September 2019

SEPTEMBER 2019

Official Publication of SDCMS

ELIMINATING

HEPATITIS C

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SEPTEMBER

CONTENTS

VOLUME 106, 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: James H. Schultz, MD President-elect: Holly B. Yang, MD Secretary: Sergio R. Flores, MD Treasurer: Toluwalase (Lase) A. Ajayi, MD Immediate Past President: David E. J. Bazzo, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve Koh, MD Kearny Mesa #1: Anthony E. Magit, 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 #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County #1: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Irineo “Reno” D. Tiangco, 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: Karl E. Steinberg, MD; #8: Alejandra Postlethwaite, MD AT-LARGE ALTERNATE DIRECTORS #1: Mark W. Sornson, 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 ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Young Physician Director: Obiora “Obi” Chidi, MD Resident Director: Vishnu Parthasarathay, MD Retired Physician Director: David Priver, MD Medical Student Director: Grace Chen

feature

6 Sharing the Task at Hand: San Diego Frontline Physicians Answer the Call for Hepatitis C Elimination

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BY CHRISTIAN B. RAMERS, MD, MPH, AAHIVS

departments 4

Terminating Patient Relationships

BY JULIE BRIGHTWELL, JD, RN, AND RICHARD CAHILL, JD

Briefly Noted: Member Highlight • Practice Management • Medical Residency • Calendar • New & Returning Members

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Mitigating the Risk of a #MeToo Lawsuit Against Your Medical Group or Practice

Physician Classifieds

BY JEHAN N. JAYAKUMAR, ESQ.

What Are You Refusing to See?

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Champions Soiree: Awakening Wellness

BY ADAMA DYONIZIAK

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

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BY HELANE FRONEK, MD, FACP, FACPh

Arming Physicians to Fight the Firearm Epidemic

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BY TAYLOR DOCTER

BY DANIEL J. BRESSLER, MD, FACP

SEPTEMBER 2019

ADDITIONAL NON-VOTING MEMBERS Alternate Retired Physician Director: Mitsuo Tomita, MD Alternate Resident Director: Nicole Herrick, 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

Crying as Revelation

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.]

t hank you

to our advertisers who have supported San Diego Physician magazine this year.

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MEDICAL BILLING

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MORTGAGE BANKING

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TECHNOLOGY

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

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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

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// PRACTICE MANAGEMENT

New Member Benefit:

CMA Partners with PatientPop to Help Physicians Grow Their Practices

Dr. Jamieson discusses the other members of his pioneering 1989 surgical transplant team.

MEMBER HIGHLIGHT

‘Living Legend’

Pioneering Transplant Surgeon Stuart Jamieson Speaks at SDCMS Event DR. STUART JAMIESON, whose research at Stanford University in the late 1970s revolutionized heart transplantation through the development of the anti-rejection drug cyclosporin, and which also made lung transplantation possible, was the star of July’s SDCMS Physician Social, co-sponsored with the City Club of San Diego.

Dr. Jamieson gave a fascinating exclusive lecture to dozens of physicians on his new book, Close to the Sun: The Journey of a Pioneering Heart Surgeon, and demonstrated why he’s named a “Living Legend” by the World Society of Cardiovascular and Thoracic Surgery.

Dr. Jamieson performed the first heart-lung transplant at UC San Diego and is the Endowed Chair in Cardiothoracic Surgery, Distinguished Professor of Surgery and Dean of Cardiovascular Affairs at the University of California, San Diego. For more information or to purchase Dr. Jamieson’s insightful book, please visit closetothesunbook.com.

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SEPTEMBER 2019

THE CALIFORNIA MEDICAL Association (CMA) has partnered with PatientPop, the leader in practice growth technology, to help physicians improve their online presence and attract more patients.

PatientPop offers an all-in-one technology solution that’s proven to help physicians thrive in the digital age.

PatientPop offers integrated solutions including online reputation management, social media marketing, and search engine optimization. Its comprehensive suite of services enables physicians to thrive in today’s competitive market.

“CMA has long supported the physician community with the knowledge and resources needed to deliver the best possible care while remaining independent,” says CMA President David H. Aizuss, MD. “Our partnership with PatientPop is great for our members since the solution helps practices grow and improve their bottom line while staying focused on patient care.”

PatientPop will provide CMA members with a free audit to evaluate the competitiveness of their digital profile and a free one-hour consultation to learn how PatientPop can help them promote their practices online, attract new patients, and retain them for life. In addition to deeply discounted service fees, CMA members save 50% off their implementation fee.

“With nearly 80% of healthcare searches beginning online today, physicians must evolve their approach to online marketing to remain competitive,” says Luke Kervin, PatientPop co-founder and co-CEO. “PatientPop replaces disparate outside marketing vendors and technology point solutions entirely. With PatientPop, physicians can attract more patients, manage their online reputation, automate the front office, and modernize the patient experience — and easily track performance metrics.”

For more information about this exciting new member benefit, visit http://compare. patientpop.com/cma to learn more.

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MEDICAL RESIDENCY

San Diego County Residency Directors Hold Leadership Summit THE MEDICAL Residency directors from across the county and our various health systems met in July at the first local DIO/GME Leadership Summit to work on making our programs stronger together. San Diego County Medical Society CEO Paul Hegyi spoke to the group about GME and loan repayment funding, Well Physician CA, and encouraging residents to become involved in the medical society.

Top Row (L to R): Dr. William Tseng, Kaiser Permanente, assistant area medical director; Tom Arneson, assistant GME director, UCSD; Dr. Matthew Keller, DIO, Naval Medical Center, Camp Pendleton; Dr. Dennis Andrade, assistant program director, Family Medicine, Kaiser Permanente; Karianne Holguin, GME director, Kaiser Permanente SCAL Residency Programs; Dr. Michelle Higginson, incoming DIO, Scripps Mercy; Dr. Renée Smilde MD, associate program director, Scripps Mercy Internal Medicine Program; Dr. Matthew Silver, program director, Kaiser Permanente, Emergency Medicine Residency Program; Dr. Christian Ramers, DIO/GME director, Family Health Center San Diego; Lorenzo Atkinson, GME manager, Family Health Center San Diego; Tricia Frost, GME coordinator, Family Health Center San Diego; Karen Velarde; Dr. Maria Carriedo-Ceniceros, DIO, San Ysidro Health; Tracy M Abrams, MSN, RN, assistant medical group administrator, Kaiser Permanente.

Bottom Row (L to R): Paul Hegyi, CEO, SDCMS; Captain Dr. Eugenio Lujan, DIO, Naval Medical Center, Balboa; Dr. Jairo Romero, program director for San Ysidro Health Family Medicine Residency; Dr. Sherry Huang, DIO, UC San Diego; Dr. Craig Collins, DIO, Kaiser Permanente SCAL Residency Programs; Dr. David Shaw, DIO, Scripps Mercy; Dr. Carrie Costantini, DIO/chair of GME, Scripps Green; Dawn Curtis, GME manager, Scripps Green.

MEMBERSHIP

Welcome New SDCMS Members!

CALENDAR SEPT 7: 9am– 4pm, Capacity Assessment Workshop: Capacity Issues With Older Adults, Keck School of Medicine of USC. State Capitol Building, Sacramento

OCT 12–16: Academy of Integrative Health & Medicine Annual Conference, Sheraton Hotel & Marina, San Diego.

Learn evidencebased integrative medicine, AMA PRA Category 1 CME accredited program

NOV 7: 5:30– 8pm, Physician Networking Opportunity and Mixer, Rock Bottom Brewery APR 2–5, 2020: California Society of Anesthesiologists Annual Meeting.

Paradise Point Resort, San Diego

New Members Ratana Bhardwaj, MD Diagnostic Radiology Scripps Clinic Medical Group La Jolla Natalie Maclean, MD Rheumatology Kaplan MacLean Rheumatology, Encinitas Angela Nahl, MD Ophthalmology LASIK Institute of La Jolla, La Jolla

Alex Sun, MD Musculoskeletal Radiology X-Ray Medical Group La Mesa Alison Zachry, MD Pediatrics North County Health Services Oceanside Leslie A. Giesemann, MD General Surgery San Diego Daniel V. White, MD Neurological Surgery Bonita

SAN DIEGO PHYSICIAN.ORG

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In a field previously dominated by subspecialists, an increasing number of primary care physicians are treating — and curing — chronic Hepatitis C (HCV) infection in patient-centered medical homes throughout San Diego County.

SHARING THE TASK AT HAND

San Diego Frontline Physicians Answer the Call for Hepatitis C Elimination

BY CHRISTIAN B. RAMERS, MD, MPH, AAHIVS

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SEPTEMBER 2019

A New Epidemic, a New Clinical Reality First described as “non-A, non-B” hepatitis in the 1980s, HCV is a blood-borne pathogen transmitted through contaminated blood transfusions, non-sterile medical procedures, tattoos, organ transplantation, intravenous drug use (IVDU), and rarely through sexual contact or sharing of personal care implements such as razors or toothbrushes. The CDC estimates that prior to the implementation of screening of the blood supply and the wave of Universal Precautions after the HIV epidemic, there were >300,000 incident cases per year in the U.S. Population-based surveys have shown that baby boomers (those born between 1945 and 1965) have an HCV seroprevalence that is 3–5-fold higher than the general population1. Hence the recommendation from the Centers for Disease Control (CDC) to offer all baby boomers one-time screening for HCV without prior acquisition of risk2.

In recent years, fueled by the opioid epidemic, >80% of new infections occur in people who inject drugs (PWID). The result is a very different looking epidemic: a bimodal age distribution with one peak in the 20–30-year range, and another in baby boomers, currently aged 54–74. It is believed that only 50% of the estimated 3 million prevalent infections have been diagnosed3. Through the lens of a “care cascade,” the large drop from those suspected of having HCV to those diagnosed does not bode well for elimination efforts. Despite the great advances in HCV therapies, if patients are not identified and linked into care, they can’t benefit from the cure, no matter how easy the treatment may be.

Historically, HCV treatment relied on Interferon and Ribavirin, a course that typically lasted a year, came with many potentially severe side effects requiring careful patient selection and intensive monitoring, and with cure rates of only 50%. Because of the intensity of side effects and patient support, typically only those with advanced liver fibrosis were offered therapy, and only highly specialized centers were able to handle the complexities of triaging, prescribing and managing these therapies4. This meant that a basic component of treatment evaluation was a liver biopsy — an expensive, invasive, specialized procedure that many patients declined. It is no surprise that estimates of the HCV care cascade showed only 16% of people with HCV infection receiving treatment and only 9% cured as of 20143.

A Changing Diagnostic and Therapeutic Landscape Enter two profound innovations that have dramatically changed the clinical and treatment landscape and made HCV treatment primed for adaptation to primary care: noninvasive fibrosis assessment via liver elastography, and short-course Direct Acting Antiviral (DAA) treatment regimens. Liver elastography is a technology similar to ultrasound that allows a clinician to assess liver damage at the bedside with a noninvasive, rapid, painless procedure that takes less than 10 minutes. The technology was developed and widely used in Europe more than a decade ago and has been available in the U.S. since 2012.

DAA therapies were first used in 2013 in combination with Interferon and Ribavirin, but in the last five years have evolved into all-oral, highly effective, eight- to 12-week regimens

Brenda Green, MD, family physician, treats HCV in her Chula Vista Family Health Center clinic.

with cure rates >95% in most cases, and safety profiles that often do not even require on-treatment monitoring5. They have rapidly become the standard of care and have enabled treatment to occur in primary care and other settings.

These innovations coupled with steep drops in drug pricing and elimination of payer restrictions have allowed HCV to be safely and easily treated in the primary care setting. California’s Department of Health Care Services initially had a policy restricting HCV therapies in the Medi-Cal program on the basis of liver fibrosis, provider specialty, as well as presence of concomitant drug and alcohol abuse, the most recent iteration of this policy has entirely removed these restrictions6.

New and Emerging Models of Care In response to this new epidemic and with new diagnostic and therapeutic tools at hand, the need for a new approach to screening and linkage to care, treatment algorithm simplification, and integration with other services was self-evident. Although for the older baby boomer cohort, electronic-health-record-based HCV testing prompts have proven largely successful — the VA health system has screened >85% of their age cohort — there has been less success in screening and diagnosis in the younger, more recently infected PWID. Many reasons may help explain this difficulty: the long clinically latent period, often asymptomatic nature of disease, low rates of interaction with the medical care system, and other competing priorities such as homelessness, poverty, addiction, and mental health challenges.

Traditional models of care wherein patients may be screened in primary care settings and referred to GI, ID, or Hepatology offices have proved to have significant limitations, particularly for the younger HCV patients who compose many new infections.

Several models have emerged in response to these new needs. Colocation of services at a primary care clinic is one model that allows patients to see a specialist in their patient-centered medical home and still benefit from an important array of integrated services.

Another model, known as the “Project ECHO” model, uses telehealth to link a multidisciplinary academic subspecialty team to rural and underserved primary care clinics in weekly didactic and case conference sessions. The ECHO model supports primary care SAN DIEGO PHYSICIAN.ORG

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In FHCSD’s HCV treatment program, primary care providers are supported by infectious disease, hepatology, and addiction specialists in a long-term community of practice. Here, Dr. Ramers consults with Dr. Sarah Rojas.

providers with ongoing subspecialty consultation to help identify patients that require in-person specialty consultation. In an evaluation of ECHO, patients treated in rural New Mexico primary care clinics had statistically equivalent cure rates compared with those treated in specialty settings7.

A growing body of scientific literature has documented successful programs in real-world primary care settings with high HCV cure rates8, 9, 10, 11. Recent recommendations from a consensus meeting endorse this approach of shifting HCV treatment to the primary care setting12. Furthermore, the National Strategy for the Elimination of Hepatitis B and C notes in one of its key recommendations: AASLD and IDSA should partner with primary care providers and their professional organizations to build capacity to treat hepatitis B and C in primary care13.

Treatment in the primary care setting is likely to keep patients closer to other complementary services that may not be offered in specialty offices such as addiction and mental health treatment and harm reduction services. The U.S. National Strategy further recommends: The most effective way to prevent hepatitis C among people who inject drugs is to combine strategies that improve the safety of injection with those that treat underlying addiction. The strategy document further states: States and federal agencies should expand access to syringe exchange and opioid agonist therapy in accessible venues13 . Dr. Andrea Daugirdas, a family physician who has been treating HCV in her primary care practice at Vista Community Clinic for the past three years, says, “One example is starting medication-assisted treatment for opioid addiction and helping expand our primary-care-based suboxone program. We can’t properly address the HCV epidemic without also confronting the opioid epidemic, and [treating HCV in primary care] has pushed me to become more competent in the care we can offer.”

‘One of the Most Gratifying Aspects of My Family Medicine Practice’ Dr. Brenda Green, a family practice physician who practices at the Family Health Centers of San Diego (FHCSD) in Chula Vista, treats HCV infection in her primary care practice. She is one of 12 primary care providers in the clinic network who benefitted from a California

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Department of Public Health (CDPH)-funded grant to become trained in HCV clinical evaluation and treatment. Dr. Green sees HCV patients independently, but benefits from a close relationship with Dr. Catherine T. Frenette, a Scripps hepatologist, and participates in a weekly ECHO program that allows her to present cases for discussion, feedback, and clinical guidance.

Dr. Green describes her experience this way: “Caring for hepatitis C patients is one of the most gratifying aspects of my family medicine practice. It has helped me grow as a person and as a physician to serve this population and continue my learning through this amazing program that integrates specialist care with primary practice.”

Dr. Daugirdas at Vista Community Clinic agrees. “As a family medicine physician treating chronic conditions such as diabetes and hypertension can sometimes get downright depressing. It feels amazing to actually be able to cure something! It’s been a privilege to witness my patients’ joy as they complete the journey of treatment and shed the stigma of infection.”

Another participant in the CDPH-funded program, Dr. Sarah Rojas, actually received HCV training during her family medicine residency program. “Offering HCV treatment in primary care ensures a much needed entry point for hard-to-reach patients.

Medication-assisted addiction treatment, mental health services and case management for homeless or marginally housed patients are critical interventions for many and are best offered in a patientcentered medical home setting.”

Primary and Specialty Care: Finding the Balance The ECHO model is one specific way to define the relationship between primary and specialty care, but the principles of collaboration need not be limited to one specific program. Dr. Daugirdas describes the balance in this way: “We now have several providers offering treatment at multiple locations and can get patients in for an initial appointment within a week. We treat most patients … from no fibrosis to compensated cirrhosis, but Child-Pugh class B or C or certain comorbidities definitely benefit from specialist care, especially if liver transplant is on the table in the future. There are some innovative telemedicine opportunities that can help those patients that are in remote areas where specialty care is out of reach.”

Dr. Frenette, a hepatologist and medical director of liver transplant at Scripps Center for Organ Transplanation, provides a specialist’s perspective: “There are not enough liver specialists in the country to care for all the HCV patients that need treatment. Given the safety and ease of HCV treatment in the DAA era it makes sense for patients to be treated by their primary care physicians with whom they’ve had a long-term relationship. Shifting some of the burden of HCV treatment to primary care will also allow patients with more advanced disease to access specialty hepatology care where procedural and transplant expertise is really needed.”

Dr. C. Bart Smoot, a family physician treating HCV in FHCSD’s

ORGANIZING THE ELIMINATE HEP C INITIATIVE FOR SUCCESS To ensure success, the Eliminate Hepatitis C San Diego County Initiative uses a collective impact model for both its structure and approach to community involvement. The initiative has working committees comprised of members representing organizations and clinical practices on the forefront of HCV testing, linkage, treatment, and advocacy.

The Advisory Committee, co-chaired by Wilma Wooten, MD, Public Health Officer and Director of Public Health Services for the County of San Diego Health & Human Services Agency (HHSA) and Paul Hegyi, Chief Executive Officer for the San Diego County Medical Society, makes critical decisions regarding the governance, vision, and cross-cutting activities of the initiative.

The Steering Committee, co-chaired by Christian Ramers, MD, infectious disease specialist and Assistant Medical Director of Family Health Centers of San Diego (FHCSD), and Dean Sidelinger, MD, Interim Deputy Public Health Officer for HHSA, acts as the coordinating committee of the initiative.

The Research and Surveillance Committee, chaired by Natasha Martin, DPhil, Associate Professor in the Division of Infectious Diseases and Global Public Health, Department of Medicine, at UC San Diego, is examining the question of how to best combine resources and information to understand the local HCV burden and to measure the progress we make toward eliminating HCV. The Access, Testing, Treatment and Prevention Committee, chaired by Christian Ramers, MD, largely comprises clinicians, pharmacists, and other direct service staff who work for agencies that offer HCV prevention and/or community-based HCV testing, treatments, and linkage services.

The Consumer Committee, co-chaired by patient advocate Rick Nash and Tara Stamos-Buesig, RADT, Case Manager II/ SUD Counselor with FHCSD, provides input to all committees and serves as a voice for those affected by, or at greater risk of being exposed to, HCV. The facilitating agency for the initiative is the American Liver Foundation, with staff support provided by their Pacific Coast Division Executive Director, Scott Suckow.

The initiative is also supported by Ryan Clary, a technical consultant, and is funded by unrestricted educational grants/support provided by a coalition of organizations, including the Alliance Healthcare Foundation, AbbVie Inc., and Gilead Sciences.

Wilma J. Wooten, MD, MPH, Public Health Officer and Director of Public Health Services for the County of San Diego, and Paul Hegyi, MBA, CEO of the San Diego County Medical Society, serve as Co-Chairs of the Advisory Committee for the Eliminate Hep C Initiative.

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Christian B. Ramers, MD, MPH, AAHIVS, an infectious disease specialist at Family Health Centers of San Diego, has integrated liver elastography into a primary carebased HCV treatment program.

Logan Heights and Sherman Heights locations, agrees. “Some patients may be so complex so as not to be practical for the typical primary care practice. That being said, with a working group and a [hepatology] specialist easily accessible, even complex cases can be handled by a primary care provider. Having the ability to treat without travel to a specialist office, in surroundings more familiar to the patient, all increase the chances of adherence and successful cure.”

The Path Toward Elimination Inspired by the WHO charge to eliminate viral hepatitis as a public health threat by 203014, the U.S. National Strategy to Eliminate Hepatitis B and C13, as well as the growing HCV elimination projects in New York State, San Francisco, and elsewhere, officials in San Diego from a diverse coalition of public and private sectors have coalesced around the idea that now is the right time to make the push for HCV elimination in San Diego. After presenting a formal proposal letter to the San Diego County Board of Supervisors, the initiative received approval to conduct planning activities throughout the year with a mandate to present findings, recommendations, and a roadmap to elimination back to the Board in November 2019.

Activities are well underway and have been organized into several committees, modeled on the work of End Hep C SF. In addition to treating HCV in her primary care practice, Dr. Daugirdas serves on the Access, Testing, Treatment, and Prevention subcommittee of the End Hep C SD initiative and has this perspective on elimination: “Expanding access to HCV treatment in the primary care setting is a crucial step in addressing this public health threat and tackling HCV-related health disparities. We have to step up to the plate to ensure that all people living with HCV have access to treatment, that people with or at risk for HCV have access to prevention and care.”

Dr. Ramers is an infectious disease specialist at Family Health Centers of San Diego.

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References: 1.

Denniston MM, Jiles RB, Drobeniuc J, Klevens RM, Ward JW, McQuillan GM, Holmberg SD. Chronic hepatitis C virus infection in the United States, National health and Nutrition Examination Survey 2003-2010.

Ann Intern Med. 2014 Mar 4;160(5):293-300. doi: 10.7326/M13-1133.

2.

Centers for Disease Control and Prevention. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. MMWR 2012;61(No. RR-4): 1-32.

3.

Yehia BR, Schranz AJ, Umscheid CA, Lo Re V. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014 Jul 2;9(7):e101554. doi: 10.1371/journal. pone.0101554. eCollection 2014.

4. Drenth JPH. HCV Treatment—No More Room for Interferonologists? N Engl J Med. 2013; 368: 1931-1932 5.

American Association for the Study of Liver Diseases and Infectious Diseases Society of America. (2017, September 21). HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Retrieved February 4, 2019, from https://www.hcvguidelines.org/evaluate/whenwhom 6. California Department of HealthCare Services - Treatment Policy for the Management of Hepatitis C. available at: https://www.dhcs.ca.gov/pages/ hepatitisc.aspx ; updated 7/1/18, accessed 3/22/19 7.

Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, Parish B, Burke T, Pak W, Dunkelberg J, Kistin M, Brown J, Jenkusky S, Komaromy M, Qualls C. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011 Jun 9;364(23): 2199-207 8.

Ramers C, Rojas S, Constantino S, et al Eliminating HCV in the Medical Home: Hepatology, GI, and ID Collaboration to Build Primary Care Capacity for Treatment; Hepatology 2018; 68:465A-466A 9. Simoncini GM, Koren DE. Hepatitis C Update and Expanding the Role of Primary Care. J Am Board Fam Med 2019; 32:428-30.

10. Norton BL, Fleming J, Bachhuber MA, Steinman M, DeLuca J, Cunningham CO, Johnson N, Laraque F, Litwin AH. High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary are clinic. Int J Drug Policy. 2017 September; 47:196-201 11. Facente SN, Burk K, Eagen K, Mara ES, Smith AA, Lynch CS. New Treatments Have Changed the Game: Hepatitis C Treatment in Primary Care.

Infect Dis Clin N Am 2018(32): 313-322 12. Dietrich DT, Ahn J, Bacon B, Bernstein D, Bourliere M, Flamm S, Kwo P, Lim JK, Ramers C, Reau N, Sulkowski M, Sussman N, Zeuzem S. A Simplified Algorithm for the Management of Hepatitis C Infection. Gastroenterology & Hepatology. May 2019 15(5): S3: 1-11 13. National Academies of Sciences, Engineering, and Medicine. (2017). A National Strategy for the Elimination of Hepatitis B and C. Washington DC: The National Academies Press.

14. World Health Organization. (2017). Global Hepatitis Report 2017. Geneva: World Health Organization

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P R AC T I C E M A N AG E M E N T

Mitigating the Risk of a #MeToo Lawsuit Against Your Medical Group or Practice Jehan N. Jayakumar, Esq

A NORTH COUNTY family medicine physician surrendered his license1 after he was accused by several patients of groping and other sexually inappropriate acts in the exam room. A San Diego-based internal medicine physician pled guilty to eight counts of sexual penetration of an unconscious person, three counts of sexual battery, and one count of possession of child pornography. Although he escaped jail time, the physician had to register as a sex offender for life and was barred from practicing medicine. 2

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The Medical Board of California relies on two important statutes related to sexual conduct. Business and Professions Code Section 726 provides that physicians who engage in any act of sexual abuse, misconduct, or relations with a patient, client, or customer are guilty of unprofessional conduct and are subject to disciplinary action. Business and Professions Code Section 729 more clearly defines unprofessional conduct of a sexual nature that can be punishable by imprisonment or fines.

A 2018 article in Harvard Business Re-

view titled “Sexual Harassment Is Rampant in Health Care. Here’s How to Stop It”3 listed three key factors that make an organization more prone to sexual harassment: “a hierarchal structure, a male-dominated environment, and a climate that tolerates transgressions.” The business of medicine “has all three of these elements,” the article stated. So much so that Twitter has its own hashtag (#metoomedicine) dedicated to sexual harassment in medicine.

However, there are ways medical groups and physicians in private practice can mitigate their risk of facing sexual misconduct claims from patients. Having a clear, zero-tolerance anti-harassment policy in an employee handbook that is circulated to every employee, regardless of their status in the organization, is a good first step.

In addition to including language about conduct between employees and patients, it is critical that an anti-harassment policy addresses conduct between employees.

Employers also need to make sure that employees read and understand the policy.

An acknowledgement form that includes descriptions of the various types of harassment (e.g., unwanted sexual advances toward any individual, quid pro quo, and inappropriate visual, verbal, or physical conduct) should also be drafted, circulated, and signed by every employee.

Practices may also want to consider prohibiting social interactions between employees and patients, including prohibiting online social media interaction. It is critical for human resource managers to work with key stakeholders, including physicians, attorneys, and employees, to establish policies and procedures that deter sexual harassment at all levels of a practice. An employee handbook with a descriptive, comprehensive anti-harassment policy, policy acknowledgement forms, and ongoing training can help to shape and institutionalize a zero-toler-

ance stance on harassment.

Physicians and medical groups also need to provide thorough and responsive channels for employees and patients to report sexual harassment or misconduct by a physician. If it is determined that any wrongdoing has occurred, prompt remedial action should be taken. Appropriate responses could include discipline and possibly immediate termination. Physicians may also have an obligation to report any sexual misconduct by other providers to the Medical Board. However, prior to taking action, practices need to conduct a thorough investigation, which includes interviews and documentation. Employers should consult with legal counsel prior to launching an investigation to ensure compliance with federal and state laws. It is also critical to take steps such as providing ongoing anti-harassment training to supervisory and non-supervisory employees, and focusing on creating a culture grounded in values

that are antithetical to harassment in order to prevent further misconduct.

Creating a zero-tolerance culture is no easy feat. Physicians need to communicate the urgency of the issue with all members of their organization, ensure that all members of the organization buy into their vision, and consistently align their zero-tolerance policy with behaviors.

Reinforcing cultural values takes time and requires cooperation from all stakeholders within an organization. Establishing and enforcing clear policies, open and responsive channels to voice complaints, and a well-defined policy are all hallmarks of a zero-tolerance culture.

Mr. Jayakumar is a founding partner of Carlson & Jayakumar LLP, a Southern California-based law

firm focused on healthcare and employment law, and business partner of the San Diego County Medical Society. For any questions about sexual harassment policies, employee handbooks, and anti-harassment training, contact Carlson & Jayakumar at (949) 2222008 or visit www.cjattorneys.com.

References https://www.10news.com/news/ team-10/exclusive-more-than-150-sandiego-doctors-disciplined-for-sex-abusenegligence 2 https://timesofsandiego.com/ crime/2015/09/25/doctor-who-sexuallyassaulted-low-income-patients-gets-nojail-time/ 3 https://hbr.org/2018/11/sexual-harassment-is-rampant-in-health-care-hereshow-to-stop-it 1

HR Policies Every Medical Practice Needs in 2019 Download CAP’s free customizable HR Manual today at CAPphysicians.com/HR20

The Cooperative of American Physicians, Inc. (CAP) is pleased to offer The 2019 Human Resources Manual for Medical Practices to help physicians and their staff implement proper HR procedures and policies that can help improve every aspect of your business operations.

SAN DIEGO PHYSICIAN.ORG

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P U B L I C H E A LT H

overdose, and more. My hope is that healthcare providers can assume a similar role when it comes to firearms. And so, after nearly a year of involvement with the organization SAFE (Scrubs Addressing the Firearm Epidemic) and attention to the work of important thought leaders like Dr. Rebecca Cunningham at the University of Michigan and Dr. Garen Wintemute at UC Davis, I have formulated a basic answer to my own challenge. This important issue and our role in addressing it are nuanced.

As a disclaimer, I am not an expert in this field. Rather, I hope to provide you with what is, at best, a basic starter pack of ammunition (see what I did there?) to fight back against firearm injury and at least a spark that might ignite further thought and conversation.

Arming Physicians to Fight the Firearm Epidemic

By Taylor Docter

EMOTION FILLS each of us as the constant waves of hate crimes and mass shootings flash across our news feeds, televisions, and phone alerts. It’s overwhelming. But this onslaught has driven me to a state of heightened awareness and sensitivity rather than desensitization and normalization. The present moment feels like a crisis, a feeling that the literature confirms.

We saw a record-breaking 30 active shooter incidents in 2017 and the number of lives lost in each individual event has been increasing with the more frequent use of automatic weapons.1 But according to the CDC, this is not just a phenomenon related to mass shootings. Injuries related to firearms have been rising over the last five to 10 years and as of 2015, deaths due to firearms outnumber those due to motor vehicle accidents.2 These deaths are not limited to homicide as one might imagine

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from the news coverage — nearly twothirds of firearm-related deaths are by suicide. While San Diego may not be the national capital of street crime or mass shootings, we are home to a large population of veterans and we have room to improve when it comes to supporting them.

The national suicide rate among U.S. veterans is 30 per 100,000. In San Diego, that number jumps to 45 per 100,000, the most common method being use of firearms.3 As a training physician, my mind goes straight to the question: What can our future, current, and past healthcare providers do to fight this epidemic?

As physicians, we have a long history of identifying and reducing patterns of injury by approaching them as a matter of public health. We were and continue to be critical leaders in efforts to improve outcomes related to motor vehicle accidents, human trafficking, tobacco use, opioid

Be knowledgeable Understand that firearm injury is a complex, multifaceted issue that includes suicide, mass shootings, street crime, accidental injury, intimate partner violence, death, mental health, disability, and more.

Educate yourself on the prevalence and presentation of firearm related injury in your community, the local laws surrounding firearm ownership, and the community resources that exist to support patients who have experienced firearm violence.

Know which patients are at risk of firearm injury and death in order to initiate informed conversations, and know the procedures for safely storing a firearm.

ASK The Annals of Internal Medicine released the statement “Yes, You Can: Physicians, Patients, and Firearms” in August 2016 defending the right of physicians to ASK and counsel patients about firearms. 4 This statement put to rest concern about regulations prohibiting physicians from having these conversations. It made a commitment to asking patients about firearms and offered recommendations for how and when to do so. The article also provides an outline for circumstances in which protected health information may be disclosed as it relates to conversations about firearms.

Counsel So you’ve ASKED a patient about firearms, now you counsel! Research shows that having firearms in the home, especially when they are not safely stored, is

associated with a long-lasting increased risk of injury and death. Counseling patients on safe storage is simple and easy and there are many resources for both you and your patients. UC Davis’s resource “What You Can Do”5 outlines three simple and easy steps to safe firearm storage: 1.

Keep firearms unloaded. 2. Keep firearms locked with a safe storage device. 3. Keep firearms stored separately from ammunition, which is also locked.

Advocate for funding and research Progress in reducing firearm injury and death has largely been limited by the lack of research that supports meaningful interventions. The practice of medicine and implementation of legislature should be based on evidence. A historical lack of funding for firearm-related research has been a significant barrier to this process.

Help by donating to organizations supporting firearm research and using your voice and social or political capital to

advocate for more funding and research so that we can implement evidence-based interventions and legislation.

Support policy change Physicians were a loud and impactful voice in the public and legislative discourse surrounding tobacco use, vehicle seatbelt requirements, and swimming pool safety.

Legislation related to firearm safety is another opportunity for us to use our expertise to protect our patients. This could range from basic policies like universal background checks that even a majority of NRA members support6 to more progressive legislation to expand denial criteria or licensing requirements.

Ms. Docter is a MD candidate, Class of 2020, at the UC San Diego School of Medicine.

1. Ducharme J. There Were More Active Shootings in 2017 Than Any Year on Record. Time. May 2018. https://time. com/5266944/2017-mass-shooting-incidents/.

2. Web-Based Injury Statistics Query and Reporting System (WISQARS).; 2017.

3. Walsh S. San Diego Tops The State For Veteran Suicides. KPBS. December 2018.

4. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: Physicians, patients, and firearms.

Ann Intern Med. 2016. doi:10.7326/M15-2905 5. What You Can Do. UC Davis Health. https:// health.ucdavis.edu/what-you-can-do/. Accessed June 13, 2019.

6. Strong B. Gun Owners Overwhelmingly Support Background Checks, See NRA as Out of Touch, New Poll Finds.

Center For American Progress. https:// www.americanprogress.org/press/ release/2015/11/17/125618/releasegun-owners-overwhelmingly-supportbackground-checks-see-nra-as-outof-touch-new-poll-finds/. Published November 17, 2015.

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SAN DIEGO PHYSICIAN.ORG

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RISK TIP

Terminating Patient Relationships

By Julie Brightwell, JD, RN, and Richard Cahill, JD

JUST AS IT IS AN acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end patient relationships that are no longer therapeutic. It is critical, however, to end the patient relationship in a manner that will not lead to claims of discrimination or abandonment.

It is appropriate and acceptable to terminate a relationship under the following circumstances: • Treatment nonadherence • Follow-up nonadherence • Office policy nonadherence • Verbal abuse, violent behavior, or threats of physical harm • Nonpayment A few situations, however, may require additional steps or a delay or even prohibit patient dismissal. Examples include: • If the patient is in an acute phase of

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•

•

•

•

treatment, delay ending the relationship until the acute phase has passed.

If the practitioner is the only source of care within a reasonable driving distance, or when the practitioner is the only source of specialized care, he or she is obliged to continue care until the patient can be safely transferred to another practitioner.

If the patient is in a prepaid health plan, the patient cannot be discharged until the practitioner complies with the terms of the payer-provider agreement.

A patient may not be dismissed or discriminated against based on limited English proficiency, or because he or she falls within a protected category under federal or state legislation.

If a patient is pregnant, the physician can safely end the relationship during the first trimester if the pregnancy is

uncomplicated and there is adequate time for the patient to find another practitioner. During the second trimester, a relationship should be ended only when it is an uncomplicated pregnancy and the patient is transferred to another obstetrical practitioner prior to the cessation of services. During the third trimester, a relationship should end only under extreme circumstances.

• The presence of a patient’s disability cannot be the reason(s) for terminating the relationship unless the patient requires care for the particular disability that is outside the expertise of the practitioner.

When terminating the relationship is appropriate and none of the restrictions mentioned above is present, termination of the relationship should be completed formally. Put the patient on written notice that he or she must find another healthcare practitioner. The written notice should be mailed to the patient by both regular mail and certified mail with a return receipt requested. Keep copies of all the materials in the patient’s medical record. More details on what to include in a written notice can be found in the expanded version of this article: www.thedoctors.com/articles/ terminating-patient-relationships.

Ms. Brightwell, JD, RN, is director of Healthcare Systems Patient Safety, Department of Patient Safety and Risk Management, and Mr. Cahill, JD, is vice president and associate general counsel of The Doctors Company. 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 considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

C H A M P I O N S F O R H E A LT H

Champions Soirée Awakening Wellness By Adama Dyoniziak

THE INAUGURAL Champions Soirée took place in the Japanese Friendship Garden on June 30 to benefit Project Access San Diego.

Congratulations to our 150 guests and sponsors for helping us raise $51,000! This generosity supports patient enabling services such as intensive care management, medical interpretation, transportation to and from medical appointments, medicine, and diagnostic tests.

Guests enjoyed an unforgettable evening with friends, amazing food, captivating entertainment, an exciting silent auction, and a special awards presentation. Hummingbirds were the theme for the soirée. In Native American culture, hummingbirds are seen as healers and bringers of love, good luck, and joy. Our hummingbird honorees were celebrated for their generous donation of their time, talent, and treasure.

The Project Access Medical Interpreter of the Year honoree was Dr. Priya KalyanMasih. She donated 200-plus hours as a medical interpreter during the past year.

Her passion for medicine and helping patients understand their medical care is very evident, and patients leave appointments feeling confident in their understanding of their diagnoses and treatment options.

The Project Access Facility of the Year honoree was North Coast Surgery Center.

Sharon Gray, its CEO, accepted the award on behalf of her facility. This team’s values of clinical quality, integrity, service excellence, teamwork, accountability, and continuous improvement exemplifies their commitment to Project Access patients.

The Civic Health Leader of the Year honoree was Nick Macchione, director of San Diego County’s Health and Human Services Agency. As the architect and strategist of “Live Well San Diego,” he champions a large-scale, social movement for population wellness. He has supported the Champions for Health (CFH) mission at every turn in his career with the

David and Sabrina Bazzo, Paul Hegyi and Meg Storer

Dr Robert Goldklang and Lauren Searles

Sharon and Mike Gray

Nick and Lisa Macchione

county. Macchione leads with passion and purpose for public good.

The Project Access Doctor of the Year honoree was Dr. Robert Goldklang. He is dedicated to providing the highest quality consults and diagnostic procedures to our patients, along with comforting care and expertise. When the CFH Board reached out to their physician friends for assistance in decreasing our GI waitlist, Dr. Goldklang engaged his fellow GI practitioners, resulting in his practice providing even more consultations and colonoscopies to our patients.

The Project Access Partner of the Year honoree was Spine & Sport. Nina Izadi, director of marketing, and Sharon Scherer, director of integration, accepted the award on behalf of their organization. Spine & Sport has been a partner since 2011, donat-

Sylvia Norman Hala Madanat Jim, Shelley Schultz David , Sabrina Bazzo Carol, Pat Tellez

ing 60 physical therapy courses. Patients gain the therapy needed to transition from surgery or injury to being once again strong and productive San Diegans.

Our first ever Trailblazer Award honoree was Dr. Jim Schultz, current president of the San Diego County Medical Society, and medical director for Project Access since its inception in 2008. Dr. Schultz engaged specialty healthcare physicians, hospitals, and surgery centers to mobilize a network of volunteers so that a safety net would be possible.

Join our hummingbirds in blazing the trail for Project Access by contacting Adama at adama.dyoniziak@championsfh.org or (858) 300-2780.

Ms. Dyoniziak is executive director of Champions for Health.

SAN DIEGO PHYSICIAN.ORG

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CLASSIFIEDS PHYSICIAN OPPORTUNITIES INTERNAL MEDICINE PHYSICIAN: Solvang, California – Established private internal medicine practice in the heart of wine country in the beautiful Santa Ynez Valley within Santa Barbara County seeks a BC/BE internist to join a busy practice within the lovely Danish town of Solvang.

Competitive salary and benefits while living and working in a small community with excellent schools, short commutes, fine restaurants, entertainment and Mediterranean climate with no smog or traffic. Enjoy excellent quality of life while practicing medicine in a small clinic affiliated with the Cottage Health System. For more information please contact Office Administrator Amy Comer at (805) 688-2600.

FAMILY PRACTICE MD/DO: Family Practice MD/ DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, well-established office. FAX or email CV to (760) 603-7719 or gcwakeman@ sbcglobal.net.

PART-TIME/FULL-TIIME RADIOLOGIST POSITION OPEN - IMPERIAL RADIOLOGY: MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The Our company is an outpatient diagnostic radiology facility in search of a part-time/ full time radiologist. All candidates must have an active California Medical License. Please contact us via e-mail at info@carlsbadimaging.com with your resume if this position is of interest to you. Thank you. Job Type: Part-Time/Full Time. Pay: TBD. 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, evidence-based 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

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SEPTEMBER 2019

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.

MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The County of San Diego invites qualified individuals to apply for the position of MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES (Job Classification: Public Health Medical Officer). Under the direction of the Deputy Public Health Officer or designee, this unclassified management position will be responsible for the medical oversight of County of San Diego, Health & Human Services Agency, California Children’s Services Division. Residency in Pediatrics or Family Medicine is highly desirable.

Please view the detailed brochure for information regarding the position, duties, and benefits. | Job Number 18412807CCSU 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.

PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Internal Medicine practice for sale near SDSU and College Area that has been in practice for thirty years. This practice has great street exposure and very accessible parking. For immediate consideration, forward your details including your contact phone, your specialty and current professional status to: chandrasmreddy@gmail. com. Only Doctors will be considered, no brokers.

HIGHLY PROFITABLE MEDSPA NOW AVAILABLE TO LICENSED PHYSICIAN: Southern California. Asking Price: $1,050,000.

Cash Flow: $410,419. This profitable and expandable company performs non-invasive cosmetic procedures, including dermal fillers, Botox, and laser treatments. Experienced staff plans to stay, and protects current physician/ owner at 30 hours/week max. If you’re ready to see online financials, a studio-quality video of their story, an industry-leading assessment, and more – visit: https://goexio.com/med-spa-landing-sd for a summary. Interested? Click on “Private Access” to sign an instant nondisclosure and unlock the entire story. Full financials available on request. Prefer a personal touch? Contact Doug Miller: (208) 7623451. doug.miller@goexio.com.

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

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

NEW OFFICE SPACE IN VISTA

500-4000 sq. ft. office units available for lease in brand new high-quality building, in second story with elevator above a thriving primary care clinic and urgent care attracting 100 patients per day of foot traffic. Street-facing and located in Vista along the growing redevelopment zone.

Please contact Richard Alvarez at Prime Investors Corp. ralvarez2@verizon.net or 760-224-9283.

OFFICE SPACE AVAILABLE: 1224 10th Street, Suite 201-A, located in the El Dorado Square building just off of Orange Ave. Ideal space for professionals, pediatric speech therapists, pediatric physical therapists, treatment room and general office use. Shared waiting area, Shared sink/hand washing station, Access to restroom on property, Elevator access available,1 parking space included, A/C, Utilities included, Cleaning service provided. 12 month lease, Approximately 830 square feet, plus shared waiting room. Rent is $2500 per month. Please email doctorlauraoffice@ gmail.com to view the space!

SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046.

OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc. and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website:www. eisenhauerobgyn.com. Looking for compatible practice types.

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: 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 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.

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 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: 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.

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/”paperlight” office, experienced MA/surgery scheduler/ referral coordinator. Please call Lisa Vaughn,

practice administrator, at (858) 278-8300 or email lmvomg@yahoo.com.

SCRIPPS ENCINITAS CAMPUS OFFICE: 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc. and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and a half-mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View space on Website: www. eisenhauerobgyn.com. Looking for compatible practice types.

MEDICAL OR DENTAL 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 HERE 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. Classy second floor suite with elevator. Perfect for entrepreneur. Partially equipped for dental or surgical practice. Terrific Opportunity. 612 square fee. $4.90/sq ft per month. Triple net lease.

Contact Kevin Gott: dynamold@aol.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.

MEDICAL EQUIPMENT / FURNITURE FOR SALE HIGH TECH FACIAL IMAGING FOR SALE: New Reveal® Imager for sale. Ideal for MedSpa or cosmetic practice. The Reveal® Imager clearly demonstrates sun damage, brown spots, red areas and more. Create a personalized printed treatment record for the patient. Contact info@ restoresdplasticsurgery.com or 858-224-2281 if interested.

MEDICAL EQUIPMENT AVAILABLE FOR DONATION: Carlsbad Imaging has medical equipment available for donation. Afinion HbA1cUsed, Siemens clinitek status+-Used, FastPackUsed. Please contact info@carlsbadimaging.com if interested.

NON-PHYSICIAN POSITIONS AVAILABLE

Financial Director to manage financial operations.

Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred.

Excellent references and background check required.

Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations, jobaxter@sdsm.com.

PLASTIC SURGERY AND FRONT DESK COORDINATOR: The ideal position for someone with a background in plastic surgery, dermatology, ophthalmology, or medical spa. Will consider those with a background in a high-end hospitality setting.

The Coordinator is primarily responsible for the day-to-day creation of an office environment that fosters highly personalized customer service.

Responsible for the front/back office daily operations including patient care, scheduling, and optimizing surgical closure rates and sale of skin care lines. Contact info@restoresdplasticsurgery. com with resume. Salary commensurate with experience.

NON-PHYSICIAN POSITIONS WANTED 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 A VALUABLE EDUCATIONAL RESOURCE: Extensive Medical Articles File for sale. Charts, illustrations, articles. Emphasis on Emergency Medicine and Internal Medicine. Collected since 1973. Fills a large filing cabinet. (Cabinet not included.) Would make a useful gift for a medical student or resident. Best offer takes. Will accept offers for 30 days after the publication of this newsletter. View in person at a North County location by appointment. (858) 451-6517.

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 Medi-Cal 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]

FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time SAN DIEGO PHYSICIAN.ORG

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

What Are You Refusing to See?

By Helane Fronek, MD, FACP, FACPh

WE EACH HAVE WAYS of functioning in the world that feel most comfortable to us, sometimes merely because they are familiar. For various reasons, even when they don’t achieve the results we want, we maintain these practices and resist suggestions to change.

When I grew up, being accommodating and getting along with others was strongly encouraged. While this improved my popularity and made my life easier, prioritizing getting along limited what I could accomplish and prevented me from getting what I really wanted. Still, the familiarity and comfort of being liked kept me from challenging this habit — until the negative consequences became too obvious for me to ignore.

In one year, someone reneged on an agreement I had contributed an enormous amount of time and money toward. I pur-

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Our insistence on doing things a certain way, even when it doesn’t get the results we want, is a form of magical thinking. chased a lame horse, recommended by two experienced trainers. And, after a series of dental procedures failed to solve my problem, the dentist stopped responding and his less experienced partner advised a plan that was sure to fail. The common denominator of these three seemingly unrelated situations was my unwillingness to confront people in a direct manner.

Our insistence on doing things a certain way, even when it doesn’t get the results

we want, is a form of magical thinking.

We pretend that somehow, next time, it will work out differently. A clever saying is that “Insanity is doing the same thing over again and expecting a different outcome.” This isn’t insanity; it’s human nature. Change is hard, as we must leave our comfort zone, challenge our self-image and reputation, and risk incurring people’s disappointment or anger. The reward? We realize we can do things differently, no longer limited by arbitrary rules.

After several unsuccessful practices in different towns, a surgeon eventually lost his hospital privileges. This painful experience was the catalyst for him to look at the role he played in each failure. He realized that his belief that “caring for the patient” was the only thing that mattered had led him to justify and ignore his and others’ inappropriate behavior. Although moving to a different location offered a “fresh start,” he left behind a reputation marred by accusations of unprofessionalism and took his willingness to ignore interpersonal aspects of care with him. As his stress increased, he again lashed out at staff members, believing their feelings were meaningless casualties compared with his important clinical work. The pain of losing his privileges outweighed the discomfort of examining his behavior and its contribution to the failures of his career. Only too late did he realize he could have prevented this terrible outcome if he had done this earlier.

As we courageously to look at the patterns in our lives and challenge the assumptions that allow our unproductive behavior, we invite greater freedom into our lives. We drop the unrealistic expectations we’ve placed on ourselves or others and allow our values and aspirations to inspire a life that is more thrilling and fulfilling than the one we left behind.

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.

POE TRY AN D M EDICIN E

An Inventory of Tears We cry feeling happy We cry when we’re sad We cry recollecting Our mother or dad

Crying As Revelation

We cry at the movies We cry as release We cry in self-pity We cry to find peace We cry cutting onions We cry in the rain We cry when adventure Dissolves into pain

By Daniel J. Bressler, MD, FACP

CRYING CAN HIJACK an office visit.

Let me give a recent (partially disguised) example. A retired school teacher came in to discuss side effects from her new diabetes medicine. In response to my innocuous question about her family, her eyes welled up as she told of her daughter’s fresh divorce.

What was I to do in response? I am experienced at diabetes management and clumsy at secondhand marriage counseling.

For many years in the wake of such outbursts, I would attempt reassurance by minimizing the tear trigger, something like “maybe it will be for the best.” Furthermore, when patients apologized for crying (as they often did), I would dismiss the apology with a patronizing “don’t worry about it.”

Anything to get back to the “business” of the office visit. As the years have gone by — and perhaps because I’ve accumulated my own share of tear-worthy experiences — I now thank my crying patients by explaining that their tears signal that they feel safe enough to cry in my presence.

Crying — the shedding of tears prompted

by strong emotion — is an activity unique to humans. Among other things, it is an opportunity to enhance the bond between people by communicating in a way that the cryer may not be able to muster through words alone. Tears convey both vulnerability and salience. They say, “this is really bothering me” or sometimes, “this is immensely important to me.” When my listening skills are attuned, tears prompt me to pay attention as something emotionally potent is unfolding.

My advice? Welcome tears that patients cry as well as the moisture that may well up in yourself in response to their crying. It will be good for the doctor-patient relationship.

Imagine that you are making a deposit into a “mutual trust account.” And just one more thing: Always keep a box of Kleenex handy.

Dr. Bressler, SDCMS-CMA member since 1988, is on the Biomedical Ethics Committee at Scripps Mercy Hospital and is a longtime contributing writer to San Diego Physician.

We cry in the morning Rising up from a dream We cry at the genius Of coffee with cream We cry in nostalgia We cry in delight We cry though resisting With all of our might We cry to surrender We cry to conceal We cry in confession We cry just to feel So welcome the tears That need to be cried When a baby is born Or a friendship has died There’s always a note To the eyes from the brain It flows with our tears To expose and explain.

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