March 2023

MARCH 2023

Official Publication of SDCMS

Dr. Lase Ajayi on Maternal Health Dr. Robert Hertzka on Politics & Medicine

San Diego Doctors in Action!

Dr. Helane Fronek on Personal & Professional Development

Dr. Daniel Bressler on Forgiveness

Celebrating Independent Physicians

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

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS. org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

Contents MARCH

VOLUME 110, NUMBER 3

FEATURES

4

Coming Together to Address Maternal Health Disparities

By Lase Ajayi, MD, FAAP

4

6

Political Action — and You — Are Vital to Protecting Physician and Patient Rights

By Robert Hertzka, MD

DEPARTMENTS

2

Briefly Noted: SDCMS Membership • Maternal Health • Public Policy

8

The Magic of Blue Ice

By Helane Fronek, MD, FACP, FASLVM, FAMWA

9

Regrets, Reckoning, and Forgiveness

By Daniel J. Bressler, MD, FACP

10

FDA Experts Are Still Puzzled Over Who Should Get Which COVID Shots and When

By Arthur Allen

16

12

Flu, RSV, or COVID-19?

By Debra Kane Hill, MBA, RN

14

More Californians Are Dying at Home. Another COVID ‘New Normal’?

By Phillip Reese

16

Here’s Why Experts Are Concerned About Bird Flu

By Kristina Fiore

18

Higher Rates of Staph Infection for Hispanics on Dialysis, CDC Says

By Joyce Frieden

20

Giving Your Best

By Adama Dyoniziak

21

Classifieds SANDIEGOPHYSICIAN .ORG

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BRIEFLY NOTED 2

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MATERNAL HEALTH SDCMS MEMBERSHIP

Holly Yang Assumes Presidency of American Academy of Hospice and Palliative Care CONGRATULATIONS

to San Diego’s own Dr. Holly B. Yang, a former SDCMS president, who assumes the presidency of the American Academy of Hospice and Palliative Care (AAHPM) this month.

“Nearly 5,500 physicians, nurses, and healthcare professionals interested in the specialty of hospice and palliative medicine represent AAHPM membership,” AAHPM’s website states. “Members work in a variety of urban, rural, and suburban healthcare settings, including hospitals, hospices, managed-care facilities, and academic institutions, with varied patient populations — from pediatrics to geriatrics. The majority of the Academy’s physician members specialize in family and internal medicine.”

Since 1988, AAHPM has dedicated itself to advancing hospice and palliative medicine and improving the care of patients with serious illness. Its activities focus on education and training, resources, networking, and advocacy.

Its core mission is “to advance hospice and palliative medicine through enhancing learning, cultivating knowledge and innovation, strengthening the workforce, and advocating for public policy to achieve our vision. The core vision of the Academy is that all patients, families and caregivers who need it will have access to high-quality hospice and palliative care.”

Dr. Yang has distinguished herself in San Diego, then California, and now nationally as a healthcare leader who is a relentless advocate for patients and physicians. She has proven herself as a force to be reckoned with in SDCMS, the California Medical Association, and the American Medical Association.

San Diego County Board of Supervisors Recognizes Maternal Health Awareness Day ON JAN. 24, THE SAN DIEGO

County Board of Supervisors, led

by Chair Nora Vargas and Supervisor Terra Lawson-Remer, recognized Maternal Health Awareness Day. In attendance was SDCMS President Dr. Lase Ajayi and Past President Dr. Holly B. Yang, along with members of the PowerMom research team.

Dr. Ajayi is a leader in researching and working to overcome disparities in maternal healthcare.

The first step is awareness, and increasing numbers of healthcare professionals and government leaders are beginning to see this serious issue and seek to improve maternal healthcare for all communities. We thank the board for the recognition and Dr. Ajayi, Dr. Yang, and PowerMom Scripps for their efforts on this important matter. Please read the related article by Dr. Ajayi on maternal health and the PowerMom research team on page 4.

The San Diego County Board of Supervisors, led

by Board Chair Nora Vargas and Supervisor Terra Lawson-Remer, recently recognized Maternal Health Day. SDCMS President Lase Ajayi, MD and former President Holly B. Yang, MD joined them for the presentation.

PUBLIC POLICY

Hertzka and Hegyi Lead Delegation of Med Students to Sacramento SAN DIEGO COUNTY MEDICAL SOCIETY LEGISLATIVE COMMITTEE Chair Robert Hertzka, MD and SDCMS CEO Paul Hegyi, MBA, for the first time in three years led a delegation of San Diego medical students who are SDCMS members to visit key state legislators in Sacramento. They had a very successful trip and were able to meet with Assemblymembers David Alvarez, Akilah Weber, MD, Tasha Boerner Horvath, and Chris Ward, as well as Assemblymember Jasmeet Bains, MD, Assembly Health Committee Chair Jim Wood, and Assembly Speaker Anthony Rendon.

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3

MATERNAL HEALTH

COMING TOGETHER TO ADDRESS MATERNAL HEALTH DISPARITIES

By Lase Ajayi, MD, FAAP MATERNAL HEALTH IS IN A STATE OF CRISIS in the United States. Maternal mortality has been steadily increasing since 1997. Despite a brief plateau phase in 2008, it continues to increase to present day. This mortality rate is particularly pronounced in non-Hispanic blacks, and Indian/ Alaskan Natives. There are many factors driving the inequity in care. They include access and coverage gaps, social determinants of health, and structural racism. In some cases, women don’t have a way to physically get the proper care they need. For example, facilities equipped to care for them simply don’t exist where they live. Consider these factors, along with implicit biases of caregivers and a systemic lack of cultural competency. With this, we can see why the system is failing women of color far more than their white counterparts.

Many women express fear of advocating for themselves.

They feel that they do not have the power to make decisions about their pregnancy. There is also mistrust between patient and doctor. It is layered in race, class, education, and lived experiences. Certainly, this creates a dynamic that can prove dangerous for Black women and their babies.

These are big problems that cannot be solved overnight, or with one singular approach. It will take open sharing of information, wide partnership, and more creative thinking.

The PowerMom research team is approaching this challenge through innovation, crowdsourcing, and community outreach. PowerMom is an app-based research platform 4

MARCH 202 3

that allows pregnant people to share health data through surveys, electronic health records, and wearables. By involving pregnant people from diverse communities throughout the United States, PowerMom aims to help achieve equity in maternity care — for all pregnant people. PowerMom is committed to uncovering patterns in healthy pregnancies.

We are working together with community organizations, advocacy groups, healthcare institutions, technology companies, payers and many others to discover answers to questions moms (and soon-to-be-moms) have about their bodies and their growing babies.

Some of these questions include: — How does healthcare access in different parts of the country influence health outcomes?

What preexisting conditions lead to early birth?

— How does the support pregnant people receive influence mood disorders and postpartum depression across a diverse population?

One solution is not enough. One organization cannot fix the system alone. We know that without a commitment to partnership, we will never see change. Without reaching out and working directly with the people affected by these outcomes, we won’t make progress.

Dr. Ajayi is a San Diego pediatrician, palliative care physician, and the president of SDCMS. She is a faculty member and director of clinical research at the Scripps Research Translational Institute, where she is the lead researcher on PowerMom.

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CALIFORNIA POLITICS AND PUBLIC POLICY

POLITICAL ACTION — AND YOU — ARE VITAL TO PROTECTING PHYSICIAN AND PATIENT RIGHTS

By Robert Hertzka, MD

From left to right, California Insurance Commissioner Ricardo Lara, Dr. Robert Hertzka, California Senate President Pro Tem Toni Atkins, and San Diego Mayor Todd Gloria.

EVERY YEAR THERE ARE LITERALLY THOUSANDS of bills introduced in the California Legislature, hundreds of which are tracked by the California Medical Association (CMA). The results of our efforts to support physician and patient-friendly legislation and oppose unfriendly legislation is written about in the pages of San Diego Physician just about every year. Many refer to this as the legislative scorecard of wins and losses.

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But even more important than all of that legislation are the actual legislators who vote on them. Politics may seem complex, and it can be, but the simple fact is that from the perspective of physicians and our patients, there are just two types of legislators. And those two types are not Democrats or Republicans, or liberals and conservatives.

From our perspective, there are legislators who see that there are problems in healthcare that need to be addressed, and from a combination of their life experiences and their gut feelings, they believe that physicians are going to be part of the solution to the problems in healthcare. And on the other side of the equation, there are those whose life experiences and gut feelings tell them that physicians are the problem.

This makes for a simple equation: If we can work with legislators and develop relationships such that most of them believe that we are part of the “solution” rather than being part of the “problem,” we will be more successful on that legislative scorecard.

Creating and maintaining those legislative relationships is where your San Diego County Medical Society (SDCMS) Legislative Committee comes in. An assiduously bipartisan group, each of whom has made a multi-year commitment to this process, we meet and educate the serious candidates for office as they emerge, with the goal of ultimately making an endorsement decision that leads to contributions from CALPAC, CMA’s political action committee.

This is a process that we at SDCMS have taken seriously for decades, and it has certainly paid dividends. Candidates seek us out early in the process, as an endorsement from the physician community is a coveted goal whether you are a Democrat or a Republican. And that relationship-building

has also led to a much better legislative scorecard among San Diego legislators — both Democrat and Republican — than any other region of the state.

Currently we are represented by seven assemblymembers and four state senators, some of whom have districts that include parts of Orange or Riverside counties. Several have been in office for two years or more, while others, such as State Senators Catherine Blakespear (D-Encinitas) and Steve Padilla (D-Chula Vista) were just elected. As an example of our process, we began policy discussions with those two nowsenators back in March of 2021 (on COVID-lockdown-Zoom no less), and eventually, after multiple meetings with many of our committee members, we decided to endorse them — after which CALPAC made significant contributions to their campaigns. Both of these new state senators are far more knowledgeable about the issues that face physicians than they were back in March of 2021, and we look forward to both voting in a physician-favorable manner for many years.

California has strict term limits, and so we know when legislators will be “termed out” and create an open legislative seat. The candidates know this as well, which is why so many announce for the seats two years in advance. That was the case in 2022 for the two state senate seats that I just mentioned, and will be the case in 2024 for one more open state senate and two open state assembly seats. Notably, we started meeting with candidates for 2024 last October and are continuing this month as serious candidates in both parties are announcing.

Finally, I would be remiss if I did not note that other good things happened for physicians in the electoral process in 2021 and 2022. One was that a San Diego assembly seat opened up in early 2021 after the incumbent was appointed to be the California secretary of state. That seat was won by our own Akilah Weber, MD (D), who ran against a wellknown opponent backed by hundreds of thousands of campaign dollars from labor unions. Dr. Weber succeeded with a combination of her own skillful campaign along with the campaign dollars from the California Medical Association as her primary backer.

And in the Bakersfield area, another similar scenario played out as another one of our own, Jasmeet Bains, MD (D), also won an open state assembly seat. She faced off against an incumbent county supervisor who was also heavily supported by labor unions, but again, the combination of her skillful campaign combined with the financial contributions of CALPAC tipped the scales in her favor.

It is important for all of you to know that there are physicians out there who are educating all of the candidates and

Dr. Hertzka with Assemblymember Akilah Weber, MD.

succeeding in turning them into more physician-friendly ones. But to get these candidates into office, all of us need to both contribute to CALPAC and support local efforts that are supporting local physician-friendly candidates.

If you go to the website for the California Medical Association, under the Take Action section you can contribute to CALPAC (https://www.cmadocs.org/calpac) and at the Grassroots Action page (https://www.cmadocs.org/grassrootsaction-center) you can learn different ways to get involved both politically and legislatively.

If you have further questions or want to discuss becoming more politically involved with the San Diego County Medical Society and the California Medical Association, please contact SDCMS CEO Paul Hegyi at (858) 565-8888. Paul serves on the CALPAC Board and has more than 25 years of experience in California politics and public policy.

Dr. Hertzka is a past president of SDCMS and CMA, a twoterm past chair of CALPAC, a past chair of AMPAC, and a past chair of the AMA’s Health Policy Council. Recently retired from the clinical practice of anesthesiology after more than 35 years, he continues to serve as the chair of the SDCMS Legislative Committee, a role he has had since 1990. Dr. Hertzka has been a member of the California Medical Association for 43 years.

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7

PROFESSIONAL AND PERSONAL DEVELOPMENT

THE MAGIC OF BLUE ICE

By Helane Fronek, MD, FACP, FASVLM, FAMWA

STEPPING ONTO ONE of Antarctica’s many islands, we were stunned by the otherworldly array of icebergs sitting on the beach. Each shape was unique, as if a sculptor had spent hours intentionally creating its distinctive points and crevices. And while the beautiful shapes alone were awe-inspiring, what was most stunning was that many of them were blue.

Growing up in Wisconsin, I lived in snow and ice for years. Accustomed to seeing gray snow along roadways and yellow snow marking the routes of dogwalkers, I had never seen blue snow before. I stood transfixed, as my mind tried to reconcile something that seemed as if it shouldn’t exist. It made me wonder what else I miss in life because it falls outside my lived experience.

Our ability to completely block out what we don’t expect is humorously 8

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illustrated in a selective attention video by Simons and Chabris on YouTube, in which 50% of people fail to notice a person in a gorilla costume walking across a court while people pass basketballs to each other.

Our minds’ resistance to seeing anything it has not already experienced or is not expecting is not a trivial aspect of human nature. In fact, it underlies a lot of injustice and limits our appreciation of the variety in life.

When we develop an opinion of any group, we tend to see similar behavior in other members of the group, regardless of how they behave. This is how implicit bias forms.

After noticing a pattern of behavior in an individual, confirmation bias encourages us to interpret their future actions through the lens of what we have already witnessed. While biases can be useful by helping us quickly formu-

late ideas about patients, they can also impair our assessment and treatment. Well documented, inequitable medical treatment of the elderly, women, obese patients, people of color, and LGBTQ+ people stems from these biases, hindering our ability to provide the best care to each patient. On a broader scale, they contribute to injustices at every level of society.

While improving the appropriateness of patient care and reducing injustice are important goals, another reason to examine the effect of our expectations is that they limit our joy in life. Expecting each day to be the same prevents us from noticing moments of beauty, kindness, connection, and awe — experiences that make our lives feel worthwhile and special. Two simple practices can help us overcome these limitations. Concluding each day by asking what felt surprising or meaningful can help us remember experiences that can contribute to our experience of life as joyful, consequential or even sacred. And when we encounter a new situation, we can pause and ask, “What more do I notice?” In these ways, we can see past our expectations and appreciate more of what life has to offer. Like the beautiful, otherworldly experience of blue ice.

Dr. Fronek is an assistant professor of clinical medicine at UC San Diego School of Medicine and a Certified Physician Development Coach, CPCC, PCC. Dr. Fronek was a member of CMA for 21 years and is now an Active Retired Member.

PHYSICIAN WELLNESS

REGRETS, RECKONING, AND FORGIVENESS

By Daniel J. Bressler, MD, FACP

Without Regrets Looking at a year gone by This part struts, that part frets All of me keeps wondering why If I might live without regrets Staring through the sky’s expanse The endless blue and contrail jets I long to see our lives enhance And not crushed down by dark regrets

NO ONE CAN LIVE BOTH honestly and without regrets.

All of us fall short, make mistakes, do things we know we shouldn’t have done, or, conversely, don’t do things we know we should have. Any fair and thorough review of a year or even a day is bound to yield plenty of errors of omission and commission.

Yet, just as a basketball player aims at sinking every shot and a tennis player at placing every stroke, we, too, can imagine a kind of idealized life, so focused and aware that we get it right every time. Hah! Such a world exists only in our imagination.

Three processes serve to counterbalance regret: reckoning, perspective, and forgiveness.

With reckoning, we do hold ourselves to account for a mistake for which we should or could have known to avoid. In a primary care medical practice such as mine, it might be an insensitive explanation, a rushed diagnosis, a lab abnormality dismissed as nonsignificant, a failure to review drug-drug interactions, a forgotten order, or a failure to doublecheck a previous EKG. A practice is a wellspring of opportunities to improve — and what is improvement if not to face an error with regret and a determination to improve?

Perspective gives you the chance to avoid going overboard with self-criticism. It may be that on your best day you would have caught that subtle opacity on the previous CT scan and initiated treatment earlier. But you’re not at your best every day. No one is. You didn’t document that the patient had had an extreme allergic reaction to that same antibiotic 10 years ago and now you’ve gone and prescribed it again with a repeat in their liver enzymes jumping by a factor of 10. But the patient did adamantly deny any medication allergies and you’ve only just learned that the new EHR didn’t properly transfer the allergy section from the old system. And so the regret is at least lightened by these considerations.

On the far other side of regret is forgiveness. Forgiveness can come after a strict critique, a balancing of all the facts, or — somewhat less usefully — after a flimsy excuse. In any case, without forgiveness (of ourselves, others, fate, God) we would be crushed by the sheer weight of accumulated regrets.

This rhyming poem, “Without Regrets,” which I finished in time for the recent New Year, is really about forgiveness. For us humans, that is the ultimate path beyond regret.

The beach fog seems to coalesce God’s face from cloudy silhouettes Instruction comes to my address “Thou shalt aspire for no regrets” I know that in the end we cease Death’s the joke each human gets But might there be a bend toward peace, Some newfound calm from old regrets?

At the plaintive close of day Its arc complete, the great orb sets Might the fading light convey That darkness needn’t bring regrets As I make a reckoning Assembling lists of all my debts I find forgiveness beckoning My sums resolved without regrets Searching for a final clue Drawn from dreams one most forgets There's that true north worth pointing to The compass mark of no regrets.

Dr. Bressler has practiced outpatient quixotic internal medicine in San Diego since 1984.

He maintains privileges at Scripps Mercy Hospital, where he served as chairman of the Biomedical Ethics Committee, and at Mission Hills Post Acute Care, where he served as medical director. Dr. Bressler has been a member of CMA for 35 years.

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9

COVID-19

FDA Experts Are Still Puzzled Over Who Should Get Which COVID Shots and When By Arthur Allen

AT A MEETING TO SIMPLIFY THE NATION’S COVID vaccination policy, the FDA’s panel of experts could agree on only one thing: Information is woefully lacking about how often different groups of Americans need to be vaccinated. That data gap has contributed to widespread skepticism, undervaccination, and ultimately unnecessary deaths from COVID-19.

The committee voted unanimously to support the FDA’s proposal for all vaccine makers to adopt the same strain of the virus when making changes in their vaccines, and suggested they might meet in May or June to select a strain for the vaccines that would be rolled out this fall.

However, the panel members disagreed with the FDA’s proposal that everyone get at least one shot a year, saying more information was needed to make such a declaration. Several panelists noted that in recent studies, only about a third of people hospitalized with a positive COVID test actually were there because of COVID illness. That’s because everyone entering a hospital is tested for COVID, so deaths of patients with incidental infections are counted as COVID deaths even when it isn’t the cause.

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The experts questioned the rationale for annual shots for everyone, given that current vaccines do not seem to protect against infection for more than a few months. Yet even a single booster seems to prevent death and hospitalization in most people, except for the very old and people with certain medical conditions.

“We need the CDC to tell us exactly who is getting hospitalized and dying of this virus — the ages, vulnerability, the type of immune compromise, and whether they were treated with antivirals. And we need immunological data to indicate who’s at risk,” says Dr. Paul Offit, director of the Vaccine Education Center and a pediatrician at Children’s Hospital of Philadelphia. “Only then can we decide who gets vaccinated with what and when.”

Dr. Offit and others have expressed frustration over the lack of clear government messaging on what the public can expect from COVID vaccines. While regular boosters might be important for keeping the elderly and medically frail out of the hospital, he said, the annual boosters suggested by the FDA and the

drug companies may not be necessary for everyone.

“The goal is to keep people out of the hospital,” he said. “For the vulnerable, it would be important for vaccines to keep up with circulating strains. But for the general population, we already have a vaccine that prevents hospitalization.”

Other panelists said the government needs to push research harder to get better vaccines. Pamela McGinnis, a retired official of the National Institutes of Health, said she had trouble explaining to her two young-adult sons why they promptly got sick after venturing out to bars one night only weeks after getting their bivalent booster. “‘Think how sick you would have gotten if you weren’t fully vaccinated’ is not a great message,” she said. “I’m not sure ‘You would have landed in the hospital’ resonates with recipients of the disease.”

Members of the FDA’s advisory committee have been irked in recent months, saying the agency didn’t present them with all the data it had on the bivalent vaccine before it was released in September. And some critics have said the FDA should have instructed drug companies to include only the newer strains of the virus in the shot.

Asked about that, Jerry Weir, a senior FDA vaccine officer, said his “gut feeling” was that a vaccine matched to a single omicron strain would have

performed better than the bivalent shot, which also contains the original COVID strain. “But the real question is where we’re headed,” he says, “and I don’t know the answer.”

Perhaps the most important presentation was from Heather Scobie, who keeps tabs on COVID at the Centers for Disease Control and Prevention. She reported that fewer than half of Americans 65 and older had gotten the latest booster, and that only two-thirds of that age group had gotten even a single booster.

Yet evidence continues to mount that it’s mostly the elderly who are at serious risk from COVID. Death rates from the disease have declined in every age group except those over 75 since April, despite the uptick in new strains. Except for the very old, the death rate has hovered around 1 in 100,000 since April. Earlier in 2022, babies 6 months old and younger were hospitalized and died at relatively high rates. Vaccination levels in the 4-and-under group hover at about 10%.

While acknowledging the FDA’s desire to regularize its COVID vaccine policy, panel members said it’s still too early to know for sure whether COVID will surge only in the winter, like flu, respiratory syncytial virus, and other respiratory infections.

“For the next few years we may not know how often we need to make a strain change in the vaccine,” said Dr. Steven Pergam, medical director of infection prevention at the Seattle Cancer Care Alliance. Or even if people who are not in poor health or elderly need additional boosters.

One vaccine-maker represented at the meeting, Novavax, said it would need to know by the end of March which strain to include in its vaccine for fall. Companies with mRNA vaccines like Pfizer and Moderna can change their formulas faster, but their products aren’t clearly better than Novavax’s.

All three of those vaccine makers revealed at the meeting that they are developing single-dose vials or prefilled syringes.

Up to now, they’ve delivered their vaccines in multidose vials, but since the government has run out of money to buy vaccines, individual pediatricians may order them in the future.

Since the vaccine must be used quickly once a vial is open, doctors are leery of wasting vaccine and losing money.

Arthur Allen, senior correspondent for Kaiser Health News (KHN) where this article first appeared, writes about the FDA and the pharmaceutical industry as well as COVID-related topics.

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11

PRACTICE MANAGEMENT

Flu, RSV, or COVID-19?

Convergence of Three Viruses Creates Risk of Diagnostic Errors

By Debra Kane Hill, MBA, RN IT IS LIKELY THAT HEALTHCARE PRACTITIONERS will see a spike in influenza (flu) and COVID-19 cases, particularly with the circulation of new omicron subvariant/s.

Additionally, respiratory syncytial virus (RSV) infection peaked unusually early this season, flooding primary care offices and hospital emergency departments with patients and creating severe shortages of pediatric hospital beds.

Public health officials are concerned that these three viruses will converge on communities and create a public health “triple threat.” Healthcare practitioners should prepare now to manage the potential onslaught of respiratory illness.

If there is any good news, it is that the guidance is similar for controlling or minimizing the spread of these three contagious respiratory illnesses. While there is no vaccine for RSV, vaccines are readily available for COVID-19 and the flu. The bad news is that all three illnesses have similar symptoms, and testing must be performed for each to effectively confirm a correct diagnosis.

Understanding the differences between the flu, RSV, and COVID-19 will help prevent misdiagnosis or delayed diagnosis when patients present with respiratory symptoms.

The American Academy of Pediatrics offers information on differential diagnosis between the three viruses, and the CDC provides specific guidance on distinguishing between the flu and COVID. General information about each virus is available from the CDC for practitioners as follows: flu, RSV, and COVID-19. The CDC addresses signs and symptoms, incubation periods, length of time for spreading the viruses, how the viruses spread, individuals at higher risk for severe illness, potential complications, and approved treatments.

Flu Season During flu season, it is possible that all three of the viruses may spread at the same time. Patients could become infected with one or all of the diseases. To counter this possibility, it is important to continue offering appropriate screening, testing, and vaccinations. Refer to the CDC’s guidance “Frequently Asked Influenza (Flu) Questions: 2022–2023 Season.” Note 12

MARCH 202 3

that both flu and COVID vaccines may be given on the same day if patients are eligible and vaccines follow the appropriate administration schedule.

Patient Safety Strategies Enhance patient safety by taking the following actions: Patient Care • Follow testing guidelines. Testing is the best method for determining which virus the patient may have while guiding you in decisions about the appropriate treatment.

• Review the CDC’s “Information for Clinicians on Influenza Virus Testing” for patients with acute respiratory illness symptoms.

• Encourage your patients (six months and older) — and especially those at high risk — to get an annual flu vaccine.

• Ensure that the patient’s health record includes standard documentation about the possibility of contracting the flu, RSV, and/or COVID-19 — including vaccination informed consent and informed refusal discussions.

• Adopt a shared decision-making approach for patients at high risk for flu or COVID-19 who are reluctant to get vaccines. Ensure that patients understand the risks of not being vaccinated. Learn more about this process with the Agency for Healthcare Research and Quality’s “The SHARE Approach: Shared Decisionmaking Tools and Training.” The shared decision-making/consent discussion should be well documented in the patient’s record.

For additional information, see our articles “Reduce Patient Safety Risks With Vaccinations, Including COVID-19” and “Communicating with COVID-19 VaccineHesitant Patients: Top Tips.”

• Refer patients to pharmacies where both the flu and COVID-19 vaccine can be administered at the same time.

• Prescribe antivirals as necessary to prevent complications.

See the CDC’s “What You Should Know About Flu Antiviral Drugs” and “COVID-19 Treatments and Medications.”

From the American Academy of Pediatrics, see “Updated Guidance: Use of Palivizumab Prophylaxis to Prevent Hospitalization From Severe Respiratory Syncytial Virus Infection During the 2022-2023 RSV Season.”

Office Measures • Encourage all staff members to get vaccinated for the flu.

Offering it at no cost to employees increases vaccination rates.

• Follow the CDC’s “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.”

Maintain, date, and document all changes in office poli-

cies related to personal protective equipment or other infection control protocol.

• Appoint someone in the office to maintain all processes and procedures related to COVID-19, RSV, and flu in a central location.

Patient Education • Distribute or display the American Heart Association infographic “Flu Shot 411.” Flu shots reduce the risk of death for people with heart disease.

• Use other infographics and print resources in your office for RSV, COVID-19, and the flu.

• Offer a free video in your waiting area to educate patients about getting vaccinated. For an example, see the Mayo Clinic Minute: “Why getting vaccinated for the flu is doubly important this season.”

• Educate patients to stop the spread of germs: » Wash hands frequently. » Maintain respiratory etiquette (including masking when possible).

PLACE YOUR AD HERE Contact Jennifer Rohr 858.437.3476 Jennifer.Rohr@SDCMS.org

» Avoid touching eyes, nose, and mouth. » Avoid close contact, particularly with those who are sick. » Disinfect frequently touched surfaces and objects. » Encourage self-isolation if sick.

Community Monitoring • Adhere to local government or public health department recommendations for additional precautions. Check transmission levels in your community: COVID-19 by County, RSV Surveillance, and Weekly U.S. Influenza Surveillance Report.

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or patient safety@thedoctorscompany.com.

Debra Kane Hill is the senior patient safety risk manager for The Doctors Company.

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13

HEALTH TRENDS

More Californians Are Dying at Home.

Another COVID ‘New Normal’?

By Phillip Reese

THE COVID-19 PANDEMIC HAS SPURRED A surge in the proportion of Californians who are dying at home rather than in a hospital or nursing home, accelerating a slow but steady rise that dates back at least two decades.

The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift. Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which data on at-home deaths is accessible in the agency’s public database.

The trend is amplified among California residents with serious chronic conditions. About 55% of Californians who died of cancer did so at home during the first 10 months of 14

MARCH 202 3

2022, compared with 50% in 2019 and 44% in 1999. About 43% of Californians who died of Alzheimer’s disease in the first 10 months of 2022 did so at home, compared with 34% in 2019 and nearly 16% in 1999.

Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021.

Nationwide data for 2022 is not yet available.

COVID’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died of COVID died in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and little understood.

The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home. “It was devastating to have Mom in a nursing home and dying, and the only way you can see Mom is through the window,” says Barbara Karnes, a registered nurse who has written extensively about end-of-life care.

At the same time, fears of COVID exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.

Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. They said more people simply want to die in a comfortable, familiar place, even if it means not fighting for every second of life with medical interventions.

“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’ They all say, ‘I want to be at home,’” says John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego.

Meanwhile, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.

“There’s been a little bit of a culture change where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning,” says Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health.

The trends have created a booming industry. In 2021, the California Department of Health Care Access and Informa-

tion listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.

That much growth — and the money behind it — has sometimes led to problems. A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.

When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers, and spiritual advisers.

Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, says Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay. To find quality end-of-life care, Andrea Sankar, a professor at Wayne State University and author of Dying at Home: A Family Guide for Caregiving, recommends seeking out nonprofit providers and having a list of questions prepared: How often will nurses visit in person? In what circumstances do patients have access to a physician? What help will be available for a crisis in the middle of the night?

While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving. “It really takes a pretty evolved family system to be able to rally to meet all of the needs,” says Tastad at Sharp HealthCare.

Several end-of-life experts said they expect the proportion of Californians choosing to die at home to keep climbing, citing a variety of factors: Medical advances will make it easier for patients to receive pain management and other palliative care at home; telemedicine will make it easier for patients to consult doctors from home; and two powerful forces in American healthcare — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento. This story was produced by Kaiser Health News (KHN), which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

SANDIEGOPHYSICIAN .ORG

15

PUBLIC HEALTH

Here’s Why Experts Are Concerned About Bird Flu Mink Paper Sets Off Alarms About Potential for Viral Recombination By Kristina Fiore WHAT APPEARS TO BE MAMMAL-TO-MAMMAL transmission of highly pathogenic avian influenza (HPAI) A(H5N1) on a mink farm in Spain has caught the attention of infectious disease epidemiologists around the world.

A paper published in Eurosurveillance last month detailed an H5N1 outbreak among farmed minks in the Galicia region of Spain in October 2022. Montserrat Agüero, of Spain’s agricultural ministry, and colleagues suspected that transmission occurred between the animals based on “the increasing number of infected animals identified after the confirmation of the disease, and the progression of the infection from the initially affected area to the entire holding.”

While none of the farm workers were infected, experts said these are the conditions that can ignite a deadly H5N1 pandemic in humans.

That paper has “sent up a yellow caution light” in the infectious disease public health community, says William Schaffner, MD, of Vanderbilt University Medical Center in Nashville, Tennessee, who is also a spokesperson for the Infectious Diseases Society of America.

“There was no evidence of infection among any of the mink caretakers, who had very sustained, close contact with those animals, so everybody took a deep breath,” Dr. Schaffner says. “But nonetheless, everybody [in the infectious disease public health community] is a little bit anxious, and they are watching this.”

There have been increasing global reports of other types of mammals picking up H5N1 — including bears, foxes, skunks, and raccoons — in what has become one of the larg16

MARCH 202 3

est and longest avian flu outbreaks in history. Fortunately, there has been no evidence of mammal-to-mammal transmission in those populations so far.

But the mink example shows that’s possible: It allows for the type of recombination of influenza viruses that could lead to a pandemic, Dr. Schaffner says.

On farms across the U.S., concern has mostly been about pigs being co-infected with human and avian influenza viruses, he notes.

“If the pig is simultaneously infected with human flu and bird flu, those viruses can exchange genetic material, and that would provide an opportunity for a bird flu virus, which hardly ever infects humans, to pick up the genetic capacity to readily spread among humans,” he says.

Indeed, in the mink, Agüero and colleagues noted a novel mutation in the PB2 gene (T271A), which they say could have public health implications. That amino acid influences acquisition of another mutation that confers human receptor recognition, they wrote.

While this change could have arisen de novo in minks, they said, the “data available are not sufficient to exclude the possibility of an unobserved circulation of avian viruses bearing this substitution in the avian population.”

Indeed, a December report from the U.K. Health Security Agency said the risk to human health of avian influenza currently stands at Level 3 out of 5: “Evidence of viral genomic changes that provide an advantage for mammalian infection.”

Dr. Schaffner said global surveillance systems are homed in on detecting a “pandemic” influenza in its early stages.

Such was the case for the most recent example of pandemic influenza, the 2009 H1N1 “swine flu” pandemic, he added.

The World Health Organization’s Global Influenza Surveillance and Response System monitors influenza viruses globally, and the CDC serves as a “Collaborating Center” in this network. The U.S. Department of Agriculture’s Animal and Plant Health Inspection Service also surveils animals for the virus, including both farmed and wild birds.

Should a pandemic occur, H5N1 vaccines are available, Dr.

Schaffner said, as the U.S. has built a stockpile of bird flu vaccines. If a new strain pops up, vaccine makers would have to modify the vaccine to attempt a better match, and ramp up manufacturing of new vaccines, he says. However, mRNA vaccine technology could cut down that timeline, he adds.

So far, this has been the deadliest avian flu outbreak on record, with almost 50 million wild and domestic birds killed or culled in the U.S. and another 50 million killed or culled in Europe.

Only one person in the U.S. has become infected with H5N1 during this outbreak — a patient in Colorado in April 2022. CDC maintains a bird flu tracker that reports data for wild birds, poultry, and humans.

The first time HPAI H5N1 was detected in North America was in 2014, and it caused widespread poultry outbreaks and deaths of wild birds in the U.S. and Canada before it disappeared in 2016, according to the CDC. It first emerged in southern China and led to large poultry outbreaks in Hong Kong in 1997. It was controlled, but not eradicated, and reemerged in 2003, spreading widely among birds throughout Asia and then later in Africa, Europe, and the Middle East.

Globally, there have been more than 860 human infections since 2003, with a substantial mortality rate of about 53%, the CDC reported.

While the risk to humans currently remains low — the only impact at the moment appears to be higher egg prices, which are also driven by inflation overall — Dr. Schaffner warned an influenza pandemic is something the U.S. should always be ready for.

“There will be another pandemic,” he says. “I hope we’ve learned lessons from having gone through COVID, so that we can do better the next time around.”

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

SANDIEGOPHYSICIAN .ORG

17

NEPHROLOGY

Higher Rates of Staph Infection for Hispanics on Dialysis, CDC Says Greatest Infection Risk Comes With Central Venous Catheter Access, Researchers Find By Joyce Frieden

HISPANIC DIALYSIS PATIENTS HAVE SIGNIFICANTLY

higher rates of Staphylococcus aureus bloodstream infections compared with white dialysis patients, according to a CDC study.

In 2020, rates of S. aureus bloodstream infections in hemodialysis patients were 40% higher among Hispanic patients versus non-Hispanic whites (adjusted rate ratio [aRR] 1.4, 95% CI 1.2–1.7, P<0.001), reported Shannon Novosad, MD, of the CDC National Center for Emerging and Zoonotic Infectious Diseases in Atlanta, and colleagues in Morbidity and Mortality Weekly Report.

“A comprehensive approach to preventive care that recognizes racial, ethnic, and socioeconomic disparities is needed,” the group wrote. “Healthcare providers and public health professionals should prioritize prevention and optimized treatment of ESKD [end-stage kidney disease], iden18

MARCH 202 3

tify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.”

The U.S. has more than 800,000 patients with ESKD, and 70% of those are treated with dialysis, Dr. Novosad and co-authors noted. Of those on dialysis, 89% receive hemodialysis and 11% receive peritoneal dialysis.

Their findings also showed that patients on

dialysis from 2017–2020 were 100 times more likely to experience S. aureus infections compared with adults not on hemodialysis (4,248 vs. 42 per 100,000 person-years).

Prevalence of ESKD is fourfold higher among Black people and more than twofold higher among Hispanics than among whites, “disparities which are thought to be attributable at least in part to underlying conditions such as hypertension and diabetes,” the authors wrote.

“Furthermore, disparities in pre-ESKD nephrology care and receipt of ESKD therapies exist for these same groups, as well as those with lower income and insurance coverage.

Black persons constitute 33% of all U.S. patients receiving dialysis, but only 12% of the U.S. population.”

Among hemodialysis patients, bloodstream infections — particularly S. aureus — are a leading cause of morbidity and mortality; 40% of S. aureus infections are of the methicillin-resistant variety (MRSA). Type of hemodialysis plays a role in infection risk, in that “risk is highest for central venous catheters (CVCs),

lower for grafts, and lowest for fistulas,” they said.

However, Dr. Novosad’s group added that “although elevated rates have been reported for both invasive MRSA infections among Black dialysis patients and hospitalizations for dialysis-related infections among adult Black patients and older Hispanic patients (aged >60 years), the association among hemodialysis-related infections, race and ethnicity, and social determinants of health is largely undescribed.”

To further explore this area, they looked at infection reports from 7,097 dialysis centers in 2020. A statistical model was used to assess potential associations between the main outcome of facility S. aureus bloodstream infection incidence with patient vascular access type and selected dialysis facility characteristics, including those related to infection control practices and Social Vulnerability Index (SVI) data.

During the year studied, 14,822 bloodstream infections were reported by 4,840 facilities. Of those infections, 34.2% (n=5,070) were found to be S. aureus.

“Among reported S. aureus bloodstream infections, 2,602 (51.3%) were identified as methicillin-sensitive and 1,923 (37.9%) as MRSA; 545 (10.7%) had no susceptibility test results reported,” the investigators noted.

They also reported that S. aureus bloodstream

infection risk was most strongly linked with patient vascular access type.

Compared with fistula access, CVC had about six times higher risk (adjusted RR 6.2, 95% CI 5.7-6.7) while graft or other had around two times higher risk (aRR 2.2, 95% CI 2.0-2.4).

Facility characteristics significantly tied to higher S. aureus infection incidence included any hospital affiliation, not being part of a chain of dialysis centers, not having a written antibiotic use policy, and location in an area with a higher proportion of people ages ≥65.

Black patients had higher crude rates of infection, but the difference was not significantly different in the adjusted analysis (aRR 1.1, 95% CI 0.9–1.2, P=0.40).

Other variables associated with higher infection rates included male sex, older age (≥65), and specific surveillance sites. “However, CVC access had the strongest effect of all factors assessed,” the authors noted, with the highest rates occurring among Black patients (ages 18–49).

They added that “65% of bloodstream infections in this age, race, and ethnicity subgroup involved CVCs, which represented the highest prevalence of CVC use among the age, race, and ethnicity groups with bloodstream infections.”

Despite those results, “potentially important associations between race

and ethnicity and vascular access type used should also be considered,” the authors said. “For example, recent national data suggest that initiation of hemodialysis with a CVC does not vary substantially by race, ethnicity, or SES [socioeconomic status], although other studies have shown associations among Black race, Hispanic ethnicity, poverty, insurance status, and shorter duration of pre-ESKD care with lower initiation with fistula.”

SES may have figured into the current results, according to the researchers. “U.S. Census Bureau tracts with lower SES factors accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections,” they said. “For example, 42.1% of S. aureus bloodstream infections among patients on hemodialysis occurred in tracts in the highest quartile of population proportion living below the poverty level, versus 10.4% in tracts in the lowest poverty quartile.”

Why was CVC access associated with a higher infection risk? Because one end of the CVC tube remains outside the body, “[it is] exposed to germs which can enter the tube and move into the bloodstream,”Dr. Novosad said during a call with reporters Monday. “Removing barriers to lower-risk vascular access types for dialysis treatments is a critical step for preventing infection. It is vital to coordinate efforts among patients, nephrologists, vascular access surgeons, radiologists, nurses, nurse practitioners, and social workers to reduce the use of central venous catheters for dialysis treatment.”

Study limitations included the inability to summarize SVI data below the county level, and the fact that bloodstream infection rates by individual SES factors could not be calculated because U.S. Census Bureau tract-level denominator data were unavailable.

“Strengthening hemodialysis bloodstream infection surveillance to more comprehensively assess social determinants of health would improve understanding of risk and address some of the limitations of this report,” the authors concluded.

Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. This article first appeared in MedPage Today. Frieden has 35 years of experience covering health policy.

SANDIEGOPHYSICIAN .ORG

19

CHAMPIONS FOR HEALTH

Giving Your Best

By Adama Dyoniziak IN 2020, JAVIER G. FELL FROM A CONCRETE wall, hurting his arm severely. He could not move his arm or rotate his elbow. Emergency room X-rays confirmed a broken elbow.

“They told me they could not treat me because I did not have insurance and it was not an emergency,” Javier explains.

“I started thinking that this was how I would always be — always with unrelenting pain.”

The local clinic referred him to Dr. Serge Kaska, an orthopedic specialist and Project Access volunteer. Dr. Kaska confirmed the diagnosis and the need for surgery. Javier did not have insurance, but Dr. Kaska took the time to tell him about Project Access and encouraged him to apply.

“The reason I volunteer with Project Access is so I can use my specific surgical skill set with trauma and fractures that may not have healed properly,” Dr. Kaska says. “I can add value to people’s lives here in San Diego.”

With the application completed, the pandemic delayed Javier’s surgery for two years. During that time, Javier, the sole family wage earner, had limited to no use of his right arm and couldn’t work or do any physical activity.

“Every time I slept I would just end up hurting myself more, so I was not sleeping,” Javier says. His emotional health declined along with his physical health. He was sad and frustrated, isolating himself from his family at home. “I didn’t feel useful. I was always angry. I yelled a lot. I did not feel like a normal person,” he continues. Javier’s mom recalls, “Leaving him alone with his thoughts and pain, and not seeing a future or a change coming, I felt so worried all that time (about suicide).”

Finally, his surgery was scheduled at Scripps Encinitas. “I was so nervous about the surgery, but Dr. Kaska explained everything really well,” Javier says. “All the nurses, doctors, and staff told me everything that was going to happen.”

The recuperation was challenging and Javier recalls being bruised and swollen for quite a while, but he was also hopeful and noticed changes in himself after the surgery. “Once I had surgery I was so thankful — to God, to Project Access, Dr. Kaska, the nurses, the hospital,” he says. Javier states he is appreciative of more things, wanting to work hard to give back. His mom states, “He is healthier, taking care of himself, 20

MARCH 202 3

DR. SERGE KASKA

he has returned to work, and seems much happier.”

Dr. Kaska was introduced to orthopedics through his own injuries playing football. “My coaches encouraged me to strive to reach my full potential,” he says.

“Both my parents were scientists, and this extra nudge propelled me into medicine.” Dr. Kaska enjoys the innovation that can be found in recognizing problems and finding solutions.

He invented C-Armor, which is a drape that keeps an x-ray machine sterile for

use in the operating room.

Time away from work includes surfing, mountain biking, and snowboarding.

Dr. Kaska holds a Mother Theresa quote close to his heart: “Because in the final analysis it is between yourself and God, and it is better to give your best.”

Since 2008, Project Access has facilitated $27 million in care for more than 7,500 uninsured patients just like Javier by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty physicians. Give your best — contact us to provide pro bono services by emailing adama.dyoniziak@ championsfh.org or calling (858) 300-2780.

Adama Dyoniziak is the executive director of Champions for Health.

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

win-win situation for all. Visit us at caremd.us.

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

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

Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

CHAMPIONS FOR HEALTH - PROJECT ACCESS SAN DIEGO: Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology. These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office. Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn.penaloza@championsfh.org or at (858) 300-2779.

PHYSICIAN OPPORTUNITIES CARDIOLOGY PHYSICIAN POSITION AVAILABLE: San Marcos cardiology office is seeking a part time cardiologist to work 1 to 2 days a week. Please e-mail CV to evelynochoa2013@yahoo.com.

MEDICAL DIRECTOR, FULL-TIME, FATHER JOE’S VILLAGES: Join us in ending homelessness! We are a dynamic team that runs an FQHC. The Medical Director oversees clinical aspects of the primary care, psychiatry, dental and behavioral health. This position will be a mix of clinic and admin time and will have direct reports (Dental Director, Director of Behavioral Health, and frontline primary care/psychiatry providers). Reports to the Chief Medical Officer, who is responsible for all aspects of the clinic. The Medical Director is a counterpart to the Clinic Director (who oversees admin staff, MA/RN team, billing, PSRs, etc.). To apply, visit https://my.neighbor.org/jobs-careers.

SEEKING MEDICAL DIRECTOR: subcontracted position 4-8 hours per month. Responsibilities: 1. Support case conferences, refractory SUD, co-occurring conditions, specialty populations. 2. Conduct clinical trainings on issues relevant to staff (e.g., documentation, ASAM Criteria, DSM-5, MAT, WM, co-occurring conditions). 3. Provide oversight and clinical supervision. 4.

Refer co-occurring conditions. 5. Lead Quality Improvement functions (e.g., Quality Improvement Projects, clinical team meetings, etc.) 6. Attend annually 5 hours of continuing medical education on addiction medicine. Required by contract with San Diego County BHS, position is for a Physician licensed by CA Medical Board or CA Osteopathic Medical Board. Contact Name: Jennifer Ratoff: e-mail: jratoff@secondchanceprogram.org, phone: 619-839-0950 PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40.

Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County? 1. Fully paid malpractice insurance. 2. 13 paid holidays. 3. 13 sick days per year. 4. Vacation: 10 days (1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years). 5. Defined benefit retirement program. 6. Cafeteria-style health plan with flexible spending. 7. Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/adolescents and or geriatric patients.

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

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

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https://apol-recruit. ucsd.edu/JPF03179 For help, contact: klsantos@health.ucsd.edu.

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family.

Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com.

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd is looking for a caring, compassionate, and competent physician for providing primary care services. We require wellorganized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide high–quality care to our patients. We provide a competitive salary, paid time off, health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency. Our CEO Dr. Venu Prabaker who has 30 years of teaching experience as a faculty at multiple universities Including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc. — will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to 5-star restaurants in San Diego. We also have a weekly one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a

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

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https:// www.governmentjobs.com/careers/sdcounty?keywords=21416207 KAISER PERMANENTE SAN DIEGO PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/physical-medicinerehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

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

This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits.

Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.

Nhcare.org.

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

The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

PRACTICE FOR SALE GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand or move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic. Located in a professionalmedical building with professional contract staff. All records and billing managed by a professional service who can assist with insurance integration.

Office, staff & equipment are move-in ready. Seller will assist buyer to ensure a smooth transition. Being on-call optional. Contact Ferdinand @ (858) 7521492 or ferdinand@zybex.com.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale.

The office is approximately 3,000 SF with 1 or 2 physician offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff

room, and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at (858) 354-1895 or email: mahdavim3@ gmail.com.

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

OFFICE SPACE / REAL ESTATE AVAILABLE

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.

PHYSICIAN OFFICE SPACE FOR LEASE: 1500 Sq ft. 3 exam room. Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance. Located in Rancho Bernardo in prime central location. Easy access to interstate 15. Palomar /Pomerado within 10 min. Security card access during off hours. $2500/month.

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

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. (858) 342-3104.

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

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area.

3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

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

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

NON-PHYSICIAN POSITIONS AVAILABLE PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research Affairs https://research.ucsd.edu/, in support of the campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding. https://apol-recruit.ucsd.edu/JPF03262/apply OFFICE MANAGER: 1. Hiring, training, managing staff on procedures/ policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/facilities management.

Daily bookkeeping, collections. 2. Ensure smooth/efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team.

4. Ensure staff working at maximum productivity/efficiency. Salary: $60-70K depending on experience/qualifications. Benefits: healthcare reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@ manageyourage.com.

ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director.

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

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