January 2024

JANUARY 2024

Official Publication of SDCMS

The View From San Diego Medical Students KIERS TEN GABALDON

HALE Y TORRES

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; William T-C Tseng, MD; Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Nicholas (dr. Nick) J. Yphantides, MD, MPH President–Elect: Steve H. Koh, MD Secretary: Preeti S. Mehta, MD Treasurer: Maria T. Carriedo-Ceniceros, MD Immediate Past President: Toluwalase (Lase) A. Ajayi, MD GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Dustin H. Wailes, MD La Jolla #1: 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: Latisa S. Carson, MD AT–LARGE DIRECTORS #1: Rakesh R. Patel, MD, FAAFP, MBA (Board Representative to the Executive Committee) #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Daniel Klaristenfeld, MD #6: Alexander K. Quick, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician: Emily A. Nagler, MD Resident: Alexandra O. Kursinskis, MD Retired Physician: Mitsuo Tomita, MD Medical Student: Jesse Garcia CMA OFFICERS AND TRUSTEES Immediate Past 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: Eric L. Rafla-Yuan, MD District I: Ran Regev, MD District I: Kosala Samarasinghe, MD District I: Thomas J. Savides, 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 District I: Randy J. Young, MD RFS Delegate: David J. Savage, MD

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Contents JANUARY

VOLUME 111, NUMBER 1

FEATURES

4

From UCSD to the State Capitol

By Kiersten Gabaldon

6

Spot the Artist

By Haley Torres

4

DEPARTMENTS

2

Briefly Noted: CMA Benefits • Federal Issues • San Diego Healthcare Community

8

Underdiagnosed and Undertreated, Young Black Males With ADHD Get Left Behind

By Claire Sibonney

10

If Ketamine Is So Safe, What Happened to Matthew Perry?

By Kristina Fiore

12

A New Test Could Save Arthritis Patients Time, Money, and Pain

By Arthur Allen

15

Should You Offer Your Services As a Paid Clinical Expert?

By Richard Cahill, JD

17

Rift Over When to Use N95s Puts Health Workers at Risk Again

By Amy Maxmen

19

An Open Door Leads to Healing

By Adama Dyoniziak

14

20

Classifieds

SANDIEGOPHYSICIAN .ORG

1

CMA BENEFITS

Welcome to the New CMADocs App! CMA’S NEW MOBILE APP LETS YOU

connect with your colleagues and engage with CMA content! Download the “CMADocs” app today from the Apple or Google Play app stores for daily news updates, events calendar, resource library, and more.

The CMADocs app connects you with the content you’re most interested in and lets you engage with CMA and other members.

Though the app provides access to valuable content for both CMA members and non-members, some features are for CMA members only.

If you’re not a CMA member and would like to access the full lineup of available features, we hope you’ll take this opportunity to join CMA. After you download the app, get the full experience by logging in using your CMA username and password (the same login you use for the CMA website, cmadocs.org). If you need assistance logging in, click on the buttons on the login page to retrieve your password or username, or to create an account.

Make sure you receive all the latest updates by enabling notifications both in the “Settings”

section found in the CMADocs app menu and in the “Notifications” settings on your mobile device.

For more information and FAQs, download our CMADocs App User Guide.

Questions? Need Help?

Contact CMA Member Services at (800) 786-4262 or memberservice@cmadocs.org.

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JANUARY 2024

FEDERAL ISSUES

THE U.S. DEPARTMENT OF EDUCATION HAS

Important PSLF Update: Income-Driven Repayment Account Adjustment Deadline Extended

extended the deadline for borrowers to consolidate commercial FFEL or Perkins loans into Department of Education government-held loans for incomedriven repayment account adjustments from Dec. 31, 2023, to April 30, 2024.

The department has updated the account adjustment page with the new deadline and has posted a new article for borrowers — ”Seven Things to Know About the Student Loan Payment Count Adjustment” — that provides additional details. The article includes important clarifications for defaulted and joint consolidation borrowers, and information for all other borrowers who could benefit from the account adjustment.

SAN DIEGO HEALTHCARE COMMUNITY

Nora Vargas, Paul Hegyi, Dimitrios Alexiou Among Those Honored by Blue Shield of California Promise Health Plan BLUE SHIELD OF California Promise Health Plan hosted its inaugural awards program, titled “Leading the Way,” at The Prado in Balboa Park. It was an evening of celebration as the health plan recognized the achievements of its providers and community partners.

San Diego County Board of Supervisors Chair Nora Vargas won the Individual Award for Inspiring Leadership.

San Diego County Medical Society CEO Paul Hegyi was honored with the Blue Shield Promise Leading the Way Award for Inspiring Leadership (Group Award) as one of the valued members of their San Diego Provider Advisory Council because of his dedication to the San Diego community, the Medi-Cal program, and to Blue Shield Promise members.

Dimitrios Alexiou of the Hospital Association of San Diego and Imperial Counties was also a recipient of the Group Award for Inspiring Leadership as a member of the Public Policy Committee.

Sixty individuals and organizations received awards at the Medi-Cal managed care plan’s dinner, with honorees representing a broad cross-section of healthcare providers, community organizations, and public officials serving Medi-Cal beneficiaries across San Diego County.

“Our progress in serving members and the communities across San Diego County is enhanced by all those who work together to improve the health and wellness of all San Diegans,” said Kristen Cerf, president and CEO of Blue Shield Promise. “We’re excited to host this event and express our deep gratitude to the individuals and organizations whose collaboration improves our combined ability to provide readily accessible, equitable, wholeperson care.”

Honorees were recognized for leadership in several categories, such as health access, partnership excellence, community outreach, innovation, distinguished service, healthcare quality, and health equity.

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3

MEDICINE AND YOUNG PEOPLE

From UCSD to the State Capitol A Medical Student’s Journey into Health Policy with Assemblymember Weber By Kiersten Gabaldon

SEASONED POLITICIANS, LOBBYISTS, AND legislative staff are common sights when the legislature is in session at California’s State Capitol. Yet nearly every summer for the past three decades, a group you might not expect can also be found in the halls of the Capitol: UC San Diego medical students. Thanks to the “Introduction to the Politics of Medicine” class taught by Robert Hertzka, MD, medical students are able to step out of their usual clinical confines and gain firsthand experience working at the intersection of healthcare and legislation.

As a second-year student at the UC San Diego School of Medicine, my journey to medical school was slightly unconventional: I had varied interests in medicine, policy, and business, and my background included growing up in an

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underserved community and working at a Big Four consulting firm. I found myself at an intriguing crossroads about what I wanted to do when I enrolled in Dr. Hertzka’s course on health policy. Under his mentorship, I was able to gain real-world experience exploring my interests.

A key component of Dr. Hertzka’s class is interning in a lawmaker’s office, and for two weeks, I was able to work closely with Assemblymember Akilah Weber, MD, and her team representing California’s 79th Assembly District. A board-certified obstetrician/gynecologist and an educator, Dr. Weber has made strides both in the medical world as the founder of the Pediatric and Adolescent Gynecology Division at Rady Children’s Hospital-San Diego, and in the political realm as a former city councilmember. As a medical student aspiring to intertwine my future medical career with policy, learning from Assemblymember Weber was an immense privilege and a perfect fit.

The internship provided a combination of observing, learning, and practical application. From examining racial biases in medical AI algorithms to crafting vote recommendations for more than 30 bills, I found myself immersed in the policy-making landscape. Some of my hands-on tasks included drafting letters to the governor and creating senate floor talking points for bills such as AB 1701 and AB 1138, which target racial healthcare disparities and bolster support for campus-based sexual assault survivors, respectively.

My internship also allowed me to attend meetings that gave me insight on policy areas outside of healthcare. I joined in on discussions of legislation relating to greenhouse gas emissions; LGBTQ+ legislation that sought to reinforce inclusivity and equity in educational settings; and met with Amazon representatives to discuss equilibrium between advertising and retail under common parent companies.

One of the most interesting and insightful meetings I attended was with the governor’s office to discuss amendments to AB 1507, Assemblymember Weber’s bill expanding flexibility for local health jurisdictions in administering Home Visting programs. The discussion was rich with insights and highlighted the balance between collaboration and negotiation that is a fundamental part of the legislative process.

The AI Roundtable with legislators and the Silicon Valley Leadership AI Work Group was another highlight of my internship. I was able to engage with industry leaders from global tech giants like Google, Microsoft, and Amazon and delve deep into the potential applications and challenges of using AI in healthcare, as well as the need to align rapid

technological advancements with ethical, moral, and communal values. The roundtable reinforced my belief in the need for collaboration between policymakers and tech innovators to shape a future where AI serves humanity ethically and effectively.

Throughout the internship, the interweaving of policy and healthcare underscored the importance of medical students and physicians actively shaping policy. The complexity of the American healthcare system, with both federal and statelevel regulations, makes it imperative for those who understand its nuances to have a voice in shaping its future.

Assemblymember Weber exemplifies this perfectly: Two of her recent bills, AB 82 (aimed at shielding minors from the potential harm of weight-loss supplements) and AB 85 (advocating for a more holistic view of health by addressing social determinants) address immediate health concerns and aim at the larger objective of preventive care and social wellbeing. Dr. Weber’s initiatives reflect a broader vision that recognizes health outcomes as the result of complex interactions between medical care, patient choices, and socioeconomic factors, and is the sort of vision that ensures we can holistically and equitably provide all Californians with high-quality care.

My experience in Dr. Hertzka’s class has undeniably influenced my path as a medical student. As I progress

through medical school and eventually step into my role as a physician leader, the insights gained will shape my approach to patient care and advocacy.

Empowered with this enriched understanding, I am more committed than ever to connecting the worlds of clinical practice and policy to effect meaningful change in healthcare.

Kiersten Gabaldon is a second-year medical student in the University of California San Diego School of Medicine PRIME-TIDE program who is passionate about promoting health equity. She is from Albuquerque, N.M., and attended Occidental College in Los Angeles, California, where

she earned a B.A. in economics. As a medical student, she is the general manager of the UC San Diego Student-Run Free Clinic in Pacific Beach, vice president of the Latino Medical Student Association (LMSA), director of fiscal affairs for the UC San Diego School of Medicine Class Council, co-president of the General Surgery Student Interest Group, and copresident of the Healthcare Innovation Student Interest Group.

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5

MEDICINE AND YOUNG PEOPLE

Spot the Artist

By Haley Torres

A PATIENT IS LYING COVERED AND SEDATED ON the operating table, only his upper and lower left limbs left exposed. The operating room is filled with a quiet and potent energy. The fellow and the residents are tableside, one team accessing the left femoral artery with the guidewire, and the other accessing the left brachial artery, both making their way into the patient’s aorta from opposite directions. Snaking their way through the vessels they are calm, patient, and self-assured in their work thus far. And to the side, under his own well-lit light, sits my attending scrubbed in at a sterile table. He is focusing intently on the work before him with several surgical tools surrounding his person.

There’s rarely any opportunity to be an active part of these sorts of vascular procedures, so I go over and watch as he carefully measures and marks an endovascular graft, which he proceeds to cut into several different pieces.

People like to describe “the art of medicine” in a way that emphasizes medicine as a skill, which it most definitely is.

Generating a differential diagnosis, creating a plan, determining dosages and time courses — all of those are skills indeed. But what some people do not realize is exactly how

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creative medicine is and how much of a literal art it can be. As a third-year medical student traversing the many different fields and specialties, I feel I am in a fortunate position to witness so many of these creative methods in action.

The procedure described was during my time on the vascular surgery service, where I had the great opportunity to see a physician-modified endovascular graft be created and successfully placed to repair a massive abdominal aortic aneurysm. This procedure involves cutting up and stitching together different grafts to repair the aneurysm while maintaining blood supply to the necessary arteries of the aorta.

One could call this a special case of engineering, but I truly like imagining it as a version of arts and crafts.

On another note, creativity is hardly associated with only tangible things. Watching a team of physicians work together to navigate through a differential, especially of a complicated patient, is like watching a linguistic dance of thoughts. The nuances of labs and clinical signs are the footwork, imaging studies can often be the jumps and spins that change the direction of the dancers, and the history of the patient is the music surrounding them, leading the rhythm. It is almost a synchronous process, but each physician brings their individuality that makes the experience unique. Almost like an elaborate jazz piece.

This phenomenon is the same with communication, which I have always viewed as a form of acting. I don’t mean to say that I find the way people in medicine communicate as false or deceiving. There is a spirit of creativity in it. Gestures used to explain, metaphors for drawing comparisons, and So. Many. Diagrams.

And let’s be honest, we color everything. Medicine loves color. Even dialysate jugs for peritoneal dialysis are colored. Is this all for a logical reason? Yes, of course!

But can’t logic and creativity be one and the same?

This is the topic of my short little essay here because during the times that medicine can feel cold and hard, there’s a sign somewhere in the ICU room, or the hemodialysis unit, or the neurology exam room, anywhere really, that reminds me how special it is to be a viewer and a growing participant in this aspect of medicine.

Haley Torres is a third-year medical student from Las Vegas who is currently studying at UC San Diego School of Medicine and strongly leaning toward internal or family medicine.

She is currently on her clinical rotations, enjoying all the new experiences and challenges that come each day.

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Access to newly available Medical Malpractice insurance.

Visit LocktonAffinityCMA.com to schedule a 15-minute call with Lockton Affinity’s dedicated team. Together, we will determine the policies you need to be fully protected.

Info@LocktonAffinityCMA.com | (800) 278-8130

The CMA Insurance Program is administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California #0795478. Coverage is subject to actual policy terms and conditions. Policy benefits are the sole responsibility of the issuing insurance company. The California Medical Association will receive a royalty fee for the licensing of its name and trademarks as part of the insurance program offered to the extent permitted by applicable law. Not available in all states.

HEALTHCARE DISPARITIES

Underdiagnosed and Undertreated, Young Black Males With ADHD Get Left Behind By Claire Sibonney AS A KID, WESLEY JACKSON WADE SHOULD have been set up to succeed. His father was a novelist and corporate sales director and his mother was a special education teacher. But Wade said he struggled through school even though he was an exceptional writer and communicator. He played the class clown when he wasn’t feeling challenged. He got in trouble for talking back to teachers.

And, the now 40-year-old said, he often felt anger that he couldn’t bottle up.

As one of the only Black kids in predominantly white schools in upper-middle-class communities — including the university enclaves of Palo Alto, Calif., and Chapel Hill, N.C. — he often got detention for chatting with his white friends during class, while they got only warnings. He chalked it up to his being Black. Ditto, he said, when he was wrongly arrested as an eighth grader for a bomb threat at his school while evacuating with his white friends. So he wasn’t surprised that his behavioral issues drew punishment, even as some of his white friends with similar symptoms instead started getting

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treatment for attention-deficit/hyperactivity disorder.

“Black kids at a very young age, we start dealing with race, we have a lot of racial stamina,” said Wade, who now lives outside of Durham, N.C. “But I didn’t understand until later on that there was probably something else going on.”

After spending years grappling with self-doubt and difficult relationships — and smoking what he called “Snoop Dogg volumes of weed” from middle school until his 20s — he learned he had ADHD and dyslexia, two diagnoses that often overlap. He was 37.

It’s long been known that Black children are underdiagnosed for ADHD compared with white peers. A Penn State report published in Psychiatry Research in September studied the extent of the gap by following more than 10,000 elementary students nationwide from kindergarten to fifth grade through student assessments and parent and teacher surveys. The researchers estimated the odds that Black students got diagnosed with the neurological condition were 40% lower than for white students, with all else being

equal — including controlling for economic status, student achievement, behavior, and executive functioning.

For young Black males, the odds of being diagnosed with ADHD were especially stark: almost 60% lower than for white boys in similar circumstances, even though research suggests the prevalence of the condition is likely the same.

The racial ADHD divide isn’t merely a health concern. It’s deepening inequity for Black children, and especially Black males, says the study’s lead author, Paul Morgan, the former director of the Center for Educational Disparities Research at Penn State. He now leads the Institute for Social and Health Equity at the University of Albany.

ADHD has been diagnosed in nearly 1 in 10 children in the United States, according to a Centers for Disease Control and Prevention study published in 2022, with rates surging nearly 70% in the past two decades. It is often a lifetime condition that can be managed with treatments including therapy and medication. Untreated, children with ADHD face much greater health risks, including drug addiction, self-harm, suicidal behavior, accidents, and untimely death.

By adulthood, many people with undiagnosed ADHD have spent years feeling isolated and hopeless, just as Wade did.

Even before Wade’s diagnosis, he was helping similar college students in a career counseling role at North Carolina State University. Today, he’s a licensed mental health and addiction counselor and doctoral student, but he said it’s been hard to see his successes.

“To the rest of the world, this is a Black man with two master’s degrees, and he’s a PhD candidate, and he has two licenses and certifications,” he said. “But to me, I’m a brother who’s had a lot of bad luck with people and jobs I’ve gotten fired from. I’ve never been promoted, ever, in my professional life.”

Wade’s experiences of race and ADHD are intertwined.

“ADHD is an accelerant to my Black experience,” he said. “I can’t separate my experiences as a Black boy and Black man from my experiences of understanding my neurodivergent identity.”

People who study and treat ADHD cite several reasons why young Black males fall under the radar, including teachers who are racially biased or have lower expectations of Black students and don’t recognize an underlying disability, and Black parents who are distrustful of teachers and doctors, fearing they’ll label and stigmatize their children.

“We’ve known for a long time that ADHD diagnoses are not made in a vacuum. They’re made in a geographic context, cultural context, racial context,” said George DuPaul, a psychology professor at Lehigh University who studies nonmedication interventions for ADHD. Studies have shown that ADHD underdiagnosis contributes to harsher school discipline and to the “school-to-prison pipeline.” Black kids routinely face punishment, including criminal prosecution, for problem behavior and mental health conditions such as ADHD, while white kids are more likely to be diagnosed with behavioral conditions and receive medical treatment and support. There’s a common saying:

“Black kids get cops, white kids get docs.”

Courtney Zulauf-McCurdy, a researcher and clinician at the University of Washington School of Medicine, focuses on decreasing mental health disparities in early childhood. By preschool, she said, Black children with ADHD symptoms are more likely to be expelled and less likely to receive appropriate treatment than their white peers.

Her research has found that teachers’ judgments of children are heavily influenced by their opinions of the kids’ parents, and that often determines whether those children are evaluated for behavioral conditions and given appropriate support — or simply kicked out of class. She said the Penn State findings confirm what she’s seen in clinics and heard from parents.

Zulauf-McCurdy also pointed to research that shows Black children are 2.4 times as likely as white kids to receive a diagnosis of conduct disorder compared with a diagnosis of ADHD. She said the racial bias and overdiagnosis of conditions such as oppositional defiant disorder, defined by symptoms of being uncooperative and hostile toward authority figures, result in more punitive consequences such as being isolated in separate classrooms.

To fix inequities in ADHD diagnosis, mental health experts see a need for increasing culturally sensitive screening and addressing Black families’ concerns about potential bias and racism. Ensuring access to information about symptoms and treatments for ADHD may help address obstacles to care.

Looking back, Wade said, he is grateful he got diagnosed, even if it came late. But, he said, learning about his condition earlier would have given him more confidence navigating school, work, and life. “If I was able to get a diagnosis, I would have had a lot more support and love in my life,” he said.

Behavioral tools and medication have made it easier for him to focus and to regulate his mood. The diagnosis has also helped him become more aware of how to manage his depression and anxiety.

“Now it’s an understanding of how I exist, how my brain works,” Wade said. “I don’t think that I’m just broken.”

Still, Wade wonders what the ADHD label would have meant for him as a child — despite his family’s privileges of money and education — before more awareness existed about the condition. Even now, he says, the remaining stigma around the diagnosis is probably worse for Black kids, who still get less benefit of the doubt than white children.

Today, Wade is helping Black and neurodivergent youth and adults identify ADHD and other conditions. It’s part of his work, but it’s also deeply personal.

“I remember how it felt to not be seen, to not be heard, and to have your needs dismissed,” he said. “It feels good to see other people getting the help that they need and know that it helps Black people as a whole and generations of those families.”

Claire Sibonney is a journalist with KFF Health News, where this article first appeared, which is an independent source of health policy research, polling, and journalism.

SANDIEGOPHYSICIAN .ORG

9

DEPRESSION

If Ketamine Is So Safe, What Happened to Matthew Perry?

While Ketamine May Aid Mental Health Conditions, It Still Can Be Dangerous By Kristina Fiore

KETAMINE HAS LONG BEEN CONSIDERED A safe anesthetic, one perceived as carrying little harm and having the potential to help treat some of the most refractory mental health conditions.

So when the Los Angeles County medical examiner determined that actor Matthew Perry’s death was chiefly due to the “acute effects of ketamine,” many were surprised — but not psychiatrists familiar with the drug, and with substance use disorders (SUDs).

“In clinical settings, ketamine is known for its safety profile. That doesn’t mean it is safe,” psychiatrist Drew Ramsey, MD, of Spruce Mental Health in Jackson, Wyo., wrote in an Instagram post. Dr. Ramsey noted a mixture of “celebrity, substance use disorders, character pathology, psychedelic medicine, and concierge medicine” may have contributed to Perry’s death.

Perry made no secret of his SUD, acknowledging his nearly life-long struggles with alcohol and opioid addiction in his recent memoir. In addition to high levels of ketamine, the autopsy also showed that Perry had therapeutic levels of buprenorphine on board, which is used as both maintenance therapy for opioid addiction and as a pain medication.

Perry also had coronary artery disease, the autopsy showed.

While he drowned in the “heated end of his pool,” according to a press release from the Los Angeles medical examiner, that was a secondary factor in his October 28 death, which was deemed accidental.

“At the high levels of ketamine found in his postmortem blood specimens, the main lethal effects would be from both cardiovascular overstimulation and respiratory depression,” the autopsy report stated, according to the New York Times.

Andrew Stolbach, MD, MPH, a medical toxicologist with Johns Hopkins Medicine in Baltimore, who reviewed the autopsy report at the request of the Associated Press, said the amount of ketamine found in Perry’s blood “would be enough to make him lose consciousness and lose his posture and his ability to keep himself above the water.”

“Using sedative drugs in a pool or hot tub, especially when you’re alone, is extremely risky and, sadly, here it’s

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fatal,” Dr. Stolbach told the AP. Smita Das, MD, PhD, MPH, of Stanford University in California and chair of the Council on Addiction Psychiatry at the American Psychiatric Association, noted that clinicians would closely monitor many parameters, such as heart rate and simultaneous medications, when giving ketamine.

“When that sort of monitoring or supervision isn’t in place, then there are a multitude of different things that can happen with external factors — if there are other medical conditions that aren’t accounted for that might put somebody at risk, or there are other substances involved,” Dr. Das told MedPage Today. “All these things can contribute to a poor outcome.”

The autopsy report stated that Perry was being treated with ketamine infusion therapy, but the medical examiner said levels in his body were in the range used for general anesthesia during surgery, and could not have been from his last therapy

session, which had been a week and a half earlier.

“It’s possible he was getting IV ketamine treatments and also illicitly abusing ketamine,” Dr. Ramsey told MedPage Today. “Illicit ketamine is fairly easy to get these days. There’s been an underground market for illicit ketamine for years.”

There’s also been a “proliferation of ketamine clinics and at-home ketamine delivery,” Dr. Ramsey said.

“You can get screened and be treated by mail-order ketamine now.”

Dr. Das noted that this is occurring “without a clear set of guidelines or protocols” on how to use these potential treatments appropriately.

This likely spelled disaster for Perry, said Dr. Ramsey: “We have a polysubstance situation where there are a lot of meds on board, [and] this is someone who is already medically compromised, with coronary artery disease and a long-term history of substance use.”

“I’m sending very caring, healing vibes to the sober companions and clinicians involved and Matthew’s family and community,” Dr. Ramsey added in his Instagram post.

Ketamine is not FDA-approved for treating any psychiatric disorder, but a derivative called esketamine (Spravato) is approved in nasal spray form for treatment-resistant depression. That product carries a boxed warning on sedation, dissociation, respiratory depression, abuse and misuse, and suicidal thoughts and behaviors.

Nonetheless, ketamine is being investigated for and has shown some promise in numerous mental health conditions, including depression, anxiety, and post-traumatic stress disorder (PTSD).

Some providers are getting ahead of the game, opening ketamine infusion clinics that have been rising in popularity over the last several years — even if they don’t necessarily have scientific evidence behind them.

Dr. Das says that’s cause for concern, especially if patients aren’t being closely monitored while they use ketamine, which isn’t free of side effects. These include nausea, drowsiness,

dissociation, hallucinations, headache, and increased blood pressure and heart rate. Ketamine also “rarely can cause very extreme paranoia and even suicidal ideation,” Dr. Das said.

“If someone is using a ketamine product, especially in an unstructured way, it can lead them to having a bad trip or a really uncomfortable experience,” she said. “It can also lead to reckless behavior or worsening of psychiatric symptoms, panic, confusion, and it can interact with other medications.”

Still, Dr. Das said she’s “hopeful” because strong research is ongoing “around novel treatments for treatment-resistant depression, anxiety, and PTSD, [and] some of this does include ketamine. Hopefully, once that research is completed, there will be an addition of these protocols to standard practice guidelines.”

Kristina Fiore leads the Enterprise & Investigative reporting team for MedPage Today, where this article first appeared. She’s been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others.

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ARTHRITIS

A New Test Could Save Arthritis Patients Time, Money, and Pain But Will It Be Used? By Arthur Allen

ERINN MAURY, MD, KNEW REMICADE WASN’T the right drug for Patti Schulte, a rheumatoid arthritis patient the physician saw at her Millersville, Md., practice.

Schulte’s swollen, painful joints hadn’t responded to Enbrel or Humira, two drugs in the same class.

But the insurer insisted, so Schulte went on Remicade. It didn’t work either.

What’s more, Schulte suffered a severe allergic reaction to the infusion therapy, requiring a heavy dose of prednisone, a steroid with grave side effects if used at high doses for too long.

After 18 months, her insurer finally approved Dr. Maury’s drug of choice, Orencia. By then, Schulte’s vertebrae, weakened by prednisone, had started cracking. She was only 60.

Schulte’s story of pain, drug-hopping, and insurance meddling is all too common among patients with rheumatoid

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arthritis, who often cycle agonizingly through half a dozen drugs in search of one that provides a measure of relief. It’s also a story of how doctors are steered by pharmacy benefit managers — the middlemen of the drug market — as well as by insurers.

Once people with inflammatory conditions such as rheumatoid arthritis reach a certain stage, the first prescription offered is typically Humira, the best-selling drug in history, and part of a class known as tumor necrosis factor inhibitors, or TNFis, which fail to significantly help about half of the patients who take it.

“We practice rheumatology without any help,” said Vibeke Strand, MD, a rheumatologist and adjunct clinical professor at Stanford. She bemoaned the lack of tools available to choose the right drug while bristling at corporate intervention in the decision. “We are told by the insurer what to pre-

scribe to the patient. After they fail methotrexate, it’s a TNF inhibitor, almost always Humira. And that’s not OK.” If there’s a shred of hope in this story, it’s that a blood test, PrismRA, may herald an era of improved care for patients with rheumatoid arthritis and other autoimmune conditions. But first, it must be embraced by insurers.

PrismRA employs a predictive model that combines clinical factors, blood tests, and 19 gene patterns to identify the roughly 60% of patients who are very unlikely to respond to a TNFi drug.

Over the past 25 years, drug companies have introduced five new classes of autoimmune drugs. TNFis were the first to market, starting in the late 1990s.

Some 1.3 million Americans have rheumatoid arthritis, a disease in which a person’s immune system attacks their joints, causing crippling pain and, if improperly treated, dis-

figurement. The newer drugs, mostly so-called biologics, are also used by some of the 25 million or more Americans with other autoimmune diseases, such as lupus, Crohn’s disease, and psoriasis. Typically costing tens of thousands of dollars annually, the drugs are prescribed after a patient fails to respond to older, cheaper drugs like methotrexate.

Until recently, rheumatologists have had few ways to predict which of the new drugs would work best on which patients. Often, “it’s a coin flip whether I prescribe drug A or B,” said Jeffrey Curtis, MD, MS, MPH, a rheumatology professor at the University of Alabama-Birmingham.

Yet about 90% of the patients who are given one of these advanced drugs start on a TNFi, although there’s often no reason to think a TNFi will work better than another type.

Under these puzzling circumstances, it’s often the insurer rather than the doctor who chooses the patient’s drug.

Insurers lean toward TNFis such as adalimumab, commonly sold as brand-name Humira, in part because they get large rebates from manufacturers for using them. Although the size of such payments is a trade secret, AbbVie is said to be offering rebates to insurers of up to 60% of Humira’s price.

That has enabled it to control 98.5% of the U.S. adalimumab market, even though it has eight biosimilar competitors.

PrismRA’s developer, Scipher Medicine, has provided more than 26,000 test results, rarely covered by insurance. But on Oct. 15, the Centers for Medicare & Medicaid Services began reimbursing for the test, and its use is expected to rise. At least two other companies are developing drug-matching tests for rheumatoid arthritis patients.

Although critics say PrismRA is not always useful, it is likely to be the first in a series of diagnostics anticipated over the next decade that could reduce the time that autoimmune disease patients suffer on the wrong drug.

Academics, small biotechs, and large pharmaceutical companies are investing in methods to distinguish the biological pathways involved in these diseases, and the best way to treat each one. This approach, called precision medicine, has existed for years in cancer medicine, in which it’s routine to test the genetics of patients’ tumors to determine the appropriate drug treatment.

“You wouldn’t give Herceptin to a breast cancer patient without knowing whether her tumor was HER2-positive,” said Costantino Pitzalis, a rheumatology professor at the William Harvey Research Institute in London. He was speaking before a well-attended session at an American College of Rheumatology conference in San Diego in November. “Why do we not use biopsies or seek molecular markers in rheumatoid arthritis?”

It’s not only patients and doctors who have a stake in which drugs work best for a given person.

When Remicade failed and Schulte waited for the insurer to approve Orencia, she insisted on keeping her job as an accountant. But as her prednisone-related spinal problems worsened, Schulte was forced to retire, go on Medicaid, and seek disability, something she had always sworn to avoid.

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Now taxpayers, rather than the insurer, are covering Schulte’s medical bills, Dr. Maury noted.

Precision medicine hasn’t seemed like a priority for large makers of autoimmune drugs, which presumably have some knowledge of which patients are most likely to benefit from their drugs, since they have tested and sold millions of doses over the years. By offering rebate incentives to insurers, companies like AbbVie, which makes Humira, can guarantee theirs are the drugs of choice with insurers.

“If you were AbbVie,” Dr. Curtis said, “why would you ever want to publish data showing who’s not going to do well on your drug, if, in the absence of the test, everyone will start with your drug first?”

What Testing Could Do Medicare and commercial insurers haven’t yet set a price for PrismRA, but it could save insurers thousands of dollars a year for each patient it helps, according to Krishna Patel, Scipher’s associate director of medical affairs.

“If the test cost $750, I still only need it once, and it costs less than a month of whatever drug is not going to work very well for you,” said Dr. Curtis, a co-author of some studies of the test. “The economics of a biomarker that’s anything but worthless is pretty favorable because our biologics and targeted drugs are so expensive.”

Patients are enthusiastic about the test because so many have had to take TNFis that didn’t work. Many insurers require patients to try a second TNFi, and sometimes a third.

Jen Weaver, a patient advocate and mother of three, got little benefit from hydroxychloroquine, sulfasalazine, methotrexate, and Orencia, a non-TNFi biologic therapy, before finding some relief in another, Actemra. But she was taken off that drug when her white blood cells plunged, and the next three drugs she tried — all TNFis — caused allergic reactions, culminating with an outbreak of pus-filled sores.

Another drug, Otezla, eventually seemed to help heal the sores, and she’s been stable on it since in combination with methotrexate, Weaver said.

“What is needed is to substantially shorten this trial-anderror period for patients,” said Shilpa Venkatachalam, herself a patient and the director of research operations at the Global Healthy Living Foundation. “There’s a lot of anxiety and frustration, weeks in pain wondering whether a drug is going to work for you and what to do if it doesn’t.” A survey by her group found that 91% of patients worried their medications would stop working. And there is evidence that the longer it takes to resolve arthritis symptoms, the less chance they will ever stop.

How insurers will respond to the availability of tests isn’t clear, partly because the arrival of new biosimilar drugs — essentially generic versions — are making TNFis cheaper for insurance plans. While Humira still dominates, AbbVie has increased rebates to insurers, in effect lowering its cost.

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Lower prices make the PrismRA test less appealing to insurers, since widespread use of the test could cut TNFi prescriptions by up to a third.

However, rheumatologist John Boone, MD, in Louisville, Ky., found to his surprise that insurers mostly accepted alternative prescriptions for 41 patients whom the test showed unlikely to respond to TNFis as part of a clinical trial. Dr. Boone receives consulting fees from Scipher.

Although the test didn’t guarantee good outcomes, he said, the few patients given TNFis despite the test results almost all did poorly on that regimen.

Scientists from AbbVie, which makes several rheumatology drugs in addition to Humira, presented a study at the San Diego conference examining biomarkers that might show which patients would respond to Rinvoq, a new immunesuppressing drug in a class known as the JAK inhibitors.

When asked about its use of precision medicine, AbbVie declined to comment.

Over two decades, Humira has been a blockbuster drug for AbbVie. The company sold more than $3.5 billion worth of Humira in the third quarter of 2023, 36% less than a year ago. Sales of Rinvoq, which AbbVie is marketing as a treatment for patients failed by Humira and its class, jumped 60% to $1.1 billion.

What Patients Want Shannan O’Hara-Levi, a 38-year-old in Monroe, New York, has been on scores of drugs and supplements since being diagnosed with juvenile arthritis at age 3. She’s been nauseated, fatigued, and short of breath and has suffered allergic reactions, but she says the worst part of it was finding a drug that worked and then losing access because of insurance. This happened shortly after she gave birth to a daughter in 2022, and then endured intense joint pain.

“If I could take a blood test that tells me not to waste months or years of my life — absolutely,” she said. “If I could have started my current drug last fall and saved many months of not being able to engage with my baby on the floor — absolutely.”

Arthur Allen is a senior correspondent for KFF Health News, where this article first appeared. He writes about the FDA and the pharmaceutical industry as well as COVIDrelated topics. He joined KFF Health News in April 2020 after six years at Politico, where he created, edited, and wrote for the first health IT-focused news team.

MEDICINE & LIABILITY

Should You Offer Your Services As a Paid Clinical Expert?

By Richard Cahill, JD HEALTHCARE PRACTITIONERS frequently serve as independent experts in professional liability claims.

You may be contacted by an attorney who asks you to review a case and render an opinion involving patient care provided by other medical, dental, or advanced practice clinicians. Counsel may also ask you to conduct a physical examination of a client injured in a personal injury matter — such as an automobile collision, industrial work accident, or products liability lawsuit.

Counsel may have obtained your name from another lawyer who is personally familiar with your professional reputation, your unflappability on the witness stand in an unrelated case, or from literature searches establishing your expertise in a particular area.

Ascertaining how the attorney came to approach you at the outset of the engagement may help inform your decision about whether you should agree to participate. Whatever the source initiating the contact, consider the following points before deciding to act as an expert witness: Do you have sufficient flexibility in your schedule and patient coverage

support to be able to appear in court or arbitration when required, often with little advance notice? Will you need to take hours out of your day to review patient records, meet with counsel, take frequent telephone calls, and appear in person for depositions and courtroom testimony?

If you cannot reasonably spare the time and do not have the practice coverage to ensure adequate follow-through for your own patients and other professional commitments, avoid offering expert opinions beyond those that you are required to give pursuant to a subpoena or judicial order. Once you make a commitment to be the clinical expert on a case, you will need to see it through regardless of the amount of time, inconvenience, or disruption to patient care that may result.

How well do you verbally spar without a script, and how do you handle the stress of being challenged in front of a room of spectators?

Lawyers representing an injured client are invariably well prepared, aggressive, and relentless in their questioning. Carefully consider whether the leadership and persuasive communica-

tion skills you use in your clinical life will translate well to the courtroom.

Some expert witnesses bristle under the often hostile and persistent grilling of adversarial attorneys. You may want to observe some expert testimony in advance to help you imagine what the experience is like.

Could your testimony be used against you at a later time?

Your status as a clinical expert and your testimony in a given case are readily retrievable by the databases maintained by law firms, professional societies, and trade organizations. If any patient ever sues you for malpractice, your expert testimony might be misconstrued, taken out of context, or otherwise used against you. Depending on the nature and content of the evidence you provide, opposing counsel may use the testimony as the basis for an administrative complaint to your state licensing board or professional society. This possibility dictates caution whenever you are asked to testify.

How well will you deal with pressure to enhance your opinion, provide more critical or supportive state-

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ments regarding another practitioner’s care, or venture outside your area of expertise in order to help the defendant’s or plaintiff’s case?

Maintaining professional boundaries and personal integrity when providing expert testimony can be surprisingly challenging once you are embroiled in the dynamics of litigation — when reputations, the plaintiffs’ livelihood, and the defendant’s financial security are at risk. To accommodate the needs of the case, you may feel pressure to stretch your opinion beyond the existing clinical evidence, facts developed during discovery, authoritative resources, or prevailing community standard. The lawyer’s primary goal is to win the case — not to focus on potential repercussions to you professionally. Maintaining appropriate professional boundaries will require your ongoing vigilance as an expert witness.

Are you prepared to defend your fee schedule or to defer or forgo payment for your services?

If you make the decision to be available as a paid expert, prepare a fee schedule that includes your hourly rate, half-day rate, and full-day rate, and specify whether these rates apply for actual courtroom testimony. Note that some experts charge a higher fee for deposition or live courtroom testimony than for patient record review or telephone consultations with counsel. If the opposing lawyer objects to your rate and files a motion with

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the judicial or administrative officer or independent arbitrator, you may need to justify it under oath. These types of pretrial conflicts can be time consuming and inconvenient, and the time expended may not be compensable.

Plaintiff’s counsel may ask you to defer being paid until after the case is resolved — which could delay payment for months or even years after you have provided your services. An additional risk may be that you will not be paid if the patient receives nothing in settlement or as a result of a plaintiff’s verdict following a trial or arbitration. Before becoming an expert witness, consider formalizing a written agreement with counsel, signed by both parties, that sets forth all payment terms and conditions.

Does your knowledge of the specialty include past and present standards of care?

Before taking on the role of being a paid expert, ensure familiarity with the specialty’s standards of care regarding the particular issues of the case. In some instances, expert witnesses have given testimony that, under cross-examination, proved inconsistent with the applicable standard of care in effect on the date in question. As a result, the practitioners were reprimanded or sanctioned by their specialty’s professional society.

Do you have insurance coverage for the role of paid expert?

Professional liability insurance poli-

cies typically do not cover functioning in the role of a paid expert. Although the risk of personal exposure or liability for serving in that capacity is generally small, it should be considered in the decision-making process.

Contact your insurance agent, broker, or underwriter to determine if you already have coverage under another policy (such as an errors and omissions policy) or if coverage is available.

Finally, at the outset of your engagement, it is important to clearly and fully disclose to the counsel retaining you any impediments to your credibility that could adversely affect the client’s claim if they were to be discovered during litigation. These include any negative malpractice judgments, licensing board actions, criminal verdicts, or pending or concluded civil matters.

Richard Cahill is vice president and associate general counsel for The Doctors Company. If you have further questions or need assistance regarding the content of this article, please contact The Doctors Company Patient Safety and Risk Management Department at (800) 421-2368 or by email.

COVID-19

Rift Over When to Use N95s Puts Health Workers at Risk Again

By Amy Maxmen

THREE YEARS AFTER MORE than 3,600 health workers died of COVID-19, occupational safety experts warn that those on the front lines may once again be at risk if the Centers for Disease Control and Prevention takes its committee’s advice on infection control guidelines in healthcare settings, including hospitals, nursing homes, and jails. In early November, the committee released a controversial set of recommendations the CDC is considering, which would update those established some 16 years ago.

The pandemic illustrated how a rift between the CDC and workplace safety officials can have serious repercussions. Most recently, the gi-

ant hospital system Sutter Health in California appealed a citation from the state’s Division of Occupational Safety and Health, known as Cal/OSHA, by pointing to the CDC’s shifting advice on when and whether N95 masks were needed at the start of the pandemic.

By contrast, Cal/OSHA requires employers in high-risk settings like hospitals to improve ventilation, use air filtration, and provide N95s to all staff exposed to diseases that are — or may be — airborne.

The agencies are once again at odds. The CDC’s advisory committee prescribes varying degrees of protection based on ill-defined categories, such as whether a virus or bacteria

is considered common or how far it seems to travel in the air. As a result, occupational safety experts warn that choices on how to categorize COVID, influenza, and other airborne diseases — and the corresponding levels of protection — may once again be left to administrators at hospitals, nursing homes, and jails or prisons.

Eric Berg, deputy chief of health at Cal/OSHA, warned the CDC in November that, if it accepted its committee’s recommendations, the guidelines would “create confusion and result in workers being not adequately protected.”

Also called respirators, N95 masks filter out far more particles than looser-fitting surgical masks but cost roughly 10 times as much, and were in short supply in 2020. Black, Hispanic, and Asian health workers more often went without N95 masks than white staffers, which helped explain why members of racial and ethnic minorities tested positive for COVID nearly five times as often as the general population in the early months of the pandemic. (Hispanic people can be of any race or combination of races.)

Cal/OSHA issued dozens of citations to healthcare facilities that failed to provide N95 masks and take other measures to protect workers in 2020 and 2021. Many appealed, and some cases are ongoing. In October, the agency declined Sutter’s appeal against a $6,750 citation for not giving its medical assistants N95 masks in 2020 when they accompanied patients who appeared to have COVID through clinics. Sutter pointed to the CDC’s advice early in the pandemic, according to court testimony. It noted that the CDC called surgical masks an “acceptable alternative” in March 2020, “seemed to recommend droplet precautions rather than airborne precautions,” and suggested that individuals were unlikely to be infected if they were farther than 6 feet away from a person with COVID. This is a loose interpretation of the

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CDC’s 2020 advice, which was partly made for reasons of practicality. Respirators were in short supply, for example, and physical distancing beyond 6 feet is complicated in places where people must congregate. Scientifically, there were clear indications that the coronavirus SARS-CoV-2 spread through the air, leading Cal/OSHA to enact its straightforward rules created after the 2009 swine flu pandemic.

Workers need stiffer protection than the general population, said Jordan Barab, a former official at the federal Occupational Safety and Health Administration: “Health workers are exposed for eight, 10, 12 hours a day.”

The CDC’s advisory committee offers a weaker approach in certain cases, suggesting that health workers wear surgical masks for “common, often endemic respiratory pathogens” that “spread predominantly over short distances.” The draft guidance pays little attention to ventilation and air filtration, and advises N95 masks only for “new or emerging” diseases and those that spread “efficiently over long distances.” Viruses, bacteria, and other pathogens that spread through the air don’t neatly fit into such categories.

“Guidelines that are incomplete, weak, and without scientific basis will greatly undermine CDC’s credibility,” said a former OSHA director, David Michaels, in minutes from an October meeting where he and others urged CDC Director Mandy Cohen to reconsider advice from the committee before it issues final guidance next year.

Although occupational safety agencies — not the CDC — have the power to make rules, enforcement often occurs long after the damage is done, if ever. Cal/OSHA began to investigate Sutter only after a nurse at its main Oakland hospital died from COVID and health workers complained they weren’t allowed to wear N95 masks in hallways shared with COVID patients.

And more than a dozen citations from Cal/OSHA against Kaiser Permanente, Sharp HealthCare, and other health

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systems lagged months and years behind health worker complaints and protests.

Outside California, OSHA faces higher enforcement obstacles. A dwindling budget left the agency with fewer workplace inspectors than it had in 45 years, at the peak of the pandemic. Plus, the Trump and Biden administrations stalled the agency’s ongoing efforts to pass regulations specific to airborne infections. As a result, the agency followed up on only about 1 in 5 COVID-related complaints that employees and labor representatives officially filed with the group from January 2020 to February 2022 — and just 4% of those made informally through media reports, phone calls, and emails. Many deaths among healthcare workers weren’t reported to the agency in the first place.

Michaels, who is now on the faculty at the George Washington University School of Public Health, said the CDC would further curtail OSHA’s authority to punish employers who expose staff members to airborne diseases, if its final guidelines follow the committee’s recommendations. Such advice would leave many hospitals, correctional facilities, and nursing homes as unprepared as they were before the pandemic, said Deborah Gold, a former deputy chief of health at Cal/OSHA. Strict standards prompt employers to stockpile N95 masks and improve air filtration and ventilation to avoid citations. But if the CDC’s guidance leaves room for interpretation, she said, they can justify cutting corners on costly preparation.

Although the CDC committee and OSHA both claim to follow the science, researchers arrived at contradictory conclusions because the committee relied on explicitly flawed trials comparing health workers who wore surgical masks with those using N95s. Cal/ OSHA based its standards on a variety of studies, including reviews of hospital infections and engineering research on how airborne particles spread.

In decades past, the CDC’s process for developing guidelines included labor representatives and experts focused on hazards at work. Barab was a health researcher at a trade union for public sector employees when he helped the CDC develop HIV-related recommendations in the 1980s.

“I remember asking about how to protect healthcare workers and correction officers who get urine or feces thrown at them,” Barab said. Infectious disease researchers on the CDC’s committee initially scoffed at the idea, he recalled, but still considered his input as someone who understood the conditions employees faced. “A lot of these folks hadn’t been on hospital floors in years, if not decades.”

The largest organization for nurses in the United States, National Nurses United, made the same observation.

It’s now collecting signatures for an online petition urging the CDC to scrap the committee’s guidelines and develop new recommendations that include insights from healthcare workers, many of whom risked their lives in the pandemic.

Barab attributed the lack of labor representation in the CDC’s current process to the growing corporate influence of large health systems.

Hospital administrators prefer not to be told what to do, particularly when it requires spending money, he said.

In an email, CDC communications officer Dave Daigle stressed that before the guidelines are finalized, the CDC will “review the makeup of the workgroups and solicit participation to ensure that the appropriate expertise is included.”

Amy Maxmen is a journalist for KFF Health News, where this article first appeared, and which is an independent source of health policy research, polling, and journalism.

CHAMPIONS FOR HEALTH

An Open Door Leads to Healing

By Adama Dyoniziak ACELA ASKED HERSELF: “WILL I ALWAYS BE like this? I prayed every day, I told God, I really need this, my kids need me, I am all they have. If you really love me, open these doors to healing.” In 2021, Acela’s journey of abdominal pain and heavy uterine bleeding began. Her physician told her that the ultrasound and biopsy showed uterine fibroids.

Scared of surgery, Acela tried home remedies. Her physician prescribed birth control pills and IUDs but no solution seemed to provide a remedy for her bleeding.

During this time, Acela could not miss work but she recalls feeling embarrassed and ashamed. “I would stain my clothes … I started packing multiple clothing options and I would sometimes have to keep working even though I would stain my clothes,” she explains. She also felt weak and experienced hip pain, leg pain, anemia, and exhaustion. Acela felt hopeless and frustrated.

The most challenging part was explaining everything to her sons. “My kids would ask me to go somewhere, and I would say, ‘Of course my loves, we will go.’ And then the day of, I could not go.” Acela saw her world get smaller and smaller, limited by her fear of a sudden heavy period.

In August, Acela was hemorrhaging and needed a blood transfusion. She was referred by TrueCare to Project Access for surgery and was told the wait was six months to a year.

“I say that God put in my life the right people at the right time. Ms. Evelyn came to my house and helped me fill out the application — it’s incredible! Who does that for you? No one!”

Surgery was scheduled for November at Palomar Medical Center with Dr. Eimaneh Mostofian, an ob-gyn with TrueCare and a Project Access volunteer. Acela was shocked. “I was of two hearts at that time — on one hand I was so excited because I was going to have surgery, and on the other side I did not feel ready, it was too fast,” she explains. Dr. Mostofian adds, “TrueCare supports me by giving me the time to be of service. With Project Access, I am able to serve patients locally. It fulfills that place in my heart in a professional realm.”

Dr. Mostofian continues: “I can make an impact throughout a woman’s life, all in one day. The scope of what is possible is endless.” A quote that Dr. Mostofian lives by is from Mother Teresa: Not all of us can do great things, but we can do small things with great love. “The trust that a patient has in their physician is necessary, so the physician’s responsibility is overwhelming and a blessing during those vulnerable moments.”

As Acela recuperated from surgery she had a wide smile, a sense of peace, and such gratitude.

She says, “I am so thankful for each of you, with your hearts … without the doctors and nurses volunteering time, I don’t think I would be here talking with you.” As Acela heals, she has been taking the boys to school and they made plans to go out for the holidays.

Since 2008, Project Access has facilitated $27 million in care for more than 9,600 uninsured patients just like Acela by providing free consultations and surgeries — all thanks to the

Top: Dr. Mostofian and Acela sharing a warm moment in pre-op.

Above: Dr. Eimaneh Mostofian

dedication of our volunteer specialty physicians. Open doors for a Project Access patient — contact us at adama.dyoniziak@championsfh.org or call (858) 300-2780.

Adama Dyoniziak is the executive director of Champions for Health.

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

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 PART-TIME CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to Dr. Keith Brady at uabresearchdoc@yahoo.com.

INTERNAL MEDICINE PHYSICIAN: Federally Qualified Health Center located in San Diego County has an opening for an Internal Medicine Physician. This position reports to the chief medical officer and provides the full scope of primary care services, including diagnosis, treatment, and coordination of care to its patients. The candidate should be board eligible and working toward certification in Internal Medicine. Competitive base salary, CME education, four weeks paid vacation, year one, 401K plan, no evenings and weekends. Monday through Friday, 8:00 am to 5:00 p.m.

For more information or to apply, please contact Dr. Keith Brady at: uabresearchdoc@yahoo.com.

FAMILY MEDICINE/INTERNAL MEDICINE PHYSICIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care and 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.

MEDICAL CONSULTANT (MD/DO): The County of San Diego is currently accepting applications from qualified candidates for Medical Consultant-Public Health Services.

Vacancies are in the Public Health Services, Epidemiology and Immunization Services Branch (EISB) and Tuberculosis (TB) Control and Refugee Health Branch.

Salary: $183,747.20–$204,900.80 annually. An additional 10% for Board Certified Specialty and 15% for relevant sub-specialty. For job posting information visit https:// www.governmentjobs.com/careers/sdcounty?keywords= 23416202PHS. 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.). See FJV Jobs to apply.

SEEKING MEDICAL DIRECTOR: subcontracted position: 4-8 hours per month. Responsibilities: 1. Support case conferences, refractory SUD, co‐occurring conditions,

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JANUARY 2024

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. PsychiatristSpecialists 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 or select this link to go directly to the Psychiatrist Specialist application.

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. InResidence appointments may require candidates to be selffunded. For more information: https://apol-recruit.ucsd. edu/JPF03179 For help contact: klsantos@health.ucsd.edu 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 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 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 seeking 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-medicinerehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 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, CA. 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 CountyHigh 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 low-income, uninsured individuals — National City (Southern San Diego

CLASSIFIEDS 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.

PHYSICIAN POSITIONS WANTED PART-TIME CARDIOLOGIST AVAILABLE AFTER 7/4/23: Dr. Durgadas Narla, MD, FACC is a noninvasive cardiologist looking to work 1-2 days/week or cover an office during vacation coverage in the metro San Diego area.

He retired from private practice in Michigan in 2016 and has worked in a San Marcos cardiologist office for the last 5 years, through March 2023. Board certified in cardiology and internal medicine. Active CA license with DEA, ACLS, and BCLS certification. If interested, please call (586) 2060988 or email dasnarla@gmail.com PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

PRACTICE FOR SALE 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 patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through the 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 in-house 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 OPERATING ROOM FOR RENT: State of the Art AAAASF Certified Operating Rooms for Rent at Outpatient Surgery of Sorrento. 5445 Oberlin Drive, San Diego 92121. Ideally located and newly built 5 star facility located with easy freeway access in the heart of San Diego in Sorrento Mesa.

Facility includes two operating rooms and two recovery bays, waiting area, State of the Art UPC02 Laser, Endoscopic Equipment with easy parking. Ideal for cosmetic surgery. Competitive Rates. Call Cyndy for more information 858.658.0595 or email Cyndy@roydavidmd.com PRIME LOCATION – MEDICAL BUILDING LEASE OR OWN OPPORTUNITY IN LA MESA: Extraordinary opportunity to lease or lease-to-own a highly visible, freewayoriented medical building in La Mesa, on Interstate 8 at the 70th Street on-ramp. Immaculate 2-story, 7.5k square foot property with elevator and ample free on-site parking (45 spaces). Already built out and equipped with MRI/CAT machine. Easy access to both Alvarado and Sharp Grossmont Hospitals, SDSU, restaurants, and walking distance to 70th St Trolley Station. Perfect for owner-user or investor. Please contact Tracy Giordano [Coldwell Banker West, DRE# 02052571] for more information, (619) 987-5498.

POWAY MEDICAL OFFICE SPACE FOR LEASE 2/1/2024: Fully built out, turnkey 1257 sq ft ADA-compliant suite for lease. Great location in Pomerado Medical/ Dental Building, next to Palomar Med Center Poway campus. Building restricted to medical/allied health/dental practices, currently houses ~26 suites. Ideal for small health practice as primary or satellite location. Lease includes front lobby, reception area, restrooms, large treatment area, private treatment/exam rooms. Located on second floor, elevator/stair access. Bright, natural lighting; unobstructed views of foothills. On-site parking; nearby bus service.

Flexible lease terms available from 3-5 years at fair market rate. Contact Debbie Summers at debjsummers3@gmail. com (858) 382-8127.

KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643 Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems.

Ample free parking. Newly constructed Class A+ medical office space/medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for use (including splint/ cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam room doubles as a minor procedure room. Ample waiting room area. In office x-ray with additional waiting area outside of the x-ray room.

Orthopedic surgery centric office space. Includes access to a kitchenette/indoor break room, exterior break room and private physician workspace. Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and mgamboa@ortho1.com for more information. Available for occupancy projected as February 2024.

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

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

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

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. $2,500/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.

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, 2,000sf, 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 feet 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.

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

For more information contact: r.pua@cox.net.

NON-PHYSICIAN POSITIONS AVAILABLE RESEARCH SCIENTISTS: (non-tenured, Assistant, Associate or Full level): The University of California, San Diego campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html are conducting an open search. Research Scientists are extramurally funded, academic researchers who develop and lead independent creative research programs similar to Ladder Rank Professors. They are expected to serve as Principal Investigators on extramural grants, generate high caliber publications and research products, engage in university and public service, continuously demonstrate independent, high quality, significant research activity and scholarly reputation. Appointments and duration vary depending on the length of the research project and availability of funding. https://apolrecruit.ucsd.edu/JPF03713/apply PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research Affairs https://research. ucsd.edu/, in support of the campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd. edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding. https://apol-recruit.ucsd.edu/JPF03262/apply 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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