July/August 2022

Page 1

Official Publication of SDCMS JULY / AUGUST 2022

Toluwalase (Lase) Ajayi

Becomes 2022–2023 SDCMS President


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Contents JULY/AUG

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 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: 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: 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.]



Toluwalase (Lase) Ajayi, MD SDCMS President 2022 Gala Speech


Sergio R. Flores, MD Immediate Past President, SDCMS 2022 Gala Speech


Gala Awards Dr. Christian Ramers: James T. Hay, MD Award


2022 Rendezvous Gala An Evening to Celebrate 152 Years of Healing



Briefly Noted: Infectious Diseases • CMA Resources • CMA Doctors


Politics and Pandemic Fatigue Doom California’s COVID Vaccine Mandates By Rachel Bluth


Patients Seek Mental Healthcare From Their Doctor But Find Health Plans Standing in the Way By Aneri Pattani


Omicron Less Likely to Cause Long COVID, Data Suggest By Judy George


10 Actions on Addiction An Interprofessional Approach By Roneet Lev, MD, Nathan A. Painter, PharmD, Christy Cotner, DNP


What We Learn by Living Between Two Kingdoms By Helane Fronek, MD, FACP, FASVLM, FAMWA








CDI Tells Insurance Companies to Immediately Stop Unlawful STI Screening Limits THE CALIFORNIA DEPARTMENT OF Insurance (CDI) is warning health insurers that refusing to cover necessary treatments and limiting coverage for sexually transmitted infection (STI) screening to one per year is unlawful. At a pivotal time when the Centers for Disease Control and Prevention (CDC) reports an alarming increase in STIs nationwide, the CDI is finding that several insurers are shifting the cost of preventive screenings, diagnoses, and treatments to patients and creating unnecessary and unlawful obstacles to preventing the spread of HIV, syphilis, chlamydia, hepatitis, and other STIs. The Affordable Care Act (ACA) and California law both prohibit limiting STI screenings of persons who are at increased risk of infection. Additionally, California law requires most health insurers to cover screening, diagnostic testing, and treatment for any health condition according to current, generally accepted standards of care. Consequently, insurers must cover clinically recommended periodic STI screening, even when it is not required preventive care under the ACA. The CDI bulletin explains that existing federal and state law requires insurance companies to: • Cover STI screening, diagnosis, and treatment in accordance with current, generally accepted standards of care. • Cover STI screenings that are within the scope of the ACA without patient cost sharing. • Cover clinically recommended STI screenings that are not defined as preventive care under the ACA. • Not impose coverage limits on STI screenings that conflict with evidence-based clinical recommendations on screening intervals.

• In pharmacy benefits, cover prescription drugs that are medically necessary to treat STIs, including direct-acting antivirals for curing hepatitis C. • Cover home self-collection test kits and laboratory costs for detecting STIs. • Cover combination antigen/antibody HIV self-tests, including combination rapid fingerstick tests, without a deductible from or other cost sharing on patients. CDI informed insurers that they must immediately eliminate any impermissible limits that they have arbitrarily imposed on coverage of clinically recommended STI screening, testing or treatment. The growing STI crisis in California and across the county has been exacerbated by the COVID-19 pandemic, disproportionately affecting youth, people of color, and gay, bisexual, and transgender people. CMA RESOURCES

CMA Updates ‘No Surprises Act’ Guide ON JAN. 1, 2022, A NEW FEDERAL LAW, the “No Surprises Act” (NSA), took effect. The NSA was designed to eliminate surprise medical bills for patients enrolled in group health plans and health insurance policies including self-funded/ERISA health benefit plans, who receive: (1) covered non-emergency services by out-of-network providers at in-network facilities, or (2) emergency services by out-ofnetwork providers. The new law was not intended to supersede state laws on surprise billing and payment and the California Department of Managed Health Care (DMHC) recently issued guidance on the interplay between state and federal law. The California Medical Association (CMA) recently updated its guide — The No Surprises Act: What Physicians Need to Know — to reflect this guidance, eligibility for the NSA Independent Dispute Resolution Process, and other information. The document — which was published to help physicians understand their rights and obligations under the NSA — is available to members only.


Two CMA Physicians Elected to AMA Board of Trustees


TWO CALIFORNIA MEDICAL Association (CMA) physicians were elected to the American Medical Association (AMA) Board of Trustees at the association’s annual meeting in Chicago.

San Diego pediatrician and palliative care specialist Toluwalase “Lase” Ajayi, MD, was elected as a trustee representing AMA’s Young Physician Section. Dr. Ajayi is the director of clinical research and diversity initiatives at Scripps Research Translational Institute, the medical director of the Scripps Mercy Palliative Care team, a pediatric hospitalist, and a home-based pediatric palliative care physician. She is currently serving as president of the San Diego County Medical Society and as the CATCH grant facilitator for the American Academy of Pediatrics CA-3 Chapter, helping to connect community pediatricians to grants for research and quality improvement. On the state level, Dr. Ajayi is chair of CMA’s Council of Medical Services. She collaborates across specialties and practice modalities to expand and modernize CMA policies on topics like the future of medical service in a postpandemic world, reducing administrative burdens, accelerating advances in telehealth for physician practice and improved access to care. At AMA, Dr. Ajayi has served in leadership positions throughout the Young Physician Section, including currently as immediate-past chair. Radiologist Alex Ding, MD, was

elected to AMA’s Board of Trustees. Dr. Ding has been active in organized medicine since medical school and has served in numerous leadership positions throughout the Federation. He currently chairs the AMA Council on Science and Public Health, and has served on the AMA Council on Legislation, AMPAC Board of Directors, and as the resident/fellow physician member of the AMA Board of Trustees. He has been a CMA member since 2003 and has served on the board of the CMA Political Action Committee (CALPAC), and on the CMA Council on Legislation and the CMA Council on Science and Public Health. Dr. Ding is also a past president of the San Mateo County Medical Association. After nearly 20 years of advocacy on behalf of the physicians of California, Dr. Ding recently relocated to Louisville, Kentucky, where he is a clinical assistant professor at the University of Louisville and is physician executivein-residence in the office of the Chief Medical Officer at Humana. “It is an honor and privilege to be elected by my peers to the AMA Board of Trustees at this critical moment for medicine,” said Dr. Ding. “AMA advocacy has provided vital lifelines throughout the COVID-19 pandemic, cutting through misinformation, validating the vaccine approval process, and offering timely support and guidance to physician practices in their time of need. I am eager to get started in this new role as we advocate for the Recovery Plan for America’s Physicians.”


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Toluwalase (Lase) Ajayi, MD, SDCMS President

2022 Gala Speech 4


I WANT TO BEGIN BY THANKING some of the many who have made tonight possible. Firstly, thank you to the Scripps Mercy Medical Staff who, in addition to sponsoring tables, also sponsored this evening’s refreshments. Next, I want to thank the institutions I work with, my colleagues and the teams who have supported me and helped me grow as I became the physician and researcher I am today. Thank you to Rady Children’s, UCSD, Scripps Research, and Scripps Health, and those of you here tonight representing those organizations. A big thank-you to Paul Hegyi and the entire staff and executive committee of the San Diego County Medical

Society. Thank you for seeing something in me that I am still working to recognize and own. A special thankyou to Jennipher Ohmstede, who is the master coordinator, the boss, and for the next year, my new work wife. Thank you, Jenn … and I’m sorry. A special shout-out to Sergio Flores and Holly Yang, who have been at the head of SDCMS these past two years and who will continue to be at my side as I transition into this role. Lastly, and certainly not least, I want to acknowledge — not thank, but highlight — my true and consistent partner who, without his unwavering support, love, and hard work, I could not accept this honor tonight. As we juggle three young children, a new puppy, four work schedules, and a total of 13 total calendars between the two of us, we consistently question our sanity — which is probably why we are still together, because our crazy matches each other. I will also add, and Jenn can testify to this, that SDCMS is part of what brought us together. So I ask that you please join me in mortifying him as we acknowledge him for being the best partner I could ever ask for, Dr. Kyle Edmonds. Now, as I thought about my remarks tonight and what I would say, a great mentor and phenomenal friend asked me three questions that I’m going to use to frame the rest of my thoughts this evening. First, she asked, “What is my guiding principle and what makes me who I am?” The answer to this question is, “my family.” You heard some of my origin story from Dr. Hertzka tonight but let me say it plainly: “I am who I am because of my family.” • My mother is the OG and unmitigated hero in my life. She teaches me through her passion and stubbornness to fight for what is right, to speak for those who can’t or won’t; her strength in leaving behind her country and family so that we could thrive in the United States. She showed me strength as she worked as the sole breadwinner when her

husband was dying from amyloidosis and her eldest daughter was being treated for recurrent cancer. • My father, who wanted so badly to see me get my white coat and who died one day short. Who was, and still is, the source of my mother’s strength. Who taught me to appreciate the quiet, and to see the good in everyone, no matter how much I may disagree. • My sisters, who will always drop anything to be with me when I need them. They teach me and give me the safe space to be me. • My children, who I would do anything for and who show me every day that I am enough just as I am. All of these examples translate to my guiding principle, which is to fight like hell for those who need it, to speak up when I see a wrong, and that I can’t just burn it all down. That, to make the difference I hope to see, collaboration is the key. Which brings me to the next question my friend asked me: “Why do I appreciate SDCMS and organized medicine?” My journey into organized medicine began in medical school with the American Academy of Pediatrics (shout-out to the AAP-CA3 chapter who are here tonight!). The AAP became my home to nerd out on policies and get into the weeds of how we build a better system of care to complement the work we do at the bedside. Then, Holly Yang made my co-fellows and me join SDCMS and I soon found myself on the board, where I started to learn about the bigger world of organized medicine and introduced me to people who challenged the way that I thought about medicine and the various barriers that physicians face in providing quality care to their patients. A particular thank-you here to Ted Mazer and many others who helped me understand the administrative, regulatory, and financial burdens that different practice modalities face and the simple fact that if we as physicians are not taken care of, then

we cannot provide the care that our patients need. SDCMS has opened my eyes and allowed me to work on these larger systemic issues while introducing me to so many new allies in the quest to fix our broken healthcare system. And I believe that I’m bringing more than a little of my own lived knowledge, too, particularly about how we need the healthcare system to work for our most vulnerable and least cared for. And this brings us to the last of Dr. Valencia Walker’s questions: “What do I dream of accomplishing together this next year that will build an even brighter legacy for SDCMS?” As usual, she saved the toughest for last. As I accept the tremendous honor of being the 152nd president, the ninth woman to be president, and the first Black woman to assume this position, this question has weighed on me and sometimes triggered my imposter syndrome. My mind seemed to be at once all over the place and blank — or at least it was until I sat down and worked through those first two questions, and then it all made sense. SDCMS and its foundation, Champions for Health, are already amazing organizations with people who came before me working to bring us all to this point. So now my job is to bring me to the table, and I am enough. I bring to this position countless lived experiences of the impact of structural racism and bias in caring for patients. I bring the knowledge that so many of you here have shared with me about the way that our healthcare system makes it hard to maintain joy in the practice of medicine. I bring the innovative solutions that I have learned though my clinical research on how to lift up the voices that often go unheard and left behind, but which are needed to help us grow and improve. Most of all, I will bring my passion and my relentless tenacity as I work with SDCMS and collaborate with all of you as we continue to make healthcare better for all of us. Thank you all.



Note: Dr. Flores was unable to attend the gala due to his daughter’s wedding. His speech was kindly delivered for him by former SDCMS President Holly B. Yang, MD, MD, MSHPEd, HMDC, FACP, FAAHPM.

Sergio R. Flores, MD, Immediate Past President SDCMS

2022 Gala Speech 6


I WOULD LIKE TO THANK EVERYONE for attending tonight. It seems like it has only been a few months since I took over as president a year ago. Although I would have loved to be here in person, my daughter’s rehearsal dinner won out. There were many plans to accomplish, but with the pandemic there have been limited opportunities. Given the restrictions, we never had the chance to visit local high schools, colleges, or universities to talk to students and encourage them to pursue a career in the medical field. This is an extremely important goal for us to continue to work on, given the upcom-

ing retirement of our aging medical staff and the critical need to increase diversity in our field to reflect the communities we serve. Despite the pandemic, we were able to have an in-person Board retreat and educational session in September during a low point in the virus where we were able to get to know each other better as we had previously only been able to meet by Zoom since 2020. It was the first time some of our newer board members had a chance to meet everyone. It was a great event appreciated by all those who were there. The UCSD Medical School graduation last year was held virtually, so I was only able to give a short recorded congratulatory message from our Medical Society. Happily, the White Coat Ceremony in August was held in person, so I was able to attend and give a welcome speech to the incoming class. It was great to see all of the bright-eyed medical students and their proud families and friends. It brought back memories of not only my own, but also my son’s UCSF White Coat Ceremony. As part of my address, I encouraged them to get involved as future physician advocates. We need to continue to foster medical student participation in organized medicine as they are an important voice and our future. As part of the California Medical Association, we were able to defeat the attack that would have devastated the Medical Injury Compensation Reform Act, or MICRA — the 1975 law which has provided a balance between compensatory justice for injured patients while providing safeguards to out-of-control medical lawsuits and maintaining access to healthcare for Californians. We were able to provide leadership and work with a coalition to come to a balanced compromise on non-economic damages and keep all of the safeguards of the original law through the new MICRA Modernization Act. We were also prepared to defeat the now-with-

drawn ballot measure threatening MICRA in November if a compromise was not able to be reached. Also, while there has been coordinated negative publicity against the California State Medical Board, as an organized physician community we were able to keep a physician majority on the board, similar to other healthcare-related boards. Ongoing, we will need to continue be a voice seeking positive improvements to the sentiment of the medical board, prioritizing physician safe practice and support. Just as we transitioned from inperson visits to mostly telemedicine with the pandemic, we now seem to be transitioning back to most patients being seen in person. There is no doubt that telemedicine will continue in one form or another as long as we continue to be compensated for the care that we provide. We will need to continue to be strong advocates for access to care both in-person and virtually through infrastructure, reimbursement, and good policy. Although less frequent now, the SDCMS COVID Clinical Town Halls we host in collaboration with San Diego County Health and Human Services and the Hospital Association of San Diego and Imperial Counties have continued, and I thank Holly, Jim Schultz, and everyone else who has participated in these educational sessions. They keep us all well informed — even this gastroenterologist! The lingering pandemic has had its up and downs, and just as we think it is winding down, the numbers start to pick up again with each new variant. Despite the increase in the number of documented infections, even though most people now are only testing themselves at home, hospitalizations have not currently increased at the same rate. This is due to our vaccination efforts and probably in some part to some acquired immunity from prior infections. It seems we all know someone who has been infected with minimal symptoms,

such as a cough or sore throat, since the Omicron variant. However, we are still required to quarantine given our work caring for those at highest risk of serious illness and death, which in turn affects our healthcare workforce availability and stress caused by staff shortages. It remains to be seen what happens next with this pandemic as well as its enduring impact on our community, and I hope you know that SDCMS will be here to help the physicians of our county meet each challenge with as much support and information as possible. Despite stressful times, our foundation, Champions for Health, is thriving. Champions helped to vaccinate thousands of patients over the past year, as well as to help provide much-needed medical care to those without other options through Project Access. We celebrated a wonderful and very moving soirée to support Champions for Health at the Air and Space Museum. Winning the 50-50 raffle was very exciting, for a few seconds — then I saw Tina staring at me and knew we would be donating it back! Participating in Project Access continues to be a very rewarding experience for myself and many other physicians. We welcome other physician volunteers, as they will always be needed, so check out championsforhealth.org for more information. I would like to thank our fantastic CEO and staff: Paul, Jen, Brandon, and Hanna for making this year a breeze. I would also like to thank the Executive Committee and Board for volunteering their time and efforts during this very difficult year. Lastly, I would really like to thank Holly for all of her help and guidance over the year. Please join me in welcoming Dr. Toluwalasé Ajayi as our new president. I know that she will be a great leader of our Medical Society! Although you will not need it, Lasé, I offer you my help anytime. PS: The owner’s manual is in the second drawer of Paul’s desk.



Gala Awards Dr. Christian Ramers: James T. Hay, MD Award Note: The following is the speech given by former SDCMS President Holly B. Yang, MD,MSHPEd, HMDC, FACP, FAAHPM, in presenting the James T. Hay, MD Award to Dr. Ramers. I HAVE THE GREAT PRIVILEGE OF not only giving Dr. Flores’ speech for him, but I also get to give out one of the awards! In 2019, the SDCMS Executive Committee decided to rename the Atlas Award to be the James T. Hay, MD Award in honor of Dr. Jim Hay, who retired in 2020 after 48 years of service in family medicine and the practice he started, North Coast Family Medical Group. A Navy veteran, Dr. Hay is also a past president of SDCMS and CMA, was speaker of the house for CMA, and was a delegate to the American Medical Association for many years. He helped found Champions for Health and currently serves on the board for the CMA foundation Physicians for a Healthy California. Dr. Hay’s dedication to the wellbeing and health of patients and physicians is truly exceptional, and so the award that carries his name has been designated to be given to someone who has shown years of exemplary service to SDCMS,



San Diego physicians, and the San Diego community. Upon learning of the name change to the award last year, in true Dr. Hay fashion, Jim donated funds to create an endowment for a $1,000 stipend to be given the awardee, with any additional earnings going to support Champions for Health. Jim wanted you all to know he really wanted to be here, but a weak and painful leg he’s been suffering from prevented him from joining us. He wanted me to tell you that he continues to be honored to be the award’s namesake and he is very proud of this year’s awardee, Dr. Christian Ramers, for having been

selected for 2022. I have known Christian for many years, initially through our work in graduate medical education. During the COVID pandemic, he has heard from me more times than he probably cares to count (by the way, Christian, we have another town hall at the end of the month — I’ll email you), yet he has always been enthusiastic and thoughtful as a physician, educator, and advocate. For those of you who don’t know him, Dr. Ramers went to medical school at UCSD, did his residency in internal medicine and pediatrics at Duke, and did a fellowship in infectious disease and earned

a master’s in public health at the University of Washington focusing on HIV and global health. He is also board certified in addiction medicine. Christian is chief of population health and director of graduate medical education at Family Health Centers of San Diego. He is also an associate clinical professor in the division of infectious diseases at the UCSD School of Medicine. Dr. Ramers’ clinical interests focus on HIV, hepatitis B and C, and caring for the medically underserved, immigrant, and refugee populations. He consults for the California Office of AIDS, the CDC, and Project ECHO on HIV and hepatitis C-related clinical care initiatives, and is a co-investigator on several NIH-sponsored research projects. He was doing all that in the Before Times. Since COVID, Christian has helped Family Health Centers rapidly adapt to provide care not only to its

regular patient population, but also to our San Diego community at large. With Christian’s leadership they have provided bilingual education, vaccination, testing, monoclonal antibodies, remdesivir, and oral COVID treatments to the community. Dr. Ramers has collaborated with the County and other Federally Qualified Health Centers to integrate access to these treatments for people across San Diego. He has done countless interviews with media to get accurate information to the public and fight the rampant misinformation about COVID, masks, and vaccines. He has been a part of multiple San Diego County Public Health Misinformation Panels established to review and counter COVID-19 misinformation shared during public commentary at the County Board of Supervisors Meetings. He has been a regular panelist to provide up-to-date education

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for physicians at our COVID Clinical Town Halls. Christian also has been providing his expertise nationally and internationally through multiple organizations, including an important series on long COVID through Project ECHO. Christian’s CV is impressive, but the thing that strikes me most about him is that he is 100% personally invested. He is in the trenches doing the hard work despite the risk, long hours, and sometimes negative response from the public during this pandemic. I respect and admire him so much for his leadership, teacher’s heart, expert clinical care, and patient advocacy. A big thank-you to Christian’s family and colleagues for your support of him. We are lucky to have him in our San Diego physician community. Please join me in congratulating Dr. Christian Ramers on being the 2022 James Hay award recipient!

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2022 an evening to celebrate 152 YEARS OF HEALING






Politics and Pandemic Fatigue Doom California’s COVID Vaccine Mandates BY RACHEL BLUTH



California Democrats vowed to adopt the toughest COVID vaccine requirements in the country. Their proposals would have required most Californians to get the shots to go to school or work — without allowing exemptions to get out of them. Months later, the lawmakers pulled their bills before the first votes. One major vaccine proposal survives, but faces an uphill battle. It would allow children ages 12 to 17 to get a COVID-19 vaccine without parental permission. At least 10 other states permit some minors to do this. Democrats blamed the failure of their vaccine mandates on the changing nature and perception of the pandemic.



They said the measures became unnecessary as case rates declined earlier this year and the public became less focused on the pandemic. Besides, they argued, the state isn’t vaccinating enough children, so requiring the shots for attendance would shut too many kids out of school. Political pressure from business and public safety groups and from moderate Democrats — along with vocal opposition from anti-vaccine activists — also contributed. Now, even as case rates start to balloon again, the window of opportunity to adopt COVID vaccine mandates may have closed, says Hemi Tewarson, executive director of the National Academy for State Health Policy. “Given the concerns

around mandates and all the pushback states have received on this, they’re hesitant to really move forward,” Tewarson explains. “Federal mandates have stalled in the courts. And legislation is just not being enacted.” Other states have also largely failed to adopt COVID vaccine requirements this year. Washington, DC, was the only jurisdiction to pass legislation to add the COVID vaccine to the list of required immunizations for K-12 students once the shots have received full federal authorization for kids of those ages. A public school mandate adopted by Louisiana in December 2021 was rescinded in May. The most popular vaccine legislation has been to ban COVID vaccine mandates of any kind, which at least 19 states did,

according to the National Academy for State Health Policy. In California, the landscape has shifted radically in just a few months. In January, a group of progressive Democrats unveiled eight bills to require vaccinations, combat misinformation, and improve vaccine data. Two were sweeping mandates that would have required employees of most indoor businesses to get shots and added COVID vaccines to the list of immunizations required for schools. “It’s important that we continue to push for vaccine mandates the most aggressively we possibly can,” state Assembly member Buffy Wicks (D-Oakland) told KHN in early 2022. She was the author of the workplace mandate bill. But the legislation imploded almost immediately. In March, Wicks’ worker vaccine mandate proposal died. It was strongly opposed by firefighter and police unions, whose membership would have been subject to the requirement. “I don’t think the anti-vaxxers carry much weight in Sacramento with my colleagues,” Wicks said. “They’re a pretty insignificant part of the equation.” The public safety unions “are the ones that carry the weight and influence in Sacramento,” she said. California Professional Firefighters and other public safety groups argued in written opposition to the bill that mandates would interfere with their ability to negotiate employment requirements with their employers. “To summarily remove these bargained policies with a blanket mandate sets a dangerous and demoralizing precedent,” wrote the group, which represents 30,000 firefighters. Schools were also supposed to be subject to a strict vaccine mandate. In October 2021, Democratic Gov. Gavin Newsom announced that California would become the first state to require shots for schoolchildren starting in July 2022. That deadline has since been pushed back to at least July 2023. And Newsom’s order came with a loophole that will allow parents to opt their kids out by claiming a “personal belief” exemption. In January, when California routinely topped 100,000 new cases a day, lawmakers introduced legislation to prohibit personal belief exemptions for COVID

vaccines — those are not allowed for any other required childhood vaccines. Again, they soon backed off, saying the vaccination rate among kids was so low that shots shouldn’t be required until they’re broadly available in pediatrician offices. About 60% of eligible Californians are fully vaccinated and have received a booster shot, while only 35% of kids ages 5 to 11 have received their first two doses, according to the California Department of Public Health. Boosters were approved for children in mid-May. Instead of implementing mandates, the state should focus on educating and reaching out to parents, says Assembly member Akilah Weber (D-San Diego), an ob-gyn who was among the legislators who introduced the package of vaccine bills. “It’s hard to make that argument that right now we need to be mandating when you have a good number of people who feel like we are past the pandemic,” she says. Lawmakers could resurrect the mandate bills, she says, if hospitals and healthcare workers become overwhelmed again. Cases are rising statewide. The rate of positive COVID tests has been as high as 7% in recent days, its highest level since February — and likely an undercount because of the people who are testing at home and not reporting results. Weber’s suggestion to better engage parents helps explain why the legislation failed, says Robin Swanson, a Democratic political consultant based in Sacramento. State and local officials never clearly communicated with the public about vaccinating kids, she explains, and didn’t effectively reach out to vulnerable populations from the outset. “You can’t build a mandate on top of distrust,” Swanson says. Outreach and public information are critical, according to Dr. John Swartzberg, a clinical professor emeritus of infectious diseases and vaccines at the University of California-Berkeley School of Public Health. But if those were paired with a mandate, he explains, the state could vaccinate and protect many more children. “In businesses that mandate vaccines, it works pretty well,” Swartzberg says. “And in schools, in particular, it works very well.”

Pro-vaccine activists who vowed to have a greater presence in the California Capitol this year also thought mandates would dramatically boost vaccination rates. But as reality set in, they shifted their focus to boosting funding for vaccination and pushing surviving bills across the finish line. “Yes, we do need vaccine requirements, and, yes, they do work,” says Crystal Strait, who leads the pro-vaccination organization ProtectUS. But she acknowledges that the situation had changed since January and said her group had to change with it: “We can’t be as simplistic as just a vaccine requirement,” she explains. Newsom’s latest state budget proposal includes $230 million for vaccine outreach and $135 million for vaccine distribution and administration. Strait’s group plans to combat vaccine misinformation among the public and wary lawmakers, including those within the Democratic ranks. “You have people saying they’re pro-science and pro-public health, but when push comes to shove, they’re not there yet,” Strait says of hesitant legislators. Generally, vaccine mandates are popular with the public. According to a March survey from the Public Policy Institute of California, 57% of Californians favored requiring people to provide proof of vaccination to go to large outdoor gatherings or enter some indoor venues like bars and restaurants. But Rose Kapolczynski, a Democratic strategist who worked on the pro-vaccine lobbying push with Strait, likened vaccine beliefs to climate change: Voters say they care, but other, more tangible issues, such as gas prices and reproductive rights, become more urgent to them. “If things were as bad now as they were in January and February, there would be more concern and action,” says Catherine Flores-Martin, executive director of the pro-vaccine California Immunization Coalition. “I’m disappointed that people are not taking the long view.” Rachel Bluth is a correspondent for California Healthline and covers the state legislature in Sacramento. This story was produced by KHN, where it appeared and which publishes California Healthline, an editorially independent service of the California Health Care Foundation.




Patients Seek Mental Healthcare From Their Doctor But Find Health Plans Standing in the Way BY ANERI PATTANI



patient visited Dr. William Sawyer’s office after recovering from COVID, the conversation quickly turned from the coronavirus to anxiety and ADHD. Dr. Sawyer — who has run a family medicine practice in the Cincinnati area for more than three decades — says he spent 30 minutes asking questions about the patient’s exercise and sleep habits, counseling him on breathing exercises, 14


and writing a prescription for attentiondeficit/hyperactivity disorder medication. At the end of the visit, Dr. Sawyer submitted a claim to the patient’s insurance using one code for obesity, one for rosacea — a common skin condition — one for anxiety, and one for ADHD. Several weeks later, the insurer sent him a letter saying it wouldn’t pay for the visit. “The services billed are for the treatment of a behavioral health condition,” the letter said, and under the

patient’s health plan, those benefits are covered by a separate company. Dr. Sawyer would have to submit the claim to it. But Dr. Sawyer was not in that company’s network. So even though he was in-network for the patient’s physical care, the claim for the recent visit wouldn’t be fully covered, Dr. Sawyer says. And it would get passed on to the patient. As mental health concerns have risen over the past decade — and reached new heights during the pandemic — there’s a push for primary care doctors to provide mental healthcare. Research shows primary care physicians can treat patients with mild to moderate depression just as well as psychiatrists — which could help address the nationwide shortage of mental health providers. Primary care doctors are also more likely to reach patients in rural areas and other underserved communities, and they’re trusted by Americans across political and geographic divides. But the way many insurance plans cover mental health doesn’t necessarily support integrating it with physical care. In the 1980s, many insurers began adopting what are known as behavioral health carve-outs. Under this model, health plans contract with another com-

pany to provide mental health benefits to their members. Policy experts say the goal was to rein in costs and allow companies with expertise in mental health to manage those benefits. Over time, though, concerns arose that the model separates physical and mental healthcare, forcing patients to navigate two sets of rules and two networks of providers, and to deal with two times the complexity. Patients typically don’t even know whether their insurance plan has a carve-out until a problem comes up. In some cases, the main insurance plan may deny a claim, saying it’s related to mental health, while the behavioral health company also denies it, saying it’s physical. “It’s the patients who end up with the short end of the stick,” says Jennifer Snow, head of government relations and policy for the National Alliance on Mental Illness, an advocacy group. Patients don’t receive the holistic care that’s most likely to help them, and they might end up with an out-of-pocket bill, she explains. There’s little data to show how frequently this scenario — either patients receiving such bills or primary care doctors going unpaid for mental health services — happens. But Dr. Sterling Ransone Jr., president of the American Academy of Family Physicians, says he has been receiving “more and more reports” about it since the pandemic began. Even before COVID, studies suggest, primary care physicians handled nearly 40% of all visits for depression or anxiety and prescribed half of all antidepressants and anti-anxiety medications. Now with the added mental stress of a two-year pandemic, “we are seeing more visits to our offices with concerns of anxiety, depression, and more,” Dr. Ransone says. That means doctors are submitting more claims with mental health codes, which creates more opportunities for denials. Physicians can appeal these denials or try to collect payment from the carve-out plan. But in a recent email discussion among family physicians, which was later shared with KHN, those running their own practices with little administrative support said the time

spent on paperwork and phone calls to appeal denials cost more than the ultimate reimbursement. Dr. Peter Liepmann, a family physician in California, told KHN that at one point he stopped using psychiatric diagnosis codes in claims altogether. If he saw a patient with depression, he coded it as fatigue. Anxiety was coded as palpitations. That was the only way to get paid, he says. In Ohio, Dr. Sawyer and his staff decided to appeal to the insurer, Anthem, rather than pass the bill on to the patient. In calls and emails, they asked Anthem why the claim for treating obesity, rosacea, anxiety, and ADHD was denied. About two weeks later, Anthem agreed to reimburse Dr. Sawyer for the visit. The company didn’t provide an explanation for the change, he says, leaving him to wonder whether it’ll happen again. If it does, Dr. Sawyer’s not sure the $87 reimbursement is worth the hassle. “Everyone around the country is talking about integrating physical and mental health,” Dr. Sawyer says. “But if we’re not paid to do it, we can’t do it.” Anthem spokesperson Eric Lail said in a statement to KHN that the company regularly works with clinicians who provide mental and physical healthcare on submitting accurate codes and getting appropriately reimbursed. Providers with concerns can follow the standard appeals process, he wrote. Kate Berry, senior vice president of clinical affairs at AHIP, a trade group for insurers, says many insurers are working on ways to support patients receiving mental healthcare in primary care offices — for example, coaching physicians on how to use standardized screening tools and explaining the proper billing codes to use for integrated care. “But not every primary care provider is ready to take this on,” she says. A 2021 report from the Bipartisan Policy Center, a think tank in Washington, DC, found that some primary care doctors do combine mental and physical healthcare in their practices but that “many lack the training, financial resources, guidance, and staff” to do so. Richard Frank, a co-chair of the task force that issued the report and director of the University of Southern California-

Brookings Schaeffer Initiative on Health Policy, put it this way: “Lots of primary care doctors don’t like treating depression.” They may feel it’s outside the scope of their expertise or takes too much time. One study focused on older patients found that some primary care doctors change the subject when patients bring up anxiety or depression and that a typical mental health discussion lasts just two minutes. Doctors point to a lack of payment as the problem, Frank says, but they’re “exaggerating how often this happens.” During the past decade, billing codes have been created to allow primary care doctors to charge for integrated physical and mental health services, he explains. Yet the split persists. One solution might be for insurance companies or employers to end behavioral health carve-outs and provide all benefits through one company. But policy experts say the change could result in narrow networks, which might force patients to go out of network for care and pay out-of-pocket anyway. Dr. Madhukar Trivedi, a psychiatry professor at the University of Texas Southwestern Medical Center who often trains primary care doctors to treat depression, says integrated care boils down to “a chicken-and-egg problem.” Doctors say they’ll provide mental healthcare if insurers pay for it, and insurers say they’ll pay for it if doctors provide appropriate care. Patients, again, lose out. “Most of them don’t want to be shipped off to specialists,” Dr. Trivedi says. So when they can’t get mental healthcare from their primary doctor, they often don’t get it at all. Some people wait until they hit a crisis point and end up in the emergency room — a rising concern for children and teens especially. “Everything gets delayed,” Dr. Trivedi says. “That’s why there are more crises, more suicides. There’s a price to not getting diagnosed or getting adequate treatment early.” Aneri Pattani is a correspondent for Kaiser Health News, where this article first appeared, and reports on a broad range of public health topics, focusing on mental health and substance use.




Omicron Less Likely to Cause Long COVID, Data Suggest Odds of Long COVID As High As 50% Less During Omicron Era BY JUDY GEORGE


HE SARS-COV-2 OMICRON variant may pose less risk for long COVID than the delta variant, UK researchers reported. About 4.5% of people who became infected with SARS-CoV-2 when omicron was the dominant strain experienced long COVID symptoms, compared with 10.8% who became infected during the delta period, reported Claire Steves, PhD, of King’s College London in England, and co-authors. Overall odds of long COVID were about 20% to 50% less during the omicron era — defined as December 2021 to February 2022 in this study — depending on age and time since vaccination, the researchers wrote in a letter to The Lancet. “While the risk of long COVID with omicron breakthrough infection is lower than delta, given the large number of people infected with omicron, there will be a significant increase in the number of long haulers as a result of omicron,” 16


noted Akiko Iwasaki, PhD, of Yale University, who wasn’t involved with the study. “We need to keep our guards up to prevent infection, even if we are vaccinated,” Iwasaki told MedPage Today. “We need to keep our masks on to prevent infection.” “Ultimately, we need a vaccine that can prevent infection or at least reduce the amount of replicating virus upon infection to prevent long COVID,” she added. “This would require mucosal immunity induced by nasal vaccines.” The findings were based on selfreported data from the UK ZOE Health Study COVID symptom app. The study included people who had a positive real-time PCR or lateral flow antigen test for SARS-CoV-2 after vaccination and no previous SARS-CoV-2 infections before vaccination. Long COVID was defined by National Institute for Health and Care Excellence (NICE) guidelines as having new or ongoing symptoms four weeks or more after

the start of acute COVID-19. Participants reported a wide range of symptoms prospectively. Steves and co-authors identified 56,003 adults who first tested positive between Dec. 20, 2021, and March 9, 2022. These people were referred to as omicron cases, as more than 70% of cases in the UK were attributed to omicron at that time. They also found 41,361 adults first testing positive between June 1 and Nov. 27, 2021, referred to as delta cases. The researchers included both symptomatic and asymptomatic infections. For the omicron period, they included only participants who tested positive before Feb. 10, 2022. Both periods had more women than men (55% for omicron and 59% for delta). In both groups, the average age was 53 and the prevalence of comorbidities was 19%. Among omicron cases, 2,501 people experienced long COVID. Among delta cases, that number was 4,469. For all vaccine timings, omicron cases were less likely to experience long COVID, with ORs ranging from 0.24 (95% CI 0.20-0.32) to 0.50 (95% CI 0.43-0.59). Results stratified by age were similar. Even at 4.5%, the potential burden of long COVID is high, Steves noted in a statement. “The omicron variant appears substantially less likely to cause long COVID than previous variants, but still, one in 23 people who catch COVID-19 go on to have symptoms for more than four weeks,” she said. Limitations of the study include its reliance on self-reported data. There was no direct testing of infectious variants and no objective measures of illness duration, Steves and colleagues acknowledged. The study population may not be fully generalizable to the UK population, they added. Judy George covers neurology and neuroscience news for MedPage Today, where she serves as deputy managing editor, and where this article first appeared.

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10 Actions on Addiction An Interprofessional Approach BY RONEET LEV, MD, NATHAN A. PAINTER, PHARMD, CHRISTY COTNER, DNP 1. Eliminate Stigma Through Clinical Understanding Substance Use Disorder (SUD), is a treatable chronic relapsing disease of the brain. Over 21 million Americans over 12 years old have an SUD. Drugs cause surges of dopamine and with continued use can downgrade the number of dopamine receptors. This new high dopamine set point becomes a baseline to just feel normal. Relapse rates for SUD are similar to those of diabetes, hypertension, and asthma. Relapse can occur at any point during recovery. Would you kick out a patient with diabetes for missing a dose of insulin? Asking patients about their methodology of previous sobriety can guide recommendations. Stigma is discrimination against an identifiable group of people. In a medical setting, stigma is manifested by annoyance at patients with SUD, giving them less of your time, dismissing their medical complaints, or kicking them out of your practice. It is normal to be frustrated by lack of resources or knowledge in helping to treat SUD — that’s why healthcare providers can partner and utilize community resources. Using first-person language is less stigmatizing. Use “a person with substance use disorder” rather than “addict” or “junkie.” It is not easy to change your language, it takes time and practice.

2. Expand Your Social History to Motivate Change Go beyond asking, “Do you smoke, drink, or use drugs?” The social history is an opportunity for education on tobacco, alcohol, and drugs. If you get a positive response, expand. For alcohol, ask, “How many drinks a week?” More than seven drinks for women or 14 for men defines at-risk drinking. For marijuana, ask about age of onset, method of use (smoke, vape, edibles), and frequency. You can change someone’s life by teaching a person that the brain is growing until age 25 and is up to seven times more susceptible to addiction during growth. Inquire about your patient’s recovery as part of a routine checkup. Ask, “How are you doing in your recovery?” Praise your patients for cessation of tobacco, alcohol, vaping, or drugs. If they are still using drugs or alcohol, ask if they want help in treatment.

3. SBIRT: Screening and Brief Intervention and Referral to Treatment SBIRT is a billable interven-

tion and is a short intervention that goes along with the expanded social history. Screening assesses the severity of substance use and identifies the appropriate level of treatment. Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care. SBIRT: https://www.samhsa. gov/sbirt

4. Make the Family History Relevant Providers often ask about family history of cancer or heart disease. If someone has a substance use disorder, ask about a family history of SUD. This can lead to an impactful conversation. Addiction may run in the family, but it does not have to be a patient’s destiny.

5. Check for Drug Interactions There are more than 500 medications that interact with CBD and more than 300 that interact with THC. Have your patient use Drugs.com interaction checker. They can enter their prescription medications and add cannabis (for THC) or cannabidiol (for CBD) and check for interactions. A life-threatening drug interaction is blood thinners with cannabis products, which can cause excessive bleeding.

6. Add Fentanyl to All Urine Drug Screens Fentanyl is the leading cause of death in the United States for ages 15–45, more than COVID or suicides. Of 18


more than 100,000 overdose deaths in 2021, over 60% of deaths were driven by fentanyl. Therefore, fentanyl testing should be included as part of any rapid turnaround urine drug panel. The standard opioid drug screen does not include synthetic opioids such as fentanyl or tramadol. The opioid test may or may not include oxycodone. California SB 864, Tyler’s bill will require all California hospitals to include fentanyl when a urine drug panel screen is ordered. A positive fentanyl test can make a clinical difference by: (1) Educating the patient; (2) Informing the provider; (3) Prompting a prescription for naloxone; (4) Motivating the patient to change behavior; and (5) Assisting outpatient clinics that do not have access to rapid testing. Fentanyl Tool Kit: https:// www.sdpdatf.org/fentanyltoolkit

7. Practice Safe Prescribing of Various CNS Depressants CNS depressants chemicals are additive. That includes opioids, benzodiazepines, sleep aids, stimulants, and cannabis. The appropriate dose of each medication used in combination can result in oversedation or overdose. Checking CURES is important for coordinating prescriptions from multiple providers. A word of caution on tramadol. Some providers are mistaken that tramadol is not an opioid or addicting. In fact, tramadol is a synthetic opioid with the same addictive factors as all opioids. The morphine

milligram equivalent for tramadol 50 mg is similar to hydrocodone 5mg. The risks of tramadol include serotonin effects and therefore must be used with caution in patients with seizures or on certain antidepressants. After opioids, benzodiazepines are the drug class most commonly involved in both intentional and unintentional pharmaceutical deaths (30%). Fifty percent of patients with an SUD will develop a benzodiazepine use disorder. Benzodiazepines are never first-line agents for anxiety or sleep. First-line medication treatment for anxiety disorders are SSRIs or SNRIs. First-line treatment for insomnia is cognitive behavioral therapy before medication. Alprazolam (Xanax) is the most frequently abused benzodiazepine. The medication has a rapid onset and short half-life. It should be limited to the prn treatment of panic disorder rather than regular monthly prescriptions. Benzodiazepine Academic Detailing: https://www.pbm. va.gov/PBM/AcademicDetailingService/Documents/ Benzodiazepine_Provider_AD_Educational_Guide. pdfControlled Substance Utilization Review and Evaluation System (CURES) https://cures.doj.ca.gov/

8. Treat Substance Use Disorder First-line addiction treatment should be part of primary care, similar to diabetes, hypertension, and asthma. Difficult cases may require specialty care, but routine care should be attempted.

Medications for addiction include nicotine replacement therapy for tobacco. Alcohol use disorder can be treated with naltrexone, acamprosate, or disulfiram. Opioid use disorder can be treated with buprenorphine. It takes just a few minutes to obtain an X-waiver to prescribe buprenorphine without mandatory education for up to 30 patients. https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner. Learning how to use buprenorphine is easy. California Bridge program has a quick start guide for buprenorphine and resources for patients. The California Substance Use Line (844) 326-2626, is available 24/7 and staffed by experienced physicians and pharmacists. Treating SUD overlaps with treatment of Any Mental Illness (AMI). Half of all individuals with SUD have AMI. Ideally, treatment of the two conditions should be coordinated. California Bridge Buprenorphine Quick Guide: https:// cabridge.org/tools/on-shift/. California Bridge: Buprenorphine What You Need to Know — for patients https://cabridge.org/resource/buprenorphinewhat-you-need-to-know/) California Substance Use Line: 844-326-2626 https://nccc. ucsf.edu/clinician-consultation/substance-use-management/ california-substance-use-line/

9. Prescribe Naloxone Illicit fentanyl has poisoned the drug supply including heroin, methamphetamine, cocaine, marijuana, and vaping products. It has been found in counterfeit pills of hydrocodone, oxycodone, Xanax, Viagra, and Adderall. That is why naloxone should be given to anyone who uses any drugs obtained outside a pharmacy. It should be given to family and friends as a backup plan.

10. Document Specific Drug Use Health policy is based on provider ICD-10 code diagnosis. Providers are requested to be specific with drug related conditions. Instead of stating “drug overdose” or “drug use,” document the specific drugs. If you can’t find a code, use the word “poisoning” - Alcohol poisoning, Methamphetamine poisoning, Cannabis poisoning, etc. Free Opioid Stewardship Session: For guidance on patients with complicated pain management issues, the Champions for Health team of physicians, pharmacists, and nurse practitioners can provide virtual sessions on opioid stewardship to meet your needs. To schedule a free, 30-minute session, please contact Katy Rogers at katy.rogers@ championsfh.org or call (619) 508-4460. Dr. Lev is an emergency/addiction physician with Scripps Mercy Hospital. Dr. Painter is a clinical pharmacist with UC San Diego Skaggs School of Pharmacy. Dr. Cotner is a nurse practitioner with Riverside Medical Clinic. All three are academic detailers and curriculum developers for the Innovations and Smart Approaches in Safe Opioid Prescribing modules with Champions for Health, funded through the Overdose Data to Action Cooperative Agreement between SDHHSA and the CDC.




What We Learn by Living Between Two Kingdoms BY HELANE FRONEK, MD, FACP, FASVLM, FAMWA



my craving to read “one more page” often leads me to read through the night to the last page. I love books that draw me in and make me think. Suleika Jaouad’s Between Two Kingdoms is that kind of book. Throughout Jaouad’s account of her illness after being diagnosed with AML at just 22 years old, I was struck not only by her perceptions and insights but by what we physicians might learn from her experiences. There are obvious lessons, such as the importance of asking patients what they are most concerned with rather



than assuming that our concerns are theirs. When caring for patients with life-threatening illness, we often narrow our focus to saving their life, easily forgetting that young patients might want to protect their possibility of fertility, frequently decimated by chemotherapy. When disease or treatment produces remote collateral damage, such as dyspareunia secondary to chemotherapy-induced menopause, we will fail to provide important guidance if we neglect to ask if patients have other concerning issues. After hearing this suggestion years ago, I began asking patients what their concerns were. I was often surprised by their

answers and always grateful they shared those concerns so I could help with what was important to them. But what stayed with me most from this haunting and beautiful book was the ruthless honesty Jaouad grows into, refusing to hide from the truth of her experiences, thoughts, feelings or behavior. With great candor, she shares priceless insights into struggles that we and our patients face: the need to feel independent amid the terror of being abandoned, while knowing how dependent we really are; the desire to have our struggles acknowledged amid the wish to project strength; and the yearning to share our fears amid our concern we will be judged. Imposter syndrome, burnout, and suicide are too common among physicians, in large part because our culture discourages and impedes this type of openness. Honesty can feel like a risky choice, often making us feel more vulnerable. As Jaoad travels across the country, visiting others who have suffered illness or loss, she finds people whose tragedies have also caused them to choose greater honesty. Can we make this choice before we encounter such tragedy in our lives? Finally, the book’s title describes the challenge that patients have of living between the kingdoms of the sick and the healthy. Even as we celebrate their “recoveries,” patients often struggle to find new footing in life. No longer sick enough to be hospitalized, they forever carry a diagnosis or side effects of treatment — reminders of how quickly the illusion of health can shatter. After a friend who was on the cusp of starting an exciting new life suffered a seizure — the first symptom of a glioblastoma — I understood that we never know what the next moment of our life will bring. We all live between the two kingdoms. How we choose to do that — with compassion or judgment, honesty or pretense — will determine the richness of whatever time we have. Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach, CPCC, PCC.


PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew. Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org. PHYSICIAN OPPORTUNITIES ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY – Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https://apol-recruit.ucsd.edu/JPF03179 For help contact: klsantos@health.ucsd.edu CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to albertochaviramd@yahoo.com. 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 boardcertified/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. TUBERCULOSIS CONTROL & REFUGEE HEALTH CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked here - https://www.governmentjobs.com/careers/ sdcounty/jobs/3223044/chief-tb-control-refugee-healthpublic-health-medical-officer-21412809uth PUBLIC HEALTH SERVICES MEDICAL CONSULTANT M.D., D.O: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs.com)<https://www.governmentjobs.com/careers/sdcounty/jobs/3148610/m-d-d-o-

medical-consultant-21416207?keywords=medical%20consult ant&pagetype=jobOpportunitiesJobs 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 Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810-8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego 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

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 four fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information, please contact Christine Van Such at (858) 354-1895 or email mahdavim3@gmail.com OFFICE SPACE / REAL ESTATE AVAILABLE CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2,000 sf, 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, BANKERS HILL: Approximately 500 sq. 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. Three examination rooms, two physician offices and a small kitchen area. 1,700 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) 4273328 or email at Feminacareo@gmail.com OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE WANTED IN HILLCREST/ BANKERS HILL AREA: Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@sbcglobal.net or (858) 945-0903. MEDICAL 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.



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