January 2025

JANUARY 2025

Official Publication of SDCMS

Meet the California Medical Association’s

NEW LEADERSHIP Shannon UdovicConstant, MD CMA PRESIDENT

René Bravo, MD CMA PRESIDENTELECT

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JANUARY 2025

Contents JANUARY

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

VOLUME 112, NUMBER 1

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

FEATURES

4

Meet the California Medical Association’s New Leadership

By Paul Hegyi, MBA

6

California Falling Short of Enrollment Goal as Mental Health Courts Roll Out Statewide

By Christine Mai-Duc

DEPARTMENTS

2

Briefly Noted: SDCMS • Practice Management

9

FDA’s Promised Guidance on Pulse Oximeters Unlikely to End Decades of Racial Bias

By Arthur Allen

12 Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement

by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

People First: Types of AI and How to Put Them to Work on Clinician Burnout and Health Disparities

By Kevin Johnson, MD, MS

14

12

Dementia Incidence Linked to Inflammatory Foods

By Judy George

16

FDA Advisers Say More Data Needed for RSV Vaccines in Young Kids

By Jennifer Henderson

18

Skipping ChestWall Irradiation After Mastectomy in Intermediate-Risk Breast Cancer

By Charles Bankhead

20

Reconnecting as a Family

By Adama Dyoniziak

21

Classifieds SANDIEGOPHYSICIAN.ORG

1

SDCMS

SDCMS Board Cheers on San Diego Gulls to Victory at Annual Holiday Event THE SAN DIEGO COUNTY MEDICAL SOCIETY’S Board of Directors held its annual holiday party at Pechanga Arena on Dec. 11. The physicians cheered on the San Diego Gulls, our local hockey team, in an intense, closely fought, 5 to 4 victory over the Henderson Silver Knights. A highlight of the experience was SDCMS President Steve Koh, MD, riding the Gulls’ Zamboni as it cleaned and smoothed the ice during intermission.

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JANUARY 2025

PRACTICE MANAGEMENT

Preparing for 2025: Verify Your Patients’ Eligibility, Benefits, and Deductibles WITH THE NEW YEAR UPON US, physicians are reminded to verify patients’ eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year means that both calendar year deductibles and visit frequency limitations reset. And, with open enrollment, patients may even be covered by a new payer.

Do your homework before patients arrive by obtaining updated insurance information and verifying eligibility at the time of scheduling, if possible. It is also best practice to remind patients when they make an appointment that their plan has a deductible that may be resetting on Jan. 1 and, if that is the case, that payment will be due at the time of service. It is also important to make copies of insurance cards when patients come in for their first visits of the new year.

Failure to collect deductibles, copays, and coinsurance at the time of service can be very costly for a practice, as your ability to collect can decrease significantly after the patient leaves the office.

Taking proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money.

Please Note: For 2025, the annual deductible for all Medicare Part B beneficiaries is $257, an increase of $17 from the 2024 annual deductible of $240.

For Medicare Part A, the inpatient hospital deductible will be $1,676 in 2025, an increase of $44 from $1,632 in 2024.

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CMA

Meet the California Medical Association’s New Leadership

By Paul Hegyi, MBA

THE CALIFORNIA MEDICAL Association convened its 153rd annual House of Delegates (HOD) meeting in Sacramento over a weekend this past fall. More than 800 California physicians and medical students, including delegates from San Diego and Imperial counties, gathered to debate and establish broad policy on current major issues that have been determined to be the most important issues affecting members, the association, and the practice of medicine.

The association also installed its new officers, including new CMA President Shannon Udovic-Constant, MD, a boardcertified general pediatrician practicing in San Francisco.

Dr. Udovic-Constant — a passionate advocate for policies to improve the health of children and communities — addressed the hundreds of physician delegates and healthcare stakeholders, outlining her vision for the largest state medical association in the country, which represents more than 50,000 California doctors.

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JANUARY 2025

“I am invigorated to have the opportunity to advocate side by side with my physician colleagues to improve the medical profession and the health of our patients and communities,” said Dr. Udovic-Constant.

“Physicians must be the architects of the future of healthcare, and CMA is positioned to lead the state in this evolution and provide a model for the country.”

Dr. Udovic-Constant is the 156th president of CMA and fifth woman to hold the position. She previously served as chair and vice chair of the CMA Board of Trustees. She is also a former president of the San Francisco Medical Society (now the San Francisco Marin Medical Society) and served on The Permanente Medical Group Board for 12 years.

Dr. Udovic-Constant has also been the chair of the CMA Political Action Committee (CALPAC) Independent Expenditure Committee and part of CMA’s Justice, Equity, Diversity and Inclusion Technical Advisory

“

Physicians must be the architects of the future of healthcare, and CMA is positioned to lead the state in this evolution and provide a model for the country.”

SHANNON UDOVICCONSTANT, MD CMA PRESIDENT

Committee (TAC), and Firearm Violence Prevention TAC. She has also served on CMA’s Council on Legislation and currently serves on the CMA delegation to the American Medical Association.

San Luis Obispo Physician René Bravo, MD, Becomes CMA President-Elect I’d also like to offer a hearty congratulations to San Diego affiliate member Dr. René Bravo, voted president-elect. Dr. Bravo will assume the CMA presidency in October 2025. He is a San Luis Obispo-based pediatrician.

Dr. Bravo will serve on the executive committee in that role for one year, and will be installed at the conclusion of next year’s annual meeting.

“I am honored to have been chosen as the new CMA president-elect,” said Dr. Bravo. “In this new role, I will represent all physicians and all practice modes with a focus on the real economic and personal needs of the physicians, all while prioritizing our patients. Our unity is our strength, and together we can strive to deliver the highest quality, science-based healthcare to all Californians.”

Dr. Bravo is a primary care pediatrician who has been serving families and children on the Central Coast for 38 years. He is the founder

and president of Bravo Pediatrics, a five-physician, single-specialty group practice where he was the managing partner before recently retiring.

“The model of finding agreement from differences of opinion in order to meet the goals of a group is my guide, and it will help me as president of CMA serve the physicians of California,” said Dr. Bravo.

Dr. Bravo is past president of the San Luis Obispo County Medical Society (now the Central Coast Medical Association), where he also served on its governing board and chaired the Physician Wellness Committee for 10 years.

At CMA, he has served as District V Trustee and on the boards of CALPAC and the CMA Foundation (now Physicians for a Healthy California).

He is a longtime delegate to the CMA House of Delegates, and has chaired many CMA committees in his 42 years of membership.

“

Our unity is our strength, and together we can strive to deliver the highest quality, sciencebased healthcare to all Californians.”

RENÉ BRAVO, MD

CMA PRESIDENT-ELECT

The full 2024–2025 CMA Executive Committee includes: President: Shannon L. Udovic-Constant, MD, San Francisco President-Elect: René Bravo, MD, San Luis Obispo Chair of the Board: Sergio R. Flores, MD, San Diego Vice Chair of the Board: Eric Hansen, DO, Hesperia Speaker of the House: Jack Chou, MD, Los Angeles Vice Speaker of the House: George Fouras, MD, Los Angeles Immediate Past President: Tanya W. Spirtos, MD, Redwood City

Paul Hegyi is the chief executive officer of the San Diego County Medical Society.

SANDIEGOPHYSICIAN.ORG

5

MENTAL HEALTH

California Falling Short of Enrollment Goal as Mental Health Courts Roll Out Statewide

By Christine Mai-Duc

6

JANUARY 2025

“

San Diego County’s program has been among the most robust, with 221 petitions filed since it launched in October 2023, although a third of the county’s participants were already under conservatorship.”

CALIFORNIA’S NEW INITIATIVE TO compel treatment for some of the state’s most severely mentally ill residents — many of whom are living on the streets — is falling short of its initial objectives.

But with the program expanding from 11 counties to all 58 on Dec. 1, state officials are projecting confidence that they can reach their goal to help 2,000 adults by the end of the year.

In the first nine months of CARE Court, 557 petitions were filed by first responders, families, or local health officials, all of whom can now request help for individuals who are ill. As of the end of June, 100 people had been placed in court-approved treatment plans, according to the latest data available.

“We’re pleased to see how many people have come through and how appropriate those referrals have been so far,” said Corrin Buchanan, a deputy secretary for the California Health and Human Services Agency, which oversees the program. “These are the right kinds of people we were hoping to serve.”

The Community Assistance, Recovery and Empowerment (CARE) Act — the first law of its kind in the nation — empowers civil court judges to order adults into monitored plans that include housing, social services, and treatment for addiction or mental illness. Until now, counties such as Los Angeles, San Diego, and San Francisco have been piloting the program, which Democratic Gov. Gavin Newsom has called a “paradigm shift” to prioritize the Californians who are sickest and most in need.

But officials in counties that have already launched the program said the low number of cases reflects the amount of time it takes — sometimes weeks or months — to find people and persuade them to enroll. And judges dismissed nearly 40% of petitions in the program’s first nine months, in part because of the program’s narrow criteria to target only those with untreated schizophrenia or

other psychotic disorders.

State officials have estimated that between 7,000 and 12,000 people will be eligible for a CARE plan. The state has directed $358 million in one-time funding, and it projects it will spend $108 million a year on the program.

CARE Court is one of a raft of changes Newsom has spearheaded to address rampant homelessness, including overhauling the public mental health system and funneling billions of dollars for counties to execute those changes on the ground. Recent moves include loosening conservatorship laws and passing Proposition 1, a voter-approved measure that gives the state more control over mental health funding previously managed by counties.

Local health representatives say they’re juggling the governor’s initiatives as he demands results to reduce homelessness.

While CARE Court was meant to target people who cycle in and out of jails and hospitals and onto the streets, county officials said they’re encountering a substantial number of clients who already have housing and, in some cases, private health insurance.

Many family members have had their hopes dashed when they find that only a small number of people qualify for CARE Court resources and that ultimately treatment is largely voluntary, county officials said. Unlike in a conservatorship, which hands all decision-making power over to the state or an adult guardian, counties can’t treat or medicate participants against

SANDIEGOPHYSICIAN.ORG

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MENTAL HEALTH

their will. But counties can rack up steep court fines if a judge determines the county hasn’t provided help.

“There’s been a tremendous need for the management of expectations, especially with family members,” said Amber Irvine, program manager for San Diego County’s CARE Court. She added that while she considers the program a success, “we need to, as a whole, adjust our expectations of what can be accomplished in a year with such a complicated program and such a complex population.”

San Diego County’s program has been among the most robust, with 221 petitions filed since it launched in October 2023, although a third of the county’s participants were already under conservatorship. Irvine said 76 of the state’s 100 CARE plan participants are from the county.

But it’s not easy. It takes county outreach workers there an average of 54 days of casual conversations, encounters in encampments, and distributing food or supplies — activities the state doesn’t typically reimburse for — to persuade someone to accept services. In some cases, that number stretches to more than four months, Irvine said.

She and others credit the state

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JANUARY 2025

for funding CARE programs, which has enabled county staff to conduct intensive outreach. San Diego County boasts the state’s first CARE graduate, a participant who was able to exit conservatorship and leave a locked psychiatric facility.

Though Irvine thought the county was overprepared with 15 new hires, the staff was able to take on less than half the anticipated caseload. Other counties have had to shift personnel from understaffed departments to prepare for CARE Court.

Staffing needs remain uncertain with the remaining counties set to launch CARE programs, said Jacqueline WongHernandez, chief policy officer for the California State Association of Counties.

In September, Newsom vetoed a bill that would have provided scholarships to mental health professionals if they agreed to work for CARE Court, citing budget pressures.

Alameda County’s contractor has prepared for the Dec. 1 launch by hiring a team of more than a dozen, including a full-time nurse, case managers, employment coordinators, and a clinician to prescribe medications.

Officials there are identifying clients already known to cycle through crisis services, so they can file petitions on

their behalf. And the county is figuring out how to tap state housing funds that allow clients to stabilize in short-term housing.

“It’s really a lot to set up,” said Kate Jones, who is helping to oversee the county’s rollout.

Mark Ghaly, who was the chief architect of the CARE program before leaving his post as California’s health secretary this fall, said he worked for many years at the county level and empathizes with counties struggling to implement multiple initiatives at the same time. He added that CARE Court was never meant to be launched in a vacuum.

“We’re going to have to see this whole tapestry of efforts come together to really make the kind of dent that I know we can as a state,” Ghaly said.

State Sen. Tom Umberg, a Democrat who co-authored CARE Court legislation, said that more healthcare providers need to be made aware of the program so they can help spot potential enrollees.

Still, one county representative worries that the public could conflate court-approved treatment plans for the severely mentally ill with solving homelessness. In 2023, California had an estimated homeless population of more than 180,000.

“The solution to homelessness in California is housing, and the more people are prevented from falling into homelessness in California, the fewer county behavioral health clients we will have,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

Christine Mai-Duc is a veteran California journalist and correspondent for KFF Health News, which produced this report.

RACIAL BIAS IN HEALTHCARE

FDA’s Promised Guidance on Pulse Oximeters Unlikely to End Decades of Racial Bias

By Arthur Allen

THE PATIENT WAS IN HIS 60S, AN African American man with emphysema.

The oximeter placed on his fingertip registered well above the 88% blood oxygen saturation level that signals an urgent risk of organ failure and death.

Yet his doctor, Noha Aboelata, MD, believed the patient was sicker than the device showed. So she sent him for a lab test, which confirmed her suspicion that he needed supplemental oxygen at home.

Months later, in December 2020, Dr. Aboelata thought back to her patient as she read a New England Journal of Medicine article showing that pulse oximeters were three times as likely to miss dangerously low blood oxygen levels in Black patients as in white ones. At a

time when Black Americans were dying of COVID at high rates and hospitals struggled to find beds and oxygen for those needing them, the finding exposed one of the most blatant examples of institutional racism in American healthcare.

“I was like, ‘Were there other patients I missed?” said Dr. Aboelata, a family physician and the CEO of Oakland-based Roots Community Health. As she shared the article with colleagues, “there was so much anger and frustration because we had every reason to believe we could rely on this device, and it was systematically not working in the population that we served.”

State attorneys general and U.S. senators have pressed the FDA to take steps to eliminate pulse oximetry’s racial bias, which has caused delays in treatment and worse health outcomes, and more recently has raised concern about the reliability of hospital AI tools that draw on reams of data from the devices.

Aboelata’s clinic has sued producers and stores that sell oximeters, demanding they pull the devices or add safety warnings to the labels. Many of her patients rely on home oxygen, which requires accurate readings for Medicare to cover.

But getting rid of the devices, central to care for heart and lung diseases, sleep apnea, and other conditions, isn’t an option.

Since the 1990s, the convenient fingertip clamps have come to stand in for many uses of arterial blood gas readings, which are the gold standard for determining oxygen levels but dangerous if not done carefully. Makers of oximeters will sell around $3 billion of them this year because they are used in nearly every hospital, clinic, and longterm care facility. During the pandemic, hundreds of thousands of Americans bought them for home use.

One of them was Walter Wilson, a 70-year-old businessman in San Jose who has had two kidney transplants since 2000. Wilson contracted COVID last December but delayed visiting a doctor because his home pulse oximetry readings were in the normal range.

“I’m a dark-complected Black guy. I was very sick. Had the oximeter picked that up, I would have gotten to the hospital sooner,” he said.

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RACIAL BIAS IN HEALTHCARE

Wilson ended up back on dialysis after several years of good health. Now he’s looking to join a class-action lawsuit against the device manufacturers.

“They’ve known for years that people with darker skin get bad readings,” he said, “but they tested them on healthy white people.”

After years of little action on the issue, the FDA in 2021 sent a safety warning to doctors about oximeters.

It has also funded research to improve the devices and promised to issue new guidelines for how to make them.

But as the FDA polishes draft guidelines it had hoped to publish by Oct. 1, clinicians and scientists are unsure what to expect. The agency has indicated it will recommend that manufacturers test new oximeters on more people, including a large percentage with dark-pigmented skin.

Because of industry pushback, however, the guidance isn’t expected to ask device makers to test oximeters under real-world conditions, said Michael Lipnick, MD, a University of California-San Francisco anesthesiologist and researcher.

Hospitalized people are often dehydrated, with restricted blood flow to their extremities. This condition, known as low perfusion — essentially, poor circulation — is particularly common with cardiovascular disease, which is more prevalent in Black patients.

Pigmentation and poor perfusion “work together to degrade pulse oximetry performance,” said Philip Bickler, who directs the Hypoxia Research Lab at UCSF. “During COVID, Black patients showed up sicker because of all the barriers those patients face in accessing healthcare.

They’re showing up on death’s door, and their perfusion is lower.”

The FDA guidance isn’t expected to require manufacturers to measure how well their devices perform in patients with poor perfusion. All this means that the FDA’s efforts could lead to devices that work in healthy dark-skinned adults but do “not fix the problem,” said

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Hugh Cassiere, who chairs a panel for the FDA’s Medical Devices Advisory Committee, at its February meeting.

A History of Inaction Although some recent industrysponsored studies have shown that certain devices work across skin tones, research dating to the 1980s has found discrepancies in pulse oximetry. In 2005, Bickler and other scientists at the Hypoxia Lab published evidence that three leading devices consistently failed to detect hypoxemia in darkly pigmented patients — especially those who were severely oxygen-depleted. Noting that these readings could be crucial to directing treatment, the authors called for oximeters to carry warnings.

The FDA’s response was modest. Its regulatory pathway for pulse oximeters clears them for sale as long as they show “substantial equivalence” to devices already on the market. In a 2007 draft guidance document, the FDA suggested that tests of new oximeters could “include a sufficient number of subjects with dark skin pigmentation, e.g., 30%.”

However, the final guidance, issued in 2013, recommended “at least two darkly pigmented subjects or 15% of your subject pool, whichever is larger.” The studies were required to have only 10 subjects. And the agency did not define “dark-pigmented.”

Testing the devices involves fitting patients with masks that control the gases they breathe, while simultaneously taking pulse oximetry readings and samples of arterial blood that are fed into a highly accurate measuring device, invented by the Hypoxia Lab’s late founder, John Severinghaus.

Bickler, who evinces the bemused skepticism of a seasoned car mechanic when discussing the scores of devices his lab has tested, said “you can’t always trust what the manufacturers say.”

Their data, he said, ranges from “completely inaccurate” to “obtained under absolutely ideal conditions, nothing like a real-world performance.”

“

They’ve known for years that people with darker skin get bad readings, but they tested them on healthy white people.”

– WALTER WILSON, DIALYSIS PATIENT

During the pandemic, a medical charity approached the lab about donating thousands of oximeters to poor countries. The oximeters it had chosen “weren’t very good,” he said.

After that, the lab set up its own ratings page, a kind of Consumer Reports for pulse oximeters.

According to its tests, some expensive devices don’t work; a few of the $35 gadgets are more effective than competitors costing $350. More than a third of the marketed devices the lab has tested don’t meet current FDA standards, according to the site.

To investigate whether real-world tests of oximeters are feasible, the FDA funded a UCSF study that has recruited about 200 intensive care unit patients.

The data from the study is being prepared to undergo peer review for publication, Bickler said.

He said the lab did not warm the hands of patients in the study, which is the customary practice of manufacturers when they test their devices. Warming assures better circulation in the finger the device is attached to.

“It affects the signal-to-noise ratio,” Bickler said. “Remember when car radios had AM stations, and you’d get a lot of static? That’s what poor perfusion does — it causes noise, or static that can obscure a clear signal from the device.”

Hypoxia Lab scientists — and doctors in the real world — don’t warm patients’

hands. But “the industry people can’t agree on how to handle it,” he said.

Masimo, a company that says it has the most accurate pulse oximeters on the market, would happily comply with any FDA guidance, Daniel Cantillon, Masimo’s chief medical officer, said in an interview.

How Much to Fix the Problem?

The very best devices, according to the Hypoxia Lab, cost $6,000 or more. That points to another problem.

With better accuracy, “you are going to reduce patient access to devices for a large proportion of the world that simply can’t afford them,” Dr. Lipnick said.

Even if the FDA can’t please everyone, its anticipated call for more people with darker skin in oximetry tests will “assure there’s real diversity in the development and testing of those devices before they come to market,” Dr. Lipnick said. “That

bar has been too low for decades.”

It is difficult to assess harm to individuals from faulty oximeter readings, because these errors are often one factor in a chain of events. But studies at Johns Hopkins University and elsewhere indicated that patients whose oxygen depletion wasn’t noticed — possibly thousands of them — had delayed treatment and worse outcomes.

Already, Dr. Aboelata said, a few manufacturers — Zewa Medical Technology, Veridian Healthcare, and Gurin Products — have responded to the Roots Community Health lawsuit by including warnings about their devices’ limitations.

There’s not much she and other

clinicians can do in daily practice, she said, other than establish a baseline reading with each new patient and be on the lookout for notable drops.

Hospitals have other tools to check oxygen levels, but correct readings are critical for outpatient care, she said.

In 2022, Connecticut enacted a law banning insurers from denying home oxygen or other services based solely on pulse oximetry readings.

But “adapting around the crappy device isn’t the solution,” said Theodore Iwashyna, the Johns Hopkins Bloomberg School of Public Health professor who co-authored The New England Journal of Medicine article. “A less crappy device is the solution.”

Arthur Allen is a senior correspondent for KFF Health News, where this article first appeared, and writes about the FDA and the pharmaceutical industry as well as topics related to COVID-19.

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ARTIFICIAL INTELLIGENCE

People First: Types of AI and How to Put Them to Work on Clinician Burnout and Health Disparities

By Kevin Johnson, MD, MS

ARTIFICIAL INTELLIGENCE (AI) isn’t new: The first neural network computer appeared in the early 1950s.

Hype about AI revved up in the 1970s, but early iterations of AI stalled out through a combination of too much hype, too much complexity, and too little attention to the human element.

We can learn from prior AI failures, not to mention failures of EHR implementation, to successfully integrate certain types of AI into daily healthcare operations. We will not solve the clinician burnout crisis or achieve equity in healthcare using AI alone, but strategic applications of AI can assist us in both areas.

The cornerstones of successful AI implementation will be people: Those who envision, lead, and train, and those

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who reskill, adapt, and integrate AI tools into frontline care, whether for administrative or for patient-facing purposes.

Four Main Types of AI Right now, generally speaking, AI works in one of four ways: 1. Diagnostic: AI can sort information into categories to answer questions about a patient’s status, playing a role of detection. For instance: Does this patient have prostate cancer?

2. Predictive: AI can assist us with pharmacogenomics, identifying patients who are likely to respond to a particular therapy. It may also be an aid to predicting length of hospital stay, risk of readmission, and other scenarios in which

hospital operations and patient safety overlap.

3. Prognostic: AI can help us anticipate the probable course of a disease and personalize patients’ care, such as when constellations of genes or variants make cancers harder to treat.

4. Generative: Generative AI can generate any new token from a set of tokens: text from text, audio from audio, pictures from pictures, and so on. Generative AI can assist us with drafting responses to routine patient questions and other at-desk tasks — but because gen-AI has a knack for confidently expressed inaccuracies, clinicians must review any information provided.

Six Key Actions for AI In medicine, we do six main things with information: (1) generate messages (a.k.a. inbox), (2) order, (3) document, (4) search, (5) summarize, and (6) guide (a.k.a. clinical decision support). AI-related tools already exist for each of those domains. Soon more organizations will have access to tools to give us better data insights and to manage revenue cycles. We’ll be able to do work with population health summarization, improve patient experiences, and get help with back-office things such as capacity management. Because of the riskbenefit ratios, these sorts of applications will likely mature more quickly than most diagnostic applications.

In terms of streamlining back-office functions, here’s some of what you can expect: • Scheduling: It’s ideal if patients can specify a need vs. a practitioner. For large organizations that have, say, 30 different types of orthopedic doctors, not all of whom are in the Department of Orthopedic Surgery, AI tools for scheduling can streamline processes for patients and organizations.

• Patient portal messages: Patient portal messages are already here,

and publications regarding the results will be emerging. When patients ask typical questions like, “What does this lab result mean?” a generative pretrained transformer, or GPT, can generate a draft answer (requiring editing).

One study found that this sort of patient portal message response tool did not reduce clinicians’ work, but did increase their satisfaction, presumably by relieving the cognitive load of crafting a message de novo.

• Clinical documentation: What if, instead of spending appointment time documenting a clinical encounter, we could consistently spend that time engaging with the patient and family? In the University of Pennsylvania Health System, we have experienced promising early results with ambient scribe technology.

Burnout Is Prevalent Burnout rates continue to hover at around 50 percent for physicians. The proportion of nurses may be higher. If you walk around any hospital, where people are exhausted and it just never ends, you’ll see it.

Burnout is a systems issue. Weights piled onto the shoulders of clinicians include overscheduling, understaffing, the perpetually increasing length of clinical notes, dealing with our famously unusable EHRs, and increases in RVU targets.

Burnout may be amplified or diminished by individual factors, including social and demographic aspects, such as for those of us who belong to the sandwich generation.

Health Disparities Call for New Screening Requirements CMS recently passed legislation that requires reporting of, and thus screening for, five health disparities: (1) food insecurity, (2) interpersonal safety, (3) housing insecurity, (4) transportation insecurity, and (5) utilities. Screening

“

Artificial intelligence will not replace radiologists ... but radiologists who use AI will replace radiologists who don’t.”

– STANFORD RADIOLOGIST CURTIS LANGLOTZ, MD, PHD

for the social determinants of health (SDOH), though it may be a step in the right direction for equity, will increase workload—which is not a step in the right direction for burnout.

Clinician leaders will need time, space, and personnel to implement SDOH screening. That means adjustments to workflows, staffing, expectations for patient encounters, and methods of data collection.

AI Can Help With Disparities and Burnout AI may give us fresh insights and lift some burdens: • Searching for disparities data: Information related to health disparities in EHRs, when it is present, is buried or scattered.

AI can help with searching and analyzing this unstructured data.

• Screening for SDOH: It can be challenging for those on the front lines of care delivery to ask patients very personal screening

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ARTIFICIAL INTELLIGENCE

questions, and some patients may feel startled, followed by embarrassed, defensive, even angry. To set the stage, some initial screening questions could potentially be completed with a chatbot from the patient’s home.

• Documentation: As ambient scribe technologies become more widely available, physicians, nurses, and advanced practice clinicians will be able to apply their training while focusing on the patient, not a computer. We’ve reaped some rewards already in a trial currently underway at Penn. Around the country, technologies like DAX are reducing clinicians’ pajama time.

• Patient portal messages: As mentioned, ChatGPT can draft messages to answer common questions — and practitioners can engineer their prompts to suit any level of health literacy (before editing the result). This techassisted drafting process intervenes in practitioners’ inbox burden, a major contributor to burnout. By addressing health literacy gaps, it battles health disparities. And by promoting clear communication, it improves patient safety.

• Other patient communications: There are chatbot projects running all around the country. In some areas, like genetic counseling, incorporating chatbots into some patient communication could increase access to human professionals.

People Before Technology To implement AI-powered tools in healthcare, we need to account for three layers of challenges: technology, process, and people.

• Technology is the smallest piece and the easiest to solve. If the question of how to implement AI-powered tools into healthcare were an iceberg, then technology would be at the surface.

However, process issues and then — at the base, and much bigger — people issues are where we find our real work.

• Process issues should be familiar to us from precedent: As veterans of the EHRconversion wars know, it’s easy to magnify the inefficiencies of an existing organizational structure through a misguided technology install. In integrating AI tools, we need to recognize and reduce our existing complexities.

• People issues will be the gorilla in the room — and also key to our success or failure. We need to address willingness, skill, comfort, and cost. Willingness comes first because people may fear that they are being asked to learn the very thing that is about to take their job. Before we can train anyone, we have to persuade people to get on board with training.

Stanford’s Curtis Langlotz, MD, PhD, a leader in radiology, has famously said, “Artificial intelligence will not replace radiologists … but radiologists who use AI will replace radiologists who don’t.” That goes for all of us.

Dr. Johnson is a professor of biomedical informatics, computer science, pediatrics, and science communication at the University of Pennsylvania; and vice president of applied clinical informatics in the University of Pennsylvania Health System.

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Key Takeaways • Diets higher in

inflammatory foods were linked to increased dementia risk in older adults.

• Risks were higher

for both all-cause dementia and Alzheimer’s dementia.

• The study tracked

Dietary Inflammatory Index scores measured at three time points over 10 years.

DIETS HIGHER IN INFLAMMATORY foods were tied to an increased incidence of dementia in older adults, longitudinal data from the Framingham Heart Study Offspring cohort showed.

Over 13 years of follow-up, higher Dietary Inflammatory Index (DII) scores averaged across three time points were linearly associated with an increased incidence of all-cause dementia (HR 1.21, 95% CI 1.10–1.33, P<0.001), reported Debora Melo van Lent, PhD, of UT Health San Antonio in Texas, and co-authors.

Similarly, higher DII scores were linearly associated with an increase in Alzheimer’s disease dementia (HR 1.20, 95% CI 1.07–1.34, P=0.002), the researchers reported in Alzheimer’s & Dementia. Findings were adjusted for demographic, lifestyle, and clinical covariates.

“Although these promising findings need to be replicated and further validated, our results suggest that diets that correlate with low DII scores may prevent late-life dementia,” van Lent and colleagues noted.

NEUROLOGY

Dementia Incidence Linked to Inflammatory Foods Study Assessed Diet at Three Time Points Over 10 Years By Judy George Previous cross-sectional research from the Framingham Heart Study Offspring cohort showed that higher DII scores — indicating more proinflammatory foods consumed — correlated with smaller total brain and gray matter volumes and larger lateral ventricular volume.

Other cohort studies, including a three-year study in Greece, tied diets with high inflammatory potential to an increased risk of incident dementia.

And clinical trial data showed the MIND diet — a hybrid of the Mediterranean diet and the DASH (Dietary Approaches to Stop Hypertension) diet that is rich in anti-inflammatory foods — had a similar effect on cognition and brain MRI outcomes as mild caloric restriction over three years, possibly due to high adherence of the control group to lifestyle advice.

However, there’s limited information about the long-term relationship between diet-driven inflammation and incident dementia, van Lent and coauthors noted.

The researchers evaluated 1,487 participants in the Framingham Heart Study Offspring study who were age 60 or older at baseline with no prevalent dementia. More than half (53%) were women, and mean baseline age was 69.

About 22% carried an APOE4 allele.

DII scores were calculated using the 126-item Harvard semi-quantitative food frequency questionnaire, which was administered at three points over 10 years from 1991 to 2001.

The DII used in the analysis consisted of 36 dietary components including nutrients, whole foods, and caffeine from food intake. Components were

categorized as anti-inflammatory or pro-inflammatory.

Anti-inflammatory components included alcohol, beta-carotene, caffeine, dietary fiber, folic acid, magnesium, thiamin, riboflavin, niacin, zinc, monounsaturated fat, polyunsaturated fat, omega-3 fat, omega-6 fat, selenium, flavan-3-ol, flavones, flavonols, flavanones, anthocyanidins, green or black tea, pepper, garlic, and vitamins B6, A, C, D, and E. Pro-inflammatory components included vitamin B12, iron, carbohydrates, cholesterol, total energy intake, protein, saturated fat, and total fat.

The mean DII score was -0.30, indicating that participants’ diets were anti-inflammatory, on average. DII scores were grouped into quartiles.

Education, body mass index, total energy intake, and smoking status varied across the four groups.

Follow-up was a maximum of 22.3 years and a mean of 12.8 years. In that span, 246 participants developed allcause dementia, mostly Alzheimer’s dementia (187 people). There were no significant interactions between DII scores and APOE4, sex, hypertension, type 2 diabetes, or cardiovascular disease in relation to incident allcause and Alzheimer’s dementia, the researchers noted.

“The most pro-inflammatory components of the DII (i.e., saturated

fat, trans fats, and total energy intake) are present in the pro-inflammatory ‘Western diet’ — a summary term for dietary patterns consumed in Western societies — which has shown an association with increased concentrations of biomarkers of systemic inflammation and risk factors of all-cause and Alzheimer’s disease dementia, and also with neurodegenerative disease-related outcomes,” they wrote. “Western diets having inflammatory potential especially known to be pro-inflammatory may have enormous implications for preventive dietary interventions.”

The study had several limitations, van Lent and colleagues acknowledged.

Its design was observational and the study cannot show causality. The findings relied on food frequency questionnaire data that may have measurement error or recall bias. In the Framingham Heart Study Offspring study, only 36 of 45 possible DII components could be assessed.

The DII was created based on studies of micro- and macronutrients and bioactive compounds in relation to inflammatory markers, not specific disease outcomes. “A limitation of this approach is that some individual DII components may have an opposite effect on the health outcome under study,” the researchers pointed out.

“For example, vitamin B12 is considered pro-inflammatory in the DII score, but the vitamin has been hypothesized to be protective for dementia risk.”

Judy George is deputy managing editor of MedPage Today, where this article first appeared. She covers neurology and neuroscience news, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more.

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PEDIATRICS

FDA Advisers Say More Data Needed for RSV Vaccines in Young Kids A ‘Very Complicated Situation’ After mRNA Vaccine Trial Was Halted By Jennifer Henderson FDA ADVISERS SAID THAT MORE data are needed to fully understand if there are broader safety concerns related to use of respiratory syncytial virus (RSV) vaccines in young children after an mRNA vaccine trial was halted earlier this year.

Moderna, which had been developing an mRNA vaccine candidate for RSV in infants and toddlers, notified the FDA in July that it had paused a phase I trial due to an imbalance of severe/ hospitalized RSV cases in RSV-naive infants ages 5 to 7 months who had received the vaccine versus placebo, raising concern for possible vaccineassociated enhanced respiratory disease (VAERD), according to FDA briefing documents.

“I think we are confronted by a very complicated situation,” said Arnold Monto, MD, of the University of Michigan in Ann Arbor, during a recent Vaccines and Related Biological Products Advisory Committee (VRBPAC) meeting.

“We know that passive acquisition of antibody is protective — highly protective — and does not produce severe disease in any way,” Dr. Monto added. “We now have a platform which should be only inducing antibody formation, which I think it’s the right antibody, [but] I think it’s very clear that there is a safety signal, and the trials cannot continue, at least in the youngest age group.”

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In Moderna’s trial, there were five cases — representing 12.5% of participants — of clinically significant severe or very severe RSV identified in the vaccine groups (all of whom had received one or two doses of a threedose schedule), compared to one case — representing 5% of participants — in the placebo group.

There is no subsequent enrollment or dosing planned; however, surveillance is continuing, according to Moderna. Notably, there is no current plan to continue the company’s RSV vaccine program in children younger than 2 years.

“I don’t see this, based on our understanding and our ability to develop any kind of new markers for severity, that we can stop or should stop development of potential vaccines using other platforms, because we really don’t understand the relationship of the platform to the severity, nor different antigenic confirmations,” Dr. Monto noted.

“This needs to be done on a vaccineplatform-by-vaccine-platform basis,” he added, and by continuing “with the very careful age de-escalation and previous infection approach, but ... with great caution, and to make sure that if there is a signal, it is caught and appropriately handled.”

Karen Kotloff, MD, of the University of Maryland in Baltimore, said that she believes “the safest path is knowing

that maternal antibody and monoclonal antibody [through the maternal RSV vaccine and monoclonal antibody nirsevimab (Beyfortus) for infants] are protective.”

“The approach that we heard of giving that to protect kids in the first year, trying to get cheaper antibodies made, and then use vaccination for kids after the first year of life, to me, seems the safest way forward to avoid the safety signals that we don’t really understand,” Dr. Kotloff added.

Guest speaker Pedro Piedra, MD, of Baylor College of Medicine in Houston, noted that “RSV vaccines are going to be extremely beneficial once we understand well the issue of safety and risk in younger infants.”

“Right now, we have nirsevimab, which is an outstanding monoclonal antibody that is providing high levels of protection against severe disease, but I want to call your attention that it’s a monoclonal antibody [and] when you use a monoclonal antibody in such a universal format, you need to expect that mutations will occur and that you may develop either resistant virus or community-resistant-emergent virus that will be resistant to that monoclonal antibody,” Dr. Piedra said. “And so to rely

“

RSV vaccines are going to be extremely beneficial once we understand well the issue of safety and risk in younger infants.”

– PEDRO PIEDRA, MD BAYLOR COLLEGE OF MEDICINE

on the monoclonal antibody to provide protection during the first year of life would raise that caveat that infants are an excellent vector, in a way that, if mutations are to arise, it would be in infants or immunocompromised hosts.”

“I want to bring that to the attention because I don’t think we can only rely on monoclonal antibodies forever ... and that we need to think downstream, that vaccines will provide broader levels of responses that may be applicable and hopefully safe in the young population,” Dr. Piedra added.

For Thursday’s meeting, VRBPAC was tasked with discussing two topics. In addition to vaccine safety in pediatric populations, including whether currently available evidence indicates a potential safety concern with RSV vaccine candidates in infants and toddlers, the committee also focused on sequential administration of RSV

monoclonal antibodies followed by RSV vaccines, and whether currently available evidence suggests potential interactions that may affect active immunization.

Along with the safety signal in Moderna’s trial, immune responses to vaccination in participants who had previously received the monoclonal antibody nirsevimab appeared blunted when compared with responses in participants who had not received nirsevimab.

“Nirsevimab may have blunted the immune response, but really in a very small number of patients, and there really are not enough data, as others have said, to draw significant conclusions about RSV vaccination of infants who receive nirsevimab,” Henry Bernstein, DO, of the Zucker School of Medicine at Hofstra/Northwell and Cohen Children’s Medical Center in New

Hyde Park, New York, said. “I think that and agree that this should be studied by vaccine platform and also the number of doses received by the children.”

More than two dozen RSV vaccines are in clinical development for children, and there are several vaccines — including Moderna’s mRNA vaccine — approved for use in older adults, adults with comorbidities, and pregnant women to confer protection to infants at birth.

The development of RSV vaccines for children has been challenging.

In the 1960s, pediatric RSV vaccine development was previously stalled due to VAERD.

Jennifer Henderson is an enterprise and investigative writer for MedPage Today, where this article first appeared.

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BREAST CANCER

Skipping Chest-Wall Irradiation After Mastectomy in Intermediate-Risk Breast Cancer No Improvement in Survival or Impact on Recurrence, but Pending Studies Leave Door Ajar By Charles Bankhead of less than 2%,” Dr. Kunkler said during a press briefing. “It has no impact on disease-free or metastasisfree survival [DFS/MFS], and we believe these findings are consistent with incremental changes and improvements in multidisciplinary care [for breast cancer] over the period of the trial.”

“Adjuvant, chest-wall irradiation should be omitted in most patients meeting the eligibility of the SUPREMO,” he stated.

POSTMASTECTOMY CHEST-WALL irradiation (CWI) for intermediate-risk breast cancer had no impact on longterm survival, results of a large British study showed.

After a median follow-up of 9.6 years, irradiated patients had a 10-year overall survival (OS) of 81.4% versus 82% for those who had no CWI. CWI led to a “clinically insignificant” reduction in chest-wall recurrence from 2.5% to 1.1%, representing a total of 29 recurrences

18

JANUARY 2025

among more than 1,600 women.

The results indicate that most women with intermediate-risk breast cancer can safely avoid CWI following mastectomy, said Ian Kunkler, MB BChir, of the University of Edinburgh in Scotland, at the San Antonio Breast Cancer Symposium (SABCS).

“Chest-wall irradiation did not improve 10-year overall survival, and it results in a clinically insignificant reduction in chest-wall recurrence

Door Not Closed — Yet Dr. Kunkler left the door open for use of CWI in selected patients, after press briefing moderator Virginia Kaklamani, MD, of UT Health San Antonio Mays Cancer Center, asked, “Come Monday morning, would you change practice based on these results?”

“There is, firstly, a caveat in that there is a preplanned subgroup analysis by age and by nodal status and by molecular subtype,” said Dr. Kunkler. “If we found patients with any tumor that had a survival of less than 80%, then I think we would be concerned about [omission of CWI] — particularly, for example, in the triple-negative patients.

We have to wait for the preplanned subgroup analysis.”

“But overall, with the exception of those tumors or maybe those patients who are very young, I think we should be avoiding chest-wall irradiation,” he added.

Recommendations might also be influenced by the ongoing MA.39 study evaluating radiation therapy in patients with estrogen receptor (ER)-positive, HER2-negative breast cancer and one to three positive lymph nodes, said Dr. Kaklamani. Additionally, the trial includes patients who undergo lumpectomy or mastectomy.

“I think what we need to do is really drill down more on these individual subsets,” she continued. “I have the same concern about patients with triple-negative breast cancer. More and more patients with triple-negative or HER2-positive disease will be receiving preoperative systemic therapy. In the end, I think this question largely applies to patients with ER-positive disease.

Then the importance of biomarkers, I think, will be the next step to really help us understand what to do.”

Dr. Kunkler fielded numerous questions from the audience following his presentation during a general session at SABCS. Perhaps most thought-provoking, Youssef Zeidan, MD, of Baptist Health in Delray Beach, Fla., asked about the clinical practice implications of SUPREMO in light of recent trials evaluating omission of axillary lymph node dissection, including the COMET trial reported at SABCS. “Clearly, the practice of axillary management has changed,” said Dr. Kunkler. “In the context of this trial, all of the patients had an axillarynode dissection, but there’s obviously data from the AMAROS trial that in patients with one to two positive nodes, radiotherapy may provide an alternative [to dissection]. I think it is possible that with targeted radiotherapy ... that it’s possible that for some of these patients, they might eventually receive axillary irradiation with no chest-wall irradiation. I think the jury probably is still out on patients who have three positive nodes.”

“We have to be careful about generalizing the results of this trial to practice, but I suspect that’s going to be the direction of travel,” Dr. Kunkler added.

Session moderator Michael Gnant, MD, of the University of Vienna in Austria, ended the discussion because of time considerations but noted a queue of more than 20 questions submitted online by virtual participants.

History, Key Results CWI has attracted growing attention since trials from Denmark and Canada, published more than 25 years ago, showed significant reductions in recurrence and improved survival with postmastectomy radiation therapy. Postmastectomy radiation became standard of care on the basis of those trials.

However, recurrence rates in the earlier trials were substantially higher as compared with contemporary cohorts, said Dr. Kunkler. Moreover, the chemotherapy regimens used at the time were likely suboptimal as compared with modern systemic therapy. Against that historical background, investigators designed the SUPREMO trial to determine the value of postmastectomy CWI in the setting of modern clinical management.

Eligible patients had pT1-2N1M0 or pT3N0M0 disease or pT2N0M0 disease if grade 3 or associated with lymphovascular invasion (LVI). All patients underwent simple mastectomy and axillary staging surgery. Patients with one to three positive nodes had a minimum of eight nodes removed.

Eligible patients met fitness criteria for adjuvant chemotherapy and adjuvant endocrine therapy (if indicated), and postoperative irradiation.

Beginning in 2006, SUPREMO investigators randomized 1,679 patients to postmastectomy CWI or none. CWI consisted of a total dose of 40–50 Gy in 15-25 fractions. The primary endpoint was 10-year OS. Secondary endpoints included local and regional recurrence, DFS, and MFS.

“

Chest-wall irradiation did not improve 10-year overall survival, and it results in a clinically insignificant reduction in chest-wall recurrence of less than 2%.”

– DR. IAN KUNKLER, UNIVERSITY OF EDINBURGH RESEARCHER

The patient population had a median age of 55 years, 92% had stage II or III disease, 25% had node-negative disease, 21% had HER2-positive disease, 11% had triple-negative breast cancer, and 38.5% had LVI. The primary analysis yielded a hazard ratio (HR) of 1.04 for CWI versus none (95% CI 0.81-1.30). Analysis of OS by nodal status showed no significant impact of CWI in patients with N0 disease (HR 1.21) or those with nodepositive disease (HR 0.97).

Patients with CWI did have a lower incidence of chest-wall recurrence (1.1% vs 2.5%, P=0.04). Though statistically significant, the difference was not clinically meaningful, said Dr. Kunkler.

The overall difference was driven by patients with node-positive disease (HR 0.30, P=0.01). Regional recurrence also favored CWI (2.7% vs 4.5%) but the difference did not achieve statistical significance (P=0.06).

Analyses of MFS and DFS also showed no significant impact of CWI (HR 1.06, HR 0.97, respectively).

Charles Bankhead is senior editor for oncology and also covers urology, dermatology, and ophthalmology for MedPage Today, where this article first appeared.

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CHAMPIONS FOR HEALTH

A patient and her son with crafts

Reconnecting as a Family

Dr. Itahi Arteaga

By Adama Dyoniziak PARENTS CARE FOR THEIR children so that their children’s lives can be better than their own. When the child becomes the parent’s caretaker, parents feel guilty about being a burden. Their very young children are stepping into adult roles such as cleaning, cooking, caring for siblings, and even helping parents at work when they are physically unable.

Champions for Health (CFH) staff identified this additional burden that lack of access to specialty medical care places not only on adults seeking services, but also on their children and grandchildren. Funded by the Conrad Prebys Foundation in July 2024, CFH began implementing “Supporting the Emotional WellBeing of Youth Caregivers and their Families,” an in-home emotional wellbeing curriculum serving youth ages 6–26. The program’s goals are to

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JANUARY 2025

improve communication among family members, to improve understanding of the impacts of chronic health needs, and to increase the youths’ ability to identify their cultural and related strengths for improved emotional wellbeing.

Using sensory and cultural activities, family members relearn how to connect with each other. Dr. Itahi Arteaga, a bilingual/bicultural occupational therapist, delivers the program. “I let the families know I am a guest,” says Dr. Itahi. “I give you tools that you might already have and that you can use in times when you may not have recognized they were yours.”

First, youth and parents discuss their needs, strengths, and concerns as a family. Each session consists of a sensory activity, psychoeducation, and time for connection and discussion.

For example, family members smell

scented candles and guess the scents.

Each note their own and others’ reaction — one person loves the scent, another thinks it’s too strong, and another person sneezes! The family talks about how the environment may impact each of them differently. Youth identify what sensory activities may soothe them and how to access that information for grounding and selfcare during stressful situations.

Early information from participants shows that they are thankful for the in-home services and the ability to be together and learn as a family. When asked about any coping skills learned, one youth reported, “I found a new breathing strategy, in which I put my hand up and I use my other hand to trace my finger. As I’m going up with my finger I breathe in, and as I go down I breathe out.” When asked about connection to family, one respondent stated, “Yes, I feel more connected because every session we have a good laugh.” Another responded, “Being together and doing exercises to calm ourselves together, and playing loteria connected us like before. The program helps the family understand that we can be together and happy, doing things that improve our relationship.”

Project Access staff provide local resources to respond to concerns raised by the youth or family, including ongoing counseling services, food pantries, connecting to a primary care provider, jobs or training, or linking them to Medi-Cal resources.

Join the Conrad Prebys Foundation with your donation, so that youth and their families can continue to reconnect and be joyful again. www. championsforhealth.org/donate

Adama Dyoniziak is executive director of Champions for Health.

CLASSIFIEDS PHYSICIAN OPPORTUNITIES

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VENOUS DISEASE SPECIALIST | NORTH COUNTY: La Jolla Vein & Vascular, the premier vein care provider in San Diego, is seeking a highly skilled and experienced Venous Disease Specialist to join our team at our newest location in Vista, CA, nestled in the stunning coastal region of North County San Diego. This full–time position offers competitive salary and benefits, including profit-sharing and a 401(k). Our state-of-theart facility operates Monday through Friday, with no weekend or night shifts, promoting an excellent work-life balance.

Ideal candidates may also consider a locum or locum-to-hire arrangement. Join us in making a difference in our patients’ lives while enjoying your dream location! Email cv to jobs@ljvascular. com. [2875-1030]

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PART–TIME PRIMARY CARE PHYSICIAN: Primary Care Clinic in San Diego searching for part-time physician for 1 to 2 days a week, no afterhours calls. Please send CV to medclinic1@yahoo. com. [2872-0909] OB/GYN POSITION AVAILABE | EL CENTRO: A successful Private OBGYN practice in El Centro, CA seeking a board eligible/ certified OB/GYN. Competitive salary and benefits package is available with a tract of partnership. J-1 Visa applicants are welcome. Send CV to feminacareo@gmail. com or call Katia M. at 760-352-4103 for more information.

[2865-0809] COUNTY OF SAN DIEGO DEPUTY CHIEF ADMINISTRATIVE OFFICER: Salary: $280,000-$300,000 Annually. The County of San Diego is thrilled to announce unique openings for Deputy Chief Administrative Officers (DCAOs) across our four County Groups: Finance and General Government Group (FGG), Health & Human Services Agency (HHSA), Land Use and Environment Group (LUEG), and the Public Safety Group (PSG). With a new Chief Administrative Officer (CAO) at the helm, the County is in an extraordinary period of transformation and opportunity. The DCAOs will direct, organize and oversee all activities within their designated Group. Additionally, the DCAOs aid the CAO in the coordination of county operations, program planning, development, and implementation. The DCAOs must demonstrate strong leadership and model our core values of integrity, belonging, equity, excellence, access, and sustainability. How To Apply: Take this opportunity to make a significant impact and drive positive change in our community. Apply now by submitting your application here: Deputy Chief Administrative Officer24210407U. COUNTY OF SAN DIEGO PROBATION DEPT. MEDICAL DIRECTOR: The County of San Diego is seeking dynamic physician leaders with a passion for building healthy communities. This is an exceptional opportunity for a California licensed, board-certified physician to help transform our continuum of care and lead essential medical initiatives within the County’s Probation Department. Anticipated Hiring Range: Depends on Qualifications. Full Salary Range: $181,417.60 $297,960.00 annually. As part of the Probation Administrative team, the Medical Director is responsible for the clinical oversight and leadership of daily operations amongst Probation facilities’ correctional healthcare programs and services. As the Medical Director, you will have significant responsibilities for formulating and implementing medical policies, protocols, and procedures for the Probation Department.

PART–TIME CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part–time cardiologist.

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

[2874-0713] FAMILY MEDICINE/INTERNAL MEDICINE PHYSICIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care and participating in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary.

If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810-8700.

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

LA JOLLA/XIMED OFFICE TO SUBLEASE: Modern upscale office on the campus of Scripps Hospital — part or full time. Can accommodate any specialty. Multiple days per week and full use of the office is available. If interested please email kochariann@ yahoo.com or call (818) 319-5139. [2866-0904] SUBLEASE AVAILABLE: Sublease available in modern, upscale Medical Office Building equidistant from Scripps and Sharp CV. Ample free parking. Class A+ office space/medical use with high-end updates. A unique opportunity for Specialist to expand reach into the South Bay area without breaking the bank. Specialists can be accommodated in this first floor high-end turnkey office consisting of 1670 sq ft. Located in South Bay near Interstate 805. Half day or full day/week available.

South Bay is the fastest growing area of San Diego. Successful sublease candidates will qualify to participate in ongoing exclusive quarterly networking events in the area. Call Alicia, 619-585-0476.

OFFICE SPACE FOR SUBLEASE | SOUTHEAST SAN DIEGO: 3 patient exam rooms, nurse’s station, large reception area and waiting room. Large parking lot with valet on-site, and nearby bus stop. 286 Euclid Ave - Suite 205, San Diego, CA 92104. Please contact Dr. Kofi D. Sefa-Boakye’s office manager: Agnes Loonie at (619) 435-0041 or ams66000@aol.com.

[2869-0801] MEDICAL OFFICE FOR SALE OR SUBLEASE: A newly remodeled and fully built-out primary care clinic in a highly visible Medical Mall on Mira Mesa Blvd. at corner of Camino Ruiz. The office is approximately 1,000 sq ft with 2 fully equipped exam rooms, 1 office, 1 nurse station, spacious and welcoming waiting room, spacious reception area, and ADA accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please contact Nox at 619-776-5295 or noxwins@hotmail. com. Available immediately.

RENOVATED MEDICAL OFFICE AVAILABLE | EL CAJON: Recently renovated, turn-key medical office in freestanding single-story unit available in El Cajon. Seven exam rooms, spacious waiting area with floor-to-ceiling windows, staff break room, doctor’s private office, multiple admin areas, manager’s office all in lovely, drought-resistant garden setting. Ample free patient parking with close access to freeways and Sharp Grossmont and Alvarado Hospitals. Safe and secure with roundthe-clock monitored property, patrol, and cameras. Available March 1st. Call 24/7 on-call property manager Michelle at the Avocado Professional Center (619) 916-8393 or email help@ avocadoprofessionalcenter.com.

OPERATING ROOM FOR RENT: State of the Art AAAASF Certified Operating Rooms for Rent at Outpatient Surgery of Sorrento. 5445 Oberlin Drive, San Diego 92121. Ideally located and newly built 5 star facility located with easy freeway access in the heart of San Diego in Sorrento Mesa. Facility includes two operating rooms and two recovery bays, waiting area, State of the Art UPC02 Laser, Endoscopic Equipment with easy parking.

Ideal for cosmetic surgery. Competitive Rates. Call Cyndy for more information 858.658.0595 or email Cyndy@roydavidmd. com.

PRIME LOCATION | MEDICAL BUILDING LEASE OR OWN OPPORTUNITY IN LA MESA: Extraordinary opportunity to lease or lease-to-own a highly visible, freeway-oriented medical building in La Mesa, on Interstate 8 at the 70th Street on-ramp.

Immaculate 2-story, 7.5k square foot property with elevator and ample free on-site parking (45 spaces). Already built out and equipped with MRI/CAT machine. Easy access to both Alvarado and Sharp Grossmont Hospitals, SDSU, restaurants, and walking distance to 70th St Trolley Station. Perfect for owner-user or investor. Please contact Tracy Giordano [Coldwell Banker West, DRE# 02052571] for more information at (619) 987-5498.

POWAY MEDICAL OFFICE SPACE FOR LEASE: Fully built out, turnkey 1257 sq ft ADA-compliant suite for lease. Great location in Pomerado Medical/Dental Building, next to Palomar Med Center Poway campus. Building restricted to medical/ allied health/dental practices, currently houses ~26 suites. Ideal for small health practice as primary or satellite location. Lease includes front lobby, reception area, restrooms, large treatment area, private treatment/exam rooms. Located on second floor, elevator/stair access. Bright, natural lighting; unobstructed views of foothills. On-site parking; nearby bus service. Flexible lease terms available from 3-5 years at fair market rate. Contact Debbie Summers at debjsummers3@gmail.com or (858) 3828127. [2856-1101] KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643 Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems. Ample free parking. Newly constructed Class A+ medical office space/ medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for use (including splint/cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam

room doubles as a minor procedure room. Ample waiting room area. In-office X-ray with additional waiting area outside of the X-ray room. Orthopedic surgery centric office space. Includes access to a kitchenette/indoor break room, exterior break room and private physician workspace. Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and scurry@ortho1.com for more information. Available for immediate occupancy.

LA JOLLA/UTC OFFICE TO SUBLEASE OR SHARE: Modern upscale office near Scripps Memorial, UCSD hospital, and the UTC mall. One large exam/procedure room and one regularsized exam room. Large physician office for consults as well.

Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available. If interested please email drphilipw@gmail. com.

ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and reception. Large parking lot with free parking for patients.

Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.

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

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

NON–PHYSICIAN POSITIONS AVAILABLE NURSE PRACTITIONER | PHYSICIAN ASSISTANT: Open position for Nurse Practitioner/Physician Assistant for an outpatient adult medicine clinic in Chula Vista. Low volume of patients. No call or weekends. Please send resumes to medclinic1@yahoo.com. [2876-1121] POSTDOCTORAL SCHOLARS: The Office of Research Affairs, at the University of California, San Diego, in support of the campus, multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search for Postdoctoral Scholars in various academic disciplines. View this position online: https://apol-recruit.ucsd. edu/JPF03803. The postdoctoral experience emphasizes scholarship and continued research training. UC’s postdoctoral scholars bring expertise and creativity that enrich the research environment for all members of the UC community, including graduate and undergraduate students. Postdocs are often expected to complete research objectives, publishing results, and may support and/or contribute expertise to writing grant applications https://apol-recruit.ucsd.edu/JPF03803/apply.

[2864-0808] RESEARCH SCIENTISTS (NON-TENURED, ASSISTANT, ASSOCIATE OR FULL LEVEL): The University of California, San Diego campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search for Research Scientists (non– tenured, assistant, associate or full level). Research Scientists are extramurally funded, academic researchers who develop and lead independent research and creative programs similar to Ladder Rank Professors. They are expected to serve as Principal Investigators on extramural grants, generate high caliber publications and research products, engage in university and public service, continuously demonstrate independent, high quality, significant research activity and scholarly reputation.

Appointments and duration vary depending on the length of the research project and availability of funding. Apply now at https:// apol-recruit.ucsd.edu/JPF03711. [2867-0904] PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research and Innovation https://research. ucsd.edu/, in support of the Campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index. html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding: https://apol-recruit.ucsd.edu/ JPF03712/apply. [2868-0904]

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

United In Wellness Gala

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Saturday, June 14, 2025 • 5-9 pm

Eve at RaDD • 975 Waterfront Place, Suite 400, San Diego, CA 92101 Unitedinwellnessgala.org For sponsorship information, please contact Gabriela Stichler at gabriela.stichler@championsfh.org or at 858-300-2789