Official Publication of SDCMS
Celebrating 150 Years
COVID-19 AND PATIENT SAFETY in the Medical Office
Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder
VOLUME 108, NUMBER 1
OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, MD
COVID-19 and Patient Safety in the Medical Office By Debbie Kane Hill, MBA, RN, CPHRM, CPPS
Urgent Request to Help Fight the Fentanyl Crisis in San Diego By Roneet Lev, MD, Steven Campman, MD, Wilma Wooten, MD, MPH, Summer Stephan, Esq., and Robert Brewer, Esq.
Briefly Noted: SDCMS Offices Go Virtual • Public Payers • Payer Issues • Drug Prescribing/ Dispensing • COVID-19
13 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.]
California Surgeon General’s Report Provides Cross-Sector Roadmap to Address Health and Societal Impacts of Adversity By Cate Powers
Keep a COVID-19 Diary: Document Now in Case of Future Lawsuits By Debbie Kane Hill, MBA, RN, CPHRM, CPPS
The Judgments and Opportunities in Being Different By Helane Fronek, MD, FACP, FACPh
Private Rights and Public Health: The Perennial Trade-Off Revealed by COVID-19 By Daniel J. Bressler, MD, FACP
Classifieds SanDiegoPhysician.org 1
BRIEFLY NOTED 2
SAN DIEGO COUNTY MEDICAL SOCIETY
After 15 Years, SDCMS Moves Out of Offices: Going Virtual AFTER 15 YEARS, THE SAN DIEGO County Medical Society has moved out of our offices in Suite 250 at 5575 Ruffin Road in Kearny Mesa, and our staff is working remotely permanently. The staff has been working successfully remotely from their respective homes since the COVID-19 pandemic necessitated the first stay-athome order in March. SDCMS’s lease had already been set to expire in December, so the move is now effective. The mailing address for SDCMS will be 8690 Aero Drive, Suite 115-220, San Diego, CA 92123. The phone number remains the same, (858) 565-8888, as does the fax number, (858) 569-1334. Champions for Health, the Medical Society’s nonprofit organization dedicated to providing healthcare assistance to San Diego County’s medically underserved communities, is moving into new offices at the United Way Building at 4699 Murphy Canyon Road, Suite 102, San Diego, CA 92123. Paul Hegyi, CEO of SDCMS, explained the decision to go virtual as a practical way to cut costs and increase organizational efficiency. “We are always looking for ways to reduce expenses and work as effectively as possible,” he says. “Staff productivity has increased while many costs have dropped during this period of remote work, and our Executive Committee decided to make this a permanent setup that reflects the benefits of technological innovation and realities of work in the 21st century. We are excited about this new chapter, which comes at the end of the 150th anniversary year of the San Diego County Medical Society.”
CMA Publishes COVID-19 Vaccine Resource Center CALIFORNIA IS IN THE FIRST STAGE OF vaccinating individuals against SARS-CoV-2, the virus that causes COVID-19. News on the availability, distribution and administration of these vaccines is changing quickly. As we have throughout this pandemic, the California Medical Association (CMA) has curated resources for physicians to follow the latest information on all things vaccine-related, including the latest information from state officials and your frequently asked questions about the vaccine. You can find the new CMA vaccine page at https://www.cmadocs.org/covid-19/vaccine.
TrusT DRUG PRESCRIBING/DISPENSING
CMS Delays Enforcement of E-Prescribing Requirement for Controlled Substances IN 2018, CONGRESS PASSED THE SUPPORT Act — the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act—to address the opioid crisis. This law requires electronic prescribing for schedule II–V controlled substances covered under a Medicare Part D or Medicare Advantage prescription drug plan beginning Jan. 1, 2021. The Centers for Medicare and Medicaid Services (CMS) in the 2021 proposed physician payment rule floated the idea of
postponing the electronic prescribing for controlled substances requirement until 2022 due to the ongoing COVID-19 public health emergency. While the final rule did not postpone implementation of this requirement, it does set a compliance date of Jan. 1, 2022. According to CMS, this was done to encourage prescribers to implement e-prescribing of controlled substances as soon as possible, while allowing physicians more time to come into compliance without penalty.
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Important Tax Info for Physicians Receiving Provider Relief Fund Payments THE U.S. DEPARTMENT OF HEALTH and Human Services (HHS) posted a recent update to its Provider Relief Fund frequently asked questions (FAQ) document regarding important tax information for physicians. HHS announced that Form 1099s will be sent to physicians who received a payment in excess of $600 during the 2020 calendar year, from either the Provider Relief Fund or the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured. These forms will be mailed by Jan. 31, 2021; however, a mailed copy will not be sent if physicians have previously established an account with UnitedHealth Group and elected to receive electronic copies of documents and notices.
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COVID-19 AND PATIENT SAFETY IN THE MEDICAL OFFICE By Debbie Kane Hill, MBA, RN, CPHRM, CPPS
Updated Nov. 23, 2020: As the pandemic hits its third nationwide surge, families are gathering for the holidays, and practices are preparing for an increase in cases. Therefore, medical offices must remain very attentive to the widespread outbreak of COVID-19, continuing to proactively take steps to safely manage patients while protecting clinical staff. Below, you will find recommendations for this season of the pandemic, such as protective recordkeeping, documentation and follow-up for noncompliance and coordination of care, managing patients who resist infection-control measures, and tracking ongoing guidance from health authorities. Vital Pandemic Recordkeeping Maintain records of staff-patient contact, i.e., who was assigned to work with the patient, either in a log or in the electronic health record. Document so that you are able to track and notify contacts in case of a COVID-19 diagnosis or probable exposure on either the patient or provider side. Further, to protect your practice, file records of staff screening and of those entering your facility in your administrative records, as well as all protocols and updated policies your office is following during this crisis. Keep records of PPE supplies/shortages, cleaning protocols followed, communications with patients, case incidence, and available medical resources within your community. Documentation that you have taken steps to follow recommended infection control protocol may be your best defense should COVID-19-related litigation occur in the future. For details, see Keep a COVID-19 Diary: Document Now in Case of Future Lawsuits, on page 14 in this issue. Managing Difficult Patients Due to our country’s current political environment, which has impacted perspectives on COVID-19, many practices are experiencing patients who believe the virus is a hoax based on “fake news” and refuse to follow safety protocols. When making an appointment for in-office visits, set expectations prior to the patient coming into the office about established infection-control protocol. If the patient is uncooperative upon arrival, ask the patient to step aside to a private area and
acknowledge their position. Listen to the patient’s concerns and remain calm. If the patient is angry, do not lose your temper, and remind the patient you are obligated to follow guidelines from the Centers for Disease Control and Prevention (CDC) as well as other government mandates, and that all infection control policies remain in place to ensure everyone’s safety. If the patient remains emotionally volatile and uncooperative, suggest the patient seek care with another healthcare provider. Planning for a Vaccine — During Flu Season • Vaccine Distribution: Under the Trump Administration, Operation Warp Speed was “created as a joint effort between the Department of Health and Human Services and the Department of Defense, engaging with private firms and other federal agencies, to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics.” In mid-August, the CDC contracted with McKesson Corporation to support vaccine distribution. Practices should begin making plans now to determine if and how they will handle administering a vaccine. For more information on Operation Warp Speed, see the Strategy for Distributing a COVID-19 Vaccine, the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, and the Vaccine Distribution Process. • Considerations During Flu Season: Due to delays in testing and misdiagnosis, patients have been turned away with COVID-19. Such situations not only put the patients and others at risk, but also put healthcare providers and hospitals at risk for litigation. We recommend that when in doubt, healthcare providers should adopt a clinical suspicion of COVID-19 to protect the patient and others. In this regard, flu season poses special challenges. Both the flu and COVID-19 are respiratory illnesses and can present in similar ways, so providers should devote attention to learning COVID-specific symptoms such as new loss of smell or taste. For further guidance, see Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors. SanDiegoPhysician.org 5
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Staying Abreast of Changes The following recommendations will assist in the ongoing screening and management of suspected COVID-19 patients in your practice: • Legislation and Guidance: Reference the CDC, your state medical board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation, as this continues to be a fluid situation. Monitor for an increase in COVID-19 cases within your community. Stay on top of current trends to protect your patients and your practice. • Screening Criteria: Follow the CDC’s patient assessment protocol for early disease detection for patients presenting to your practice. Patients should be screened using these guidelines: Overview of Testing for SARS-CoV-2 (COVID-19). We recommend that you check this CDC website often for any updates in screening criteria. Essential visitors to your facility should also be assessed for symptoms of coronavirus and contact exposure and redirected to remain outside if suspect. • Accepting Patients: It is strongly recommended that practices do not turn patients away simply because a patient calls with acute respiratory symptoms. All patients should be triaged over the phone or via telemedicine and managed according to CDC recommendations. Refusing assessment/care may lead to concerns of patient abandonment. • Designated Triage Location: Check with your local public health authorities for locations designated to triage suspected patients, so exposure is limited in general medical offices. Community emergency preparedness plans have been activated so that parties are coordinating efforts to deliver effective public health intervention. • Telehealth Triage: With community spread and the resurgence of COVID-19 in some states, the CDC recommends alternatives to face-to-face triage and visits if screening can take place over the phone, via telemedicine, through patient portals or online self-assessment tools, or through a designated external triage station. Licensed staff should be trained in triage protocol to 6
determine which patients can be managed safely at home versus those who need to be seen either at the office or at a properly designated community facility. See Healthcare Facilities: Managing Operations During the COVID-19 Pandemic. The CDC provides Phone Advice Line Tools, which includes sample phone script, a clinical decision-making algorithm, and advice messages. The Doctors Company offers resources on telemedicine in our COVID-19 Telehealth Resource Center as does the CDC: Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. For a list of telehealth COVID-19 rules by state, visit Federation of State Medical Boards: COVID-19. • Patient Testing: Physicians should determine which patients require testing based on presenting symptoms, history, contact exposure, community transmission of disease, and for early identification in special settings (e.g., nursing home admission). When there is a reasonable presumption that a patient may have been exposed to COVID-19, contact the local or state health department to coordinate testing using available community resources. See the CDC’s Testing for COVID-19 and Overview of Testing for SARS-CoV-2 (COVID-19). The CDC advises, “Healthcare providers should immediately
notify their local or state health department in the event of the identification of a PUI (Person Under Investigation) for COVID-19.” The CDC offers the Clinician Call Center, which is available to healthcare personnel to assist with diagnosis, clinical management, and infection-control protocol. Dial (800) CDC-INFO [(800) 232-4636] and ask for the Clinician Call Center. • Elective Services: Check with regional governmental and health authorities on the provision of nonessential and elective healthcare visits and grouprelated activities. States and counties vary depending on number of cases, availability of personal protective equipment (PPE), and availability of hospital beds. For diagnostic and therapeutic interventions, including surgery, the CDC provides the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic. Also, the American College of Surgeons (ACS) published Clinical Issues and Guidance on triage and management of surgical cases, including specialty guidelines. Many states continue or have reinstated restrictions on the provision of nonurgent, elective surgeries and procedures (See ACOS: COVID-19: Executive Orders by State on Dental, Medical, and Surgical Procedures). In some states, violations may result in
My Employee Got Stuck with a Dirty Needle ... Now What? CAP’s Free Guide Can Help You Protect Your Practice and Your Patients! Future-Proofing Your Practice: Eight Resources and Lessons for Success During the Pandemic and Beyond was created by CAP’s team of risk and practice management experts to help physicians: • Navigate today’s uncertain scenarios • Find new opportunities for practice profitability • Ensure safe and successful business operations • And much more! As a leading provider of superior medical malpractice coverage in California for more than 40 years, The Cooperative of American Physicians, Inc. (CAP) is pleased to offer this free resource to help physicians and their staff run a safe and successful practice.
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physician jail time, fines, or complaints to the medical board. Check with state and local regulatory agencies for any related mandates. Office Messaging: Practices should post front-door signage requiring patients and visitors who are exhibiting COVID-19 symptoms or who have had contact exposure to immediately notify facility personnel via telephone for instructions on accessing care. Include information on the practice website regarding new office policies for appointments, telephone assessment/telemedicine, and visitors. Also, post COVID-19 resources for patients [e.g., the CDC’ Coronavirus (COVID-19) page and COVID-19 Frequently Asked Questions] with a reminder to maintain physical distance, to wear a facemask, and to follow local orders to lessen community spread. If the office is closed, update voicemail messages to address telephone assessment, telemedicine, and how to reach the physician in the event of an emergency. Physical Distancing: To maintain physical distancing within your facility, require that patients sit at least 6 feet or more apart. Patients should be asked to wait in their car if that option is available. Remove magazines and toys from the waiting room. Routinely disinfect the waiting room throughout the day. Develop a cleaning schedule and checklist for your facility, and document in administrative files that it is followed. Suspected Infection: Evaluate patients on a case-by-case basis. If presenting symptoms and/or contacts are suspicious, and it is determined that the patient must be seen, have the patient call prior to their arrival to make preparation for accommodation. When possible, conduct the patient evaluation outside your facility at a designated triage location. If that is not possible, immediately isolate the patient coming into the office (segregating them from other patients in the facility) in a designated regular exam room with dedicated patient care equipment. A back entrance should be utilized. Patient Precautions: For individuals entering your facility, instruct them to put on a facemask, utilize tissues, practice good hand hygiene, and
properly dispose of any contaminated protective equipment/tissues in a designated waste receptacle. Educational resources, including posters for use in the medical office, are available from the WHO and for healthcare workers from the CDC (Contact Precautions, Droplet Precautions, and Airborne Precautions). Reference the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) for patient management guidance. • Provider/Staff Precautions: Follow Standard Precautions and Transmission-Based Precautions, including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit-tested. If there is a shortage of N95 respirators in your facility, access current CDC respirator recommendations and review Optimizing Personal Protective Equipment (PPE) Supplies. Remember that patients will scrutinize your adherence to infection control protocol; ensure that staff follow it precisely. Failure to do so may result in medical board complaints, negative social media reviews, and the patient leaving the practice permanently. Provide updated staff training on infection control protocol as needed. • Limit Exposure: Limit staff exposure to suspected patients, with the exam room door kept closed. Ideally, the designated exam room should be at the back of the office, far away from other staff and patients. • Surface Disinfection: Once the patient exits the room, conduct surface disinfection while staff continues to wear PPE. For general guidance, see Clinical Questions about COVID-19: Questions and Answers. The CDC has updated guidelines for considerations on how long exam rooms should remain vacant between patients. Be mindful that according to the CDC and research published in the New England Journal of Medicine, it is unknown exactly how long the virus remains active once a room is vacated. Follow the CDC for updated guidance on how COVID-19
spreads: “It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes. This is not thought to be the main way the virus spreads.” • Patient Education: Provide up-to-date, factual information on the virus to suspected COVID-19 positive patients and their close contacts, including how to follow infection-control practices at home, such as in-home isolation, hand hygiene, cough etiquette, waste disposal, and the use of face masks. Remind patients and their families to access information about the virus through reputable sources such as the CDC, not social media. • Provider/Staff Exposure: Screen healthcare personnel daily for symptoms/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed and monitored. See Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. Should providers and/or staff test positive within your facility, conduct and document a risk assessment identifying contacts, type of interaction, and PPE in use, then contact local health authorities for additional instruction. The CDC provides guidance here under the section “Infection Control,” as does the American Dental Association: What to Do if Someone on Your Staff Tests Positive for COVID-19. Disclosure to patients may be necessary depending on the type of exposure that occurred, if any, but always take necessary steps to protect the privacy of the infected employee. Telephone calls directly to the patient are the most efficient method of notification, followed by mail. Suggested notification may include, “We are calling to inform you that someone in our office tested positive for COVID-19 on the day of your visit,” followed by recommendations for assessment and any needed follow-up. The health department may assist with patient notification if determined to be necessary. Contact your patient safety risk manager at The Doctors Company, as needed, for additional guidance. For return-to-work guidance,
review the Criteria for Return to Work for Healthcare Personnel with SARSCoV-2 Infection (Interim Guidance). • Staff Training: Assess the need for additional staff training to review screening and triage protocols, patient management, use of PPE, patient communications, and any revision in policies and procedures that have been made to adapt to the evolution of the crisis. Document all training provided to staff and maintain records in administrative files. • Team Briefs: Conduct daily staff briefs/ huddles and end-of-day debriefs. This provides all staff opportunities to discuss anticipated issues during the day and identify concerns, pre- and post-clinic, including COVID-19 updates. Acknowledge the need to provide emotional support to staff, who may be dealing with fear or other stressors, through employee assistance programs or other support mechanisms. Communicate resources to employees. Managing Legal Risks, Staying Vigilant COVID-19, declared a global pandemic by the World Health Organization (WHO), continues to infiltrate multiple continents, infecting more than 40 million worldwide, with global deaths reaching beyond 1 million. Within US borders, more than 8 million Americans have been infected, with the death rate approaching 225,000. Government authorities in some states continue to mandate shelter-inplace, as new outbreaks continue to cluster in many regions across the United
States. Other states are reopening, while some areas are again shutting down. Medical offices are faced with challenges including in-pandemic rules for operation and the provision of “catch-up” care for patients who had clinical services postponed while offices were closed, or who put off contacting their physician because of infection fears. Daily, the CDC continues to process data and advise clinicians on COVID-19 through its website and televised press conferences, while government authorities at all levels mandate legislative updates for the provision of safe healthcare operations. Because this continues to be a moving target, physicians and all healthcare facilities must remain well-informed and current on public health guidance for screening protocols and patient management, as well as regulatory requirements impacting their practices. By now, most healthcare facilities and physician practices have encountered COVID-19 patients. Early on, medical facilities and the entire healthcare industry were poorly prepared for this outbreak, leading to early mistakes when clinicians encountered cases they had not anticipated seeing. Due to issues with diagnostic testing, and because the clinical presentation of patients suspicious for COVID-19 infection resembled patients with fairly routine cold, flu, or seasonal allergies (or presenting with no symptoms at all), delays in diagnosis and treatment have been common. But with improved testing capabilities, and by following current clinical guidelines, facilities where patients receive care
can be more effective in identifying and treating COVID-19 in a timely manner. Careful screening with a bias for suspicion that a patient might have COVID-19 will serve healthcare providers well in this situation. As we move forward, we emphasize that keeping office policies and procedures current while following recommended guidelines, with documentation of adherence in both administrative files and medical records, is key to litigation defense in the future. The dynamics surrounding the virus will continue to change in the weeks and months ahead. What must not change is that physicians and care teams should remain vigilant and adapt their practices accordingly. They should be exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as they become available from the CDC. Supplementary Resources: • The Doctors Company: COVID-19 Resource Center for Healthcare Professionals • The Doctors Company: Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors • CDC: Information for Healthcare Professionals about Coronavirus (COVID-19) • CDC: Clinical Questions about COVID-19: Questions and Answers • CDC/NIOSH Update: COVID-19 Vaccine Development 10 October 2020 • Framework for Equitable Allocation of COVID-19 Vaccine—The National Academies Press (Free download) • American Academy of Family Physicians (AAFP): Checklist to Prepare Offices for COVID-19 • The Doctors Company: Burnout During COVID-19: How Healthcare Professionals Can Manage Stress • ECRI: COVID-19 Resource Center • ACS: Be Prepared: Patient-Surgeon Discussion Guide • John Hopkins Global Case Map: Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering Debbie Kane Hill is senior patient safety risk manager for The Doctors Company. SanDiegoPhysician.org 9
D RU G P R E S C R I B I N G/ D I S P E N S I N G
URGENT REQUEST TO HELP FIGHT THE FENTANYL CRISIS IN SAN DIEGO Four Steps to Save Lives By Roneet Lev, MD, Steven Campman, MD, Wilma Wooten, MD, MPH, Summer Stephan, Esq., and Robert Brewer, Esq.
ear Colleagues: San Diego County is in crisis due to illicit fentanyl that is coming across the border in unprecedented quantities. The number of fentanyl deaths is at a record high and there are immediate steps that can be taken by the medical community. We are asking you to take four steps: (1) Automatically and universally include fentanyl in urine drug screens in hospitals; (2) Prescribe naloxone to any patient that you believe is using illicit drugs, not just illicit opioids; (3) Connect patients to addiction resources, and (4) Cooperate with law enforcement investigations as appropri-
ate. We believe that these simple steps will save lives in our community. The San Diego Fentanyl Crisis Fentanyl overdoses define the current opioid epidemic this year â€” more than prescriptions or heroin. San Diego, the port of entry for much of our nationâ€™s illegal drug supply, is being hit hard. The San Diego Medical Examiner office is reporting record high fentanyl deaths. In 2019, San Diego had 152 fentanyl deaths and 2020 will double that volume. Some emergency physicians have intubated more patients from a fentanyl overdose than COVID-19.
hospital fentanyl test is sufficient to give the medical examiner probable cause of death and give some peace to the family.
Why Add Fentanyl to a Urine Drug Test? A positive fentanyl test can: 1. Warn the provider 2. Warn a patient 3. Warn friends 4. Lead to a prescription for naloxone for the patient as well as friends and loved ones 5. Connect to addiction treatment You can save more lives with public health intervention If you have a patient with COVID, the county will do contact tracing to prevent the spread. If you have a patient with diarrhea that is traced to bad lettuce or onions, there will be contact tracing and alerts. If you treat a patient who overdosed on fentanyl, especially unintentionally, you should think about who else is getting poisoned or killed. Others need to be warned, and the drugs need to be removed to avoid further poisoning. You will learn and become a better doctor The mix of fentanyl and methamphetamine is a popular combination for agitated delirium. Patient may not have the classic pinpoint pupils and decreased respirations. Patients may complain they feel “weird” after using methamphetamine and other drugs that contain fentanyl. If they become aware that they consumed fentanyl, that knowledge will make them careful and even motivate them to seek treatment for their addiction. You will discover that an estimated
50% of cocaine deaths and 25% of methamphetamine deaths also test positive for the presence of fentanyl. You can assist with death determination A 33-year-old female presented to the ED in cardiac arrest. She was admitted to the ICU on life support. Her differential diagnosis included MI, PE, and even drug overdose. Her standard urine drug screen was positive for cocaine and THC, but negative for opioids. It was later discovered that the patient received death threats and may have been slipped fentanyl intentionally. A fentanyl test was added a few days after admission and was positive. However, she received fentanyl as part of her ICU medications. If only she had the fentanyl test done the first time. … This case has been repeated multiple times in ICUs throughout San Diego, including a pediatric overdose. A family desperate for answers can never get a definitive cause of death if a patient is placed on a fentanyl drip before a drug test for fentanyl is obtained. A medical examiner investigation will impound blood that remains in the hospital lab to determine what drug was ingested; however, many times the deaths occur several days after admission, when admission blood samples have already been discarded by the hospital laboratory. You can ask the lab to hold blood and urine in cases when an overdose death is a possibility. If a presumptive urine fentanyl screen is documented and other causes for the arrest are excluded, the
(1) Automatically and Universally Include Fentanyl in Urine Drug Screen Fentanyl is a synthetic opioid that does not show up on routine urine drug screens. Drug screens commonly include the “federal 5” of drug testing: opioids, THC, PCP, amphetamine, and cocaine. Most hospitals include additional drugs such as benzodiazepines, oxycodone, and methadone. To date, the United States has no FDA-approved, point-of-care, test-urine strips for fentanyl that is part of a multidrug panel. Therefore, smaller clinics and doctors’ offices cannot obtain a rapid fentanyl test. All hospitals can and should have rapid fentanyl testing capability that utilizes a separate reagent that is used with the hospital chemical analyzers. A survey of all 24 hospital laboratories in San Diego and Imperial counties have identified some hospitals that follow a gold standard of including fentanyl automatically and universally each time a urine drug test is ordered. If you care about a rapid THC or methamphetamine result, you should also care about fentanyl. We are urging the medical community to work with your lab to make sure you have access to rapid fentanyl testing. A fentanyl testing toolkit is available on the San Diego Prescription Drug Abuse Task Force website and includes what fentanyl tests are available as well as the results of the laboratory survey. (2) Prescribe Naloxone to Patients Who May Be at Risk of Fentanyl Overdose Naloxone is typically prescribed to patients who are on high-dose opioids, opioids and benzodiazepines, or those addicted to heroin or fentanyl. According to CDC Wonder 2018 data, fentanyl has been associated with 25% of the methamphetamine deaths, 50% of cocaine deaths, and, locally, even in a case of vaped fentanyl. People who use SanDiegoPhysician.org 11
D RU G P R E S C R I B I N G/ D I S P E N S I N G illicit drugs rarely limit themselves to one drug, and some obtain counterfeit pills of oxycodone, hydrocodone, and alprazolam that contain fentanyl. Therefore, prescribe naloxone to patients who may be using any illicit drugs, not just opioids. You can also give a prescription to concerned family and friends without an additional medical evaluation. (3) Connect Patients to Addiction Treatment San Diego has resources for patients with addiction. Patients can be referred to 211 or call 1 (888) 724-7240 for outpatient and residential drug treatment programs. The San Diego Prescription Drug Abuse Task Force has a directory of resources. (4) Collaborate With Law Enforcement The medical community has a third-party responsibility to the community outside the single patient they are treating. This is the standard of care applied with STD treatment, food borne infections,
lapses of consciousness such as seizures and driving, and COVID contact tracing. Similarly, we are asking for consideration of potential additional injured people when it comes to treating drug overdoses. In response to the increasing number of fentanyl deaths, law enforcement agencies began investigating overdose deaths. The goal is to identify dangerous drug dealers to prevent these poisons from being distributed through our community and to pursue distributors up the chain of distribution. Law enforcement contacted by a hospital has been able to identify a â€œJohn Doeâ€? overdose patient and unite that patient to family as well as connect several at-risk people at the scene to treatment. San Diego County and Imperial County law enforcement agencies have narcotic divisions. In addition, DEA leads a specialized overdose team that travel with a portable mass spectrometer and fentanyl testing strips. Early identification of the drugs involved helps identify emerging
trends. For example, in late August, the Narcotics Team identified a new counterfeit hydrocodone pill that drug couriers are bringing to our community. Two people were found dead, dropping in the hallway of their home, after consuming half of the counterfeit pill, which actually contained fentanyl and no hydrocodone. Law enforcement may present to the hospital to investigate community overdose clusters or possible homicides. Please be aware of these investigative teams and cooperate in the same manner as you do other law enforcement involved cases. They wish to partner with you in saving lives. Dr. Lev is former CMO, White House Office of National Drug Control Policy. Dr. Campman is chief deputy medical examiner for San Diego County. Dr. Wooten is San Diego County Public Health Officer. Summer Stephan is the District Attorney of San Diego County. Robert Brewer is United States Attorney for the Southern District.
Tracy Zweig Associates A
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Seeking FM/DO/IM/ Psychiatrist in San Diego County Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: email@example.com or fax to 760-414-3702
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ADVERSE CHILDHOOD EXPERIENCES
California Surgeon General’s Report Provides Cross-Sector Roadmap to Address Health and Societal Impacts of Adversity By Cate Powers
HE OFFICE OF THE CALIFORNIA SURGEON GENERAL
has released the first California Surgeon General’s Report, “Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health.” The report serves as a blueprint for how communities, states, and nations can recognize and effectively address Adverse Childhood Experiences (ACEs) and toxic stress as a root cause to some of the most harmful, persistent, and expensive societal and health challenges facing our world today. The report provides clear and equitable response solutions, models and best practices to be replicated or tailored to serve community needs. It brings together global experts across sectors, specialties, regions, and disciplines to drive science-based approaches to primary, secondary and tertiary prevention strategies for ACEs and toxic stress. “ACEs and toxic stress are a public health crisis in California and throughout our nation. But ACEs are not destiny,” said California Surgeon General Nadine Burke Harris, MD. “I am thrilled to share this report as a roadmap for prevention, early detection and cross-sector, coordinated interventions to address ACEs and toxic stress in a systematic way. None of these strategies are sufficient alone and each extends the reach of others.” The report offers a detailed collection of: • The science, scope, and impact of ACEs and toxic stress • Recognizing toxic stress as health condition amenable to treatment • The public health approach for cutting ACEs and toxic stress in half within a generation • California’s response to ACEs and toxic stress • What lies ahead for the ACEs movement The report further specifies cross-sector strategies for addressing ACEs and toxic stress at the state level, prioritizing prevention, equity in outcomes, and enhanced coordination across healthcare, public health, social services, early childhood, education, and justice. Throughout the report, the impact of COVID-19 is highlighted, recognizing the pandemic’s association with significant increases in ACEs, toxic stress risk and rates of ACE-Associated Health Conditions.
“With the recent and historic challenges, everyone is experiencing increased stress. However, we recognize that those who have experienced ACEs are at greater risk for developing adverse health outcomes as a result of this stress,” says California Health Human Services Agency Secretary Mark Ghaly, MD. “There has never been a more important time for California to have a traumainformed workforce and evidence-based strategies to address toxic stress than in this moment.” California is a leader in addressing ACEs and toxic stress to improve outcomes for the state’s residents. The state is taking aggressive steps through the first-in-the-nation ACEs Aware initiative, to establish routine ACE screening in primary care, and develop a network of care, including cross-sector coordination supports aligned with primary care. The full report, executive summary, 12 topical and sector specific briefs, social media toolkit, and more can be found at https:// osg.ca.gov/sg-report. Cate Powers is communications director for the Office of the Calfiornia Surgeon General. SanDiegoPhysician.org 13
C O V I D -1 9
KEEP A COVID-19 DIARY Document Now in Case of Future Lawsuits
By Debbie Kane Hill, MBA, RN, CPHRM, CPPS
or months, physicians and practice managers have been in crisis mode due to COVID-19 and have faced daunting challenges daily. What the future holds relative to the evolution of COVID-19 remains unknown, but it is certain that litigation for COVID-related claims is on the horizon and will impact physicians in all medical specialties and practice models. According to attorney John E. Hall Jr., founding partner of Hall Booth Smith in Atlanta, Georgia, which specializes in defense of high-exposure cases involving hospitals and medical malpractice claims, COVID-19 claims are looming in the next one to three years. “The bigdollar plaintiff firms and the plaintiff conglomerates are already starting to advertise for these cases, and they’re starting to file them,” Hall says. “There are over 800 cases filed already. Many of those are in the long-term care scenario but [they] are developing every day and in a variety of other areas.” Are there existing medical liability protections in place? What types of claims are anticipated? What steps can physicians take now to prepare to de14
fend claims in the future? These important questions were recently addressed by Mr. Hall and other expert healthcare executives and attorneys at The Doctors Company’s 2020 Virtual Executive Advisory Board (EAB) meeting. Are There Existing Medical Liability Protections in Place? The Public Readiness and Emergency Preparedness Act (PREP Act) provides a significant safeguard for physicians. Congress originally passed the act in 2005 to provide immunity during the H1N1 epidemic. Secretary of Health and Human Services Alex Azar declared a public health emergency in January 2020 pursuant to the act due to COVID-19. The act provides complete preemption, meaning that “any state law or other federal law that contravenes the PREP Act is replaced by the PREP Act. Except in cases of death or severe injury caused by willful misconduct, the PREP Act provides complete immunity, with no liability under those circumstances” if the claim is COVID-19 related and the case is tried in the federal court system, according to Mr. Hall. In addition to the
PREP Act, states have established some level of immunity for medical practices through healthcare immunity orders or executive limited liability orders. These orders vary by state and are meant to provide protection to the medical community for COVID-related claims. What Types of Claims Are Anticipated? It is expected that COVID-driven claims will take a variety of forms. Some claims may allege: • Delayed or missed diagnosis caused by failure to follow up on previously ordered tests and consults (while the office was closed or due to lack of a reliable tracking system). • Failure to triage and assess or testing issues, resulting in missed COVID-19 diagnosis and delayed intervention that contributed to community spread.
Historian name/title (person documenting timeline/checklist) Staffing Related Provider directory (attach if needed) Staff directory (attach if needed) Staffing levels (furloughs, sick leave, reduced hours, etc.) Witnesses. Who worked with practice during this time? Who can testify to efforts made by practice to comply? Should include both internal managers/ leaders and external consultants, vendors, etc. Community Infection Rates Population/geographics (particular demographics in your county, city, etc.) Infection rate Death rate Number of hospital beds available ICU beds available Ventilator availability
Communications and Training with Staff
Copies of meeting minutes
Social distancing practiced?
Copies of staff education programs and sign-in sheets
Provide pictures of waiting room and other common areas
Waiting room masks, sanitizer, etc.?
Staff publications/HR newsletters/emails
Waiting room signage (store a PDF or photo)
Communication with Vendors, Government Offices, Other Third Parties
Visitors policy (store a PDF or photo of your posted policy)
Cleaning schedules (save checklists)
Copies of COVID-19 compliance checklists you have followed
Screening of patients (include records)
Screening of employees (include records)
Federal notifications/recommendations (CDC, HHS, FDA, DEA, etc.)
Patient exposures? How managed?
Clinical Care Issues
Tracking of labs, tests, consults (system used, e.g., EHR, log, etc.)
Quarantine policy (save records)
Procedures being performed? Type?
Return-to-work policy (save records)
Facilities in use (name, type)
Infection control policies and procedures (save records)
Restrictions on procedures? Describe
PPE: Shortages? Types in use?
Case review by whom for determining if someone eligible for procedure
PPE vendor records/purchase orders
Informed consent or medical record notifications related to COVID-19?
CDC guidelines during this time period
Types of COVID-19 testing used
Communication With Patients
Attach sample letters
Testing turnaround time
Notification of exposure letters (addressed to specific patients)
Current research for COVID-19 patient management
Signage within practice
Notices on website
Patient education materials related to COVID-19
Social media notifications
Sample COVID-19 Checklist for the Medical Office
What worked well? HIPAA considerations Other: Add other timeline items as appropriate
C O V I D -1 9
• Failure to immunize, resulting in disease, when parents were fearful to bring children into the office. • Delayed care in office visits, testing, labs, and procedures, including surgical interventions. • Failure to adhere to infection control protocol and/or lack of PPE, resulting in patient or staff illness. • Limited resources: Allocation of medications and equipment, meaning access to ventilators/hospital beds, etc. Most likely the claims that involve loss of life or serious injury will allege failure to diagnose or delayed diagnosis due to practices being closed for business after tests were ordered or referrals made prior to COVID-19. Patients whose information has been lost in the system and are not adequately tracked may miss important medical follow-up appointments, leading to adverse health outcomes. Also, delays in procedures and surgical interventions are of significant concern, and we are already seeing these types of claims reported to The Doctors Company. What Steps Can Physicians Take Now to Prepare to Defend Claims in the Future? Mr. Hall suggests that one of the best ways to establish defense of these claims is for practices to begin developing a timeline/diary now describing how COVID-19 events unfolded within their specific practice and community. Because COVID-19 has been a moving target, and mandates and guidelines have been very fluid, keeping records of these changes via a timeline/diary is important for documenting how your practice responded to the crisis. Some considerations may include: 16
• Was your practice ever unable to obtain PPE? • What was the infection rate within your community at a given time? • Did you follow infection control protocols per Centers for Disease Control and Prevention (CDC) guidelines? If so, what were those guidelines at the time? Documenting these items now ensures information is captured in its most accurate form, rather than trying to reestablish the facts years later. This information will not appear in patient medical records, yet it paints the landscape as to how the practice adapted to a very volatile crisis. It will form the foundation for your defense. As Mr. Hall notes: “Think of this three years from now … and a jury is thinking about this case. Juries have a very short mind span, so they do not remember the crisis and the pandemic and how this was going at the time. It’s imperative that we take good notes and [develop] outlines now.” Crucially, he adds, “It is important to note that this information should be gathered at the direction of an attorney, peer, or quality committee so as to protect the information from discovery.” Appoint a practice historian who is responsible for developing and keeping the timeline up to date and well documented. This can be a physician, practice manager, or risk manager, but it should be someone familiar with the overall operations of your COVID-19 response who will reliably maintain the timeline from start to finish. To provide guidance on what types of items to document, The Doctors Company provides a sample checklist of important record-keeping elements and recommends keeping this in an administrative diary. You can
adapt this checklist to fit your practice; these are merely suggestions of details to include, but it is important to document basic compliance efforts within the environment and timeframe. This checklist should be completed at a defined interval based on your practice, community, and pace of change. Mr. Hall also recommends that you remind future jurors that the care provided to your patients transpired during the COVID-19 pandemic by including the following in every patient chart: • Please note that this care is given at a time of national public health emergency due to the pandemic caused by COVID-19 (novel coronavirus). As a result, it is acknowledged and understood that the spread of COVID-19 within our communities places an incomprehensible strain on our providers and hospital systems, including the resources, equipment, beds, treatment options, and services available in support of patient care. • It is further acknowledged and understood that the provider, during the COVID-19 pandemic, endeavors to remain operational and provide care to all patients commensurable with the resources available and existing at this time. Further, it is acknowledged that the transmission risks, treatment process, and diagnosis are novel, and without well-defined guidelines. • It is further acknowledged that, due to the novel and emergency nature of this pandemic, treatment is provided utilizing the provider’s best judgment and best currently known practices, within the limits of resources. Debbie Kane Hill is senior patient safety risk manager for The Doctors Company.
PERSONAL AND PROFESSIONAL DEVELOPMENT
The Judgments and Opportunities in Being Different By Helane Fronek, MD, FACP, FACPh
S I APPROACHED THE SHARP CURVE ON MY BIKE,
I saw the drop-off at the end of the concrete path we were riding on. I knew that if I wasn’t able to negotiate the curve, I would tumble off the path. I hit my brakes and suddenly felt the impact of the hard concrete. An hour later I was looking at my pelvic fractures, whose repercussions were about to dominate my life for several months. I’ve always felt that every physician can benefit from being a patient. In the 1991 movie The Doctor, William Hurt undergoes a dramatic transformation from an arrogant, dismissive doctor to one who sees the humanity in his patients and colleagues. Watching my father undergo multiple surgical procedures and deal with numerous medical illnesses opened my mind and heart to what it’s like to be a patient or helpless family member, and informed my own interactions as a physician. This injury, however, opened my eyes to something deeper and more ubiquitous in life.
In time, I was delighted to move beyond the confines of our home by using a walker, only to be struck by the many stares my presence drew. I wondered what caused so many people to stare at me. Were they imagining what happened to me or what illness I had? While that was true for some, I believe that for most people, I had become interesting simply because I was now different. Like an accident we pass, we have difficulty averting our eyes from people who are different. If they are very tall or short, have a different skin color, speak a different language, or move in unusual ways, we notice them. What usually follows is some form of judgment of the ways in which we are different. As a society, one of the only things we seem to agree on is
that we are divided. Each side sees the other in stark terms, judging not only their actions but their motivations, seeing only the ways in which we are different. At these times, it’s important to remember that the antidote to judgment is curiosity. The podcast To See Each Other explores what happens when progressive community organizers engage in curious, listening conversations with people in rural parts of America — areas some people describe as “Trump country.” Only when we listen to people without trying to convince them can we discover their real concerns. Only by being listened to do people feel heard and able to trust. As we approach the political and social divisions in our country, let’s reject the simplistic narratives we hear and read and instead choose to open our minds and hearts to people on both sides of the divide. Each of us has a story, with dreams, fears, and hurts. Hearing others’ stories helps us have compassion for their situation and allows us to see different perspectives. Many times, we also find out what we have in common — the perfect place to begin working together to solve our mutual challenges. Dr. Fronek is a clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach. SanDiegoPhysician.org 17
ETHICS AND MEDICINE
Private Rights and Public Health:
The Perennial Trade-Off Revealed by COVID-19 By Daniel J. Bressler, MD, FACP
Southern California, we might adapt this old adage thus: “Your right to drive recklessly ends at my bumper.” Trade-offs around driving are useful public health analogies because they are so familiar. Speed limits, seat belts, air bags, driver’s licenses, vision criteria, hot-dogging, drunk driving, and agelimits all have been negotiated over time by society. A universal 15 mile-per-hour speed limit would undoubtedly reduce the 38,000 American and 1.4 million worldwide yearly death toll from motor vehicle accidents. And yet, we’ve come to a mediated agreement that allows individuals to drive three to five times that speed and to take on the accompanying risk for themselves (and to inflict that risk on others) because of the competing right for people to get where they’re going. The decision about how fast to allow people to drive (along with what kind of cars they’re allowed to drive, whether they must wear a seat belt, how much smog their car is allowed to produce) ends up being an iterated trade-off between private rights and public health. There are some uniquely thorny parts to the public health aspects of the Covid-19 pandemic: asymptomatic spread, very different death rates among different age and racial groups, politicization of science-reporting, and the possibility of intentional disinformation campaigns in this era of social media bots.
One might pointedly ask in the COVID era: is not wearing a mask around other people the moral equivalent of driving 65 miles per hour on a residential street? The answer you get will depend on your political orientation (i.e., how much does a government have the power to control your personal behavior), how you read the epidemiologic data (the degree to which masks truly reduce spread), the group to which you belong, your anecdotal experience, and on your personal risk tolerance. The importance of risk tolerance comes up frequently in a primary care medical practice such as mine. Patients accept or reject recommended screening tests (colonoscopy, mammography or blood tests) or therapies for asymptomatic hypertension or elevated cholesterol based on both their risk tolerance and their personal experience. I do my best to make recommendations based on the latest scientific evidence base but patients have their own evidence base. Sometimes what they choose based on their own experience, beliefs and values disagrees with what I recommend. This “conflict” is relatively tame because I explicitly respect their right to self-determination and because these are adults making decisions that typically affect only their own health. Going back to the driving analogy, at worst they are high-speed driving alone on an isolated track, such that the risk they are taking is a purely personal one. Risk-taking in a pandemic is alto-
“Your right to swing your arm leaves off where my right not to have my nose struck begins”
gether different. It is more like managing a fire than a colonic polyp. If you don’t get a colonoscopy, you increase your chances of getting colon cancer. But if you don’t tend to a fire smoldering in your backyard, you’re risking burning not just your own house, but the entire neighborhood. It underlines the connection between who we are as individuals and as social beings. Even the most isolated among us live to some extent in a community. As we’ve discovered in this era of social distancing, we still need to go to the grocery store or the pharmacy, educate our children, and tend to the sick. And with every social interaction, this damned virus has a chance to spread and persist.
It seems that the U.S. has a harder time with the imposition of public health restrictions on individual behavior than most other countries based on our powerful and cherished tradition of liberty. This tradition traces back to Thomas Jefferson’s notion of the independent, selfsufficient, isolated small farmer serving as the backbone of a democratic society. This ideal continues to influence how Americans see themselves and behave centuries since we have stopped being a country of small independent farmers. Many of the freedoms we still cherish — religion, association, travel, speech — first found their expression in a very different country. This ideal has helped
spark American creativity, entrepreneurship, and independence of thought. That said, some of the societal conflicts we face in the COVID era (including importantly, the urban-rural one) derive from the gaps between the Jeffersonian ideal and the reality of a population that is mostly urban and highly interdependent. There eventually will be a “technical fix” for this pandemic — some combination of vaccines, medications, herd immunity, and viral evolution. As a society, we have an opportunity to look beyond this fix to engage the larger political challenges that face us in light of the fact that this will not be our last pandemic. Explicitly, how can we more
skillfully mediate this most American tension between individual freedom (including the freedom to take risks) and public safety? Moreover, how do we do this in a world where the end of your fist may be disguised as a respiratory virus one-thousandth the diameter of a human hair and the end of my nose isn’t just a sensitive facial structure, but an entryway for a pathogen capable of infecting and killing its owner? Dr. Bressler, SDCMS-CMA member since 1988, is a former chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician. SanDiegoPhysician.org 19
CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or Sub-Investigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential. Our team of Clinical Research Professionals will conduct the clinical trials under your supervision. Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact firstname.lastname@example.org or email@example.com or Afalconer@paradigm-research.com. PHYSICIAN OPPORTUNITIES NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other lowincome, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at firstname.lastname@example.org. DEPUTY PUBLIC HEALTH OFFICER - COUNTY OF SAN DIEGO: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Salary: $220-230,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy and procedure, developing strategy, and overseeing quality assurance and quality improvement efforts for County of San Diego health services programs. Salary: $190-200,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to email@example.com. Immediate opening. INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evalu-
ation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email firstname.lastname@example.org. CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to email@example.com or via fax to (760) 510-1811. PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides familyfocused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, upto 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds. sdcoxmail.com or (619) 504-5830 with resume in .doc, .pdf or .txt. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 291-6637/ firstname.lastname@example.org. You may view our open positions at: https://jobs.graybill.org/. BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to email@example.com. PHYSICIAN CONSULTANT FULL-TIME: San DiegoImperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application. DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $$230,000 Annually. TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current California medical license. Appli-
cants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.Bhatia@sdcounty.ca.gov or call (619) 542-4008. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/sharpcare/ or email interest and CV to firstname.lastname@example.org. PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowship-trained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position. Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 977-6300 or email Ngoc.B.Truong@dmu. edu. PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at (760) 943-1011. CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research. Contact E-Mail: CL9636750@gmail. com. PRACTICES WANTED PRIMARY CARE PRACTICE WANTED: Looking for a retiring physician in an established Internal Medicine or Family Medicine practice who wants to transfer the patient base or sell the practice. Please call (858) 281-1588. PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces. To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068.
OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to Pomerado Hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914. KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at email@example.com for more information. SUBLEASE IN SHARP HOSPITAL: Sublease of a shared office space on the Sharp Hospital campus a small office on the third floor that is now shared with one other physician. Includes: two exam rooms, an office for the doctor, space for three employees, and a small amount of storage space. Please contact firstname.lastname@example.org for more information. REDUCED PRICE - EL CAJON MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 3,700 square foot standalone medical building with 11 exam rooms & huge private parking lot available for sale or lease! Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $950,000. Asking Lease: $5,500/month + NNN. Terms are negotiable. Seller financing is available. Please contact: Dillon.Myers@ TonyFrancoRealty.com | (619) 738-2318. MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/ space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share part-time, half days or full days 4 exam rooms. Rent depends on usage. For more information, call (858) 550-0330 EXT 106. ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking. Contact Jean at (858) 673-9991. MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease. The office is located in Imperial county and is approximately 910 sqft. Please email us at email@example.com with any with further questions or needed details. NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, 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: Digital X-ray suite, 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. Contact Harish Hosalkar at firstname.lastname@example.org or call/text (858) 243-6883. (Posted 1/29/20) MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call (858) 430-6656 or text (619) 417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at (858) 622-9076 if you are interested.
LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hosptial between 1-5 and 1-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call (858) 344-9024 or (858) 320-0525. SHARED OFFICE SPACE: Office Space, beautifully decordated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call (619) 606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on useage. Contact Jo Turner (619) 7334068 or email@example.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959. MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at firstname.lastname@example.org. MEDICAL EQUIPMENT / FURNITURE FOR SALE OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact email@example.com or (760) 753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi. firstname.lastname@example.org or 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions. Thank you. NON-PHYSICIAN POSITIONS AVAILABLE PART-TIME BILLER POSITION AVAILABLE: Pain
Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to email@example.com. DIRECTOR OF NURSING - PUBLIC HEALTH SERVICES - COUNTY OF SAN DIEGO: The Director of Nursing in Public Health Services (PHS) will lead the clinical nursing enterprise of PHS, serving on the Executive Team of the PHS Department. This position will directly oversee clinical nurse management and all nursing personnel for six programmatic branches within PHS, as well as directly oversee all Public Health Nurse Managers or Leads in each branch. This position will work with Public Health Nurses in other Health and Human Services Agency (HHSA) departments such Aging and Independence Services, Child Welfare Services, and Regional Operations. Additionally, this position will have a dotted reporting line to HHSA’s Chief Nursing Officer and receive direction from the Chief Nursing Officer to HHSA-wide nursing practices. Salary: $124,092.80-$150,822.80 annually. PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to firstname.lastname@example.org. EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486. FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations email@example.com. NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact firstname.lastname@example.org. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. Please contact: (619) 913-7568 | email@example.com | www.rudolphia.consulting.
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