February 2022

Official Publication of SDCMS FEBRUARY 2022

Omicron and Isolation

in California’s Nursing Homes

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD

Contents FEBRUARY

VOLUME 109, NUMBER 2

Features

4

In California Nursing Homes, Omicron Is Bad, but So Is the Isolation

By Linda Marsa

6

Caring for Dementia Means Caring for the Caregiver

By Glenn Panzer, MD

AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Timothy Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: Sergio R. Flores At-Large: Albert Ray, MD At-Large: Robert E. Hertzka, MD At-Large: Theodore M. Mazer, MD At-Large: Kyle P. Edmonds, MD At-Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At-Large Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request.

Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org.

San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

14 Departments

2

Briefly Noted: CMA Member Resources * Practice Management * Trial Lawyers/MICRA

10

COVID in Kids Under 5 May Look Like Croup, Pediatricians Warn

By Kara Grant

11

CDC Tells Pharmacies to Give 4th COVID Shot to Immunocompromised Patients

By Liz Szabo

12

Biden Administration’s RapidTest Rollout Doesn’t Easily Reach Those Who Need It Most

By Hannah Recht and Victoria Knight

I’m Over COVID Symptoms, but Still Testing Positive. Am I Infectious?

By Jennifer Henderson

16

Neurologists Are Actively Working to Reduce High Drug Costs

By Orly Avitzur, MD, MBA

18

Freedom, Finally

By Adama Dyoniziak

19

Autism, ADHD Carry Higher Risks of Mortality

By Lei Lei Wu

20

A Perfectly Human Family

By Helane Fronek, MD, FACP, FACPh

21

Classifieds

SA NDIEGOPH YSICI A N.ORG

1

BRIEFLY NOTED 2

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CMA MEMBER RESOURCES

Questions About California’s New Electronic Prescribing Mandate?

EFFECTIVE AS OF JAN. 1, ALMOST ALL

prescriptions written in California must be transmitted electronically. To help physicians understand the new e-prescribing requirements, the California Medical Association (CMA) published an FAQ, “Frequently Asked Questions: California’s Electronic Prescribing Mandate,” available only to members.

The electronic prescribing mandate was contained in a law passed by the California State Legislature in 2018. The bill (AB 2789) had a threeyear delayed implementation to allow physicians and other prescribers the opportunity to select and implement an electronic prescribing platform. But the delay ends at the end of this year.

The law is partially based on the Medicare electronic prescribing for controlled substances (EPCS) requirement. Although the Centers for Medicare and Medicaid Services in the 2022 Medicare Physician Fee Schedule delayed implementation of the EPCS requirement for an additional year, to Jan. 1, 2023, that does not

have any direct effect on the state requirement.

Much of the language of California’s requirement was copied straight from the federal regulations. Unlike the Medicare requirement, however, the state mandate applies to almost all prescriptions, not just those for controlled substances. In that respect, the state mandate is much broader than the Medicare one and will affect many more physicians.

CMA opposed AB 2789 when it was being debated in the legislature and offered the author possible amendments that would have created some accommodations in the law. But the proposed amendments were rejected, as the Legislature saw AB 2789 as just an extension of the Medicare requirement.

CMA also hosted a webinar, Preparing for California’s Electronic Prescribing Mandate, which is now available for on-demand viewing.

CMA members are also always welcome to call the CMA Member Helpline at (800) 786-4262 to request one-on-one assistance.

PRACTICE MANAGEMENT

CMA Recoups $33 Million on Behalf of Physician Members IN 2021, THE CALIFORNIA MEDICAL

Association (CMA) recovered nearly $3.2 million from payers on behalf of physician members.

This is money that would have likely gone unrecouped if not for CMA’s direct intervention.

That’s because California physicians have a powerful ally when it comes to dealing with problematic payers — CMA’s Center for Economic Services (CES). Staffed by practice management experts with a combined experience of more than 125 years in medical practice

operations, the CES team has recovered more than $33 million from payers on behalf of its physician members during the past 13 years.

CMA members can call on CMA’s practice management experts for free, one-on-one help with contracting, billing, and payment problems by contacting reimbursement helpline at (888) 401-5911 or economicservices@cmadocs.org.

Learn more about how CMA’s practice management experts can help you at cmadocs.org/ces.

MICRA

Hundreds of Organizations Join Together to Oppose Measure That Would Gut MICRA

TRUST

THE CALIFORNIA MEDICAL ASSOCIATION (CMA) AND ITS LOCAL COUNTY

medical societies have joined together with hundreds of organizations in opposing the so-called Fairness for Injured Patients Act (FIPA) because it will devastate our healthcare delivery system, hurt community health centers, and raise healthcare costs for all Californians.

For many years, California’s medical liability system has been protected by a bipartisan series of laws called MICRA (Medical Injury Compensation Reform Act), which has balanced the rights of injured patients while keeping healthcare more accessible and affordable for all patients.

FIPA will be on the ballot this November and, if passed, will effectively eliminate MICRA’s protections. Funded by a wealthy, out-of-state trial attorney, this proposition would be a windfall for lawyers at the expense of California’s most vulnerable patients.

MICRA ensures that injured patients receive compensation while preserving access to healthcare by keeping providers in practice and hospitals and clinics open.

Without MICRA’s protections, many of California’s neediest populations could face reduced access to these much-needed services.

This flawed initiative would: • Eliminate the cap on both non-economic damages and attorneys’ fees.

The initiative creates a new category of injuries that are not currently recognized under California law. This new, broadly defined category of malpractice lawsuits allows for unlimited attorneys’ fees and unlimited non-economic damages.

• Reward lawyers before patients. Current law allows for patients to be paid for future damages over time as their treatment and recovery continues. This measure requires all damages to be paid in a large lump sum and increases the risk that patients could run out of money before their recovery is complete.

These lump-sum payments allow trial attorneys to collect more in fees.

• Result in more, not less frivolous lawsuits. Unlike other judicial transparency laws in California, this measure would expressly prohibit judges from independently verifying the truthfulness of statements made by trial attorneys in certain court filings known as “certificates of merit” and from disciplining them for dishonesty.

According to the nonpartisan Legislative Analyst’s Office, this flawed initiative will drive up healthcare costs for all Californians by tens of millions “to high hundreds of millions of dollars annually.” This initiative would obliterate existing safeguards for medical lawsuits — resulting in skyrocketing healthcare costs and huge windfalls for attorneys.

This is not the first attempt to alter MICRA, but it is the most damaging. Now, CMA and hundreds of other organizations are part of a growing coalition to defeat FIPA this November.

The future of MICRA is on the line. We know that through our collective efforts, we can defeat this dangerous measure and ensure continued access to care for millions of Californians.

We need your help to educate millions of Californians about the disastrous impact this initiative would have on our healthcare system. For more information on how you can help defeat FIPA, please visit protectmicra.org.

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SA NDIEGOPH YSICI A N.ORG

3

NURSING HOMES COVID-19

In California Nursing Homes, Omicron Is Bad, but So Is the Isolation

BY LINDA MARSA

D

INA HALPERIN HAD BEEN

cooped up alone for three weeks in her nursing home room after her two unvaccinated roommates were moved out at the onset of the omicron surge. “I’m frustrated,” she said, “and so many of the nursing staff are burned out or just plain tired.”

The situation wasn’t terrifying, as it was in September 2020, when disease swept through the Victorian Post Acute facility in San Francisco and Halperin, a

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63-year-old former English as a Second Language teacher, became severely ill with COVID. She spent 10 days in the hospital and required supplemental oxygen.

Since the pandemic began, 14 residents of the nursing home have died of COVID, according to state figures.

Over time, Victorian Post Acute has gotten better at dealing with the virus, especially its milder omicron form, which accounted for 31 cases as of Jan. 27 but not a single illness serious enough to

cause hospitalization, says Dan Kramer, a spokesperson for Victorian Post Acute.

But the ongoing safety protocols at this and other nursing homes — including visitor restrictions and frequent testing of staff and residents — can be soul-killing. For the 1.4 million residents of the nation’s roughly 15,000 nursing homes, the rules have led to renewed isolation and separation.

“I’m feeling very restless,” Halperin says. She has Cushing’s syndrome, an

autoimmune disease that caused tumors and a spinal fracture that left her mostly wheelchair-bound and unable to live independently. Although she has residual COVID symptoms, including headaches and balance problems, Halperin, who has lived in the nursing home for nine years, is usually quite sociable. She volunteers in the dining room, helps other residents with their activities, and shops and runs errands during her frequent forays outside the building.

But COVID infections have again spiked at nursing homes around the country. In California, 792 new nursing home cases were reported on Jan. 19, compared with fewer than 11 cases on Dec. 19, 2021. However, the death rates are not nearly as bad as they were during pre-vaccine COVID surges. From Dec. 23, 2021, to Jan. 23, 2022, 217 nursing home residents died of COVID in California. By contrast, in just the week from Christmas 2020 to New Year’s Day 2021, 555 people died at nursing homes in the state.

Those numbers, and others cited in this article, don’t filter out patients who entered hospitals for treatment of other conditions but tested positive for COVID upon admission — a common occurrence during the omicron wave.

To keep nursing home residents out of overwhelmed hospitals, California public health officials have mandated masking and imposed strict vaccination and testing requirements for visitors and staffers at the homes, according to Dr. Zachary Rubin, a medical epidemiologist with the Los Angeles County Department of Public Health. “Our approach is to prevent cases from coming into the facility, stop transmission once it gets into the facility, and to prevent serious outcomes,” he says.

Rubin acknowledges that some of these policies may seem like they’re doing more harm than good — but only temporarily, he hopes.

The omicron surge has created staffing shortages as nurses and aides call in sick, and the strict testing requirements have the effect of limiting visits by friends and relatives who provide crucial care and contact for some residents, bathing and grooming them, overseeing their diets and medications, and making sure they’re not being neglected.

Nationally, a federal mandate requires all workers in federally funded facilities

to be fully vaccinated by Feb. 28. The deadline was extended to March 15 for 24 states that challenged the requirement in court. Last month, California issued a similar order, which also requires nursing home staffers to receive booster shots by Feb. 1.

However, while vaccination rates for staff members and residents are high in California (96% for staffers and 89% for residents), only 52% of nursing home workers and 68% of their residents in California have received boosters, according to Jan. 23 figures from the Centers for Disease Control and Prevention.

At Victorian Post Acute, 95% of staff and 92% of residents had been vaccinated with boosters as of Jan. 27, Kramer says.

Across the state, many unvaccinated staff members claim religious exemptions. Others say they can’t get vaccinated at their workplaces and don’t have time to get shots on their own, says Deborah Pacyna, a spokesperson for the California Association of Health Facilities, which represents the nursing home industry in Sacramento.

“We’re going to have to deal with that as the deadline approaches. If they’re not boosted, does that mean they can’t work?” she asks. “That would be an extraordinary development.”

The state hasn’t indicated how it will enforce mandates, especially for boosters, says Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform.

Most nursing home visitors, as of Jan. 7, must be fully vaccinated — including boosters, if eligible — under California Department of Public Health requirements. Guests also must present a negative COVID test taken within one or two days, depending on the type of test. The federal government is sending four rapid tests to families that request them, and the state of California has distributed 300,000 tests to nursing homes.

That’s “better than nothing,” says Pacyna, but it may not be enough for families that visit several times a week.

Some experts think any policy that tends to restrict visitors sets the wrong priority.

“Limiting visitation is bad psychologically,” says Charlene Harrington, a professor emeritus in social and behavioral sciences at the University of CaliforniaSan Francisco who has done extensive

research on nursing homes. Numerous studies have shown that social isolation and loneliness can lead to depression, worsening dementia and cognitive decline, anxiety, a loss of the will to live — and increased risk of mortality from other causes.

Besides, Harrington says, most nursing home outbreaks are caused by infected staffers, who often work multiple jobs because of the low pay.

Maitely Weismann visits her 79-yearold mother, who has dementia and uses a wheelchair, at a Los Angeles residential facility several times a week. Her mother deteriorated considerably during the initial lockdown, and Weismann is doing her best to slow her mother’s decline, she says.

“It’s much harder to do this during the pandemic because there are so many barriers to entry,” says Weismann, cofounder of the advocacy group Essential Caregivers Coalition. “Family caregivers can’t actually tell if a loved one is doing OK through a screen, or a window, or a phone call.”

Responding to the critical healthcare staff shortages, the CDC issued emergency guidelines in December — California followed suit in January — that allow workers who have been exposed to or test positive for COVID to return to work if they are asymptomatic.

It’s a short-term, last-resort measure, Rubin says. “It’s just not possible to adequately take care of people and do the daily activities of living if you don’t have a nurse or caregivers. You just can’t operate the place.”

On one recent day alone — Jan. 24 — more than 10,300 workers were out sick — which is roughly a tenth of the combined staff in California nursing homes.

To deal with the crunch, says Pacyna, “we’re asking people to work extra hours, knowing that the peak is near and this isn’t going to last forever.”

In the meantime, families continue to worry about their loved ones. “When residents are isolated, they become completely dependent on the caregivers in the facility,” Weismann says. “But when staff stops coming to work, the system falls apart.”

Linda Marsa is a reporter for Kaiser Health News, where this article first appeared.

SA NDIEGOPH YSICI A N.ORG

5

DEMENTIA

Caring for Dementia Means Caring for the Caregiver

BY GLENN PANZER, MD

T

HE BEST CARE CAN BE

provided by caregivers who are rested, and who take the time for self-care — similar to airline passengers being told, “Put your own oxygen mask on first.” The patient’s continued health and wellbeing depends on a family caregiver. That person must be willing and able to handle the patient’s complex health, financial, legal, and social needs. Just as with care for an individual with dementia, the job can continue for months, or more commonly years.

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Who Are the Caregivers?

According to the 2021 Alzheimer’s Disease Facts and Figures report (alz.org/ facts) there were over 1 million caregivers in California alone in 2020. Unpaid caregivers are providing an increasing proportion of the care needed, increasing by more than 20% since 2009.

Caregivers tend to be women (67%), married or living with the individual (60%), or providing care for a parent or in-law (50%). Female caregivers may experience slightly higher levels of burden, impaired mood, depression, and

impaired health than caregivers who are men, with evidence suggesting that these differences arise because female caregivers tend to spend more time caregiving, assume more caregiving tasks, and care for someone with more cognitive, functional, and/or behavioral problems. Of dementia caregivers who indicated a need for individual counseling or respite care, the large majority were women (individual counseling, 85%, and respite care, 84%).

Racial disparities of Alzheimer’s disease and related dementias (ADRD) mirror the disparities of other chronic diseases including hypertension, diabetes, and COPD. Older Black and Hispanic Americans are disproportionately more likely than older White Americans to have Alzheimer’s or other dementias.

A higher proportion of lower-income individuals and people of color are cared for at home rather than in congregate settings. BIPOC caregivers are less likely to use respite services and indicate greater care demands, less outside help/ formal service use, and greater depression when compared with white caregivers.

As those afflicted with dementia can live with the disease for four to 20 years, the slow, insidious, and uncertain progression of the disease can take a substantial toll on caregivers.

Health and Economic Impacts of Alzheimer’s Caregiving Caring for a person with Alzheimer’s or another dementia poses special challenges. For example, people in the moderate to severe stages of Alzheimer’s dementia experience losses in judgment, orientation, and the ability to understand and communicate effectively. Family caregivers must often help people with Alzheimer’s manage these issues. The personality and behavior of a person with Alzheimer’s are often affected as well, and these changes are among the most challenging for family caregivers.

Individuals also require increasing levels of supervision and personal care as the disease progresses, and caregivers can experience increased emotional stress and depression; new or exacerbated health problems; and depleted income and finances due in part to disruptions in employment and paying for healthcare

SA NDIEGOPH SanDiegoPhysician.org YSICI A N.ORG 7

Steps to Support Caregivers 1. Understand the multitude of impacts borne by caregivers.

2. Include caregivers as a member of the care team by identifying who they are, including them in appointments and conversations with the patient, and documenting their presence at visits and contact information in the patient’s medical record.

3. Utilize a care team approach with social workers, nurse practitioners, and other members of your office staff. Make referrals to palliative care teams as appropriate.

4. Assess and address the caregiver’s physical and mental health, wellbeing, capacity and willingness to be a caregiver, and any unmet needs.

5. Be familiar with care options, system supports, and community resources, and address caregiver needs via referral to appropriate services, including medical consultation, disease education resources, and online and community resources.

6. Create care plans for both patient and caregiver that are matched to their needs and reflect goals of care and advance care planning.

7. Train caregivers on behaviors as a form of communication, particularly as the patient’s ability to communicate verbally diminishes.

8. Add information to EHR to track progress and to make use of appropriate billing

codes.

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or other services for themselves and the people living with dementia.

Caregiver Emotional and Social Wellbeing The intimacy, shared experiences, and memories that are often part of the relationship between a caregiver and the person living with dementia may be threatened due to the memory loss, functional impairment, and psychiatric/behavioral disturbances that can accompany the progression of ADRD. Although many caregivers report positive feelings about caregiving, such as family togetherness and the satisfaction of helping others, they also frequently report higher levels of stress. It is important to emphasize to

caregivers the importance of self-care to meet their own emotional and social needs. Spousal dementia caregivers are more likely than non-spousal caregivers to experience an increased burden over time, particularly when the loved one experiences behavioral changes and decreased functional ability.

Depression and Mental Health Caregivers of people with dementia were significantly (30% to 40%) more likely to experience depression and anxiety than non-caregivers. Dementia caregivers often lack the information or resources necessary to manage growing demands. More than half of women with children under age 18 felt that caregiv-

ing was more challenging than caring for children; 59% of caregivers felt they were “on duty” 24 hours a day, and many felt that caregiving during this time was extremely stressful.

For some caregivers, the demands of caregiving may cause declines in their own health. Evidence suggests that the stress of providing dementia care increases caregivers’ susceptibility to disease and health complications, negatively influences the quality of caregiver’s sleep, and lowers the healthrelated quality of life. Eighteen percent of spousal caregivers die before their partners with dementia.

Appropriate Interventions Through Stages of the Disease Providers can suggest interventions to improve the health and wellbeing of dementia caregivers by relieving the negative aspects of caregiving. These may delay admission of the person with dementia to long-term care facilities by providing caregivers with skills and resources (emotional, social, psychological, and/or technological). Specific approaches used in various interventions include: • Psychoeducational approaches: caregivers learning about disease and caregiving • Case management and/or counseling • Support groups and other social supports • Respite • Self-care: exercise, personal care, nutrition • Consideration of medication for behavioral management If caregiver needs are unmet, chances are much higher that your patient’s needs will be unmet as well. Community resources, as well as resources available through the provider’s health system should be recommended. The Alzheimer’s Clinical Roundtable website provides handouts for caregivers.

Caregiver Tips sheets and other resources are available at ChampionsforHealth.org/alzheimers.

Dr. Panzer is the chief medical officer emeritus of The Elizabeth Hospice, chair of the San Diego Dementia Consortium, and chair of the Alzheimer’s Project Caregiver Support and Education Committee. He has been a member of SDCMS since 2003.

PLACE YOUR AD HERE Contact Jennifer Rohr at (858) 437-3476 or Jennifer.Rohr@SDCMS.org

SA NDIEGOPH YSICI A N.ORG

9

COVID-19

COVID in Kids Under 5 May Look Like Croup, Pediatricians Warn Barking Cough May Be Specific to Omicron

BY KARA GRANT

C

HILDREN UNDER 5 YEARS

old infected with the omicron variant of COVID-19 are presenting with symptoms of croup, an upper airway infection that causes a barking cough, pediatricians have recently reported.

Croup isn’t an uncommon diagnosis in kids ages 6 months to 3 years, and most cases are mild and treatable. With omicron impacting young, vaccine-ineligible children at high rates — especially in comparison to previous strains of the virus — pediatricians are noticing an increase in patients with croup-like symptoms who test positive for COVID-19.

Experts suspect that this overlap could be omicron-specific. Early evidence has shown that this variant infects the upper respiratory tract and has a harder time getting into the lungs, unlike previous variants.

Eric Ball, MD, a pediatrician at Children’s Health Orange County in Southern California, told MedPage Today that COVID-19 cases started to spike in his young patients just before Christmas. His older, vaccinated patients generally come in with mild symptoms, he says. But for children under 5, the disease appears to be more serious.

“Croup is one of many things that we are seeing these kids present with,” Dr. Ball explains. “But, as a general rule, the people who have not had vaccines, which largely are the little children, are getting sicker than the people who have been vaccinated and have some protection against COVID.” 10

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Dr. Ball admitted more children to the hospital for COVID-19 in the first weeks of 2022 than he did for all of 2021.

As of Jan. 10, he said he was on his sixth admission.

This increase in hospital admissions for COVID-positive children with symptoms of croup has also been seen at Children’s Hospital Los Angeles (CHLA).

“In general, we don’t get a lot of hospitalizations for croup. It’s something that usually we can manage in the emergency [department] and we might have a handful of hospitalizations,” Susan Wu, MD, a pediatric hospitalist at CHLA, told MedPage Today. “But I have seen several patients admitted with croup due to COVID in the last couple of weeks. ... That is unusual.”

Omicron may look like croup in young kids because of how similar the symptoms are: barky cough, difficulty breathing, often a fever, she notes. For Wu and other pediatricians, recognizing that croup can be a possible symptom of COVID is crucial; a heightened awareness of this may urge parents to take more caution, potentially preventing the spread of COVID-19 to other young children, grandparents, or immunocompromised family members.

With many schools returning to inperson learning this month, Dr. Wu says she is preparing to treat more pediatric COVID cases.

“We know that [the Los Angeles Unified School District] has robust policies regarding vaccinations and masking, but we know omicron is very contagious,” she says. “So we’ve remained ready to take care of any additional kids that may become infected with the opening.”

In an interview, Daniel Rauch, MD,

chief of pediatric hospital medicine at Tufts Children’s Hospital in Boston, pointed out an especially odd development: Many kids with COVID who are over the typical croup age are presenting with croup-like symptoms.

“It’s unusual just because of the physics of it. The airway is bigger, so you don’t typically see croup in older kids,” Dr. Rauch told MedPage Today. “So, it was a little surprising that we had a couple of kids hospitalized with croupy symptoms in that age group who turned out to have COVID.” At the end of December, a patient as old as 9 came in with croup and then tested positive for COVID, he says, noting that he was unable to confirm if the patients over 5 with croup were vaccinated.

Aaron Milstone, MD, a pediatric infectious disease expert at Johns Hopkins University School of Medicine in Baltimore, said it’s too early to tell whether the presentation of croup in kids with COVID is unique to omicron — but he believes that it is.

“There are two options: one is that this variant is different, and it’s affecting the respiratory tract of kids differently. And the other option is that earlier variants may have also caused croup, but there just weren’t as many pediatric cases of COVID so it didn’t get brought to people’s attention,” Dr. Milstone says.

“But I think it’s more likely that omicron is different, and this is a variant-specific presentation.”

Kara Grant is on the Enterprise & Investigative Reporting team at MedPage Today, where this story first appeared. She covers psychiatry, mental health, and medical education.

VACCINES COVID-19

CDC Tells Pharmacies to Give 4th COVID Shots to Immunocompromised Patients

BY LIZ SZABO

T

HE CENTERS FOR DISEASE

Control and Prevention reached out to pharmacists to reinforce the message that people with moderate to severe immune suppression are eligible for fourth COVID shots.

The conference call came a day after KHN reported that immunocompromised people were being turned away by pharmacy employees unfamiliar with the latest CDC guidelines.

White House chief of staff Ron Klain tweeted that “immune-compromised people should get the shots they need,” adding that the CDC “is going to send stronger messages to pharmacies to make sure this happens.”

Pharmacists who joined the call said it took place a few hours after Klain’s tweet.

The CDC “reiterated the recommendations, running through case examples,” says Mitchel Rothholz, chief of governance and state affiliates for the American Pharmacists Association, who joined the CDC call.

Rothholz says he “asked for a prepared document … that clearly laid out the recommendations … so we can clearly and consistently communicate the message.

They said they would but don’t know how long that will take.”

The CDC recommends one additional shot for the 7 million American adults whose weak immune systems make them more vulnerable to COVID infection and death. This group includes people with medical conditions that impair their immune response to infection, as well as people who take immune-suppressing drugs because of organ transplants, cancer, or autoimmune diseases.

Although people with obesity or diabetes are at high risk of developing severe disease or dying from COVID, they’re not considered immunocompromised.

For other people ages 5 or older, the CDC recommends a primary vaccine series of two doses of mRNA vaccine.

Adults also may receive the one-dose Johnson & Johnson vaccine, which the CDC says may be safer for people who have had a severe allergic reaction to an mRNA vaccine.

Anyone older than 12 can get one booster dose to combat waning immunity five months after the last shot in their primary series, regardless of which vaccine they received. Vaccines are not yet

authorized for children younger than 5.

The CDC first recommended fourth shots for immunocompromised people in October. The agency has been working to educate pharmacists and other health providers since then, says CDC spokesperson Kristen Nordlund. Those efforts included a conference call with health officials from every state that had thousands of participants, as well as an additional call to physicians. The CDC has streamlined its website with booster advice several times. In its guidance to pharmacists, the CDC notes that patients don’t need to provide proof that they are immunocompromised.

Alyson Smith, who was turned away from a Walgreens drugstore after booking a vaccine appointment online, says she was pleased that the CDC is trying to help.

“I appreciate that the CDC is listening to patient and physician concerns and hope they will examine their processes for clear messaging and comprehensive dissemination of information,” Smith says.

In a statement before the publication of KHN’s first story, Walgreens said it continuously updates its pharmacists on new vaccine guidance.

Some healthcare leaders said the CDC should have done a better job of publicizing its advice on booster shots for the immunocompromised.

The call with pharmacists “should have been done many weeks ago,” says Dr. Eric Topol, founder and director of the Scripps Research Translational Institute.

“I’m glad that the White House team is finally pushing forward on this.”

Dr. Ameet Kini, a professor of pathology and laboratory medicine at Loyola University Chicago Stritch School of Medicine, says he hopes the large pharmacies that have been turning people away will issue news releases and update their websites “explicitly stating that they are offering fourth doses” to immunocompromised people. He says pharmacies also need to update their patient portals and provide “clear guidance for their pharmacists.”

Liz Szabo is a senior correspondent and enterprise reporter for Kaiser Health News, where this article first appeared.

She focuses on the quality of patient care and has covered medicine for two decades.

SA NDIEGOPH YSICI A N.ORG

11

COVID-19

Biden Administration’s Rapid-Test Rollout Doesn’t Easily Reach Those Who Need It Most

BY HANNAH RECHT AND VICTORIA KNIGHT

R

ECENTLY, THE BIDEN

administration launched two programs that aim to get rapid COVID tests into the hands of every American. But the design of both efforts disadvantages people who already face the greatest barriers to testing.

From the limit placed on test orders to the languages available on websites, the programs stand to leave out many people who don’t speak English or don’t have internet access, as well as those who live in multifamily households. All these barriers are more common for non-white 12

FEBRUA RY 2022

Americans, who have also been hit hardest by COVID. The White House told KHN it will address these problems but did not give specifics.

It launched a federally run website on Jan. 18 where people can order free tests sent directly to their homes. But there is a four-test limit per household. Many homes could quickly exceed their allotments — more than a third of Hispanic Americans plus about a quarter of Asian and Black Americans live in households with at least five residents, according to an analysis of Census Bureau data by

KFF. Only 17% of white Americans live in these larger groups.

“There are challenges that they have to work on for sure,” says Dr. Georges Benjamin, executive director of the American Public Health Association.

Also, as of Jan. 15, the federal government requires private insurers to reimburse consumers who purchase rapid tests.

When the federal website — with orders fulfilled and shipped through the United States Postal Service — went live this week, the first wave of sign-ups exposed serious issues.

Some people who live in multifamily residences, such as condos, dorms, and houses sectioned off into apartments, reported on social media that if one resident had already ordered tests to their address, the website didn’t allow for a second person to place an order.

“They’re going to have to figure out how to resolve it when you have multiple families living in the same dwelling and each member of the family needs at least one test. I don’t know the answer to that yet,” Benjamin says.

USPS spokesperson David Partenheimer says that while this seems to be a problem for only a small share of orders, people who encounter the issue should file a service request or contact the help desk at 1-800-ASK-USPS. A White House official said 20% of shipments will be directed every day to people who live in vulnerable ZIP codes, as determined by the Centers for Disease Control and Prevention’s social vulnerability index, which identifies communities most in need of resources.

Another potential obstacle: Currently, only those with access to the internet can order the free rapid tests directly to their homes. Although some people can access the website on smartphones, the onlineonly access could still exclude millions of Americans: 27% of Native American households and 20% of Black households don’t have an internet subscription, according to a KHN analysis of Census Bureau data.

The federal website is currently available only in English, Spanish, and Chinese.

According to the White House, a phone

line is also being launched to ease these types of issues. An aide said it is expected to be up and running by Jan. 21. But details are pending about the hours it will operate and whether translators will be available for people who don’t speak English.

However, the website is reaching one group left behind in the initial vaccine rollout: blind and low-vision Americans who use screen-reading technology. Jared Smith, associate director of WebAIM, a nonprofit web accessibility organization, says the federal site “is very accessible. I see only a very few minor nitpicky things I might tweak.”

The Biden administration emphasized that people have options beyond the rapid-testing website. There are free federal testing locations, for instance, as well as testing capacity at homeless shelters and other congregate settings.

Many Americans with private health plans could get help with the cost of tests from the Biden administration reimbursement directive. In the days since its unveiling, insurers said they have moved quickly to implement the federal requirements. But the new systems have proved difficult to navigate.

Consumers can obtain rapid tests — up to eight a month are covered — at retail stores and pharmacies. If the store is part of their health plan’s rapid-test network, the test is free. If not, they can buy it and seek reimbursement.

The program does not cover the 61 million beneficiaries who get healthcare through Medicare, or the estimated 31 million people who are uninsured.

Medicaid and the Children’s Health Insurance Program are required to cover at-home rapid tests, but rules for those programs vary by state.

And the steps involved are complicated.

First, consumers must figure out which retailers are partnering with their health plans and then pick up the tests at the pharmacy counter. As of Jan. 19, however, only a few insurance companies had set up that direct-purchase option — and nearly all the major participating pharmacies were sold out of eligible rapid tests.

Instead, Americans are left to track down and buy rapid tests on their own and then send receipts to their insurance providers.

Many of the country’s largest insurance companies provide paper forms that customers must print, fill out, and

mail along with a receipt and copy of the box’s product code. Only a few, including UnitedHealthcare and Anthem, have online submission options. Highmark, one of the largest Blue Cross and Blue Shield affiliates, for instance, has 16-step instructions for its online submission process that involves printing out a PDF form, signing it, and scanning and uploading it to its portal.

Nearly 1 in 4 households don’t own a desktop or laptop computer, according to the Census Bureau. Half of U.S. households where no adults speak English don’t have computers.

A KHN reporter checked the websites of several top private insurers and didn’t find information from any of them on alternatives for customers who don’t have computers, don’t speak English, or are unable to access the forms due to disabilities.

UnitedHealthcare and CareFirst spokespeople said that members can call their customer service lines for help with translation or submitting receipts. Several other major insurance companies did not respond to questions.

Once people make it through the submission process, the waiting begins. A month or more after a claim is processed, most insurers send a check in the mail covering the costs.

And that leads to another wrinkle.

Not everyone can easily deposit a check.

About 1 in 7 Black and 1 in 8 Hispanic households don’t have checking or savings accounts, compared with 1 in 40 white households, according to a federal report. Disabled Americans are also especially likely to be “unbanked.” They would have to pay high fees at checkcashing shops to claim their money.

“It’s critically important that we are getting testing out, but there are limitations with this program,” says Dr. Utibe Essien, an assistant professor of medicine at the University of Pittsburgh School of Medicine. “These challenges around getting tests to individuals with language barriers or who are homeless are sadly the same drivers of disparities that we see with other health conditions.”

Hannah Recht is a data reporter at KHN, where this article first appeared. Victoria Knight is a KHN reporter covering a wide range of healthcare issues from Washington, DC.

SA NDIEGOPH YSICI A N.ORG

13

COVID-19

I’m Over COVID Symptoms, but Still Testing Positive. Am I Infectious?

Infectiousness May Linger Beyond the 5-day Isolation Period Recommended by the CDC BY JENNIFER HENDERSON

A

S HIGH LEVELS OF COVID-19

transmission persist, people continue to wonder how long they should isolate after learning they’re infected.

One especially perplexing predicament is what to do when you continue to see positive results on a rapid antigen test, but it’s been five days (or more) and your symptoms have resolved. So, what could cause someone to continue to test positive?

It may be due to weakened virus that continues to replicate, Benjamin tenOever,

14

FEBRUA RY 2022

PhD, a microbiologist at NYU Grossman School of Medicine, told MedPage Today.

It may also happen as a result of broken virus genomes.

Because the omicron variant tends to stay localized in the upper respiratory tract, especially in those who are vaccinated and boosted, that may lead to more nucleocapsid protein in the back of the throat and nose, he says. And broken virus genomes can remain present after viruses make bad versions of themselves.

“If you are testing antigen positive, you should assume a low level of virus infection,” tenOever says. “You are possibly

transmissible.” This possibility may be difficult to grapple with on the heels of recently updated guidance from the CDC. In December, the CDC announced that those testing positive for COVID-19 could isolate for just five days if they are asymptomatic, down from a previous recommendation of 10 days. Though the CDC has since clarified that rapid antigen testing toward the end of that period is the best approach, the agency hasn’t directed people to seek it out.

This approach differs from that of the U.K., which recently updated its own guidance to say that people can stop isolating after five days only if they have two negative rapid antigen tests taken on consecutive days.

The first test should not be taken before the fifth day after symptoms have started (or the day a test was taken if symptoms were not present), the U.K. Health Security Agency states. The isolation period remains 10 days for people without negative results from two tests on consecutive days.

The CDC notes that the reduced isolation period was prompted by data that suggest most transmission “occurs early in the course of illness, generally in the one to two days prior to onset of symptoms and the two to three days after.”

A paper published in The Lancet in December, and cited by CDC in its updated guidance, found that “[e]vidence from 113 studies done in 17 countries shows that SARS-CoV-2 viral RNA can be detected as early as six days before symptom onset, concentrations peak around the time of symptom onset or a few days later, and it usually becomes undetectable from upper respiratory tract samples about two weeks after symptom onset, and with no

substantial differences between adults and children.”

These studies suggest that “the mean period of infectiousness and risk of transmission could be restricted to the period between two and three days before and eight days after symptom onset.”

However, these data predate the omicron surge. And the CDC’s latest approach to isolation isn’t foolproof.

A new study from Harvard University that looked at a small number of cases from the National Basketball Association’s COVID-19 testing program found that more than half of omicron cases identified within a day of a previous negative test were still infectious five days after a first positive test, dipping to 25% on day six and 13% on day seven. The study — which was not peer-reviewed — used PCR testing.

Isolation periods, testing out of them, and the possibility of lingering infectiousness are definitely being discussed in medical circles, Geoffrey Baird, MD,

One especially perplexing predicament is what to do when you continue to see positive results on a rapid antigen test, but it’s been five days (or more) and your symptoms have resolved.

PhD, chair of the department of laboratory medicine and pathology at the University of Washington School of Medicine in Seattle, told MedPage Today.

This is especially relevant when it comes to staffing shortages that are occurring across the country.

Overall, the question of “what is the

real value of the test on any one specific day” persists, Baird says. “This is the challenge of doing public health.”

It’s about striking a balance between what is “medically right and accepted by the population,” he adds.

Ultimately, the country will need to determine how it will use rapid antigen tests going forward and whether that includes testing out of isolation, he says.

The percentage of people that would continue to test positive days or even weeks after their symptoms have subsided is likely very limited, tenOever points out. If it is well beyond 10 days and you are still testing positive, seeking out further medical advice or evaluation may be warranted.

Jennifer Henderson is an enterprise and investigative writer for MedPage Today, where this article first appeared. She has covered the healthcare industry in New York City, life sciences, and the business of law, among other areas.

PLACE YOUR AD HERE FEBRUARY 2020

Official Publication of SDCMS

Celebrating 150 Years

MARCH 2020

Official Publication of SDCMS

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

Artificial Intelligence and Medicine THE DEBATE

PREVENTION DIABETES Reversing the Risks

DEMENTIA Reducing the Burden How to Engaging Patients GUN SAFETY

BUILD TRUST

Seeking FM/DO/IM/ Psychiatrist in San Diego County

BREAST CANCER Preventing Deaths

in 15-Minute Office Visits

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

Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic.

Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred.

Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

www.vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled

SA NDIEGOPH YSICI A N.ORG

15

PHARMACEUTICAL PRICES

Neurologists Are Actively Working to Reduce High Drug Costs I’ve Personally Witnessed the Consequences of Medication Inaccessibility BY ORLY AVITZUR, MD, MBA

16

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T

HE COST OF LIFESAVING medications in the U.S. is far too high — a situation which has become increasingly alarming over time. Nearly one in four Americans has difficulty paying for their prescription drugs, and as a neurologist, I’ve personally witnessed the consequences of this unfold in my own practice.

Nearly all my patients with chronic conditions have stories about their struggles to afford medications and, sadly, some end up abandoning them at their pharmacies due to the cost. Others must endure longstanding battles with insurers who put up barriers to accessing medications, especially high-cost specialty drugs. At the same time, we also

have witnessed new, remarkably effective breakthrough therapies for neurologic conditions such as migraine and spinal muscular atrophy, but each costs tens to hundreds of thousands of dollars — in one case, millions of dollars.

In the world of neurology, one of the most prominent examples of high prescription drug costs is for diseasemodifying therapy for multiple sclerosis (MS) — the list price often approaches $100,000 per year. Despite having many treatments that compete in this market, including some that have been available for more than 20 years, annual costs for disease-modifying therapies in MS continue to rise. I’ve also watched as companies buy up therapies that are essential and then raise the price to

astronomical levels, as was the case with amifampridine (Firdapse), which went from being widely available for free to costing $375,000 overnight, prompting a rebuke from Sen. Bernie Sanders (I-Vt.).

This trend is unsustainable for people who rely on these medications and for the healthcare system overall, which pays more than double compared to other similar nations on average.

It is for these reasons that the American Academy of Neurology (AAN) has made lowering the costs of prescription medications a top priority. In support of this goal, over the last five years we have advocated empowering Medicare to directly negotiate drug prices; requiring transparency in how drugs are priced; and encouraging strong oversight by the key committees in Congress. We also have fought arbitrary barriers employed by insurers that restrict patients’ access to life-saving therapies — like fail-first step therapy policies — that often arbitrarily deny care and create roadblocks to providing the best evidence-based care for our patients.

Thousands of our member neurologists and neuroscience professionals have contacted Congress and the administration over the years in support of these goals, often to share stories about the unique impact of high drug costs on their patients. The AAN has joined coalitions such as the Campaign for Sustainable Rx Pricing, which is dedicated specifically to addressing this issue. We have also collaborated with Patients for Affordable Drugs, which is a leader in shaping the national debate on this issue.

To support these aims, the AAN has advocated for numerous pieces of legislation over the years, offered by both Democrats and Republicans. The most recent and prominent example was endorsing several provisions within the Build Back Better Act (BBBA). Specifically, the AAN supported provisions that would permit Medicare to directly negotiate prescription drug prices for the first time, limit excessive annual increases in drug prices that outpace inflation, and create an out-of-pocket spending maximum of $2,000. We believe these provisions would significantly improve patient access to therapies.

The recent opinion piece on MedPage Today by Milton Packer, MD, “Why Are Physicians Silent About Outrageous Drug Prices?” advocated for strong physician involvement in drug pricing. We agree and have been vocal activists in this effort. The AAN’s endorsement of the BBBA provisions was only one of many actions we have taken to lower the costs of prescription drug prices. However, Packer implied that the Academy was more focused on avoiding reductions in physician reimbursement related to drugs than on wanting to lower the costs of prescription medications. This assessment misses the bigger picture of the Academy’s approach for two reasons.

First, the AAN and many of its members individually have a long history of advocacy on reducing drug prices unrelated to physician payments, as outlined in this piece. Second, Packer’s perspective discounts the financial realities of a medical practice and the nuances of the AAN’s position. The AAN has stated that we are eager to find a way to realign incentives away from higher-priced physician-administered medications, but we believe this needs to be addressed separately from the larger BBBA negotiations to ensure that access to life-saving therapies is not disrupted. Two prior attempts, from two different administrations, at reforming the reimbursement system for physician-administered drugs have failed. This is not an easy issue, and in our view, finding a better way requires developing creative solutions through stakeholder collaboration conducted through regular order in Congress.

The time is upon us to lower prescription drug prices. It is essential that Congress act to ensure that Americans have access to critical therapies, and the AAN will continue to work to support these efforts to ensure that our patients have the best care possible.

Dr. Avitzur is the current president of the American Academy of Neurology (AAN) and the immediate past chair of the AAN Medical Economics and Practice Management Committee. She is also the current editor-in-chief of the patient and caregiver magazine Brain & Life. This opinion piece first appeared in MedPage Today.

SA NDIEGOPH YSICI A N.ORG

17

CHAMPIONS FOR HEALTH

Freedom, Finally

BY ADAMA DYONIZIAK

I

MAGINE NINE YEARS OF

abdominal pain and hemorrhaging so severe that your loved one is in the emergency room every two weeks. Your wife or sister or mother needs surgery, but is told time and again that emergency MediCal does not cover the expensive procedure that your family can’t afford. She uses over-the-counter pain medication and hot water bottles, but the pain, hemorrhaging, and severe blood loss persists from an ever-growing cyst. This is Gloria’s story.

Gloria struggled to find a stable job, but most jobs would hurt her physically.

The pain made her feel out of control and depressed. Her illness affected the entire family, never knowing when they would need to rush Gloria to the hospital.

“It took a bit away from each of us. She is suffering and we are also suffering,” says her husband, Charlie.

“I could not be at the birth of my two grandchildren,” Gloria recalls. One hospital visit for pneumonia led her to Dr. Globus at Volunteers in Medicine for follow-up. Gloria’s severe hemorrhaging frightened her family members, so Dr. Globus referred her to Project Access.

Evelyn Peñaloza, her Project Access Care Manager, scheduled her with Dr. Keerti Gurushanthaiah, an ob-gyn at IGO Medical Group.

Dr. Guru, as her patients call her, volunteered at a community clinic with uninsured patients early in her career, then eventually joined Project Access and was a board member of Champions for Health. The best part of her job is getting to know patients during their course of care, building relationships and making someone feel better. “The best thing about being an ob-gyn is making a difference in people’s lives,” Dr. Guru says.

Gloria says that from the first appointment, she knew “Dr. Guru is very caring, attentive, and humble — humble because at that moment, she, as a surgeon, was so willing to help someone like me, who felt like a nobody.” Before going into surgery, 18

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Dr. Guru asked Gloria if she was ready.

“I just started crying and told her thank you, because you cannot imagine what this means for me and my family,” Gloria recalls.

Gloria and Charlie speak about the difference in her life after surgery with one word: “freedom.”

“Project Access patients are so grateful after the surgery,” Dr. Guru says.

“They have gone through so much pain, exhaustion, and anemia that they feel amazing after the surgery and are beyond thankful after their recovery.”

“There is a huge rock lifted off us,” Gloria says. “I can stand up, I can do things, I can play with my grandkids, I have more energy!”

Gloria is thankful for everyone’s help: from the doctors and staff at Volunteers in Medicine to Evelyn’s calls, support, and encouragement. Gloria hopes “God will continue to bless Dr. Guru so that she can keep helping people because she gave me peace and tranquility.”

Dr. Guru, past chair of the Physician Recruitment Committee for Project Access, adds: “I would strongly encourage physicians to volunteer with Project Access. It is very easy to volunteer. Patients are ready for their appointment with all

Top: Project Access patient Gloria C. and her husband, Charlie C. Above: Keerti Gurushanthaiah, MD.

needed documentation, and your office just needs to schedule the appointment.

Volunteering with Project Access is a very rewarding experience.”

Gloria concurs. “I would like to ask for help for other doctors that can open their hearts and minds to donate more of their time, more for this program so that they can help people to have a better life like me now. Now I have better health and better opportunity.”

For more information about volunteering your talent to help give Project Access patients freedom from pain, contact us at www.championsforhealth.org.

Adama Dyoniziak is executive director of Champions for Health.

PSYCHIATRY ADHD

Autism and ADHD Carry Higher Risks of Mortality Some of the Risk for Mortality in Those With ASD May Arise From Its Link to ADHD Diagnosis

BY LEI LEI WU

P

EOPLE WITH AUTISM

spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) have a higher risk of mortality, according to a systematic review and meta-analysis.

All-cause mortality was more than doubled in people with ASD (rate ratio [RR] 2.37, 95% CI 1.97–2.85, I2 89%) and in those with ADHD (RR 2.13, 95% CI 1.13–4.02, I2 98%), reported Ferrán CataláLópez, PhD, of the Institute of Health Carlos III in Madrid, and colleagues.

Among those with ASD, deaths from natural causes were increased (RR 3.80, 95% CI 2.06–7.01, I2 96%), as were deaths from unnatural causes (RR 2.50, 95% CI 1.49–4.18, I2 95%). For those with ADHD, deaths from natural causes were not significantly increased, but deaths from unnatural causes were higher than expected (RR 2.81, 95% CI 1.73–4.55, I2 92%).

“This systematic review and metaanalysis comprehensively assess for the first time, to our knowledge, the available evidence regarding the risk of mortality in persons with ASD or ADHD,” the authors wrote in JAMA Pediatrics.

“Higher mortality rates have been documented in the field of ASD for longer than they have in the field of ADHD, owing to the well-established higher risks for drowning, pedestrian-auto crashes, suicide, seizure disorders, and other medical conditions associated with ASD that can lead to a shorter life expectancy,” wrote Russell Barkley, PhD, of Virginia Commonwealth University School of Medicine in Richmond, and Geraldine Dawson, PhD, of Duke University School of Medicine in Durham, North Carolina, in a corresponding editorial.

One study in Denmark found that individuals with ASD had three times higher

rates of attempted suicide and suicide compared with the general population, they noted. Other studies have also highlighted associations with substance use, eating disorders, and sleeping problems, among others.

ADHD itself is a comorbidity of ASD, Barkley and Dawson said. “It is possible that some of the risk for early mortality in individuals with ASD arises from its association with ADHD diagnosis.”

“The key message is that, in most cases, whether natural or unnatural, public health screening and prevention strategies could increase the lifespan and quality of life for individuals with these neurodevelopmental conditions,” they wrote. A recent randomized trial suggested that early intervention could reduce the severity of ASD symptoms in toddlers.

“Understanding the mechanisms of these associations may lead to targeted strategies to prevent avoidable deaths in high-risk groups of children and young people as an approach to improve public

health,” Catalá-López and team wrote.

They recommended that healthcare professionals routinely collect data on health outcomes related to ASD and ADHD. Primary care physicians need to become more aware of the connection between ASD and ADHD diagnosis and early mortality, Barkley and Dawson echoed.

This systematic review and meta-analysis included 27 observational studies with a total of 642,260 individuals from 1988 to 2021 that reported mortality rate ratios in people with ASD or ADHD compared with either the general population or a population with no ASD or ADHD. Fourteen studies on ASD included 206,162 participants, while 12 studies on ADHD included 433,761 participants. The median follow-up time for the studies was 16 years (range 3–33 years).

Females with ASD had higher mortality rates (RR 4.87, 95% CI 3.07–7.73, I2 91%) than males (RR 2.09, 95% CI 1.50–2.92, I2 94%). There were no such sex discrepancies in all-cause mortality for those with ADHD. “[These] results should be interpreted with caution because there was evidence of heterogeneity between study estimates of the mortality risks,” CataláLópez and colleagues noted. They also acknowledged that most of the included studies were from Western countries.

Lei Lei Wu is a staff writer for MedPage Today, where this article first appeared.

SA NDIEGOPH YSICI A N.ORG

19

PERSONAL AND PROFESSIONAL DEVELOPMENT

A Perfectly Human Family

BY HELANE FRONEK, MD, FACP, FACPH

A

T A RECENT MEMORIAL,

family members shared perspectives on the man’s life and his impact on them. “We had a perfectly human family,” one son remarked.

What is “a perfectly human family?” I wondered.

The patriarch was a strong-minded, brilliant man, used to being in charge.

With five independent, creative, and motivated children, interactions did not always appear “perfect.” And yet, the stories revealed a form of perfection we might learn from as we meet the challenges and demands of a medical career.

First, let’s consider what it means to be perfect. Many physicians believe there is a right and wrong way to practice — that perfect practice will prevent complications and keep patients. We feel we have failed when a complication occurs or a patient’s life ends. The irony is that complications are part of medicine and each patient eventually dies. In this way, we set ourselves up to feel inadequate.

Fortunately, an experience with one patient changed my view of perfection.

She was avidly dedicated to fitness, so when she developed a foot drop following a procedure, I felt devasted, thinking only of the loss she would suffer.

Instead, the injury caused her to spend more time with family, where she found a new sense of joy and connection. Her willingness to accept that her new reality enriched her life showed me that “perfection” is complex and often not what our profession considers perfect.

And what does it mean to be human?

While we share much, each human is unique. In this large family, differences in values, lifestyles, and goals abounded.

As each person shared their delight in living authentically as the unique 20

FEBRUA RY 2022

human they were, it reminded me that a common lament among physicians suffering from burnout is that they no longer feel valued as individuals. Instead, they are “providers” who are considered interchangeable and easily replaceable.

In fact, each physician brings a unique constellation of strengths, skills, and passions that we would be wise to value within our profession.

Finally, the concept of family. As individual preferences revealed themselves, the family found a way to encourage and celebrate their differences. Previous hurts were forgiven, and relationships grew in trust and closeness. Again, I

recall a patient whose son chose a life partner who seemingly disregarded everything my patient cared about. I recall her struggle, and how her love for her son and dedication to her family eventually bridged the chasm that separated them. We, too, can make space for the differences among us, encouraging each other’s authenticity and even finding appreciation for the ways in which these differences add texture and interest to our lives and to the care we provide.

By doing this, we create a family: a group of humans who celebrate our differences, appreciate that we share the privilege and challenges of being a doctor, and choose to encourage and care for each other. By transforming our profession into “a perfectly human family,” we would feel valued, understood, and supported by each other. That feels pretty perfect to me.

Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

CLASSIFIEDS PHYSICIAN OPPORTUNITIES

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

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.

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-medicine-rehabilitation. 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 Physi-

cian (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.

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

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.

OFFICE SPACE AVAILABLE – 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.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities.

This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory.

The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited.

Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego).

The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 2002426 EXT 1046 or at crubio@samahanhealth.org.

PRACTICE FOR SALE

OFFICE SPACE / REAL ESTATE AVAILABLE

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 SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959.

NON-PHYSICIAN POSITIONS AVAILABLE 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.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital

SA NDIEGOPH YSICI A N.ORG

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$5.95 | www.SanDiegoPhysician.org

PRSRT STD U.S. POSTAGE

San Diego County Medical Society 8690 Aero Drive, Suite 115-220 San Diego, CA 92123

PAID DENVER, CO PERMIT NO. 5377

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