August 2018

AUGUST 2018 OFFICIAL PUBLICATION OF SDCMS

APPROACHES TO MENTAL HEALTH IN SAN DIEGO COUNTY

N O R C A L

G R OU P

OF

COMPANIES

MEDICAL PROFESSIONAL LIABILITY INSURANCE

PHYSICIANS DESERVE Offering top-tier educational resources essential to reducing risk, providing versatile coverage solutions to safeguard your practice and serving as a staunch advocate on behalf of the medical community.

Talk to an agent/broker about NORCAL Mutual today.

NORCALMUTUAL.COM | 844.4NORCAL

© 2016 NORCAL Mutual Insurance Company MAY 2017

B

nm5001

Benefits the Community Wellness & Diabetes Prevention Programs at

5th Annual

SATURDAY, NOVEMBER 10 FLETCHER COVE, SOLANA BEACH Honorary Chair, County Supervisor Kristin Gaspar 2:00p Registration & Wellness Expo 3:30p 5K Run/Walk Start South

ern C alifo ONLY rnia‛s Sunse t Bea ch Ru n

Presented By:

e

Early Bird: $40 After Oct 1: $45 Day of: $50

Liv

ic

us

M

Food

po Fitness Ex

In Partnership With:

5575 Ruffin Rd., Ste 250, San Diego, CA 92123 www.SB5K.org 619.381.1632

AUGUST

CONTENTS

VOLUME 105, NUMBER 8

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 SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: David E. J. Bazzo, MD President-elect: James H. Schultz, MD Secretary: Holly B. Yang, MD Treasurer: Sergio R. Flores, MD Immediate Past President: Mark W. Sornson, MD, PhD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Jamie M. Jordan, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Veena A. Prabhakar, DO South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD

features

GEOGRAPHIC ALTERNATE DIRECTORS East County: Heidi M. Meyer, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO

14 Headline Article:

Psst… It’s OK to Talk About Mental Illness in San Diego

BY CATHRYN NACARIO, RN, MHA

17 What a Patient With Mental Illness Wants Doctors to Know

8

BY JULIE BENN

AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD

18 An Integrated Approach to Addiction Care in San Diego County

ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Margaret Meagher

BY NICOLE ESPOSITO, MD, AND LUKE BERGMANN, PHD

22 The Value Of —And Need For — Mental Health Integrated Care

8

BY STEVE KOH, MD, MPH, MBA

Distracting Devices in Healthcare

BY SHELLEY RIZZO, MSN, CPHRM

departments

10

4

San Diego Physician Combines Three Passions in One Project: A Medical Thriller

Briefly Noted • Calendar • CMA Physician Involvement • Membership

6 Op-Ed: SB 1156 Takes California Back to the Bad Old Days

BY THEODORE M. MAZER, MD

BY SDCMS STAFF

12 Burnout Is a System Issue

BY JAMES SANTIAGO GRISOLIA, MD

ADDITIONAL NON-VOTING MEMBERS Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD

26 Physician Marketplace Classifieds

7 Health Net Federal Services Experiences Significant Challenges With TRICARE Transition

2

AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Alexandra E. Page, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD

28

BY CALIFORNIA MEDICAL

Adverse Childhood Experiences and the Potent Beliefs That Undermine Health

ASSOCIATION STAFF

BY HELANE FRONEK, MD, FACP, FACPh

AUGUST 2018

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.]

sdmedicalrealestate.com

sharedAMBITION We are members of your healthcare community – working with you to achieve the best outcomes for your practice. Whether you are renewing a lease, buying a building, relocating or expanding, our medical office expertise and strategic solutions will advance your patient care. While you improve the health of your patients, we improve the health of your real estate.

Healthcare Practice Group | 858.410.1200 Paul Braun | RE lic. #00891709 Chris Ross | RE lic. #01469025 Kelly Moriarty | RE lic. #01963162 © 2018 Jones Lang LaSalle IP, Inc. All rights reserved. All information contained herein is from sources deemed reliable; however, no representation or warranty is made to the accuracy thereof.

Jones Lang LaSalle Brokerage, Inc.© RE lic. # 01856260 SAN DIEGO PHYSICIAN.ORG

3

/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// CALENDAR 2018 NEPO Summit. At the Westin Pasadena: SEPT 13-15 Academy of Integrative Health and Medicine Annual Conference. Sheraton Hotel and Marina San Diego: SEPT 22-26 CSU Institute for Palliative Care National Symposium. At Hyatt Mission Bay: OCT 11-12 UCSD School of Medicine Marks Its 50th Anniversary With Alumni Reunion Weekend: OCT 12-14 Top Doctors Gala at Farmer and the Seahorse Restaurant: OCT 19 SDCMS Physician Mixer & Networking Social, Rock Bottom Brewery, La Jolla.

OCT 25. Please email johmstede@sdcms.org Cardiovascular, Allergy & Respiratory Summit (CARPS) at Wyndham San Diego Bayside. NOV 8-10. Optional workshops NOV 7 Champions for Health 5K Run/Walk at Fletcher Cove in Solana Beach: NOV 10 Pain Care for Primary Care (PCPC) at Wyndham San Diego Bayside. NOV 16-17: Optional Addiction workshop NOV 15.

CMA PHYSICIAN INVOLVEMENT

CMA Now Accepting 2018 Q4 Testimony on Resolutions As part of its policy-making process, the California Medical Association (CMA) allows members to submit resolutions for debate and discussion throughout the year. These resolutions will be considered by the standing Councils and Subcommittees, and will be presented to the Board of Trustees for consideration to be adopted as policy for the association.

There are now 14 new resolutions open for consideration in the fourth quarter of 2018.

• 112-18: A More Appropriate Approach to a Parkinson’s Disease Database • 207-18: Reducing Hassle Factor in Quality Improvement Programs • 208-18: Medication Assisted Treatment (MAT) and Telemedicine • 209-18 Change Immunizations from Medicare Part D to Part B Coverage • 307-18: Live Streaming of CMA BOT Meetings • 308-18: Solo and Small Group Practice Forum Representation • 309-18: Update to CMA Bylaws Re: Delegate and Alternate Representation as Elected • 502-18: Support for Dissemination of Negative Results • 503-18: Divestment From the Gun and Ammunition Industries • 504-18: Gun Violence: Compensation for Healthcare Expenditures • 505-18: Holding the Pharmaceutical Industry Accountable for Opioid-Related Costs • 506-18: Physicians and Jury Duty • 602-18: Reform of the Medical Board of California • 603-18: Closing the Gender Pay Gap In Medicine After testimony closes, the resolutions and all the testimony will be forwarded to the appropriate CMA council or subcommittee for consideration. Member testimony and feedback will be considered by the councils and subcommittees as they make policy recommendations to the Board of Trustees. The trustees will then take action on the recommendations at their next meeting in the first quarter of 2019.

Please click on the CMA website to access the discussion portal for year-round resolutions. You will need to log in with your CMA web account. Before providing testimony, please take a moment to read any background materials and/or analyses, which can be found in the upper right corner of each resolution page.

How to submit a resolution If you are interested in submitting a resolution for consideration in the first quarter of 2018-2019, the submission deadline is Oct. 16, 2018. You are encouraged, however, to submit resolutions well in advance of the deadline to ensure that your policy idea is considered promptly. Submit resolutions for consideration at www.cmadocs.org/resolutions/submit.

Please read the guidelines before submitting a resolution. Resolutions that do not follow the guidelines will be rejected.

Contact: CMA Member Resource Center, (800) 786-4262 or memberservice@cmadocs.org.

4

AUGUST 2018

////////////////////////////////////////////////////////////////////////////////////////////////// MEMBERSHIP

Welcome New and Returning SDCMS-CMA Members!

Welcome Returning Members!

Isaac Bakst, MD Neurology La Jolla (858) 552-8828 David Chang, MD Internal Medicine East County (619) 462-9010 Kristin Cadenhead, MD Psychiatry La Jolla (619) 543-6445 Nancy Graff, MD Pediatrics La Jolla (858) 496-4800

Anna Mizzell, MD Cardiovascular Disease La Jolla (858) 657-8530 Minh Nguyen, DO, MBA, MHA, MPH Occupational Medicine Kearny Mesa (619) 297-9610 Alexander Khalessi, MD Neurological Surgery Hillcrest (310) 906-6861 Garth Jacobsen, MD General Surgery Hillcrest (858) 784-1898

Tudor Hughes, MD Diagnostic Radiology Hillcrest Simerjot Jassal, MD Internal Medicine Hillcrest (619) 543-3692 Daphne Lacoursiere, MD Obstetrics and Gynecology La Jolla (619) 543-7878 Jeffrey Lee, MD Ophthalmology Hillcrest

Welcome New Members!

Stephanie Lessig, MD Neurology North County

Tyson Ikeda, MD Family Medicine North County (858) 657-7750

Natalie Afshari, MD Ophthalmology La Jolla

Dustin Lillie, MD Family Medicine North County

Lori Daniels, MD Cardiovascular Disease La Jolla (858) 657-8530

Jill Buckley, MD Urology Hillcrest (619) 543-2009

Irene Litvan, MD Neurology La Jolla (858) 657-8540

John Kasawa, MD Family Medicine East County (858) 349-8826

Edward Cachay, MD Infectious Disease Hillcrest

Christopher Longhurst, MD Pediatrics Hillcrest (858) 249-6880

Michelle Pelle, MD Dermatology Hillcrest (619) 542-0013 Bryan Leek, MD Orthopaedic Surgery La Jolla (844) 377-7678 Erin Whitaker, MD Internal Medicine Hillcrest (619) 519-9935

Sara Edwards, MD General Surgery Hillcrest (619) 543-7096 Negin Field, MD Family Medicine South County (619) 866-2989 Eduardo Grunvald, MD Internal Medicine La Jolla (858) 657-7237 Kama Guluma, MD Emergency Medicine Hillcrest

Alexander Norbash, MD Neuroradiology Hillcrest (619) 543-2890

Francesca Torriani, MD Infectious Disease Hillcrest (619) 543-8258 Lori Wan, MD Internal Medicine Hillcrest (858) 496-4800

Gregory Polston, MD Anesthesiology La Jolla (858) 457-5002

Gabriel Wardi, MD Emergency Medicine Hillcrest (858) 249-6800

Erin Reid, MD Hematology La Jolla Jamie Resnik, MD Obstetrics and Gynecology North County

Akilah Weber, MD Obstetrics and Gynecology La Jolla (858) 657-8745

Bernice Ruo, MD Internal Medicine La Jolla (858) 657-7000

Philip Weissbrod, MD Otolaryngology Hillcrest (858) 249-4070

Charlotte Sadler, MD Undersea Medicine Hillcrest (858) 249-6800

Douglas Ziedonis, MD Psychiatry La Jolla (858) 657-7000

William Sandborn, MD Internal Medicine La Jolla (619) 543-3247

Jessica Kingston, MD Obstetrics and Gynecology Hillcrest

Robin Seaberg, MD Anesthesiology Hillcrest

Ronald Mathiasen, MD Otolaryngology North County (858) 621-4090

Gregory Seymann, MD Hospitalist North County (619) 471-9186

Marlene Millen, MD Internal Medicine La Jolla (858) 249-5400

Sunny Smith, MD Family Medicine La Jolla (858) 534-6110

Anushirvan Minokadeh, MD Critical Care Medicine (Anesthesiology) Hillcrest (858) 703-4191

Mounir Soliman, MD Psychiatry La Jolla (619) 233-3432

SAN DIEGO PHYSICIAN.ORG

5

A DVO C AC Y

Op-Ed: SB 1156 Takes California Back to the Bad Old Days

By Theodore M. Mazer, M.D.

This op-ed was originally published in The Desert Sun newspaper NOT LONG AGO, health insurance companies limited access to insurance and quality healthcare for millions of Californians using notorious practices like post-claim underwriting to deny patients care the moment they got sick.

Frighteningly, a new bill introduced in Sacramento would drag us back to that past, giving insurance companies broad new powers to decide which kidney dialysis patients would be allowed to keep private insurance coverage for treatment, and which ones would not, based on how their premiums are financed.

Senate Bill 1156, by Sen. Connie Leyva (D-Chino), would allow insurance companies to deny coverage for low-income dialysis patients just because they receive charitable premium assistance to help pay their insurance premiums.

Patients on kidney dialysis depend on

6

AUGUST 2018

machines to do the job of their failed kidneys. They need dialysis treatment three times a week, for three to four hours at a time, to survive. Dialysis is literally a lifesaving treatment.

Because dialysis patients need treatment so often and for such a long period of the day, once diagnosed with kidney failure, many patients can no longer work. As a result, these patients have difficulty maintaining private insurance for themselves and their families. Nonprofit charities often help pay premiums so that these workers can keep private insurance for themselves and their families.

SB 1156 would shut out patients who are dependent on outside help for essential kidney treatment and make it harder for them to find the care they need. It would allow insurance companies to deny coverage just because patients receive charitable assistance. The bill would create a separate and unequal healthcare system — a premium system for those who can afford it,

and one that denies essential health services to people who cannot.

At the same time, SB 1156 would slash what insurance companies must pay to dialysis clinics for treatment of patients who receive charitable assistance, reducing these payments to the Medicare rate, which is notoriously low and barely covers the cost of care. Disturbingly, there is no requirement that insurers must pass along any savings to patients or those insured.

Bottom line? Patients would lose care while insurance companies profit.

This bill is a giveaway to insurance companies that would have disastrous consequences for low-income kidney patients and would inevitably lead to cutbacks in services or even dialysis center closures across the state.

The impacts would be felt particularly hard in areas where access to care is already limited, like rural areas, where there are fewer privately insured patients. Patients could either end up traveling greater distances for treatment or seek treatment in already-overcrowded emergency rooms, where dialysis is far more expensive than in an outpatient clinic.

We must do everything we can to continue to expand access to quality healthcare for those who need it and ensure that medical decisions are being made by medical professionals — not insurance company middlemen who are motivated only by profit.

Healthcare choices should be made based on what’s best for the patient. SB 1156 is a step in the wrong direction that would put poor patients at risk and make it even harder for thousands of kidney patients across California to get the care they need.

CALL TO ACTION FOR SDCMS MEMBERS: Learn how you can impact SB 1156 and other legislation that affects your patients and you by visiting https://www.cmadocs.org/ grassroots-action-center, or sign up for the CMA’s Legislative Hot List to learn about other important bills: https://www.cmadocs.org/ News/Legislative-Hot-List

Dr. Mazer is president of the California Medical Association.

PAY E R I S S U E S A N D R E I M B U R S E M E N T

signed to 3,800 out-of-network PCMs were reassigned to network PCMs (which includes physicians, nurse practitioners and physician assistants). Although HNFS published information about the end of the transition period in its online provider bulletins, the payor did not directly notify the 3,800 PCMs that their TRICARE Prime patients were being reassigned.

HNFS is also experiencing significant provider directory accuracy issues. To address this issue, HNFS has partnered with its parent company, Centene, and LexisNexis to improve the accuracy of its provider directory and expects improvements over the next 30–120 days.

Health Net Federal Services Experiences Significant Challenges With TRICARE Transition

By California Medical Association Staff

ON JAN. 1, 2018, Health Net Federal Services (HNFS) became the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region, serving approximately 2.9 million beneficiaries in 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services (UMVS). The California Medical Association (CMA) has learned that HNFS has experienced implementation issues related to provider contracting and credentialing, beneficiary reassignment to new primary care managers (PCM), and provider directory inaccuracies.

The contracting and credentialing issues in California are reportedly related to problems with HNFS staffing turnover, and include the following: • completed provider contracts that were not entered into the HNFS system;

• HNFS unable to locate countersigned provider contracts; • cases where the contracting or credentialing processes were never completed.

HNFS shared in recent discussions with CMA that it has identified the providers impacted by the breakdowns and is actively working to expedite completion of the credentialing and contracting processes.

Additionally, CMA has learned that as part of the TRICARE transition, DHA allowed TRICARE Prime beneficiaries to receive care from PCMs previously in the UMVS network that were not yet in the HNFS network without incurring out-ofnetwork fees through June 30. The purpose was to allow HNFS additional time to contract with providers and develop its provider network.

When the transition ended, approximately 44,000 California enrollees as-

What Can Physicians Do? Questions about contract status? Physicians with questions about their contracting and/or credentialing status with HNFS can check the HNFS credentialing status tool at www.tricare-west.com. For additional information, contact Megan Herrera, Director of HNFS Provider Network Management, at (619) 285-3607 or megan.herrera@hnfs.com.

Affected by patient reassignment? Physicians affected by the reassignment of patients to a HNFS network PCM who are interested in participating in the HNFS provider network can contact Megan Herrera with HNFS at (619) 285-3607 or megan.herrera@hnfs.com. Once the contracting and credentialing process has been completed, HNFS reports that during July and August it will reassign the affected enrollees back to the original PCM. For more information on PCM reassignments, visit the HNFS Tricare West website.

Provider Directory: Practices are also encouraged to check HNFS’ online provider directory to confirm participation status and demographic information. If demographic updates are needed, physicians can submit updates via HNFS’ online tool.

If the directory does not accurately reflect participation status, contact HNFS at (844) 866-9378.

For more information on the West Region transition issues, see the HNFS FAQ. CMA is working with HNFS to ensure these issues are resolved quickly and adequately. Physicians with questions or concerns can contact HNFS directly at (844) 866-9378 or CMA’s Center for Economic Services at (888) 401-5911.

SAN DIEGO PHYSICIAN.ORG

7

R I S K M A N AG E M E N T

looping, and it becomes harder and harder to stop the cycle.

Distraction can also be both a symptom of and a contributor to healthcare provider stress and burnout. As a symptom of burnout, digital distraction is a way to escape a stressful environment. As a contributor to burnout, digital distraction impedes human interaction because of the sheer volume of data demanding our attention.

Distracting Devices in Healthcare Malpractice Implications By Shelley Rizzo, MSN, CPHRM

DIGITAL DISTRACTION in healthcare is emerging as a great threat to patient safety and physician wellbeing.1 This phenomenon involves the habitual use of personal electronic devices by healthcare providers for nonclinical purposes during appointments and procedures.2 Some call it “distracted doctoring.” Matt Richtel, a journalist for The New York Times who won a Pulitzer Prize for his work on distracted driving, coined the term “distracted doctoring” in 2011.3 Like driving, attending to a patient’s complex care needs is a high-risk activity that requires undivided attention and presence in the moment to ensure the safety and protection of others.

But the threat might more aptly be called “distracted practice,” as it impacts all healthcare workers and staff. While distraction is particularly concerning in the operating room, emergency room, and critical care areas, it can impact all healthcare settings — including the office practice. Personal electronic devices can create a digital distraction so engaging that it consumes awareness,

8

AUGUST 2018

potentially preventing healthcare providers from focusing on the primary task at hand — caring for and interacting with patients. The consequences can be devastating.

Our Devices Are Addictive In today’s electronic culture, it has become unthinkable to be without personal electronic devices. Growing evidence shows that our personal electronic devices and social media are addictive.4 The reason is dopamine. Our dopamine systems are stimulated by the unpredictable, small, incomplete bursts of information with visual or auditory cues. For example, we are never quite sure when we will receive a text message and from whom.

We may keep checking to see who liked our recent Facebook post. And when our devices ding or vibrate, we know our reward is coming. Yet as when gambling or playing the lottery, the anticipation of the reward is (usually) better than the reward itself. This results in more and more of what some call “seeking” and “wanting” behaviors. Then instant gratification encourages dopamine

Medical Malpractice Implications For most healthcare providers, distractions and interruptions are considered part of the job; it is the nature of their work. If we consider healthcare distraction on a continuum, on one end are distractions related to clinical care (e.g., answering team member questions or responding to surgical equipment alarms). On the other end of the continuum are distractions unrelated to clinical care (e.g., making personal phone calls, sending personal text messages, checking social media sites, playing games, or searching airline flights).

From a litigation perspective, the distinction between distractions related to clinical care and those unrelated to clinical care is important. In a medical malpractice claim where there is an allegation that an adverse event was caused by distracted practice, a distraction caused by a clinical-care-related activity may be found to be within the standard of care and is, therefore, often defensible. But where it can be shown that the distraction was caused by non-patient matters, the plaintiff’s attorney will certainly use that against the defendant. In these situations, the defendant’s medical care may not even enter the equation, because during eDiscovery the metadata (i.e., cell phone records, scouring findings from hard drives) serves as the “expert witness.” Even if the defendant’s clinical care was within the standard, the fact that there are cell phone records indicating that the healthcare provider was surfing the Internet or checking personal email may imply distraction and could potentially supersede all other evidence.

Preventing Distractions Complex problems require a multifaceted approach. Organizations, teams, and individuals all should take responsibility and ownership for reducing the risks associated with digital distraction. The following are risk management strategies to prevent distractions and enhance patient safety.

Organizations • Create awareness °° Recognize the extent of the problem and risks. °° Model appropriate personal electronic device use behaviors. °° Tier communication to batch nonemergent messages. °° Refrain from sending texts on nonurgent matters. °° Do not expect immediate responses for non-urgent matters.

• Educate system-wide °° Train all healthcare providers and staff at orientation and conduct annual refreshers on safety concerns, legal risks of using personal electronic devices when providing care, deviceuser etiquette, and the addictive potential of technology. °° Use simulation-based learning where distractions and interruptions are introduced during high-risk procedures. °° Use case studies of real-life examples where distraction was alleged to play a role in an adverse event.

• Deploy technology solutions °° Manage facility-issued devices. °° Create technology-free zones. °° Limit internet access to work-related sites only — EMR, labs, images, pharmacy formulary, state Rx databases, and decision support/cognitive aids.

• Enforce °° Monitor compliance with systemwide protocols and guidelines. °° Clearly define how personal electronic devices are used in patient care areas.

Teams • Reinforce situational awareness and mindful practices with your team or department through: °° Unit-specific protocols: “Sterile Cockpit” and “Below 10,000 Feet” protocols limiting or eliminating nonessential activities during critical phases of procedures and high-risk activities. °° Empowering every team member to speak up when they have a safety concern. For example, encourage team members to speak up when they notice another member is so focused on a personal electronic device that he or she has lost situational awareness

about the patient’s clinical condition. °° Applying TeamSTEPPS® principles: leadership, situational awareness, mutual support, and communication.

• Create a process where employees can be reached via a call to a central location, with messages relayed to the employee by a staff member. This alleviates employees’ desire to have their personal electronic devices nearby in case of a family emergency.

• Monitor compliance as part of the team’s quality measures.

Individuals • Take personal responsibility — ignore distractions, especially during high-risk procedures, and make sure to speak up, set an example, and remain vigilant.

• Practice situational awareness: °° Pay attention to what is happening in the present moment. °° Increase attention, focus, and concentration. °° Leave your device behind.

New CME Courses Address Distracted Practice Concerns Two new CME courses from The Doctors Company, How Healthcare Leaders Can Reduce Risks of Distracted Practice in Their Organization and The Risks of Distracted Practice in the Perioperative Area, address addiction to personal electronic devices and provide strategies that individuals and organizations can use to minimize the patient safety risks associated with distractions from these devices.

Find these courses and explore our extensive catalog of complimentary CME and CE activities at http://www.thedoctors. com/patient-safety/education-and-cme/ ondemand/.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

TrusT A Common sense ApproACh To InformATIon TeChnology Trust us to be your Technology Business Advisor hArdwAre  sofTwAre neTworks emr ImplemenTATIon seCurITy  supporT mAInTenAnCe

(858) 569-0300

www.soundoffcomputing.com

Endorsed by

Ms. Rizzo is Patient Safety Risk Manager II for The Doctors Company.

SAN DIEGO PHYSICIAN.ORG

9

MEMBER PROFILE

San Diego Physician Combines Three Passions In One Project: A Medical Thriller

By SDCMS Staff

10

AUGUST 2018

PHYSICIAN RICHARD A. BROWN, an orthopedic hand surgeon and 26-year member of SDCMS, achieved a near lifelong dream earlier this year when he self-published a medical thriller — Scalpel’s Cut — which he has also turned into a successful fundraising device for Doctors Without Borders.

Dr. Brown first had the idea for the book 25 years ago, and actually wrote the ending for it back then. But life intervened — a knee injury, a growing family, and medical practice kept him from completing it and realizing his dream to be a novelist.

The dream returned four years ago after attending a Chargers football game with friends. Another doctor told him a story of working in an anatomy lab on Halloween and the tale inspired Dr. Brown to resume work on his own story. After that, he spent an enormous amount of time and energy writing and editing the novel to make it ready for publication.

In fact, the biggest surprise for Dr. Brown in completing Scalpel’s Cut was the rigorous requirements of editing. He had a professional editor and 10 other people read it and offer edits. The editing process proved to be long, slow, and difficult.

Dr. Brown views the book as an opportunity to “open up the medical world to laypeople” and help educate them. It’s written to give the reader a realistic view into practicing medicine through a doctor’s eyes. The novel, while fictional, provides a greater understanding of what a physician is thinking and concerned about while revealing some of the stresses faced on a regular basis.

The book was originally perhaps a bit too realistic for some people. Dr. Brown actually had to water down the language used in the operating room scenes because people thought the language was too honest and coarse — even though it came from real-life experiences and captured actual OR conversations.

The storyline for the thriller is a conspiracy launched by a mysterious group called the Cooperative, which is behind a massive fraud at a hospital. The hero, perhaps unsurprisingly, is an orthopedic surgeon who seeks to stop the wrongdoers.

The novel is available on Amazon.com and Kindle, and has received glowing reviews, including from many physicians,

who have commented on how it puts a voice to their own experiences and who appreciate how well it captures what Dr. Brown calls “the joys and frustrations” of practicing medicine.

Dr. Brown says the novel was cathartic to write. “When I had frustrations at the hospital, I was able to express it in a literary format,” he says. “It’s an outlet I encourage other physicians to pursue. I think it’s beneficial.”

Dr. Brown says the most important goal of the novel is raising money for Doctors Without Borders, which he calls an “amazing organization that has been our chief charity of choice for years.” All proceeds from book sales go the respected international relief group. Both his website and a special bookmark that accompanies the novel encourage readers to make an additional donation to support the charity.

His website has links for both buying the book and donating to Doctors Without Borders. Dr. Brown has already significantly exceeded his initial fundraising goal of $20,000 by 50%, generating more than $30,000 in book sales and contributions.

Dr. Brown has already started work on his second book, and it’s going much faster than his first one. He has a title — Scalpel’s Plunge: End of the Party, an outline, and more than 40 pages already written.

This follow-up novel will include some of the characters from the first book, and takes place in South Africa, where Dr. Brown and his wife of 37 years, Ellen, a former nurse, will be volunteering at a rural medical facility next August.

The second book, Dr. Brown says, “has more focus on politics with baseline medical material but not as much of a medical focus.” Given that so many readers commented on enjoying the plot twists of his first book, he is making sure to include plenty in the latest effort.

Dr. Brown lives with Ellen in Del Mar and maintains practices in La Jolla and Mammoth Lakes. They have three grown children together.

Sales and donations can be made at Dr. Brown’s website, www. scalpelscut.com.

CMA MEMBER HELP LINE! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262

SAN DIEGO PHYSICIAN.ORG

11

PHYSICIAN WELLBEING

Burnout Is a System Issue

By James Santiago Grisolía, MD

12

AUGUST 2018

AS PHYSICIANS, our training impels us to take charge, accept responsibility, accept blame. Perfectionism and working harder drive us, guilt winds us ever tighter. When our health system crumbles around us, each of us wants to fix things by working harder, maybe strengthening ourselves so we can work harder yet.

However, physician burnout rates hover near 50% in study after study, with modest differences according to specialty and practice style. When burnout becomes the norm, we cannot overcome a failing system solely through individual effort. We must fix the underlying conditions. Resilience is a personal issue, but burnout is a system issue.

In the lab, you can train a dog to avoid shocks by choosing the right stimulus. But if you gradually make the two stimuli indistinguishable, the dog gets punished apparently at random, but still with an intense feeling of personal responsibility. This is the laboratory paradigm for creating experimental neurosis. This is also how American healthcare treats doctors.

When physicians reap rewards (financial and/or altruistic) for successful outcomes, or successfully comforting patients in bad outcomes, we feel that we make a difference.

This meaningfulness permits us to endure long hours and difficult conditions. When doctors feel unable to effectively help our patients or get bogged down in meaningless work, burnout results.

Physician dissatisfaction was never talked about, much less measured, until the 1970s. The few historical measures all suggest that burnout or chronic dissatisfaction have been climbing steadily since. Why? We live in the world of experimental neurosis. Physician autonomy became a quaint historical notion. Major tests, treatment decisions, and specialist referrals increasingly run into a maze of denials, authorizations, and phone interviews by non-MDs following scripted questions to approve or deny. Dr. Alex Mercandetti aptly calls this “The Revenge of the C Student,” capturing exactly how it feels to the harried doc who must beg a high school graduate for an MRI. Losing control, yet still feeling responsible for the patient outcome. BZZZZT!!

Physicians are competitive. Rather than fighting and approving every MRI, it’s much better to show each physician how her utilization compares to anonymized peer data.

This works in the hospital setting for cost and quality measures, without the expensive

and humiliating authorization apparatus.

Electronic health records (EHR) further erode our autonomy. A recent AMA timemotion survey found we physicians spend about 50% of our day on EHR and related deskwork, nearly double the 27% we spend in actual face-to-face time with patients.

Sadly, EHR designers are not physicians; even the simplest clinical tasks usually take too many clicks, too many screens, too much intellectual time and energy. Tasks that should be automated devolve to the most highly trained employees. Speeding the process with medical scribes can pay for itself with increased productivity, but only in the right context. In a busy ED, for example. Cost and privacy issues impede widespread use.

What would help? First, hospitals and large medical groups must insist on unburdening the most highly paid professionals, freeing physicians and even “physician extenders” like PA’s and NP’s to focus on

patient goals. Computer documentation must be programmed to consume less time, and to be completed by less trained personnel. Easing government regulatory burdens would help, but the primary failure rests with people who write code for EHR systems.

Insurers happily give up most oversight when they offload risk to medical groups.

IPAs and other contracting organizations must find the most efficient means of cost containment. Comparing cost profiles with other physicians (allowing intelligently for case mix and intensity) saves time and personnel. Peer influence indirectly affects outlier practices, without baring brass knuckles.

Physicians must offload direct patient emails and messages to staff with appropriate oversight. The coming physician shortage should inspire us to create and lead teams who deal with the routine while the physician time focuses on the complex, the

unusual, and the delicate.

Our society as a whole founders in a crisis of meaninglessness, where economic and existential crises overlap and merge. At a time of psychological and spiritual crisis, physicians fortunately engage in work with real meaning: improving quality of life and fixing what we can. Provided we can create enough autonomy to feel like more than cogs in a machine. And that we don’t feel penalized (BZZZT!) for what we can’t control.

While our patients’ welfare still comes first, “You can’t give what you ain’t got.” So we have a stewardship duty to advocate for ourselves within our own systems of care.

If we don’t take care of ourselves, we won’t be able to care for our patients or our own families.

Dr. James S. Grisolia is editor-in-chief of San Diego Physician. He is a neurologist serving as Director of Stroke and of Rehab for Scripps Mercy Hospital.

Surgeons Needed for Expanding Nationwide Surgical Practice • Full or part-time positions • Competitive pay • • Flexible schedule, complete autonomy • • No call • Add revenue to your current practice • Contact us for more information: Phone: (877) 878-3289 • Fax: (877) 817-3227 Email CV to Jobs@AdvantageWoundCare.org

www.AdvantageWoundCare.org

SAN DIEGO PHYSICIAN.ORG

13

M E N TA L H E A LT H

PSST …

IT’S OK TO TALK ABOUT MENTAL ILLNESS IN SAN DIEGO

BY CATHRYN NACARIO, RN, MHA

14

AUGUST 2018

MENTAL ILLNESS. It’s a condition that’s been hidden in the closet, marginalized, denied, pushed aside, laughed at, misunderstood, and feared. Yet it’s also one of the most commonly experienced illnesses around, and — by the way — it’s also treatable.

First, let’s look at the statistics. Approximately 58 million folks in the United States live with mental illness — that’s one in five of us. If we look at this on a local level, close to 750,000 people in San Diego County have mental illness. That’s enough to fill the former San Diego Chargers’ stadium 10 times over, and represents 22 percent of the county’s population.

A 2013 San Diego County Health and Human Services report calculated that more than half of adults were unable to work for more than eight days due to mental problems. This is in standing with the World Health Organization that estimates mental illness costs the global economy $1 trillion in lost productivity annually.

According to The California Healthcare Foundation, of those incarcerated in 2015, 38 percent of female prison inmates and 23 percent of the male prison population received mental health treatment. It has been said that the prisons and jails have become the de facto mental health facilities in our state and nation.

However, keep in mind that most people with mental illness are not violent. In fact, only 3–5% of violent acts can be attributed to individuals living with a serious mental illness. According to the U.S. surgeon general, people with mental illnesses are more likely to be victims of violent crime rather than perpetrators. This fact is surprising to many people since the media often automatically connects violence to mental illness without evidence to support their theory.

The truth is mental illness can be deadly — to those who have it. Approximately 90 percent of those who die by suicide have an underlying mental illness. In fact, suicide is the tenth leading cause of death in the U.S. and accounts for more than double the amount of lives lost to homicide.

Some of the most commonly occurring mental illnesses are anxiety, depression, and bipolar disorder, with depression being the leading cause of disability worldwide. While overall more women than men experience mental health disorders, it should be noted that mental illness is considered an “equal opportunity disease.”

It can truly affect anyone regardless of age, gender, race, reli-

gion, or income level, and the statistics bear this out. While more than a quarter of people in homeless shelters have mental illness, more than 50 percent of U.S college students report feeling lonely and hopeless, and one in every 12 makes a suicide plan, according to national data on campus suicide and depression.

Speaking of young people, 50 percent of all cases of mental illness begin by age 14 and 75 percent begin by age 24. There is an average of a 10-year gap in experiencing symptoms and seeking and receiving treatment. Only 44 percent of adults with diagnosable mental health problems and less than 20 percent of children and adolescents receive treatment.

A mental illness of any kind can, by definition, affect a person’s thinking, feeling, moods, ability to relate to others, and capacity for dealing with the ordinary demands of daily living. At the National Alliance on Mental Illness (NAMI San Diego), educators describe mental illness as a biological brain disorder. Just as diabetes is a disorder of the pancreas, the organ affected by mental illness is the brain. And, like diabetes or high blood pressure or cancer, it is nothing to be ashamed of.

Yet what mental illness is not is just as important as what it is, according to NAMI San Diego. Mental illness is not the result of a personal weakness and it doesn’t come from a lack of character, intelligence, or integrity. It is a biological illness that affects many parts of a person’s life, but cannot be cured by willpower. If it could be, this disease would likely be wiped off the face of the earth in a matter of minutes. Unfortunately, it’s not that easy.

However, after all those negative statistics, here’s a more positive number: 80 to 90 percent of those who do seek and receive treatment for their mental illness see improvement with their symptoms.

It’s not always cut and dried, and there can be much trial and error with treatment options and medications. However, mental illness is ultimately treatable — and living in recovery is possible.

And what exactly is recovery in regard to mental illness? It is different from more straightforward types of healing. For example, when a broken leg is treated and the patient recovers, there is no more broken leg. We consider this patient to be recovered. Yet with mental illness, NAMI San Diego defines recovery as more of a fluid process. It’s the experience of moving through and beyond the limitations of one’s disorder. It is living well with what we’ve got and it is a journey rather than just a destination.

So, if mental illness is so common, and if it is an illness like any other and it is treatable, then why is it so difficult to talk about? In one word: stigma. That bitter mark of disgrace or infamy; a stain or reproach on one’s reputation. The disapproval and shame felt by people exhibiting characteristics that society considers wrong or unusual. A disapproving label, a rejected stereotype, marginalization. A strong lack of respect for a person or group of people. Sounds awful, doesn’t it? So while we don’t do this as much with other diseases, mental illness takes the brunt of the stigmatization. But why?

Our experiences, training, conditioning, and even professional biases are a common part of not only being a caregiver, but a human being. Stigma is embedded in even seemingly benign descriptors we use for people. The schizophrenic in room two. The bipolar in the lobby. The list goes on. While it is a longer sentence, stating that he is a person who has schizophrenia or she experiences bipolar disorder puts the person first and not their disorder.

Person-first language is one small but significant change that can be made to overcome stigma on a daily basis.

When individuals are called by their own name and not their disease, it is empowering. When they are recognized as experiencing suffering but are not defined by it, it is life-giving. When misconceptions or negative generalizations are left by the wayside, light can shine through the marks of disgrace, shrinking the stains of reproach. It’s actually pretty easy to do by simply recognizing folks with mental illness (or any type of disease) as people first.

Mental illness may not be as comprehensible as other ailments or conditions because we don’t yet understand everything there is to know about the brain nor the interaction of brain and body.

But we do know that when the brain is affected, just about everything else can be too. This is why you might see patients with underlying mental health challenges presenting in your office with SAN DIEGO PHYSICIAN.ORG

15

M E N TA L H E A LT H

complaints of fatigue, chronic pain, headaches, upset stomach, appetite changes, insomnia, tics and twitches, chronic sinusitis (studies have linked it to depression), stress-related skin irritations, cavities (often exacerbated by dry mouth caused by psychiatric medication), and adrenaline rush from anxiety that can often mimic symptoms of a heart attack.

While psychiatric medications have vastly improved over time, side effects such as obesity and diabetes are all too common. For example, around 25 percent of candidates for weight loss surgery have a mood disorder. While it can be easy to look at a person who seems unmotivated to exercise or lose weight as lazy or careless, a deeper dive may very well reveal that the patient is either struggling with an undiagnosed mental health challenge or experiencing a common side effect from a medication that may actually be helping their mood, but hurting their body. Treatment for mental illness is necessary and often successful but almost always tricky too.

Another aspect of mental illness that is hard for practitioners, friends, and family members alike to understand is the phenomenon of people who have a diagnosed mental illness not being medication compliant. Why on earth would a person go off their medication if it helps them? Within the question lies the answer: they feel better often without realizing it’s the medication that has helped them do so, and figure they don’t need to take it anymore.

The aforementioned negative side effects of psychiatric medication are also a deterrent to being compliant. Yes, the medication might help a person’s mood level out, but often at the cost of sexual dysfunction, weight problems, blood pressure fluctuations, rashes, fatigue, and many other unpleasant experiences that range from annoying to unbearable.

However, many people who do take psychiatric medications realize that trial and error is a part of getting their “cocktail” of medicine fine-tuned enough to work with their individual chemistry and condition. Yet knowing even when that happens, it is rarely set in stone. Flexibility is crucial for both peers and loved ones alike when it comes to a treatment plan.

Interestingly enough, there is a life cycle to mental illness,

although, as one might guess, it’s not linear. A person can zigzag from crisis mode to stabilization and then relapse and repeat the process in a whole different order. The mental health system is difficult to navigate even in the best circumstances, let alone when a person — and their loved ones — finds themselves in a crisis situation. Fortunately, there’s an app for that.

Known as San Diego’s Voice on Mental Illness, NAMI San Diego has developed a mobile app called oscER, which stands for “online support companion in an emergency situation.”

Both oscER and the companion app for children, oscER Jr, can be downloaded in your phone’s app store or online from a home computer at www.namisandiego.org.

Information pertaining to mental health resources in San Diego County is at your fingertips with oscER. There are easy-tonavigate sections on what to do before, during and after a crisis, complete with answers to questions like what’s a 5150 or 5250?

What are different mental health diagnoses? What’s my loved one experiencing? What can I do to help? There are resources for everything from local legal services to urgent walk-in centers and where to find education and support.

In addition to the app, NAMI San Diego offers support, education and advocacy services free of charge to everyone affected by mental illness, which is really all of us in one way or the other, either by having it or knowing someone who does. One of the unique things about NAMI San Diego is that it understands there is a rotating life cycle to mental illness and offers numerous programs at every stage to help, even the stage of prevention.

“Everything we do at NAMI San Diego is to make mental illness OK to talk about,” says Julie Benn, communications specialist for NAMI San Diego. “Because if it’s OK to talk about, then it is OK to learn about, recognize signs and symptoms, and to ultimately get help. But none of that can happen if we don’t get the conversation started and keep it going. Our programs are specifically designed with that goal in mind.”

What began as a small group of concerned parents of adult children with mental illness meeting around a San Diego kitchen table 40 years ago has grown into a nonprofit organization with almost 1,000 affiliates located throughout every state in the nation. The flagship programs include comprehensive education and resources for family members and peers as well as stigmabusting presentations, programs to help folks reengage in their lives after hospitalizations, support groups, family and community outreach, faith-based trainings, peer and family support specialist programs, business education and much more.

In celebration of their 40th birthday this year, NAMI San Diego is holding a very special Color Ball and Inspiration Awards on Oct. 11, 2018 at the San Diego Natural History Museum. This annual fundraiser honors people and organizations that have made a positive difference in our communities in regard to mental wellness and, yes, making it OK to talk about. It is the second largest fundraiser for the organization next to the NAMI Walk, which is held every spring.

For a full list of NAMI San Diego services, and information on the upcoming Color Ball “Night at the Nat,” please visit www. namisandiego.org.

Cathryn Nacario is the chief executive officer of the National Alliance on Mental Illness San Diego.

16

AUGUST 2018

CULTIVATING COMPASSION

WHAT A PATIENT WITH MENTAL ILLNESS WANTS DOCTORS TO KNOW BY JULIE BENN WE’RE IN THIS together, you and me.

And whether I come to you for a broken bone or osteophytes in my ears, thyroid problems, strep throat, or any other myriad ailments, there’s something about me you should know.

I have mental illness. Whether you gather this from the large number of psychiatric medications on the med list I just handed to you, or you read the diagnoses I scribbled down in the “pre-existing conditions” section on the patient intake form (where there is never enough room to list all of them), or I actually screw up my courage to the sticking place and outright tell you myself, I do have it and I thought you should know.

If that makes you feel uncomfortable, don’t worry, I’m likely much more scared of you than you are of me. Not because you’ve done anything wrong, we’ve just met after all. But because I am afraid you will think me to be crazy and dismiss who I am. I am afraid after you scan the long list of conditions that reads like an eye chart (OCD, MDD, PTSD, ADD, DD, GAD, etc) you will label me incompetent before our first hello. I am afraid that you will not see me but rather a pre-conceived notion of what I might be and how difficult it may be to treat someone like me.

Maybe you’ve had hard experiences with folks who have mental illness that feed into an image of non-compliance.

Or perhaps you’ve seen the latest news story of another mass shooting and that makes you wary of anyone who might experience unstable moods. Or maybe, just maybe, mental illness is something you or a loved one also experience, and the pain of potentially seeing mirrored symptomology is, at the very least, distracting.

All of these scenarios have validity to them, and I am not saying you are wrong for thinking of them before you shake my hand. I am just saying, well, look at me. Everyone who has mental illness experiences it differently. We are all unique and individual, and while I may have the same diagnoses of someone you ‘ve had trouble with in the past, I’m still me sitting here in my paper gown before you. I’m not them.

And even if something happens and I get triggered because of past traumas as perhaps other patients have, please know that this snapshot in time of my experience is not the sum of who I am, nor was it likely the complete picture of who they are. People who live with mental illness are not defined by their disorder, or, at least, they shouldn’t be.

After all, we have mental illness, not the other way around.

At any rate, here we are together now, you and me. As long as we’re both here, why don’t we form a partnership?

Here’s what I’d like to have happen: Tell me what you are going to do before you do it, and keep me informed as you go along. Keep talking. Let me know how long a particular procedure or part of the exam will take. Keep me posted as it happens.

Sometimes it is hard for me to focus, especially in potentially scary situations (like this) when I am getting a diagnosis or prognosis. Please be very clear with me and help me remember by writing things down for me or encouraging me to do so. Draw diagrams or use other visual aids, as I may be able to remember those easier.

If you are prescribing medication, please let me know what it is for and if/ how it could affect my other medications or mental health conditions.

When you hand me the prescription, let me know you believe it will help me, and if it doesn’t, we can still work together to find something else that can.

Encourage me to ask questions and speak up about concerns. Please be patient with your patient. When I am distressed, sometimes I tend to go mute and it may take me a bit longer to form my sentences. Let me know that’s OK, and possibly offer me some paper to write it out if I can’t put voice to my words at the moment.

Be open to me wanting to do my own research too. Not that I’m disagreeing with you, I just mainly want to be an informed patient and learn more about whatever condition I am experiencing. It will help me feel less out of control and will potentially help us communicate down the line.

What can you expect of me in return? When the lines of communication are open and I feel safe with you, I will try my very best to be compliant and work with you — not against you.

I will view us as a team. I will sing your praises in the form of referrals.

And, when you treat me with kindness and compassion, I promise that I will remember you forever, doc.

Julie Benn is the communications specialist for NAMI San Diego. After graduating with degrees in journalism and psychology, Julie spent a decade working as an award-winning journalist and advertising copywriter in various San Diego businesses before joining NAMI San Diego and in 2006. Julie brings her unique experience as a person who lives with mental illness to her position, enabling her to offer an “insider” perspective to the work she does for NAMI.

SAN DIEGO PHYSICIAN.ORG

17

T R E AT I N G A D D I C T I O N

AN INTEGRATED APPROACH TO ADDICTION CARE IN SAN DIEGO COUNTY

BY NICOLE ESPOSITO, MD, AND LUKE BERGMANN, PHD

IT IS WELL KNOWN that harms from addiction account for much of our community’s morbidity and mortality risk. Cigarette smoking remains the leading preventable cause of death in the U.S.,1 and excessive use of alcohol is associated with increased rates of cancer, liver disease, heart failure, and injury.2 The CDC estimates that nearly 90 thousand people die each year of causes related to excessive alcohol use. Meanwhile, addiction to illicit drugs has received unprecedented attention in light of the current opioid epidemic and is associated with a host of health risks, including infectious endocarditis, and liver and kidney disease. In a particularly alarming trend, mortality from opioid overdose in the last three years has led to a decreased average lifespan among certain demographic cohorts in the U.S.3 Indeed, the prevalence of substance use disorder (SUD) is estimated to be around 25 million people in the U.S., almost as many as are estimated to have diabetes. But where nearly 75% of people with diabetes are in treatment for it, only 10% of those with substance use disorder access specialty care for their addictions.4 This statistic reflects the complex challenges in treating a highly stigmatized disorder for which many people feel ambivalent about seeking care. Thus, a central tenet of traditional addiction treatment has been that patients must “hit rock bottom” before they will be receptive to or successful in any formal program.

But this poor rate of access to care also reflects the fact that the addiction specialty care system is itself marginalized from the rest of healthcare. The separation of care for SUD from mainstream healthcare is attributable to multiple factors: Among others, the healthcare industry has not fully embraced care for addiction because patients with addiction are “too difficult”; there is lingering uncertainty among healthcare professionals about the utility of medical interventions for SUD; and the specialty care system has deliberately insulated itself from other health and service sectors as a means to protect people with addictions from potentially harmful scrutiny.5 As a result, the addiction specialty care system evolved for decades in a silo, with common practices but without adherence to evidence based standards of care or emphases on outcome metrics that are consistent with healthcare practice in this country. Over the last decade or so there have been efforts

18

AUGUST 2018

Get the mortgage benefits you deserve with the Bank of America® Doctor Loan1 to bridge the two domains, but these have mostly floundered or have achieved only very local success.6 But now, as a part of the County’s vision for healthy, safe, and thriving communities, called Live Well San Diego, a different kind of effort to integrate the specialty substance use disorder care system with mainstream healthcare is underway. On July 1, 2018, the County of San Diego implemented the Drug Medi-Cal Organized Delivery System (DMC-ODS), for SUD treatment with individuals insured by Medi-Cal as well as for low-income residents.

With DMC-ODS, we now have an unprecedented opportunity to accelerate the integration of SUD specialty care with the mainstream healthcare system, to dramatically improve access to services as well as outcomes. DMC-ODS is an infusion of resources through the County to establish adherence to evidence-based practices and standardized level-of-care assessment, using criteria developed by the American Society of Addiction Medicine. Under DMC-ODS, providers of specialized care for addiction will be able to identify levels and intensity of care that are appropriate for individual patient needs; these may include outpatient, intensive outpatient, or residential settings, and will allow continuity between care levels as patients move up or down on the continuum of care.

Care plans will also facilitate linkage across health systems and social systems to address the whole person. This will ensure that individuals with SUD as well as physical health and psychiatric comorbidities can stay connected to all the services integral to supporting sustained recovery.

For example, programs will have case managers to ensure care transitions and linkages across services, with attention paid to mental health, social services, and physical health, including vaccinations and smoking cessation. Programs will even link clients to mutual-aid or other informal recovery supports to leverage the vast recovery community outside of formal treatment and service networks.

An important element of care for SUD is the recovery environment. Responding to the fact that 30% of individuals enroll-

Low down payments. As little as 5% down on a mortgage up to $1 million and 10% down on a mortgage up to $1.5 million.2 Flexible options. Student loan debt may be excluded from the total debt calculation.3

Call me to learn more.

Billy Cafcules Senior Lending Officer NMLS ID: 1485046 858.692.9698 Mobile billy.cafcules@bankofamerica.com mortgage.bankofamerica.com/billycafcules

An applicant must have, or open prior to closing, a checking or savings account with Bank of America. Applicants with an existing account with Merrill Edge®, Merrill Lynch® or U. S. Trust prior to application also satisfy this requirement.

Eligible medical professionals include: (1) medical doctors who are actively practicing, (MD, DDS, DMD, OD, DPM, DO), (2) medical fellows and residents who are currently employed, in residency/fellowship, or (3) applicants who are medical students or doctors and are about to begin their new employment/residency or fellowship within 90 days of closing. Must be actively practicing in their field of expertise. Those employed in research or as professors are not eligible. For qualified borrowers with excellent credit. PITIA (Principal, Interest, Taxes, Insurance, Assessments) reserves of 4 – 6 months are required, depending on loan amount.

2 Minimum down payment requirements vary by property type and location; ask for details.

3 Additional documentation is required.

Credit and collateral are subject to approval. Terms and conditions apply. This is not a commitment to lend. Programs, rates, terms and conditions are subject to change without notice. Bank of America, N.A., Member FDIC. Equal Housing Lender. ©2018 Bank of America Corporation. ARY89JD7 | AD-07-18-0108 | HL-112-AD | 02-2018 1

CMA MEMBER HELP LINE! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262

SAN DIEGO PHYSICIAN.ORG

19

T R E AT I N G A D D I C T I O N

ing in SUD care report that they are homeless, San Diego County’s DMC-ODS has allocated funding for housing support during treatment. As is the case for people with physical and mental health issues, most people with SUD can be effectively treated in outpatient settings if they have healthy living circumstances.

In addition to an increase in case management services and housing support, DMC-ODS also enhances access to group and individual therapies that are evidence based, such as motivational interviewing, relapse prevention and, critically, the use of medications in treating addiction. The opioid treatment programs in our community (which treat opioid use disorder with medications such as methadone and buprenorphine), for example, are now a part of the County system of care. This will increase seamless access to MAT (medication for addiction treatment) and reduce stigma associated with opioid substitution therapies, which has been longstanding despite the substantial evidence supporting their effectiveness. Moreover, capacity building for medically supervised withdrawal management services will be a focus within the first year of DMC-ODS implementation, with attention paid to developing an outpatient network of screening and care delivery to unburden busy emergency departments, which are currently our County’s main resource for prescribing

WANT TO REACH PHYSICIANS

IN SAN DIEGO COUNTY?

withdrawal management medications.

An ongoing challenge for the integration of care for substance use disorders will be the dearth of physicians practicing within the specialty care system, making access to medications for addiction treatment limited.

Indeed, the success of the DMC-ODS integrated care model will be best realized as our community’s physicians become engaged. Primary care physicians play a critical role in identifying and screening for chronic illnesses and initiating referrals to treatment. But increasingly, primary care practices are able to provide meaningful care for common chronic illnesses, including SUD, within their clinics. There is ample evidence, for example, supporting SBIRT (Screening, Brief Intervention, and Referral to Treatment) as a means to improve the health of people who drink excessively. With the SBIRT protocol, primary care practices use standardized screening tools such as the Alcohol Use Disorder Identification Test to identify patients who are at risk of alcohol use disorder. Physicians utilize brief motivational interviewing techniques to intervene for those with risky drinking behaviors and refer patients with more severe disease to specialty care. And in communities hardest hit by the opioid epidemic, primary care physicians have been at the front lines of treatment provision,

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Abracadabra….

WE CAN MAKE IT EASIER THAN PULLING A RABBIT FROM A HAT. CONTACT DARI PEBDANI TO LEARN MORE. 858.231.1231 DPebdani@SDCMS.org 20

AUGUST 2018

Locum Tenens Permanent Placement Voice: 800-919-9141 or 805-641-9141 FAX : 805-641-9143 t zw eig@ t r acyzw eig.com w w w.t r acyzw eig.com

saving thousands of lives by offering buprenorphine treatment to those with opioid use disorder in a setting where patients may be more receptive to care.7 For all patients with addiction (connected to treatment or not), physicians can play a critical role in offering preventive care measures such as hepatitis vaccinations, smoking cessation, and sexually transmitted infection screenings. Physician leadership is necessary to foster the culture change necessary for a new era of outreach, engagement, and effective treatment for individuals with SUD. As the County of San Diego takes steps toward transforming the SUD system of care, our ongoing partnerships with community physicians will be necessary each step of the way. We invite you to share your opinions, ideas and clinical experiences to shape future care delivery for individuals with substance use disorder at Info-dmc-ods.hhsa@sdcounty.ca.gov. For more information about the County of San Diego’s DMC-ODS implementation, please go to www.sandiegocounty.gov/dmc Dr. Esposito is assistant clinical director at the County of San Diego Health and Human Services Agency Behavior Health Services.

Mr. Bergmann is director of Integrated Services at the County of San Diego Health and Human Services Agency.

Citations 1. Centers for Disease Control and Prevention (https://www. cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm) 2. 2003. Rehm J1, Gmel G, Sempos CT, Trevisan M. “Alcoholrelated morbidity and mortality.” Alcohol Res Health 3. 2017. Deborah Dowell, MD, MPH et al “Contribution of Opioid-Involved Poisoning to the Change in Life Expectancy in the United States, 2000-2015” Journal of the American Medical Association (JAMA) 4. 2016. Surgeon General’s Report on Alcohol, Drugs and Health (https://addiction.surgeongeneral.gov/executivesummary) 5. William White, Slaying the Dragon 6. Institute of Medicine report from 1990 (https://www.nejm. org/doi/full/10.1056/NEJM199009203231230 7. 2018. Larochelle et. Al. “Medication for Opioid Use Disorder After Nonfatal Opioid Overdose” Annals of Internal Medicine

THE SUMMIT ON NEURODEGENERATIVE DISORDERS New Information on Underlying Causes, Diagnostics, and Treatment Strategies NOVEMBER 9-11, 2018 | SAN DIEGO, CA Attendees on Friday receive a FREE Organic Acids Test, worth $299!

To register, visit: www.IMMH.org/neurosummit

Use promo code SDP10 for 10% off!

913.915.5136

|

info@immh.org

|

Presented by

IMMH.org/neurosummit SAN DIEGO PHYSICIAN.ORG

21

I N T E G R AT E D C A R E

THE VALUE OF — AND NEED FOR — MENTAL HEALTH INTEGRATED CARE

BY STEVE KOH, MD, MPH, MBA

22

AUGUST 2018

MENTAL ILLNESS’ IMPACT on the wellbeing of the whole person cannot be overstated. Attempts to track the disease’s burden in society consistently rank mental illnesses as one of the top contributors to disability. Health People 2020, as reported by the Office of Disease Prevention and Health Promotion, reports that 18.1% (43.6 million) of adults in the U.S. suffer from mental illness and 4.2% (9.8 million) suffer from serious mental illness in any given year. These account for 18.7% of all years of life lost to disability and premature mortality. And despite efforts to curb suicide rates, it continues to be one of the top 10 causes of death in our country. Locally, along with obesity and diabetes, mental illness is one of the top disease categories impacting San Diegans. These sobering figures are actually deemed to be lowball estimates of the impact of mental illness.

When viewed from the perspective of negative contributions to the overall wellbeing of an individual, no other illness as a co-morbid condition ranks higher than mental illness. If mental illness is added to a list of active medical conditions, it virtually guarantees that one’s general medical condition will be impacted for the worse.

The reason for this is several fold. Mental illness can directly impact medical treatments by leading to non-adherence, continued unhealthy behavior, and increasing no-show rates. It can worsen and contribute to medical illnesses, and treatment for mental illness can often lead to complicated medication regimens.

One cannot discuss mental illness without thinking about alcohol and other drug (AOD) abuse.

While the medical, funding, and policy authorities often separate AOD from general and mental illnesses, to many of us, we think of it as one of the main sources of disability and confounding factors in a patient’s wellbeing, and part of the complex mental health picture of a patient. Any general practice provider will attest to the difficulty in working with patients with a co-morbid AOD condition. This, in combination with chronic medical illness and mental illness, then forms the third part of the triad of diagnoses that significantly contributes to morbidity of our patients.

The medical complication of these cooccurring disorders directly leads to high medical costs, health provider burnout, and poor health outcomes. The current model of care delivery is not up to task in dealing with this complexity. This model can be best described as being individualprovider-focused, and expects the patients to navi-

gate the healthcare system between siloed providers dealing with individual diagnoses. For example, a primary care provider would refer to psychiatry for chronic mental illnesses like major depressive disorder and also would refer to addiction specialists for alcohol abuse. Often, these providers are at different institutions and practices, and do not readily have access to a patient’s medical records. More often than not, it’s difficult to find specialists in mental health and addictions to refer the patients to. Finally, it’s often unclear when a patient should be treated in a primary care setting or in a specialty setting. In this confusing environment, integrated care can provide some of the solution.

Value of Integrated Care One major challenge faced by healthcare providers is that of care coordination. Complicated patients with the triad of chronic medical, mental, and substance-use issues cannot be cared for in a disjointed care delivery system. Arguably, one of the first and most effective models of care coordination is IMPACT (Improving Mood — Promoting Access to Collaborative Treatment). Developed at the University of Washington, it was originally designed to address depression in primary care settings that requires systematic follow-up. It has since been utilized to good effect for other conditions like anxiety, PTSD, co-morbid mood disorders with heart disease, cancer, and diabetes. IMPACT is an integrated care approach in a primary care setting. It identifies mental illness with screenings and designs intervention with specific referral strategies. An individual patient care plan is then developed with buy-in and support from the entire treatment team. The team consists of a trained care manager or navigator, a primary care provider, an embedded consulting psychiatrist, behavioral health specialists, and the patient. The care manager is essential in the care coordination within the team. The care plan can consist of integrated health education, evidence based therapies, self-management, medications, and behavior modification support. The team closely follows and tracks the progress of the patient so that treatment adjustment can be made quickly. This model of care has shown to be effective and cost-efficient.

Taking the concept beyond primary care and moving away from just care coordination, integrated models focus on targeted care system navigation and patient tracking within a patient-centered perspective that ignores the artificial silos between chronic medical, mental, and substance-abuse illnesses. Targeted care system navigation means that by using patient-centered data analysis, one can allocate a care team member to focus on major issues facing a patient and focus providers to target specific symptoms and diagnoses that can make the greatest impact on overall health.

This can be done by using screening tools like depression and anxiety scales to objectively find undiagnosed mood disorders and/ or AOD screening tools to measure the impact of alcohol and substance use on the patient’s health.

Positive screening and the degree of severity can help the care team member to coordinate the care of the patient to the appropriate level of specialty care. It can also monitor the impact of combined health outcome values in an individual to assess for the best approach to care; for example, biomarkers like blood pressure can SAN DIEGO PHYSICIAN.ORG

23

I N T E G R AT E D C A R E

each member. To be truly integrated then, it is important that the team be clearly defined, team member’s roles are described, and primacy of the patient is recognized. This way, each component of the integrated team is focused on shared duty to the patient’s overall wellbeing, regardless of the severity level of each subcomponent of his/her diagnosis.

be tracked with a depression scale and daily activity indexes to determine how underlying hypertension, depression, and sedentary lifestyle are individually and collectively impacting health. Constant vigilance in care coordination is needed. Patient tracking in terms of cardinal symptoms and their objective severity level can be valuable in ensuring that the care team is providing treatment appropriate to the stage of disease that a patient is in. This leads to a stratified provider role in the care of the patient; for example, as a patient’s chronic medical condition worsens but mental and substance use issues are stabilized, the care can be focused around the primary care provider. As the reverse happens, a specialty mental health provider can take more of an active role in treatment.

An additional benefit to an integrated care team is the constant learning that improves its function and effectiveness. This is possible when the model is not simply a co-located mental healthcare or coordinated care. Co-located care is when a psychiatrist, psychologist, behaviorists, or therapists are simply placed within a space where primary care or specialty medical care is being delivered. This allows for quick curve-sides and referral within the same geographical space. However, it can essentially continue the independent and siloed approach to a patient between different provider groups.

Coordinated care is the usage of care managers or navigators to link different providers within a health system and to external providers when needed. This supports the need of individual patients and providers as the core care coordination happens centrally. However, this does not mean that true integration of the patient’s overall health has occurred. In an integrated care model, the team functions to seamlessly consider the impact of the three chronic diseases to one another and to overall health. It relies on each team member to educate one another so that effectiveness of the team can be improved regardless of the level of involvement by

24

AUGUST 2018

Creating an Integrated Care Model The value of an integrated care model is the overall efficiency in care delivery to a complicated patient population. The model can achieve this with limited resources by utilizing them more effectively and leveraging the team concept to deliver higher quality care. To create such a model, one must first make a system-wide commitment to integrated care. This is important to ensure that any cost (fiscal and otherwise) involved in creating an integrated care model is clearly identified and discussed. The cost should then be compared to return on investment of such a model to the patients that we are caring for. Secondly, one must determine the goals of the team being created. This can be highly dependent on the focus of care and often is delineated by a primary care versus specialty care model.

In the former, it is best to think about how a large patient caseload can be approached in a systematic way, and to create a team that can be fluid and mobile in its approach to case volume per team member. For example, for a primary care clinic that’s responsible for a thousand patients, the team needs to be able to come up with a strategy to stratify the patients into diagnosis and severity level, and target providers to where the patient is. In the latter, team members should be identified based on specific skills designed to get a patient to his/her goals. For example, in an obesity-focused clinic, the team members should be jointly focused on weight loss and maintenance of weight for its panel of patients.

After first setting the goals and then determining the team needed to achieve them, next one must develop an overall strategy to care that is data driven. This often involves close examination of existing EHR and IT systems that the team uses (at times, even a creation of one). EHR and IT should be thought of distinctly. EHR should be dynamic, scalable, distributable, and accessible to all members of the team. It must be able to allow for data analytics as needed by the team. The IT system should be ideally incorporated within an EHR but often is separate as an electronic communication tool. This system should be leveraged to allow for eConsults and televisits between team members so that integrated communication can happen at all levels. Finally, there has to be a strategy to do interval outcome measures. As a chronic disease care model, there may not be terminal outcome measures, but continual collection of target measures that can help inform and modify the team’s approach to individual patients, and to the patient population of interest.

Clearly, the current model of care is failing to make a significant impact on the needs of our patients with co-occurring medical, mental, and substance use disorders. An integrated model of care represents one approach to dealing with this complicated patient population. Hopefully, as this model becomes more prevalent, it can be modified and improved on to better serve our county’s healthcare needs.

Dr. Koh is an associate professor at UC San Diego and also serves as director of Outpatient Psychiatric Services in Hillcrest, director of the TeleMentalHealth Program, and director of the Community Psychiatry Program.

REVENUE CYCLE MANAGEMENT PRACTICE MANAGEMENT SYSTEMS CONTRACTING & CREDENTIALING

Seeking FM/DO/IM Physicians in San Diego and Orange Counties Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic.

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

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

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

www.vistacommunityclinic.org

GET PAID FOR THE CARE YOU DELIVER!

CALL US

858-598-5654

EMAIL US

info@askmbs.com

VISIT US

askmbs.com

We will help you advance your practice and maximize revenue with our extensive experience in billing, reimbursement analysis and insurance contracting. This ability, combined with our attention to minimizing overhead expenses through streamlining systems and integration of current technology, will result in the healthy and sustainable growth of your practice.

EEO/AA/M/F/Vet/Disabled

It will be if you partner with the

IS YOUR MARKETING PLAN AS STRONG AS THIS GUY?

SAN DIEGO COUNTY MEDICAL SOCIETY

Contact Dari Pebdani to learn more.

858.231.1231 DPebdani@SDCMS.org

SAN DIEGO PHYSICIAN.ORG

25

CLASSIFIEDS PHYSICIAN OPPORTUNITIES

SURGEONS NEEDED FOR EXPANDING NATIONWIDE SURGICAL PRACTICE FT/PT positions available.

Competitive pay and flexible schedule with complete autonomy. Add revenue to your current practice. For more information, contact us: P: 1-877-878-3289 F: 1-877-817-3227 or email CV to: JOBS@ADVANTAGEWOUNDCARE.ORG www.AdvantageWoundCare.org PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives.

Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com PART-TIME MEDICAL DOCTOR WANTED – IMPERIAL RADIOLOGY: Our company is an outpatient diagnostic radiology facility in search of a part-time Medical Doctor to help cover contrast administration. All Candidates must have an active California Medical License. Please contact via email info@ carlsbadimaging.com with your resume if this position is of interest to you.

FAMILY PRACTICE/INTERNAL MEDICINE PHYSICIAN NEEDED: Primary care physician wanted for established private practice in San Diego. La Jolla Village Family Medical Group has been caring for patients of all ages for 29 years in the UTC/La Jolla area of San Diego. We provide comprehensive preventive medicine, illness management, travel medicine, sports medicine, evidencebased chiropractic care, weight management, and more. Call responsibilities minor, hours consistent with a healthy work/life balance.

Our office is modern, clean, and well appointed. Our staff is supportive, cohesive, and friendly. This a real family practice.

Board-certified, California licensed MD and DO physicians who are passionate about medicine and interested in this opportunity

should send their CV and cover letter addressed to Tricia at officemanager@ljvfmg. com. Let us grow your practice according to your unique specialty interests and style.

Responsibilities include: Provide excellent care, become part of a cohesive team, light call, maintain accurate and detailed medical records using HER, comply with all laws applicable to family practice/internal medicine, including HIPAA, recommend lifestyle changes as appropriate to improve quality of life, Full-time, Part-time.

PHYSICIAN NEEDED: Family Practice MD. San Ysidro Health is looking for an MD for our Family Practice center. The Family Practice MD manages and provides acute, chronic, preventive, curative and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics and internal medicine. Bilingual preferred but not required. Medical school graduate, CPR, CA MD and DEA License, board certified or eligible in primary care specialty. For more info on San Ysidro Health, visit: http://www.syhealth.org/ If interested, please email CV to Meagan.underwood@ syhealth.org.

DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/part-time BC or BE eligible Dermatologist to join our team.

Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base.

Work with two 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, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at 858-761-7362 or email jmaas12@hotmail.com for more information.

INTERNAL MEDICINE POSITION AVAILABLE: Unique opportunity to practice outpatient internal medicine in beautiful North San Diego County. Practice is part of a well-established internal medicine group with a long history of outstanding care in the community, seeking physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, recently renovated office, small group environment, autonomy and very high quality patient care are among the many benefits of this opportunity. Office is located near San Diego coastal communities and is accessible from all parts of San Diego County as well as

Orange County. Seeking BC/BE applicants.

Please send CV to portofino3@aol.com or call 619-248-2324.

PHYSICIANS WANTED: Premier Medical Group is seeking to establish a family practice at the Kearny Mesa Medical Center in San Diego, CA. Part-time or full-time family practice or internal medicine physicians needed, M.D. or D.O. Physicians must be PPO contracted with most major insurance companies. Most overhead expenses covered and flexible hours available. Compensation is 100% of collected revenues. Premier Medical Group is located in the Kearny Mesa Medical Center (858-715-1822).

PRACTICE FOR SALE OB/GYN PRACTICE FOR SALE IN SAN DIEGO: ASKING $480,000,00. FY 2017 Gross $1,445,688,00. Established practice for 38 years. Suburban district. Easy freeway access. Dedicated and experienced staff able to stay on board through sale. Situated within a modern, high-end building. The region’s fast-growing population assures for an expanding client base. Features 3200 sq. ft. of working space; 6 fully equipped patient rooms (5 exam & 1 surgery rooms with surgical lighting and fully adjustable treatment tables). Furnished waiting room and reception area; doctor’s private office, sterilization area, staff lounge and storage. ADA compliant. Contact: dixon@ cwmc4women.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call 858-832-2007.

PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call 858-257-7050 OFFICE SPACE / REAL ESTATE AVAILABLE OFFICE SPACE AVAILABLE: La Jolla (Near UTC) office for sublease or to share: Scripps Memorial medical office building, 9834 Genesee Ave, great location by the front of the main entrance of the hospital between 1-5 and 1-805. Multidisciplinary group and available

TO SUBMIT A CLASSIFIED AD, email Editor@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

26

AUGUST 2018

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals.

Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for Sofia or call Dr. Shurman, (858) 344-9024.

SHARED OFFICE SPACE AVAILABLE: Shared Office Space: Very attractive 1 or 2 exam rooms available, medical spa office ‘Exquisite Md Spa’ in Bankers Hill near Balboa Park. Available 5 days per week. Reasonable rates. Call Claudia at 619-501-4758.

OFFICE SPACE AVAILABLE IN MISSION VALLEY: Unique space for lease in Mission Valley. 1300 sq. ft office space in medical/ surgical office building, single story, ample free parking. Is currently in use as physical therapy suite with reception area, small waiting room, private treatment room, separate office, bathroom in suite and hook ups for washer/dryer. Easy access to all freeways. Available approximately August 1, 2018. Please contact Joan McComb, Executive Director, CA Orthopaedic Institute.

619-291-8930 or cell 619-840-0624.

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@gmail.com or call/text (858) 243-6883 (Posted 6/11/2018) SHARED OFFICE SPACE AVAILABLE: Established orthopedic group seeks additional orthopedic surgeon for partnership or overhead sharing opportunity.

Our office is centrally located in Kearny Mesa near Highway 163 and Balboa, easy access to freeways, affiliations with Sharp, Scripps.

Extensive referral base, EMR/”paper-light” office, experienced MA/surgery scheduler/ referral coordinator. Please call Lisa Vaughn, practice administrator, at (858) 278-8300 or email lmvomg@yahoo.com. (posted 5/7/2018)

MEDICAL OR DENTAL BUSINESS SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located in the center of Hillcrest/Bankers Hill. Just renovated!

The second story of this beautiful two story building is available for lease. A private gated entrance leads to a 1,139 square foot upstairs with 4 to 5 consultation rooms, waiting room with adjoining private deck and full bathroom.

Additional security gate and mailbox.

Separate address. Wood floors, refinished windows, natural light, quiet street, walkable to restaurants. On-site parking with up to 8 parking spaces available! Asking: $3,000/ month. Terms are negotiable. This will rent fast so hurry! Click for photos. Please contact: hillcrestofficerental@gmail.com 858.775.5075 OFFICE SPACE FOR RENT: La Jolla -lease - medical or dental related practice or business in a small boutique office space located in the center of beautiful La Jolla, California. Perfect opportunity for psychiatrist, psychologist, counselor, dentist, physician, surgeon, any dental or medical related occupation welcome.

Located in medical dental building. Come join these great practices. 612 sq feet, classy second floor suite with elevator.

Perfect for entrepreneur. Partially equipped for dental practice, surgical practice.

Terrific opportunity. $4.90 per sq/ft per month triple net lease contact Kevin Gott: dynamold@aol.com (Posted 3/22/18) OFFICE SPACE FOR RENT: Office space for rent, multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner 619 733 4068 or jo@siosd.com OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com.

NONPHYSICIAN POSITIONS AVAILABLE MEDICAL OFFICE MANAGER/ CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work.

PRODUCTS / SERVICES OFFERED

DATA MANAGEMENT, ANALYTICS AND REPORTING Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries.

Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting.

(619) 913-7568 | info@rudolphia. consulting | www.rudolphia.consulting PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to MediCal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

MEDICAL EQUIPMENT/FURNITURE FOR SALE MEDICAL EQUIPMENT AVAILABLE FOR DONATION: Carlsbad Imaging has medical equipment available for donation. Afinion HbA1c-Used, Siemens clinitek status+Used, FastPack-Used. Please contact info@ carlsbadimaging.com if interested.

SAN DIEGO PHYSICIAN.ORG

27

P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

Adverse Childhood Experiences and the Potent Beliefs That Undermine Health

By Helane Fronek, MD, FACP, FACPh

BEING A PHYSICIAN is joyful when we see patients whose medical conditions formerly impaired the quality of their lives and, because of our care, now live fuller, happier, and healthier lives. When our patients ignore our advice or continue selfdestructive behaviors we may feel sadness for them, but more often we feel frustrated and angry. We forget there are reasons why we each do the things we do. Many of these reasons are rooted in childhood experiences. Only when the reason is discovered and addressed will the behavior change.

Some children are raised in violent

28

AUGUST 2018

homes or suffered neglect or abuse. Even in “model” environments, children have difficult experiences. A friend ridicules them.

A parent ignores their needs. A sibling is favored. As adults, we may understand these situations. The friend might be jealous, the parent works long hours to support the family, one child receives more attention because he is ill or less capable. But children who are dependent on the adults in their lives frequently interpret these situations as evidence that they are not good enough or are inherently flawed. This core belief affects decisions throughout their lives. Espe-

cially if the situation is dire, as with abuse, violence, trauma, or neglect, children frequently believe they are not given love because they are unlovable — they are not worth caring for. This belief underlies selfdestructive behaviors and makes patients resistant or refractory to our care.

In their groundbreaking work, Vincent Felitti, MD, and his group at Kaiser found that obesity was often utilized as a protective strategy by patients from very dysfunctional households or who had been abused; thus, efforts to treat it were often unsuccessful. They recognized that “obesity … is not the core problem to be treated, any more than smoke is the core problem to be treated in house fires.” They later defined Adverse Childhood Experiences, varying forms of abuse, neglect and household dysfunction that lead to disrupted neurodevelopment; social, emotional, and cognitive impairment; chronic health conditions; disability; social problems; and early death.

These findings implore us to become curious, rather than dismissively labeling patients “non-compliant” when they are unable to follow good health recommendations or they demonstrate risky behaviors.

Unfortunately, physicians are wary of wading into the territory of childhood abuse or difficult experiences lest they trigger emotions they feel unprepared to deal with.

As Dr. Felitti explains, this rarely happens.

Instead, patients appreciate the opportunity to share their stories. He suggests we introduce the subject by asking generally if anything happened during childhood that was difficult for them to go through, and then ask how they feel it has affected their health or decisions about their health.

As we struggle to increase productivity and decrease health costs, we might be reluctant to attempt this type of inquiry.

Yet, if we can uncover the root cause of our patients’ inability to support their health, we may save time, money, and a great deal of suffering while adding to our own joy of practicing medicine.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com.

t hank you

TO OUR ADVERTISERS WHO HAVE SUPPORTED SAN DIEGO PHYSICIAN MAGAZINE THIS YEAR.

INSURANCE

The Doctors Company (800) 852-8872 www.thedoctors.com/SDCMS Cooperative of American Physicians, Inc. (800) 356-5672 www.CAPPhysicians.com Norcal Mutual Insurance Company (844) 4NORCAL www.norcalmutual.com

BANKING

First Republic Bank (855) 886-4824 www.firstrepublic.com

COMMERCIALREAL ESTATE

JLL Healthcare Practice Group (858) 410-6377 www.sdmedicalrealestate.com

DATA MANAGEMENT

Rudolphia Consulting (619) 913-7568 www.rudolphia.consulting

EMPLOYMENT

Advantage Surgical & Wound Care (877) 878-3289 www.AdvantageWoundCare.org



Please contact these vendors for your business needs.

MEDICAL BILLING

Medical Billing Strategies (619) 260-0999 askmbs.com

MORTGAGE BANKING

Bank of America billy.cafcules@bankofamerica.com ed.woolery@bankofamerica.com

OFFICE SPACE

WeShareMD (832) 937-4273 www.wesharemd.com

TECHNOLOGY

Soundoff Computing (858) 569-0300 www.soundoffcomputing.com

Tracy Zweig & Associates (800) 919-9141 www.tracyzweig.com Vista Community Clinic (760) 631-5000 www.vistacommunityclinic.org

Additional information can be found at the Practice Management Resources page at www.SDCMS.org.

SAN DIEGO PHYSICIAN.ORG

29

$5.95 | www.SANDIEGOPHYSICIAN.org

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca 92123 [ Return Service Requested ]

Working continuously to balance the

SCALES OF JUSTICE. We’re taking the mal out of malpractice insurance.

As a relentless champion for the practice of good medicine, we continually track, review, and influence federal and state bills on your behalf. All for one reason: when you can tip the scales in favor of the practice of good medicine, you get malpractice insurance without the mal. Find out more at thedoctors.com

PRSRT STD U.S. POSTAGE

PAID DENVER, CO PERMIT NO. 5377