January 2023

JANUARY 2023

Official Publication of SDCMS

2022

YEAR IN REVIEW

Celebrating Independent Physicians

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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 OFFICERS President: Toluwalase (Lase) A. Ajayi, MD President–Elect: Nicholas (dr. Nick) J. Yphantides, MD, MPH Secretary: Steve H. Koh, MD Treasurer: Preeti S. Mehta, MD Immediate Past President: Sergio R. Flores, MD GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, 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: Alexander K. Quick, MD La Jolla #1: Karrar H. Ali, DO, MPH (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD (Board Representative to the Executive Committee) AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Daniel Klaristenfeld, MD #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician: Emily Nagler, MD Resident Director: Alexandra Kursinskis, MD Retired Physician: Mitsuo Tomita, MD Medical Student: Jessica Kim CMA OFFICERS AND TRUSTEES President: Robert E. Wailes, MD Trustee: William T–C Tseng, MD, MPH Trustee: Sergio R. Flores, MD Trustee: Timothy A. Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: William T–C Tseng, MD, MPH At–Large: Albert Ray, MD At–Large: Robert E. Hertzka, MD At–Large: Theodore M. Mazer, MD At–Large: Kyle P. Edmonds, MD At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At–Large: David E.J. Bazzo, MD, FAAFP At–Large: Sergio R. Flores, MD At–Large Alternate: Bing Pao, MD CMA DELEGATES District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS Delegate: Rachel B. Van Hollebeke, MD

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.]

Contents JANUARY

VOLUME 110, NUMBER 1

FEATURES

4

2022 Year in Review

By Paul Hegyi, MBA

8

Quixotic Medicine Finding Inspiration in Dr. William Osler, The Bodhisattva, and the Man of La Mancha

By Daniel J. Bressler, MD, FACP

DEPARTMENTS

2

Briefly Noted: SDCMS Staff, Covered California, SDCMS Leadership, Immunization

11

A Better Way to Start the New Year

By Helane Fronek, MD, FACP, FASVLM, FAMWA

12

Substance Use Among Teens Generally Holding Study, Report Finds

By Joyce Frieden

8 14

After Election Win, California’s AG Turns to Investigating Hospital Algorithms for Racial Bias

By Mark Kreidler

16

Obesity Absent in OneFourth of Kids with Type 2 Diabetes

By Kristen Monaco

18

Is Legislation to Safeguard Americans Against Superbugs a Boondoggle or a Breakthrough?

By Liz Szabo and Arthur Allen

20

I Can Finally Eat Without Fear of Pain

By Adama Dyoniziak

12

21

Classifieds SANDIEGOPHYSICIAN .ORG

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BRIEFLY NOTED 2

JANUARY 202 3

SDCMS STAFF

Meet Alex Kriksciun: SDCMS Membership Coordinator I’M ALEX KRIKSCIUN, AND I HAVE THE PRIVILEGE OF SERVING AS YOUR MEMBERSHIP COORDINATOR. Outside of work, I’m a movie buff, particularly for ’80s and ’90s horror — Wes Craven is my favorite director, with some of my favorite movies being Scream, The People Under the Stairs, and Nightmare on Elm Street 3. My favorite non-horror movies include When Harry Met Sally, Eternal Sunshine of the Spotless Mind, and Parasite. I also watch the show Solar Opposites on Hulu; my girlfriend is the showrunner’s assistant, and I’m endlessly proud of her.

I went to college at USC, starting in the film school but ultimately graduating from the communications school. This is where I fell in love with college football — as I write this, I am nervously watching our conference championship game.

In addition to movies and college football, I love to travel. Two of my favorite cities to visit are New Orleans and New York City because of their food, art, and especially public transit. My ideal vacation is one where I never have to drive — just walking and taking the bus/metro/subway.

Prior to SDCMS, I was a sales and client manager at a nationwide, online-only tutoring service.

Before that, I was the individual giving manager at a children’s museum in Santa Monica, where I also oversaw its membership program.

If you ever see me at one of our member socials, please come up and chat! I’d love to learn more about you. What can we do better? What would you like to see from us moving forward? Or, if you don’t want to talk business, talk to me about movies, travel, transit, college football, or anything else that may be on your mind. Can’t wait to speak with you!

Reach Alex at: Alex.Kriksciun@SDCMS.org or 858.565.8888 (Main SDCMS number)

COVERED CALIFORNIA

CMA Publishes Guide to Help Californians Navigate Covered California Changes in 2023 IN 2022, COVERED CALIFORNIA, CALIFORNIA’S HEALTH BENEFIT EXCHANGE, saw an increase in statewide enrollment of approximately 9.8% from 2021. There are now approximately 1.7 million individuals enrolled in qualified health plans, which represents the highest enrollment ever for Covered California. To help physician practices understand their participation status, which products are being offered and what changes to expect, the California Medical Association has published a new tip sheet, “Navigating Covered California: Preparing for changes in 2023.” The tip sheet is available free to members.

TRUST SDCMS LEADERSHIP

SDCMS Board of Directors Gathers in Person for Holiday Party THE BOARD OF DIRECTORS OF THE SAN DIEGO COUNTY MEDICAL Society gathered in person for its holiday party, a rare treat after missing it the past two years. Physicians and their significant others enjoyed the gorgeous view of San Diego and delicious food and drink at the legendary Bali Hai restaurant on Shelter Island.

The gathering heard from SDCMS President Dr. Lase Ajayi, MD, CEO Paul Hegyi, former SDCMS President and Immediate Past President of the California Medical Association Dr. Bob Wailes, MD, as well as former SDCMS President Dr. Will Tseng, MD, and former SDCMS President Dr. Sergio Flores, MD.

IMMUNIZATION

New Law Requires Providers to Submit Immunization Data to a California Registry EFFECTIVE JAN. 1, 2023, A NEW STATE LAW REQUIRES California healthcare providers who administer vaccines to enter the immunizations they administer into a California immunization registry (CAIR OR RIDE/ Healthy Futures). They will also be required to include race and ethnicity information for each patient in the immunization registry to support assessment of health disparities in immunization coverage.

Physicians who are not already participating in an immunization registry should start the enrollment process as soon as possible. For more information about CAIR or to start the enrollment process, visit the CAIR website. (Providers in Alpine, Amador, Calaveras, Mariposa, Merced, San Joaquin, Stanislaus, or Tuolumne counties will need to enroll in RIDE/Healthy Futures.)

Contact the CAIR Help Desk (CAIRHelpdesk@cdph.ca.gov or 800-578-7889) or your local CAIR representative with any questions or if you want to find out whether your practice is already participating in CAIR. For more information, see the California Department of Public Health Immunization Registry FAQs.

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SANDIEGOPHYSICIAN .ORG

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2022

YEAR IN REVIEW

By Paul Hegyi, MBA

IN A MOMENT WHEN SO MUCH FEELS LIKE IT is changing, there is one constant: Physicians want to help people. In 2022, you and our other members have found every possible way you can do so. For that, I thank you.

First, I’d like to acknowledge the role San Diego’s physicians played locally. In the recent impact report, Champions for Health found that donations and volunteers enabled them to provide more than 30,000 COVID vaccine doses, many in the most under-resourced areas in San Diego. More than 80% of vaccine sites were in health-equity-priority zones — double the state recommendation. Your membership and donation helped get vaccines into the hands of those who need it most.

Your membership also played a big role in public health education, disseminating much needed information throughout San Diego. Due to the membership of people like you, there were more than 150 Speaker’s Bureau presentations educating more than 3,000 San Diegans, with public health events continuing in 2023.

I think 2022 will be remembered as the year of transition to a new normal, following the heights of the COVID pandemic.

Events and meetings returned as in-person affairs, in some but not all cases, as the convenience of virtual gathering continues to be preferred by many. We shared that hybrid practice, with some committees meeting in person when there was value for that and others continuing virtually. Throughout, all of our standing committees met regularly.

Our largest in-person activity was the decision to hold our gala for the first time since 2019. A massive success, 4

JANUARY 202 3

this was the highest turnout gala we’ve had in over a decade. Participants highlighted how much they valued interacting in person again after such a long time away. Supervisor Nathan Fletcher and Assemblywoman Dr. Akilah Weber, MD, each gave keynote addresses. Thankfully, we avoided becoming a super-spreader event as many others around that time sadly were.

Advocacy continued to be at the forefront of society activity, highlighted by efforts to protect the Medical Injury Compensation Reform Act (MICRA). At the end of April, CMA and Californians Allied for Patient Protection seized an opportunity to end one of the longest running political battles in California. The legislative deal (AB 35), which modernizes MICRA while preserving its underlying principles, has ushered in a new and sustained era of stability around malpractice liability. Your engagement and feedback created a long-term solution that gives you the protection you need to best care for patients.

Throughout the MICRA efforts and after, SDCMS continued to work with state and national organizations to ensure the relationship between physician and patient remains sacred and that all of our patients have equitable access to the right care at the right time. Our delegation to CMA’s Annual Legislative Day was the largest in my seven years with the society (including numerous students and residents). We actively engaged with candidates in three open legislative contests, endorsing Steve Padilla, David Alvarez, and Catherine Blakespear, all who went on to win in November.

CMA member Dr. Jasmeet Bains, MD, joined the Cali-

fornia Assembly as its third physician legislator, while incumbent assemblymembers Dr. Joaquin Arambula, MD, and our own Dr. Weber were reelected. At the federal level, representatives Dr. Ami Bera, MD, and Dr. Raul Ruiz, MD, were reelected to Congress. CMA also saw its ballot measure positions reflected in election results, including the rejection of Prop. 29 (dialysis clinic requirements) and passage of Prop.

31 (ban on flavored tobacco).

We achieved significant victories on health information technology issues by extending the COVID telehealth waivers into 2023; permanently extending key Medi-Cal telehealth payment parity; eliminating e-prescribing burdens (AB 852); and helping physicians comply with the new federal information blocking rule while protecting patients’ sensitive medical information (SB 1419).

After literally thousands of physicians spoke up, Governor Newsom vetoed the dangerous AB 2236, which would have allowed optometrists to perform eye surgeries that require use of a scalpel or an injection and “anterior segment lasers” if they met minimal specified education and training conditions that are far inferior to the requirements that ophthalmologists must meet. Members highlighted that all Californians deserve to have well-trained physicians to provide high-quality care, and they expect the State of California to ensure strict safety standards to protect patients.

All this is to say that in more than 150 years as a medical society, I don’t know that we have ever been as needed as we are now. Among all the challenges, we’ll keep doing what we do best — helping people. We’re continuing to host public health education events for both the public and physicians. And with the return of our Physician Socials and the creation of our Physician Wellness Committee, we’re doing everything we can to give physicians the space, opportunity, and resources they need to heal, learn, and grow.

SDCMS physicians continued to earn and serve in leadership positions throughout medicine. Our current president, Dr. Toluwalase Ajayi, was elected to the AMA board of trustees — the first San Diegan to serve in that role. Dr. Robert Wailes completed his term as president of CMA this October, where our Dr. Sergio Flores currently serves as vice chair of the board of trustees. Dr. Holly Yang was appointed to chair CMA’s Governance Reform Technical Advisory Committee, charged with identifying and developing proposals to improve various attributes of CMA’s governance structure. She also serves as the president-elect of the American Academy of Hospice and Palliative Medicine. Dr. Karl Steinberg is the immediate past president of AMDA: The Society for PostAcute and Long-Term Care Medicine.

After 22 years, Thomas Henderson retired as executive director of the Imperial County Medical Society (ICMS)

effective Aug. 31. SDCMS and ICMS have long had a close relationship, including being paired as a delegation to CMA, which we have now expanded into a management services agreement. The SDCMS team has 40 years of collective experience working in organized medicine. Together with the ICMS board of directors we are committed to providing the highest quality services to our physician members for their professional needs as we work as an advocate for improving the doctor-patient relationships in the healthcare community. There are many unique challenges physicians and their patients face in a rural setting and we’re committed to ensuring that every patient receives the highest quality of care.

Looking to 2023, CMA will be leading an effort to infuse an additional $6 billion annually into the Medi-Cal system.

Proposition 56 from 2016 successfully added more than $1 billion to the Medi-Cal system, providing increased payments for a total of 23 CPT codes, through both the feefor-service and managed care delivery systems. Yet overall Medi-Cal rates remain woefully behind Medicare and the actual cost of providing care, resulting in access challenges for patients who are in the most need. This new source of funding will stabilize the Medi-Cal system, opening access and ensuring that your practice is able to see these patients.

Look for more on this initiative during the first part of 2023.

I believe passionately in organized medicine and am proud of the success we’ve had in recent years. That success has only been made possible because of you and the many other members that have joined together to protect both physicians and patients in California. Thank you for your membership and I look forward to seeing you at one of our member events over the next year.

Paul Hegyi is the CEO of the San Diego County Medical Society.

SANDIEGOPHYSICIAN .ORG

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In a year where the world was starting to return to “normal,” the California Medical Association (CMA) seized the opportunity to make big gains for physician practices in several areas, from modernizing crucial malpractice legislation, preserving reproductive rights and encouraging grassroots engagement. This year’s achievements include:

MICRA Modernization Facing another statewide ballot proposition that would have effectively eliminated MICRA’s cap on non-economic damages, CMA and Californians Allied for Patient Protection seized an opportunity to end one of the longest running political battles in California. The legislative deal (AB 35), which modernizes MICRA while preserving its underlying principles, has ushered in a new and sustained era of stability around malpractice liability.

Reproductive Rights After the Supreme Court’s Dobbs decision, CMA worked with the Future of Abortion Council to protect and expand access to reproductive health care in California, leading to 15 bills signed into law, $200 million in the state budget and the passage of Prop. 1 to enshrine abortion rights into California’s constitution.

Election Victories CMA member Jasmeet Bains, M.D., joined the California Assembly as its third physician legislator, while incumbent assemblymembers Joaquin Arambula, M.D., and Akilah Weber, M.D., were re-elected. At the federal level, representatives Ami Bera, M.D., and Raul Ruiz, M.D., were re-elected to Congress. CMA also saw its ballot measure positions reflected in election results, including the rejection of Prop. 29 (dialysis clinic requirements) and passage of Prop. 31 (ban on flavored tobacco).

Federal Loan Forgiveness

Billing and Burdens

The U.S. Department of Education overhauled the Public Service Loan Forgiveness Program, including the specific fix that CMA advocated for that will allow all eligible California physicians to receive loan forgiveness.

CMA recouped more than $1 million this year (nearly $40 million over 14 years) on behalf of physician members through direct payor interventions. CMA also stopped Cigna’s burdensome modifier 25 policy.

Health IT CMA achieved significant victories on health information technology issues by extending the COVID telehealth waivers into 2023; permanently extending key Medi-Cal telehealth payment parity; eliminating e-prescribing burdens (AB 852); and helping physicians comply with the new federal information blocking rule while protecting patients’ sensitive medical information (SB 1419).

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2022 YEAR IN REVIEW Grassroots Engagement CMA saw unprecedented grassroots physician engagement, with nearly 4,000 messages sent to policymakers. These physician voices were key in helping to defeat AB 2060 (public member majority on Medical Board of California) and AB 2236 (allowing optometrists to perform surgical procedures).

Public Health Funding CMA helped administer both the KidsVaxGrant ($22+ million) and COVID-19 Test to Treat Equity Grant ($59 million) programs, providing critical funding for community pediatric vaccinators, public health systems and community health centers.

Community Health Centers CMA saw rapid membership growth among community health centers, resulting in an expansion of our mode of practice forums and House of Delegates representation.

Retention Payments CMA helped secure $1.3 billion in the state budget to provide retention bonuses for many of California’s physicians and other health care workers to stabilize the health care workforce.

Universal Health Care CMA successfully advocated for full-scope Medi-Cal coverage for all income-eligible Californians by January 1, 2024, making California the first state to expand its Medicaid program to provide full benefits to all eligible individuals regardless of age or documentation status.

Virtual Grand Rounds CMA completed its 28th Virtual Grand Rounds webinar, providing critical COVID-19 continuing medical education to over 13,000 attendees while expanding topics to include other public health concerns such as long COVID, monkeypox and wildfire smoke.

Visit cmadocs.org/year-in-review to learn more!

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PHYSICIAN WELLNESS

Quixotic Medicine Finding Inspiration in Dr. William Osler, The Bodhisattva, and the Man of La Mancha By Daniel J. Bressler, MD, FACP

SOME DAYS IT FEELS LIKE NEITHER MY WIT nor my willpower is up to it. I’ll look back on the day and see it as a series of lost causes. The EHR was down for half an hour, which put me behind. The blood sugars on my patient with diabetes remained disturbingly high in spite of aggressive insulin adjustments. The gloom of my depressed patient continued to suck out any joy from their life. Despite the ablation and meds, the patient with paroxysmal atrial fibrillation kept reverting back to that irregularly irregular rhythm. The prior authorization bureaucrat at the other end of the line stonewalled as I sought permission to prescribe a new migraine medicine for a patient who has already failed 8

JANUARY 202 3

trials of multiple others. Et cetera, et cetera.

At such times I ask myself whether it’s me that’s a failure or whether, rather, I am trying to achieve things beyond the reach of any non-imaginary primary care doc. Are the goals that I set for myself (and thus, the goals I set for my patients) just too high? Are

the ideals of the textbooks, the consensus guidelines, or the published papers beyond the reach of realworld clinicians? If a drug or procedure helps half the patients, why is it that some days the other 50% all end up on my practice roster? And, at an even deeper dimension of pessimism, aren’t all of my efforts doomed to failure anyway if I follow patients long enough? If one disease doesn’t defy treatments now, won’t another one come along on some tomorrow and do so?

In the face of such demoralizing reflections, who can I look to for inspiration? Who are the exemplars of bravely sailing on in the face of such clinical, practical, and existential headwinds?

In the pantheon of historical medical sages, one standout is the figure of Sir William Osler, the physician-philosopher who helped lay the foundations for modern, evidence-based medicine in the late 19th and early 20th century.

Definitely a relic of a different era, he was already decidedly and quaintly “old school” when his proverbs were nostalgically recited by heart by sentimental senior professors at Harvard during my medical school and residency years in the ’70s and ’80s. And yet, even now four decades later, there is a certain calming timelessness to his wisdom.

His writing is rich with quotable nuggets. One of

them speaks to the notion of keeping an even keel when you seem to be getting nowhere in your clinical progress. As he famously advised a group of graduating medical students: “Be calm and strong and patient. Meet failure and disappointment with courage. Rise superior to the trials of life, and never give in to hopelessness or despair. In danger, in adversity, cling to your principles and ideals. Aequanimitas!”

How would Dr. Osler’s famous equanimity fare in the face of EHR outages, prior authorization stonewalling, and COVID-19 misinformation? Probably just fine. The frustrations and failures of his era had to have been at least as demoralizing as those of ours. I find his steady confidence in continuing to strive in the face of setbacks to be inspiring, even in 2022 as I write these words.

In searching outside of medicine for other “champions of the endless to-do list,” I think about a mythical exemplar from world religions. In Buddhism, a Bodhisattva is an idealized person who has placed herself/himself on a path toward enlightenment through seeking to help others. Like other religious saints in their goodness and purity, these figures aim above all else to be of service to others. One version of the first stanza of the famous “Vow of the Bodhisattva”

states, “Suffering beings are numberless, I vow to liberate them all.” The vow goes on to list other similarly ridiculously impossible tasks as aspirational goals for those who would seek a spiritual awakening. Apparently, such a person finds inspiration rather than intimidation from having more to do than anyone can realistically expect to achieve.

For primary care, one of the main challenges is the sheer breadth of what we are tasked with handling, as the first responder or later adviser. The problems span from the relatively trivial to the life-threatening. Here, just for fun and in alphabetical order no less, are the conditions I managed over the past few months: angina, bronchitis, CHF, diabetic neuropathy, earwax, Factor V Leiden mutation, GERD, hypertension, irritable bowel syndrome, jitteriness, knee pain, loneliness, marital stress, nummular eczema, obesity, psoriasis, queasiness, rhabdomyolysis, sarcoidosis, tinnitus, ulcerative colitis, vertigo, Wilms Tumor, xeroderma, yeast infection, zoster. Obviously I am not a master of each of these problems, and very often (e.g. CHF, Wilms tumor) there will be at least one subspecialist involved in the patient’s care. Nevertheless, these patients still come to me with questions or a request for my direct opinion. It’s therefore

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PHYSICIAN WELLNESS

incumbent on me to have at least passing familiarity with all these conditions.

The availability of such online tools as UpToDate allow me efficient refresher courses as I dive into such a conversation. Sometimes looking back on the day I feel as much like a medical student as a veteran practitioner. That is one of the drawbacks to being a generalist.

Specialists, too, can draw up their own lists of frustratingly unsolvable clinical problems.

For the spine specialist it might be failed back syndrome. For the cardiologist it might be intractably progressive congestive heart failure. For pediatricians there’s the struggle to treat kids who have misinformed and hostile parents. No specialty is without its clinical frustrations and its own demands for persistent effort in trying to cure the seemingly incurable or answering their own quixotic quest.

In Man of La Mancha, a modern musical adaptation of the 17th century novel Don Quixote by Miguel de Cervantes, the hero sings of his goal of correcting the wrongs of the world, regardless of how unlikely his chances of success: To dream the impossible dream, to fight the unbeatable foe, the bear with unbearable sorrow...to right the unrightable wrongs. Cervantes wants us to admire Quixote’s ambition to do the right thing even while seeing the ultimate folly of its aims.

Somehow when you’re following patients over the very long term you have to keep in mind simultaneously the idea of optimal therapy with the idea of ultimate failure. No matter what, except in rare cases, chronic diseases progress. That’s why they’re called “chronic.” Sometimes when a patient faces a long-term problem and is overwhelmed, I remind them to shrink the timeframe of their concern. This is a technique used by psychotherapists (“one day at a time”) and in nursery rhymes (“inch by inch, life is a cinch”). Osler, too, had advice in this vein, reminding us to think not of the amount to be accomplished, the difficulties to be overcome, or the end to be attained, but set earnestly, at the little task at your elbow, letting that be sufficient for the day.”

We physicians are everyday soldiers fighting what is, in the end, a futile battle against life’s endless barrage of harms. We score temporary victories that we call cure or remission or repair in a war that our side will eventually lose.

Yet, re-orienting the timeframe from “a lifetime” to “dayto-day” or even “year-to-year” we do win. We drive cancers 10

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into remission, bypass otherwise fatal arterial narrowings, help fractures heal functionally, and infections resolve. Our management of chronic illnesses delays complications in such a way that patients receive years or decades more of vitality. The autoimmune dysfunction becomes less disruptive, the angina milder, the dyspnea less limiting. We reduce or lessen the sting of outrageous fortune and so allow some greater happiness in our patients’ lives. We are pedestrian heroes, commemorated not in song or religious parable, but in the simple thank-you cards we get. We also can honestly and honorably congratulate ourselves knowing that we do make life better for others, sometimes a little and sometimes a lot. And that is how, after a day like the one I described above, I still manage to be grateful for my place in the world as someone whose calling and job is to relieve suffering and, in carrying out that task, to make the world a little better than it would have been without me. In that regard, I take my humble little place in the lineup that includes Sir William Osler, the Bodhisattva, and Don Quixote of La Mancha.

Dr. Bressler has practiced outpatient Quixotic internal medicine in San Diego since 1984. He maintains privileges at Scripps Mercy Hospital, where he served as chairman of the Biomedical Ethics Committee, and at Mission Hills Post Acute Care, where he served as medical director.

PERSONAL AND PROFESSIONAL DEVELOPMENT

A Better Way to Start the New Year

By Helane Fronek, MD, FACP, FASVLM, FAMWA

AMONG NEW-YEAR TRADITIONS — FIREWORKS, champagne, and yes, the polar bear plunge — is the declaration of resolutions. Many focus on healthier behaviors or establish a higher bar for learning or accomplishment. This year, I’ll learn to speak Spanish, read a book every month, get a promotion. Donna Ashworth, in her poem “Let It Be So,” offers another perspective to begin our year.

After I shared this with a dear friend, among the kindest and most generous people I know, Let It Be So she replied that perhaps it would Why do we start a new year with promises to improve? help her not be so hard on herself.

Who began this tradition of never-ending pressure?

There is something awry with a I say, the end of a year should be filled with congratulation for all we survived. culture that promotes feelings of And I say a new year should start with promises to be kinder to ourselves, to underunworthiness. Making people feel stand better just how much we bear, as humans on this exhausting treadmill of life. bad about themselves may instill And if we are to promise more, let’s pledge to rest, before our bodies force us. fear that can shape particular Let’s pledge to stop, and drink in life as it happens. behaviors, but it has never been Let’s pledge to strip away a layer of perfection to reveal the flawed and wondrous the way to bring out our best. humanity we truly are inside.

Some worry that self-compasWhy start another year, gifted to us on this earth, with demands on our already sion leads to laziness and conover-strained humanity, dones bad behavior. In fact, data when we could be learning to accept that we were always supposed to be imperfect? prove this is a false concern. SelfAnd that is where the beauty lives, actually. compassion is not indulgence, And if we can only find that beauty, we would also find peace. but an acknowledgment that we are human, make mistakes, and can hurt others. It provides a safe route to admit our mistakes, feel Dr. Fronek is an remorse for their impact, and begin to find other ways of reminder on your phone acting that leave more positive effects in our world. to pause and notice the assistant professor of So, congratulations to you for all you have survived in beauty around you? Can clinical medicine at 2022! We’ve certainly had a lot to contend with. What are you begin to treasure UC San Diego School you most proud of having survived? What strengths or out“imperfections” in yourself of Medicine and a side resources helped you do that? and others as the only true Certified Physician As physicians, we will continue our lifelong commitment ways we find intimacy and Development Coach, to learning and caring. But, in what ways can you begin love in this world? Greater CPCC, PCC. to be kinder to yourself? Can you find even a bit of time peace — and a truly in your busy life to gift your only body with rest, so it can happier new year — will support you in finding enjoyment in 2023? Can you set a follow.

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11

ADDICTION

Substance Use Among Teens Generally Holding Steady, Report Finds But alcohol use among high school seniors rose significantly in 2022 compared with 2021 By Joyce Frieden

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MOST TYPES OF SUBSTANCE USE AMONG teens held steady in 2022 after falling sharply in 2021, according to results released in December from a survey funded by the National Institute on Drug Abuse (NIDA).

Eleven percent of 8th graders, 21.5% of 10th graders, and 32.6% of 12th graders reported illicit drug use in the past year, NIDA’s Monitoring the Future survey showed. These proportions were similar to those from 2021, which represented a drop from the prior year.

“Reported use for almost all substances decreased dramatically from 2020 to 2021 after the onset of the COVID-19 pandemic and related changes like school closures and social distancing,” the institute said in a press release.

“It is encouraging that we did not observe a significant increase in substance use in 2022, even as young people largely returned to in-person school, extracurricular activities, and other social engagements,” NIDA Director Dr. Nora Volkow, MD, noted.

The annual survey, conducted by researchers at the University of Michigan in Ann Arbor, looks at substance use behaviors and related attitudes among 8th, 10th, and 12th graders in the U.S. Students self-report their substance use behaviors over various time periods, such as the past 30 days, the past 12 months, and over their lifetime. The survey also documents students’ perceptions of harm, disapproval of use, and perceived availability of drugs. For the 2022 survey, investigators collected 31,438 surveys from students enrolled across 308 public and private schools.

Among high school seniors, the survey found that 31% used marijuana in the past 12 months. “These levels are significantly lower than they were during the pre-pandemic years of 2020 and 2019, when prevalence levels were 35% and 36%, respectively,” the investigators wrote. “The decline from 35% in 2020 to 31% in 2021 is the largest one-year decline among 12th grade students ever recorded in the 48 years of the survey for this measure.”

The percentage of 12th grade students who vaped nicotine within the last 12 months in 2022 was 27%, as it was in 2021.

As with marijuana use, these numbers represent a significant drop from 2020 and 2019, when the prevalence level was 35% in both years. Also, as with marijuana, “the decline from 35% in 2020 to 27% in 2021 is the largest one-year decline recorded for 12th grade students since the survey began tracking nicotine vaping in 2017,” they noted.

Use of alcohol in this group took a different trajectory from marijuana and nicotine, with the percentage of 12th grade students who used alcohol within the last 12 months hitting 52%, a statistically significant increase from the 2021 level of 47%, the researchers found. “With this increase, prevalence in 2022 returned to pre-pandemic levels and does not significantly differ from the 55% level recorded in 2020 (or the 52% level of 2019).”

The researchers also looked at use of prescribed attention deficit-hyperactivity disorder (ADHD) medications and found that among 12th grade students, use rose significantly in 2022 — to 15% — from 11% in 2021. “It is possible that the need for treatment of ADHD increased during the pandemic due to adolescents experiencing more stress,” they said.

“Another possibility is that sheltering at home during the pandemic may have made any attention issues of adolescents more salient to their parents, who then sought out medical care for their children.”

As for the steady state of marijuana and nicotine use, they posited two different possibilities. “First, it is possible that the factors that disrupted and lowered drug use during the pandemic in 2021 continued into 2022,” the investigators wrote.

“These include disruptions in adolescents’ ability to use drugs outside of parental supervision, to obtain drugs, and to interact with friends who use drugs and may encourage drug use.”

“Second, an alternative scenario is that a one-year delay or halt in drug use during adolescence may lower adolescents’ drug use levels for the rest of their lives,” they continued.

“This could occur if absence of drug use reduces involve-

ment with peer groups that encourage the use of drugs, and/or these adolescents have been spared psychological or neurological changes that increased their susceptibility for future drug use. In future years we will be able to see which of these two scenarios plays out.”

Dr. Rahul Gupta, MD, MPH, director of the White House Office of National Drug Control Policy, praised the survey results. “I am encouraged by today’s data that show the vast majority of young people are continuing to avoid substance use,” he said in a statement. “At the same time, it is imperative that we continue to invest in evidence-based prevention strategies and raise awareness about the risks to youth of illicit drugs, including fake pills and marijuana, since we know perceived risk can play an important role in youth prevention.”

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

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13

RACIAL BIAS IN HEALTHCARE

After Election Win, California’s AG Turns to Investigating Hospital Algorithms for Racial Bias By Mark Kreidler

CALIFORNIA ATTORNEY GENERAL ROB BONTA sailed to victory in the Nov. 8 election, riding his progressive record on reproductive rights, gun control, and social justice reform. As he charts a course for his next four years, the 50-year-old Democrat wants to target racial discrimination in healthcare, including through an investigation of software programs and decision-making tools used by hospitals to treat patients.

Bonta, the first Filipino American to serve as the state’s top prosecutor, asked 30 hospital CEOs in August for a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms, and guide billing practices. In exchange, he offered them confidentiality. His goal, Bonta told KHN, is to identify algorithms that may direct more attention and resources to white patients than to minorities, widening racial disparities in healthcare access, quality, and outcomes.

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“Unequal access to our healthcare system needs to be combated and reversed, not carried forward and propagated, and algorithms have the power to do either,” Bonta says.

It’s too early to know what Bonta will find, and his office will not name the hospitals involved. The California Hospital Association said in a statement that such bias “has absolutely no place in medical treatment provided to any patient in any care setting” and de-

clined to comment further.

Advocates have high hopes for what Bonta will find — and for the next four years. “We expect to see a lot more from him in this full term,” says Ron Coleman Baeza, managing director of policy for the California Pan-Ethnic Health Network. “There is much more work to do.”

Last year, Gov. Gavin Newsom appointed Bonta as attorney general after Xavier Becerra left the position to join the Biden administration as secretary of the U.S. Department of Health and Human Services. In the Nov. 8 election, which won him his first full term, Bonta faced Republican challenger Nathan Hochman, a former federal prosecutor who campaigned on prosecuting violent criminals and pulling the deadly synthetic opioid fentanyl off the streets. In contrast, Bonta advocated for gun control and decriminalizing lower-level drug offenses, and in January advised law enforcement officials not to prosecute women for murder when a fetus dies, even if their drug use contributed to the death.

In unofficial results, Bonta had about 59% of the

statewide vote, compared with 41% for Hochman.

Bonta, formerly a state legislator representing the East Bay, will be eligible to run for a second full term, which could allow him to serve for nearly 10 years.

His wife, Democratic state Assemblymember Mia Bonta, was among the public officials who discussed their abortion experiences after a leaked draft of a U.S. Supreme Court opinion that was published in May revealed the justices would likely repeal Roe v. Wade. After they did, the attorney general threatened legal action against local jurisdictions that tried to adopt abortion bans.

Bonta called healthcare a right for all Californians and said he wanted to help people of color and low-income communities get more access to doctors and treatments, as well as better care. “It’s something I’ve been actively working on as an elected official my entire career, and even before that,” says Bonta, whose father helped organize health clinics for Central Valley farmworkers.

But health equity remains an elusive goal, even as it has become a catchphrase among advocates, researchers, politicians, and healthcare executives. And as with most aspects of the state’s mammoth healthcare system, progress comes slowly.

The Newsom administration, for example, will require managed-care plans that sign new Medicaid contracts to hire a chief equity officer and pledge to reduce health disparities, including in pediatric and maternal care. The state’s Medicaid program, known as Medi-Cal, serves nearly 15 million people — most of whom are people of color. But those changes won’t come until 2024, at the earliest.

State lawmakers are also trying to minimize racial discrimination through legislation. In 2019, for example, they passed a law that mandates implicit bias training for healthcare providers serving pregnant women. Black women are three times as likely to die from having a baby as white women.

In recent years, researchers started warning that racial discrimination was baked into the diagnostic algorithms that doctors use to guide their treatment decisions. One model predicted a lower rate of success for vaginal births among Black and Hispanic women who previously had a cesarean delivery than among white women, but failed to take into account patients’ marital status and insurance type, both of which can affect the success rate of a vaginal birth.

Another, used by urologists, assigned Black patients coming into emergency rooms with “flank pain” a lower likelihood of having kidney stones than non-Black patients — even though the software’s developers failed to explain why.

Some researchers likened such medical algorithms to risk assessment tools used in the criminal justice system, which can lead to higher bail amounts and longer prison sentences for Black defendants. “If the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy,” they wrote in The New England

Journal of Medicine in 2020.

Bonta is seeking the hospital industry’s cooperation in his algorithm investigation by framing racial and ethnic disparities as injustices that require intervention. He said he believes that his inquiry is the first of its kind and that it falls under the California Department of Justice’s responsibility to protect civil rights and consumers. “We have a lot of depth,” he said of his 4,500-employee agency.

Coleman Baeza and other advocates for healthcare consumers said the attorney general should also monitor nonprofit hospital mergers to ensure that healthcare facilities don’t reduce beds in underserved communities and crack down on predatory medical lending, particularly in dental care.

“They violate existing consumer protections, and that falls squarely within the AG’s jurisdiction,” says Linda Nguy, a senior policy advocate for the Western Center on Law and Poverty.

Nguy urged Bonta to go after underperforming health plans when they fail to contract with enough providers so patients can get timely appointments, even though the California Department of Managed Healthcare is the state’s main health insurance regulator.

“During COVID, the health plans were essentially given a pause on reporting of their timely access,” Nguy says. “But

that pause is over, and the plans have to meet these requirements. He can ask for that utilization data.”

Bonta remains circumspect on a particular issue related to race.

His office has been facilitating California’s reparations task force, which issued a nearly 500-page preliminary report this year that noted that Black Californians had shorter life expectancies and poorer health outcomes than other groups. In surveys of hospitals across the country, Black patients with heart disease “receive older, cheaper, and more conservative treatments” than white patients, the report said.

The task force could recommend cash compensation for Black Californians who can establish ties to enslaved ancestors, but Bonta hasn’t endorsed that plan. The final report is due in July.

“If we can move the needle, then we should,” Bonta says. “There are a whole set of different possible solutions, pathways to get there.”

Mark Kreidler is a journalist for Kaiser Health News, where this report first appeared.

This story was produced

by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

SANDIEGOPHYSICIAN .ORG

15

ENDOCRINOLOGY

Obesity Absent in One-Fourth of Kids with Type 2 Diabetes Global Study Supports Obesity As a Risk Factor, Not Prerequisite, for Diabetes Screening By Kristen Monaco AMONG KIDS WITH TYPE 2 DIABETES (T2D), obesity was common but far from universal in a look at the condition worldwide.

In fact, only 75% of pediatric cases were found to also have obesity, with a rate of 77% at the time of diagnosis, according to a systematic review and meta-analysis of nearly 9,000 kids with T2D published in JAMA Network Open.

Although only 4.2% of children with type 2 diabetes in the Americas had a BMI in the normal range, this was more common in other parts of the world like Oceania (16.4%) and Asia (14%), Dr. M. Constantine Samaan, MD, MSc, of McMaster Children’s Hospital in Hamilton, Ontario, and colleagues found.

While acknowledging the low to moderate risk of bias, variable levels of evidence, and high heterogeneity, Dr. Samaan’s group pointed to potential impact on care: “Understanding the contribution of body mass to the evolution of insulin resistance, glucose intolerance, and T2D and its comorbidities and complications is crucial for creating personalized interventions to improve outcomes,” he wrote.

Obesity within diabetes differed between boys and girls.

Only 59% of females with type 2 diabetes had obesity; on the other hand, 79% of males had comorbid diabetes and obesity.

This translated into a 2.1-times higher prevalence of obesity for males with type 2 diabetes versus females (95% CI 1.333.31, P=0.03).

Beyond sex differences, a slew of racial differences emerged as well. Asian patients with T2D had the lowest prevalence of comorbid obesity while white patients had the highest.

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White patients

89.86% African American and African Canadian patients

84.47% Middle Eastern patients

82.19% Hispanic and Latino patients

81.30% Indigenous patients

76.73% Asian patients

64.50%

Loosely reflective of racial differences, regional differences from around the world also emerged. North America had the highest prevalence of obesity among kids with T2D (81%), followed by the Middle East (78%), Oceania (74%), Asia (69%), and Europe (68%).

These findings really underscore how BMI-based measures to screen for and predict diabetes in youth are lacking, Samaan’s group explained. While most guidelines advise looking for an elevated BMI as the first sign of diabetes, the researchers said that guidelines should instead recommend a more comprehensive and “more sophisticated” screening approach. They suggested incorporating other diabetes risk factors like family history, lifestyle, hormones, growth, markers of insulin resistance, and insulin production capacity — just to name a few.

“The two main mechanisms driving T2D include insulin resistance and insulin deficiency,” they wrote. “In children with T2D, beta cell dysfunction manifests with substantial impairments in first- and second-phase insulin secretion, and children with T2D and normal weight have lower insulin secretory capacity than patients with T2D and obesity.

The decline in beta cell function in children with T2D is 20% or greater per annum, which is almost double the rate seen in adult T2D.” Ultimately, Samaan’s group advised that when screening for type 2 diabetes in children, obesity should be considered as a risk factor and not a prerequisite, especially when other risk factors are present.

The meta-analysis included data from 53 studies, with a total of 8,942 participants. The majority of studies included used the 95th percentile of BMI for age and sex to define obesity.

After the study’s publication, the CDC updated the BMIfor-age growth charts, expanding them to include children and adolescents with severe obesity. The charts now extend to a BMI of 60, and severe obesity is defined as 120% of the 95th percentile, reflecting the rising prevalence of greater degrees of obesity among kids and teens.

The most common risk factors for type 2 diabetes in the meta-analysis were family history and maternal gestational diabetes. Acanthosis nigricans, polyuria, and polydipsia were the top clinical presentations. Most youth were treated with oral hypoglycemic agents, while others were also treated with insulin, diet alone, or a combination of approaches.

Kristen Monaco is a writer for MedPage Today, where this article first appeared, who focuses on endocrinology, psychiatry, and nephrology news.

SANDIEGOPHYSICIAN .ORG

17

INFECTIOUS DISEASES

Is Legislation to Safeguard Americans Against Superbugs a Boondoggle or Breakthrough?

By Liz Szabo and Arthur Allen WITH TIME RUNNING OUT IN THE 2022 congressional session, a bipartisan coalition of lawmakers and infectious disease specialists is scrambling to pass a bill aimed at spurring the development of antibiotics to combat the deadly spread of drug-resistant pathogens.

The PASTEUR Act, as amended, would provide $6 billion in federal funding over several years to give drugmakers incentive to develop and manufacture lifesaving medications for the small but growing number of infections highly resistant to antibiotics.

A range of supporters in the healthcare and drug sectors say the measure would fix the “broken market” for antibiotics by providing stable funding for an industry that tends to focus its research on areas considered good business opportunities. In recent years, most major drug companies have abandoned antibiotic development due to lackluster sales, and several smaller ones involved in the work have declared bankruptcy.

But the measure also has staunch critics in the medical community who deride it as a multibillion-dollar boondoggle and giveaway to Big Pharma. They argue it won’t solve the longer-term problem of relying on profit as the primary motive to discover and develop antibiotics.

“This is a very clever maneuver to get the taxpayers to bail out an industry that’s foundering,” says Dr. Brad Spellberg, an infectious disease specialist and the chief medical officer at the Los Angeles County+USC Medical Center. “If the government is going to spend money on this, it should spend it smartly.”

The PASTEUR Act, which stands for Pioneering Antimicrobial Subscriptions to End Upsurging Resistance, was introduced by Sens. Michael Bennet, a Colorado Democrat, and Todd Young, an Indiana Republican, and in the House by Reps. Mike Doyle, a Pennsylvania Democrat, and Drew Ferguson, a Georgia Republican. It has more than 65 bipartisan co-sponsors across both chambers.

People for and against the bill agree that antimicrobial resistance is a critical problem the federal government needs to address. Superbugs that can’t be treated kill more than 35,000 Americans and an estimated 1.27 million people 18

JANUARY 202 3

worldwide each year.

While pharmaceutical companies can make billions on medications that patients take for months or years, such as cancer therapies and cholesterol-lowering drugs, the industry often loses money on antibiotics, which are prescribed for only a few days or weeks, says Amanda Jezek, senior vice president for public policy and government relations at the Infectious Diseases Society of America.

Hospitals are trying to administer fewer antibiotics, whose use stimulates the growth of resistant organisms, and are particularly hesitant to employ newer antibiotics that target bugs highly resistant to drugs. That’s because such bacteria infect a minority of patients, and using the new drugs widely would only cause more mutations and resistance, Jezek says.

“When someone makes a new antibiotic, the first thing that infectious disease doctors say is, ‘Don’t use it,’” says Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, who helps oversee antibiotic use at his hospital. “We need to save it until we really need it, because we don’t want to lose this drug.”

Instead of paying by the pill for antibiotics — a practice that encourages companies to promote their use — the PASTEUR Act would allow the federal government to advance lump sums for promising FDA-approved drugs that could then be administered to patients covered by government insurance programs such as Medicare and Medicaid. Such payments would provide manufacturers enough income to cover their costs for these drugs, even if they were rarely used.

But critics, including Public Citizen, say the PASTEUR Act offers the pharmaceutical industry what amounts to a windfall, without standards rigorous enough to ensure that new drugs are really safer and more effective than existing ones. And they cite a recent study that showed the vast majority of hospital deaths in patients with invasive bacterial infections were caused by treatable bugs, often in very old or frail patients.

Opponents also argue that drugmakers already have access to financial incentives to create antibiotics. Federal agencies including the National Institutes of Health and the Biomedical Advanced Research and Development Authority have invested hundreds of millions of dollars during the past decade in antibiotics research. Drugmakers also have access to financing from nonprofits such as CARB-X and Wellcome, as well as public-private partnerships such as the AMR Action Fund.

Congress and the FDA in recent years have made it easier for companies to get antibiotics approved and extend their marketing exclusivity.

The problem is not funding, but rather a lack of vigorous approval standards at the FDA, says Dr. Reshma Ramachandran, an assistant professor at the Yale School of Medicine.

The FDA approved 15 new antimicrobial drugs between 2016 and 2019. But a recently published study indicates these drugs often appear no more effective than older medications, even as companies charge up to 100 times more for them.

That explains why these drugs don’t sell, says Dr. John Powers, a former FDA official, clinical professor at George Washington University School of Medicine, and one of the study’s authors. “Insurers aren’t paying, doctors aren’t using them, because the evidence doesn’t show patients do better on them than older drugs,” he explains.

Dr. Powers argues that FDA reviews of new antibiotics don’t put enough emphasis on how they benefit patients. In one clinical trial of cefiderocol, for example, the drug was better at killing bacteria, but 34% of patients taking it died, compared with 18% taking older drugs. The FDA approved cefiderocol under a policy that allows approval of new drugs even if trials show they are less effective than old ones by as much as 10%.

“We need evidence these drugs improve patient outcomes,” Dr. Powers says. “They may kill more bacteria, but doctors don’t treat bacteria — doctors treat patients.”

Dr. Spellberg and other researchers have proposed an alternative. A federally funded nonprofit, or several nonprofits,

endowed with $1 billion to $2 billion, could fund antibiotic research for decades, he predicts. A board made up of patient advocates, doctors, industry representatives, and others would regularly update an official list of which pathogens to target, aiming to ensure taxpayer dollars are being used where they’re most needed.

Each nonprofit would include microbiologists, medical chemists, and pharmacologists “all under one roof,” Dr. Spellberg adds. “They would not focus on one drug, per se.

They would focus on discovering and developing new, impactful technologies.”

Supporters counter that the PASTEUR Act already includes built-in quality controls.

The bill would create a committee, similar to the board that Dr. Spellberg proposes, to identify the most dangerous superbugs. PASTEUR also would fund $500 million in federal grants to help hospitals improve stewardship of antibiotics — programs that manage their use with an eye to preventing the spread of resistant organisms — prioritizing rural and safety-net hospitals that serve low-income patients.

The United Kingdom has adopted a similar program, which supporters hope could demonstrate the effectiveness of subscription models.

Even supporters of PASTEUR, such as Dr. Thomas Frieden, a former director of the Centers for Disease Control and Prevention, note that antimicrobial resistance is a complex, long-term problem to be attacked on multiple fronts.

Hospital controls on antibiotic use have dramatically reduced the prevalence of one class of “nightmare bacteria,” the carbapenem-resistant Enterobacterales. Other tools, such as new vaccines, could reduce bacterial threats, Dr. Frieden says. Doctors also could prescribe fewer antibiotics if they had rapid tests to allow them to quickly distinguish between viral and bacterial infections, and to determine which bacteria have mutations requiring a special approach.

“The idea here is not to come up with one superior best antibiotic,” says Dr. Cornelius Clancy, a University of Pittsburgh professor of medicine who supports the PASTEUR Act. “The point is to have a pipeline.”

Liz Szabo is a senior correspondent for Kaiser Health News, where this story first appeared, who focuses on the quality of patient care and has covered medicine for two decades.

Her stories about cancer and overtreatment for KHN have won numerous awards. Arthur Allen is also a senior correspondent for Kaiser Health News, where he writes about the FDA and the pharmaceutical industry as well as COVID-related topics. He joined KHN in April 2020 after six years at Politico.

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19

CHAMPIONS FOR HEALTH

I Can Finally Eat Without Fear of Pain

By Adama Dyoniziak

VELIA A. SAW THE CONNECTION BETWEEN what she ate and her increasing pain. “I was always nauseous, I had pain in my stomach area,” she says. “It hurt like childbirth contractions sometimes, but worse.” Over time, she developed a fear of eating, and of food. The fear of pain stopped her from leaving the house, except to work. Velia couldn’t miss work. She recalled many days where she would force herself to push through even the most severe pain for the sake of her children.

Eventually, the symptoms were too much. “I felt very bad, I was vomiting very badly, and I forced myself to walk to my doctor’s office,” she explains. Her physician told her she had gallstones, prescribed pain medication, told her to change her diet, and referred her to Project Access for surgery. There would be a wait due to the pandemic. Worse, Velia couldn’t afford the surgery and knew that the only other option was emergency surgery, which potentially loomed in her future.

Velia’s fear of eating got to the point where she just didn’t eat. Her two sons, 12 and 18, understood that she was not eager to leave the house, or to eat outside the home. “I had medicine to help with the pain,” she says. “I would go to work thinking I was OK, but would end up working with the pain, taking pain pills, and somehow getting through the work day.

I had to have a lot of faith that things would work out.”

After two years of waiting, Velia was relieved to finally see a physician. Dr. Cheryl Olson is a general surgeon with Surgical Associates of La Jolla and a Project Access volunteer since 2016, providing pro bono consultations and surgeries to 40 patients so far. “I love being a surgeon because you get to solve a medical dilemma, a puzzle, by taking a patient from diagnose to complete resolution,” Dr. Olson explains.

“Gallbladder patients are gratifying, because then they can finally eat and feel happy with no pain. They usually live for a long time suffering from gallstones, so it’s rewarding to make a difference.”

“Dr. Olson was very nice and very thorough,” Velia says.

“She reviewed everything and when we were ready to 20

JANUARY 202 3

DR. CHERYL OLSON

operate, she explained the operation and asked me if I had questions.”

Six months post-surgery, Velia says “I feel much better, no pain — and I can eat now! Thank you to the doctor and the nurses and Project Access. They knew what I needed. I am so grateful all they did for me. May God help you so that you can keep helping people to feel better.”

Dr. Olson appreciates learning from her experiences with patients. “I have the opportunity to do something pretty amazing every day,” she says.

“Patients are anxious and distressed. We have very serious conversations, but we try to allay their fears and help them understand.”

About working with Project Access, Dr. Olson

says, “The best thing about volunteering is the heartfelt gratitude from patients. The best thank-you I ever received was from the daughter of a Project Access patient who gave me a bouquet of roses and a handwritten note that said, ‘Thank you for taking care of the most important person in my life. He’s my everything.’ I still have the note. It always brings tears to my eyes.” Dr. Olson considers it a privilege and pleasure to provide her patients with the highest level of coordinated care for any surgical need. She strives to treat each patient with the kindness and expertise she would want for her own family.

Since 2008, Project Access has facilitated $24 million in care for 7,500plus uninsured patients just like Velia by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty physicians. Join us in transforming lives — contact us to provide pro bono services at adama.dyoniziak@championsfh.org or call (858) 300-2780.

Adama Dyoniziak is the executive director of Champions for Health.

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ ChampionsFH.org.

CHAMPIONS FOR HEALTH - PROJECT ACCESS SAN DIEGO: Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology. These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office.

Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn.penaloza@championsfh.org or at (858) 300-2779.

PHYSICIAN OPPORTUNITIES MEDICAL DIRECTOR, FULL-TIME, FATHER JOE’S VILLAGES: Join us in ending homelessness! We are a dynamic team that runs an FQHC. The Medical Director oversees clinical aspects of the primary care, psychiatry, dental and behavioral health. This position will be a mix of clinic and admin time and will have direct reports (Dental Director, Director of Behavioral Health, and frontline primary care/psychiatry providers).

Reports to the Chief Medical Officer, who is responsible for all aspects of the clinic. The Medical Director is a counterpart to the Clinic Director (who oversees admin staff, MA/RN team, billing, PSRs, etc.). To apply, visit https://my.neighbor.org/jobs-careers.

SEEKING MEDICAL DIRECTOR: subcontracted position 4-8 hours per month. Responsibilities: 1. Support case conferences, refractory SUD, co-occurring conditions, specialty populations. 2. Conduct clinical trainings on issues relevant to staff (e.g., documentation, ASAM Criteria, DSM-5, MAT, WM, co-occurring conditions). 3. Provide oversight and clinical supervision. 4. Refer co-occurring conditions. 5. Lead Quality Improvement functions (e.g., Quality Improvement Projects, clinical team meetings, etc.) 6. Attend annually 5 hours of continuing medical education on addiction medicine. Required by contract with San Diego County BHS, position is for a Physician licensed by CA Medical Board or CA Osteopathic Medical Board. Contact Name: Jennifer Ratoff: e-mail: jratoff@secondchanceprogram.org, phone: 619-839-0950 PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40. Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County? 1. Fully paid malpractice insurance. 2. 13 paid holidays. 3.

13 sick days per year. 4. Vacation: 10 days (1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years). 5. Defined benefit retirement program. 6. Cafeteria-style health plan with flexible spending.

7. Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/adolescents and or geriatric patients.

This is the specialty journey level class in the series that requires a fellowship or experience in child and adolescent psychiatry or forensic psychiatry. For more information visit our website at sandiegocounty. gov/hr.

PRIMARY CARE PHYSICIAN: Imperial Valley Family Care Medical Group is looking for Board Certified/Board Eligible Primary Care Physician for their clinics in Brawley & El Centro CA. Salaried/full time position. Please fax CV/salary requirements to Human Resources (760) 355-7731. For details about this and other jobs please go to www. ivfcmg.com.

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd. edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology.

The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https:// apol-recruit.ucsd.edu/JPF03179 For help, contact: klsantos@health. ucsd.edu.

CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to albertochaviramd@yahoo.com.

high–quality care to our patients. We provide a competitive salary, paid time off, health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency. Our CEO Dr. Venu Prabaker who has 30 years of teaching experience as a faculty at multiple universities Including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc. — will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to 5-star restaurants in San Diego. We also have a weekly one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a win-win situation for all. Visit us at caremd.us.

RADY CHILDREN’S HOSPITAL PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeks board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/ month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/ sdcounty?keywords=21416207 KAISER PERMANENTE SAN DIEGO PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-5031860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct 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. Job duties include providing complete, high quality primary care, and participation 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.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit?

We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH 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.

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com.

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 low-income, 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 crubio@samahanhealth.org.

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd is looking for a caring, compassionate, and competent physician for providing primary care services. We require well-organized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide

GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand or move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong

PRACTICE FOR SALE

patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic.

Located in a professional-medical building with professional contract staff. All records and billing managed by a professional service who can assist with insurance integration. Office, staff & equipment are move-in ready. Seller will assist buyer to ensure a smooth transition. Being on-call optional. Contact Ferdinand @ (858) 752-1492 or ferdinand@ zybex.com.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 physician offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as inhouse billing section, staff room, and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at (858) 354-1895 or email: mahdavim3@gmail.com.

OFFICE SPACE / REAL ESTATE AVAILABLE PHYSICIAN OFFICE SPACE FOR LEASE: 1500 Sq ft. 3 exam room.

Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance. Located in Rancho Bernardo in prime central location. Easy access to interstate 15. Palomar /Pomerado within 10 min. Security card access during off hours. $2500/month.

Contact: (619) 585-0476. Ask for Peg. HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital. Office is approximately 2000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/ Pulmonary/Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@ sdpulmonary.com or call (619) 819-7224.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Beautifully appointed office in Hillcrest next to Mercy Hospital to sublease or share. Office is approximately 1500 sq feet and has AAAASF certified operating room to share or use as needed. Currently occupied by plastic surgery, the office is ideal for Dermatology, Gynecology, Podiatry, or other specialty. Multiple days per week full use of office available as needed.

Please contact amez.cookie@gmail.com or at (619) 961-7200.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway.

Share rent. 2100 sq ft office in professional building. Utilities included.

Great opportunity in a very desirable area. (858) 342-3104.

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4,000/mo. No need to spend a penny. Call Dr. Vin, (619) 405-6307 vsnnk@yahoo.com OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500sq foot suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at (619) 501-4758.

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information, please contact Katia at (760) 427-3328 or email at Feminacareo@gmail.com.

OFFICE SPACE/REAL ESTATE WANTED MEDICAL OFFICE SPACE WANTED IN HILLCREST/BANKERS HILL AREA. Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@ sbcglobal.net or (858) 945-0903.

NON-PHYSICIAN POSITIONS AVAILABLE OFFICE MANAGER: 1. Hiring, training, managing staff on procedures/ policies. Monitors continuing compliance and office statistics.

Oversee stocking/maintenance of supplies, retail. Equipment/facilities management. Daily bookkeeping, collections. 2. Ensure smooth/ efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/efficiency. Salary: $60-70K depending on experience/qualifications. Benefits: healthcare reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@ manageyourage.com.

ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.

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