Axel participated in all sessions with his family. He said that the sensory experiences were new, not an activity that he had participated in before, and that it took getting used to. “Having time together, that regular time each week, us being all together, that was what changed,” he explains.

“That was what made the difference.”

One activity stood out to Axel, in which a picture was viewed by each family member, and they shared what they saw. They spoke about how each of them has their perspective and sees the same picture in a different way.

According to Axel, “this topic and talking about how we are not the same, we don’t see things the same, talking about that helped us better connect and appreciate each other.”

When asked if he would recommend the program to other young people, Axel said that he already thought about a couple of people he knew would benefit. “I would tell them that your family gets strengthened,” he says.

“These are things we would never have done, and maybe things we would not have said. It will help you understand each other, realize you all love each other very much, and learn to say these types of things out loud. … These kinds of programs can help us break some of the generational barriers we face, and address traumas from the past. If not us now, then who?”

Join Champions for Health with your contribution for youth and their families to reconnect after the trauma of long-term illnesses. Thank you for making San Diego the healthiest place to live. www.championsforhealth.org/ donate

Adama Dyoniziak is executive director of Champions for Health.

CLASSIFIEDS PRACTICE ANNOUNCEMENTS

PHYSICIAN POSITIONS WANTED

VIRTUAL SPEECH THERAPY AVAILABLE: Accepting new pediatrics and adult patients. We accept FSA/HSA, Private pay, Medicare, Medi-Cal, and several commercial insurance plans pending credentialing. Visit virtualspeechtherapyllc.org or call 888-855-1309.

PART–TIME CARDIOLOGIST AVAILABLE: Dr. Durgadas Narla, MD, FACC is a noninvasive cardiologist looking to work 1-2 days/ week or cover an office during vacation coverage in the metro San Diego area. He retired from private practice in Michigan in 2016 and has worked in a San Marcos cardiologist office for the last 5 years, through March 2023. Board certified in cardiology and internal medicine. Active CA license with DEA, ACLS, and BCLS certification. If interested, please call (586) 206-0988 or email dasnarla@gmail.com.

PSYCHIATRIST AVAILABLE: Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

PHYSICIAN OPPORTUNITIES VENOUS DISEASE SPECIALIST | NORTH COUNTY: La Jolla Vein & Vascular, the premier vein care provider in San Diego, is seeking a highly skilled and experienced Venous Disease Specialist to join our team at our newest location in Vista, CA, nestled in the stunning coastal region of North County San Diego. This full-time position offers competitive salary and benefits, including profit-sharing and a 401(k). Our state-of-the-art facility operates Monday through Friday, with no weekend or night shifts, promoting an excellent work-life balance. 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] FAMILY MEDICINE/INTERNAL MEDICINE PHYSICIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide outpatient care for acute and chronic conditions to a diverse adult population.

San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care and participating in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@ sdfamilycare.org or call us at (858) 810-8700.

OFFICE SPACE / REAL ESTATE AVAILABLE 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) 271-0476 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 highend 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 619-7765295 or noxwins@hotmail.com. Available immediately.

RENOVATED MEDICAL OFFICE AVAILABLE | EL CAJON: Recently renovated, turn-key medical office in freestanding singlestory 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) 9168393 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 Laser, 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 onsite 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.

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 Tri-City 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/JPF04188/apply 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/JPF04189/apply

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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