November/December 2019

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

PREVENTION DIABETES Reversing the Risks DEMENTIA Reducing the Burden GUN SAFETY Engaging Patients BREAST CANCER Preventing Deaths

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NOVEMBER /DECEMBER 2019

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CONTENTS

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

VOLUME 106, NUMBER 10

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

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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 ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Brian Rebolledo, MD Alternate Resident Director: Nicole Herrick, 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

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.]

features

4 The Diabetes Prevention Program (DPP) BY AMELIA BARILE-SIMON, MPH;

departments 2

WOOTEN, MD, MPH

Briefly Noted: Public Health • Legislative Issues • Practice Management

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Reducing the Burden of Dementia Through Increased Screening

Top Docs Celebrated!

CHESLEY BLEVINS, MPH; THOMAS R. COLEMAN, MD, MS; AND WILMA J.

BY ABRAHAM CHYUNG, MD, PHD

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Stem Cell Therapy: What Your Patients Need to Know

Study Finds Public Support for Healthcare Providers Talking About Gun Safety

BY CHRISTOPHER J. ROGERS, MD, AND MARY A. AMBACH, MD

BY CALIFORNIA MEDICAL

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ASSOCIATION STAFF

Physician Classifieds

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One-Third of Breast Cancer Deaths Could Be Prevented

What Grief and Loss Can Teach Us About Gratitude

BY ADAMA DYONIZIAK

BY HELANE FRONEK, MD, FACP, FACPh

SAN DIEGO PHYSICIAN.ORG

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// LEGISLATIVE ISSUES

Governor Signs CMA Bill to Require Insurers to Pay for Telehealth Services

PUBLIC HEALTH

Physicians Urged to Report VapingAssociated Pulmonary Injury THE CALIFORNIA DEPARTMENT of Public Health (CDPH) is urging physicians to be vigilant in reporting cases of vapingassociated pulmonary injury (VAPI) to their local health departments. Since June 2019, 102 California cases of vaping-associated pulmonary injury requiring hospitalization have been reported to CDPH. Although the exact cause of illness is not yet known, patients report vaping the cannabis compounds tetrahydrocannabinol (THC) and/or cannabidiol (CBD), and some patients also report vaping nicotine products. VAPI is a clinical diagnosis of exclusion when infectious, rheumatologic, neoplastic, cardiac, or other processes cannot explain an acute pulmonary illness in a patient known to vape cannabinoids and/or nicotine. If e-cigarette or vaping product use is suspected as a possible cause for a patient’s lung injury, a detailed history of the substances, sources, and devices used should be obtained, and efforts should be made to determine if any remaining product, devices, and liquids are available for testing. CDPH is also urging everyone to quit vaping altogether, no matter the substance or source, until current investigations are complete. For those who continue, consumers are urged to avoid buying any vaping products on the street, to purchase cannabis products from licensed businesses (whose products are tested), never modify a store-bought vape product, monitor themselves for respiratory illness, and seek immediate medical attention if they experience symptoms related to VAPI. Please see the CDPH Health Advisory for more information.

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GOVERNOR NEWSOM HAS SIGNED a California Medical Association (CMA)-sponsored bill to increase patient access through telehealth. The bill (AB 744, Aguiar-Curry) will require health insurers to cover services provided via telehealth in the same way they would an in-person encounter. Patient access to providers and healthcare services is an ongoing concern throughout the state. Telehealth overcomes access and cost barriers by utilizing technology to better harness physician time and expertise, and connects patients to their care providers more quickly, efficiently, and conveniently. Although California law does recognize telehealth as a legitimate means of providing healthcare services, the language is insufficient to ensure that physicians are reimbursed for services provided via telehealth. Studies have demonstrated telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings. “This important legislation recognizes the need to update and modernize our healthcare system, to improve access to care for patients and make care easier and more convenient,” says CMA President David H. Aizuss, MD. “By creating a more consistent and reliable reimbursement structure for telehealth services, this bill will ensure that Californians, regardless of their location, have better access to necessary medical care, reduce overall costs of care for patients and to the system, and facilitate better physician communication with patients.” This bill requires that payer contracts issued, amended or renewed after Jan. 2, 2021, to specify that the payer will reimburse physicians for services delivered through telehealth services on the same basis and to the same extent that the payor reimburses for the same services provided in person.

////////////////////////////////////////////////////////////////////////////////////////////////// PRACTICE MANAGEMENT

Webinar: Are You Getting Your Prop. 56 Supplemental Medi-Cal Payments? THE SUPPLEMENTAL MEDI-CAL payments — made possible by the Proposition 56 tobacco tax funding — increase payments on 23 CPT codes. While there is no additional action required by providers who are reimbursed on a fee-forservice basis, physicians with capitated contracts must submit encounter data to the payer in order to receive the supplemental funds. Without the encounter data, the plan or its delegated entity will be unable to determine the services eligible for payment, which will result in nonpayment of the supplemental funds. To learn more about the supplemental payments, including how to ensure you’re

getting your fair share, the California Medical Association (CMA) is hosting a one-hour webinar — Proposition 56 funds: What’s new for FY 19–20 and beyond—on Dec. 4 at 12:15 p.m. The webinar will discuss the services eligible for FY 19–20 supplemental payments, payment amounts, tips on ensuring your practice receives the full amount of eligible funds, and the distribution timelines. Presenters will also discuss the new funding for the value-based payment program, and developmental and trauma screenings. Registration is free for CMA members and their staff ($99 for nonmembers).

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THE DIABETES PREVENTION PROGRAM (DPP)

An Evidence-Based Solution to Reverse the Risk of Diabetes

BY AMELIA BARILE-SIMON, MPH; CHESLEY BLEVINS, MPH; THOMAS R. COLEMAN, MD, MS; AND WILMA J. WOOTEN, MD, MPH

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PREVENTION This article introduces the national prediabetes epidemic, offers an evidence-based solution available to San Diegans, and outlines action steps that physicians can take to help their patients. Almost half of San Diego adults may have untreated prediabetes and as many as 90% don’t know they have it. If left untreated, up to one-third of people with prediabetes will progress to diabetes within five years.1 The good news is that the progression from prediabetes to diabetes is reversible. Prediabetes — the intermediate state of hyperglycemia with glycemic parameters higher than normal, but not high enough to be diagnosed with type 2 diabetes — is an important stage for physicians to intervene. Healthcare professionals are in a unique position to reverse this alarming trend, by increasing patient awareness, improving screening and testing practices, and referring patients to diabetes prevention programs. Physicians and their healthcare teams can help prevent diabetes and the related chronic conditions that greatly affect a patient’s quality of life.

Action Steps for Physicians: How Can You Help Prevent Diabetes? Physicians can help prevent diabetes by: • Increasing awareness of prediabetes among healthcare teams and patients, • Screening and testing patients for prediabetes, and • Referring eligible patients to a CDC-recognized Diabetes Prevention Program (DPP) Lifestyle Change Program.

The DPP Lifestyle Change Program in San Diego County

1. Increase Awareness Among Healthcare Teams and Patients A major challenge in addressing prediabetes is lack of awareness, as nearly 90% of people with prediabetes don’t know they have it.4 Awareness is thus crucial, as we know that prediabetes can be reversed through lifestyle changes. Healthcare professionals hold the key to diagnosing and treating prediabetes before it’s too late. In a study published in the March 2016 issue of the Journal of the American Board of Family Medicine, researchers looked at the extent doctors were screening people with prediabetes, telling them about it, and providing treatment. Lead investigator Arch G. Mainous and his colleagues looked at data from the 2012 National Ambulatory Medical Care Survey, a survey of physician office visits that contributes to national estimates of United States medical care. The researchers studied visits to general, family, or internal medicine providers by patients age 45 years and older who had physician-ordered blood tests done within the past 90 days. These researchers found that almost 34% of the patients had prediabetes, but of those patients, less than 1% received a diagnosis of prediabetes. Further, three-fourths of those with prediabetes were not provided with an appropriate treatment plan. Patient awareness of prediabetes and the efficacy of the DPP Lifestyle Change Program is also crucial. Physicians are encouraged to assess risk for prediabetes during routine office visits; test and evaluate blood glucose level based on risk status; and provide patients with their status and treatment opportunities to prevent progression to diabetes. Further, the entire healthcare system benefits from these actions. Developing support for the local DPP Lifestyle Change Programs encourages collaboration among our region’s community-based organizations, employers, insurers, healthcare professionals, government, academic researchers, and other stakeholders to prevent or delay the onset of type 2 diabetes.

Locally, as many as 46% of San Diego adults are estimated to have prediabetes and are on the path to develop type 2 diabetes.3 The County of San Diego Health and Human Services Agency (HHSA) began offering the DPP Lifestyle Change Program in San Diego with funding from the CDC in 2014. Through this grant, HHSA initiated a broad-based initiative to establish critical infrastructure, systems, and capacity-building resources to scale the CDC’s program locally. By the end of the grant, in 2018, more than 25 organizations in San Diego had committed to training staff as lifestyle coaches and offering the DPP Lifestyle Change Program.

2. Screen and Test for Prediabetes The United States Preventive Services Task Force (USPSTF) diabetes screening guidelines recommend screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Additionally, patients at risk for prediabetes may warrant screening based on family history, comorbid conditions, or individual risk factors such as race, ethnicity, and previous gestational diabetes. Screening for undiagnosed type 2 diabetes can help prevent or reduce small

What You Should Know About the DPP Lifestyle Change Program Once diagnosed with prediabetes, overweight patients can benefit from an evidence-based Lifestyle Change Program sponsored by the Centers for Disease Control and Prevention (CDC). The DPP Lifestyle Change Program helps participants adopt health behaviors, such as eating more fruits and vegetables and being physically active at least 150 minutes per week. The results have the potential to be very significant. The original randomized clinical trial for the DPP found that the Lifestyle Change Program was more effective than metformin and that participants who lost 5–7% of their body weight could prevent or delay type 2 diabetes by up to 58%. Subsequent findings from the DPP Outcomes Study also showed other positive benefits, as well as cost-benefit to the program.2 The DPP Lifestyle Change Program provides a one-year structured program to empower patients to take charge of their health and wellbeing. In addition to learning how to eat healthier and integrate physical activity into their daily lives, participants receive peer support, coaching, and tools to develop problem-solving, stress-reduction, and coping skills to ensure long-lasting lifestyle changes.

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blood vessel complications (such as blindness, kidney failure, or amputations) and cardiovascular disease. Before referring a patient to a DPP Lifestyle Change Program, screen them for eligibility. To be eligible for referral to a CDCrecognized DPP Lifestyle Change Program, patients must meet the following requirements: Be at least 18 years old; and • Be overweight (body mass index ≥25; ≥23 if Asian); and • Have no previous diagnosis of type 1 or type 2 diabetes; and • Have a blood test result in the prediabetes range within the past year (as noted below) ° Hemoglobin A1C: 5.7%–6.4%, or ° Fasting plasma glucose: 100–125 mg/dL, or ° Two-hour plasma glucose (after a 75gm glucose load): 140–199 mg/dL; or • Be previously diagnosed with gestational diabetes 3. Refer Patients to a DPP Lifestyle Change Program For patients who are diagnosed with prediabetes, a referral from their medical provider is the critical connection between awareness and action. Once you’ve determined a patient is eligible, direct them to a DPP Lifestyle Change Program that is conveniently located near the patient’s work or home. For a list of local DPP Lifestyle Change Program locations, visit https://nccd.cdc.gov/ DDT_DPRP/Programs.aspx. An online video is available that illustrates how a practice like yours can screen, test, and act today to prevent diabetes. https:// preventdiabetesstat.org/

DPP Coverage Options There are three primary mechanisms to cover all or part of a DPP Lifestyle Change Program: some private healthcare insurance plans, Medicare, and Medi-Cal. The following information describes each mechanism in detail. Private Healthcare Insurance Plans The Affordable Care Act requires that private healthcare insurance plans cover, without cost-sharing, the preventive services recommended by the USPSTF. Screening for prediabetes and diabetes, and referral to intensive behavioral counseling interventions such as the DPP Lifestyle Change Program for individuals screened and determined to have prediabetes, are in alignment with the USPSTF recommendation. Depending on the type of office visit, practices can use several CPT and ICD codes to bill for prediabetes screening and counseling. Please consult with the patient’s plan for further details about its coverage policies and procedures. Medicare Diabetes Prevention Program Medicare beneficiaries may be eligible to participate in the Medicare Diabetes Prevention Program (MDPP). The MDPP differs in the design of the program and eligibility requirements from the traditional DPP Lifestyle Change Program. The MDPP includes a

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core benefit consisting of at least 22 peer-coaching sessions over 12 months. Beneficiaries who achieve and maintain a required minimum weight loss of 5 percent from the first core session will also be eligible to receive ongoing maintenance sessions, after the 12-month core services period, to help them continue healthy lifestyle behaviors. In November 2017, the Centers for Medicare and Medicaid Services (CMS) released policies and procedures pertaining to beneficiary eligibility criteria, payment structure, and supplier enrollment requirements and compliance standards aimed to enhance program integrity. For more information and a map of enrolled MDPP suppliers, visit https://innovation.cms. gov/initiatives/medicare-diabetes-prevention-program. Medi-Cal Coverage of the Diabetes Prevention Program Effective for dates of service on or after January 1, 2019, the DPP became a Medi-Cal covered benefit. Medi-Cal’s program is consistent with the federal guidelines and incorporates many components of the CMS MDPP and is administered by the California Department of Health Care Services (DHCS). The following are state-generated resources and reference materials for beneficiaries and providers regarding Medi-Cal’s DPP benefit: • Frequently Asked Questions: DHCS’ responses to commonly asked questions regarding Medi-Cal’s DPP benefit: https:// www.dhcs.ca.gov/services/medi-cal/Documents/DPP_ FAQ _Clean.pdf. • Managed Care All Plan Letter (Nov. 16, 2018): The All Plan Letter provides guidance specifically for Medi-Cal Managed Care Plans and is not intended for Medi-Cal DPP providers: https://www.dhcs.ca.gov/formsandpubs/Documents/ MMCDAPLsandPolicyLetters/APL2018/APL18-018.pdf. • DPP Curriculum Translations: DHCS is working to translate the CDC-approved curriculum into DHCS’ required threshold languages. Once finalized, DHCS will publish the translated materials on the DHCS website: https://www.dhcs.ca.gov/services/ medi-cal/Pages/Diabetes-Prevention-Program.aspx. To ensure providers stay up to date with important DPP infor-

PREVENTION

mation, DHCS encourages providers to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to the upcoming changes. Providers may sign up for MCSS by completing the MCSS Subscriber Form at http://files.medi-cal.ca.gov/pubsdoco/mcss/mcss.asp. For more Medicare and Medicaid coverage-related resources, see the National Diabetes Prevention Program Coverage Toolkit from National Association of Chronic Disease Directors at https:// coveragetoolkit.org.

Conclusion For most people, diabetes is a preventable disease. The key to preventing type 2 diabetes is identifying prediabetes and getting blood sugar levels within the normal range. By following the key action steps to increase awareness, improve screening and testing, and refer patients to a DPP Lifestyle Change Program, healthcare professionals can help patients make the life-altering decision to reverse the risk of diabetes. Physicians have a critical role in counseling patients to make simple lifestyle changes that can help them avoid or delay the onset of type 2 diabetes and some of the sequelae related to this common, yet serious disease.

References 1 Babey, S.H., Wolstein, J., Diamant, A.L., Goldstein, H. (2016). Prediabetes in California: Nearly half of California adults on path to diabetes. Los Angeles, CA: UCLA Center for Health Policy Research and California Center for Public Health Advocacy. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27197309. National Institute of Diabetes and Digestive and Kidney Diseases. (2008). Diabetes prevention program. National Diabetes Information Clearing House. Retrieved from https://www.niddk.nih. gov/about-niddk/research-areas/diabetes/diabetes-preventionprogram-dpp. 2

UCLA Center for Health Policy Research (2016). Prediabetes: A Generation in Jeopardy [Press release]. Retrieved from https://insight.livestories.com/s/prediabetes-a-generation-injeopardy/56d78b0659ea410013b63fb5/.

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4 Centers for Disease Control and Prevention (2018). Prediabetes: Your chance to prevent type 2 diabetes. Retrieved from https:// www.cdc.gov/diabetes/basics/prediabetes.html.

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REDUCING THE BURDEN OF DEMENTIA THROUGH INCREASED SCREENING BY ABRAHAM CHYUNG, MD, PHD

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PREVENTION

H

ealthcare professionals are well aware of the problems associated with aging of the baby boomer generation. Incidence and prevalence of medical conditions that afflict the elderly are expected to increase significantly. In this context, there is growing concern with regard to the complaint of memory loss. Everyone experiences some degree of memory impairment as they get older. That is an expected part of normal aging. However, some people develop more serious degrees of memory dysfunction. For such patients, dedicated medical evaluation may lead to diagnosis of Alzheimer’s disease or one of the other dementias. Demand for cognitive screening to clarify matters in that regard is projected to increase in the coming years to epidemic proportions. The number of older adults in our community continues to rise. In 2018, an estimated 84,400 San Diegans had Alzheimer’s disease or other dementias. By 2030, more than 115,000 residents are projected to have such a diagnosis according to data collected by the Alzheimer’s Association and San Diego County HHSA. There are costs associated with such staggering numbers. It is currently the number three cause of death in San Diego County. Furthermore, dementia care in San Diego is projected to cost more than $320,000 during a person’s lifetime, totaling $52 billion over the next decade. To address this rising tide, The Alzheimer’s Project was developed under the leadership of County supervisor Dianne Jacob. This is a countywide effort that brought interested parties together to brainstorm potential strategies to deal with this crisis. In the Clinical Roundtable, there are doctors representing KaiserPermanente, Scripps Health, Sharp Healthcare, UC San Diego, and private practice. Through open and honest discussion facilitated by Michael Lobatz, MD, neurologist and co-chair of the Clinical Roundtable, it was recognized that this problem is too big to be solved by any one healthcare system. Similarly, there are simply not enough specialists in neurology, psychiatry, and geriatrics to provide necessary medical evaluation for all the patients in this growing population. One of the indicators used currently to measure patient care is access. As the elderly population continues to grow in number, it is inevitable that their access to specialists will become increasingly limited. As this scenario becomes more commonplace, it is anticipated that patients will turn to their primary care doctors to manage their concerns for memory impairment. However, primary care physicians are already tasked with an overwhelming number of health concerns to address in a typical clinic visit. In this context, The Alzheimer’s Project Clinical Roundtable developed best practice guidelines for initial screening, more detailed evaluation, and clinical management for patients presenting with memory complaint. These guidelines, first published in 2016 and updated in late 2018, provide a streamlined approach for differentiating those with normal aging from others who truly have a memory disorder even in the setting of a busy clinical practice. Furthermore, the primary care doctors may gain confidence in knowing that they are providing the same medical care as all other doctors throughout San Diego County who are following these guidelines.

These guidelines may be incorporated in the workflow of any clinical practice. There is not one particular approach that is required. Some doctors may choose to do the cognitive assessment themselves. Others may elect to have their support staff perform the cognitive testing. It is recommended to limit the initial assessment to the MiniCog test, a brief cognitive screening test, especially if other active medical issues are being managed simultaneously. Those patients who are identified as potentially having a memory disorder may be scheduled for a separate visit for more detailed cognitive evaluation, such as the Montréal Cognitive Assessment (MOCA). Additionally, the guidelines provide a reasonable approach for ordering blood work and imaging studies as appropriate. The Clinical Roundtable has provided training to more than 2,000 physicians and residents since the initial publication of the guidelines in December 2016. To determine if dissemination of this information can truly have an impact in clinical practice, a pilot study was recently performed at Scripps Clinic. The Internal Medicine department has multiple clinic sites in San Diego. Two of those clinics are located in Carmel Valley and Rancho Bernardo, separated by a distance of about 12 miles. Clinical staff at both sites are comprised of physicians, nurse practitioners, and physician assistants. Those working in Rancho Bernardo received “intervention,” defined by encouragement from clinical leadership to utilize the guidelines. The published guidelines booklet was distributed. Also, their support staff were trained to perform the cognitive screening tests. On the other hand, no such intervention was provided to the clinical staff working at Carmel Valley, who served as the control group for this study. Of course, there are inherent limitations of this study. Most importantly, there has been considerable community-wide physician education prior to the study. Through Grand Rounds presentations, multiple webinar sessions, independent distribution of the guidelines booklet, and individual pursuit of CME activities, even providers at the control site are expected to be aware of the medical issues relevant to evaluation of memory dysfunction. Regardless, comparing the numbers of new diagnosis made prior to and after the intervention reveal an interesting trend. Specifically, data for ICD-10 coding collected from the electronic health record shows that after the intervention, the number of patients diagnosed with dementia at Rancho Bernardo increased. Simultaneously, the number of patients diagnosed with more generic memory disorders declined. This trend suggests that the participants are becoming more comfortable with diagnosing patients with dementia when clinically appropriate, instead of deferring that decision to a specialist. Of note, that trend was not observed at Carmel Valley. Siu Ming Geary, MD, Internal Medicine Specialist and Vice President of Primary Care at Scripps Clinic Medical Group, recognized early on the value of utilizing the clinical guidelines, and volunteered to initiate the pilot study at her Rancho Bernardo clinic site. “With a number of clinical initiatives going on at the same time, we had to make cognitive screening easy for the prac-

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PREVENTION

It has been predicted nationally that 50% of people with dementia do not have a diagnosis, due to a variety of reasons.

titioners. We have copies of the MiniCog in all the exam rooms, and staff are trained to conduct the test with patients. We removed barriers to make the process easy,” says Geary. “Our physicians already do a lot of screening, but the training and guidelines have made screening more comfortable, and we can do it more easily. Making a diagnosis of dementia, like any other terminal illness, is never a comfortable discussion,” adds Geary. “But by the time we get to a dementia diagnosis, we have had several conversations and so it is not a shock to patients or their families. The Guidelines algorithms take us through all the steps necessary to reach the correct conclusions.” The outcome of this pilot study reinforces the need to continue the effort to disseminate The Alzheimer’s Project guidelines to the primary care doctors of San Diego. Screening patients for memory dysfunction should be encouraged at either an acute care appointment or an annual exam. The guidelines clarify which tools to use and in what context. At Scripps Clinic, a 10-question cognitive impairment screening is incorporated into the electronic health record. “If we do not conduct this screening during the Medicare Annual Wellness Visit, we are unable to bill for the visit,” says Dr. Geary. “If a patient has difficulties with these tasks, I immediately conduct a MiniCog screening, and as indicated may move on to a MOCA at a follow-up visit. This has saved substantial time from conducting the MOCA with all patients.” Beyond the clinical criteria for making diagnosis of dementia, the guidelines were designed for comprehensive medical evaluation to also identify reversible causes of cognitive dysfunction. When found, initiating appropriate treatment quickly may improve outcome. Family nurse practitioner Bonnie Marblestone, PhD, FNP-BC, was among those who volunteered for the study. Her practice is primarily with acute care situations. Marblestone recalled seeing a patient exhibiting memory impairment. “Since the patient had significant cognitive deficits, I conducted the MOCA and followed the protocols for evaluation, including labs. The patient had a vitamin D deficiency and a UTI. By following the protocol, I was able to assess the patient more effectively, as the lab studies are now more comprehensive.”

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Moreover, the guidelines clarify when diagnostic testing is not indicated. Timothy Foster, PA, also sees mostly acute care in his practice, but has seen several patients who did not pass the MiniCog or MOCA, and were referred to imaging. He remarked that the protocols “could reduce unnecessary use of labs and imaging by patients concerned with their memory who come in and ask for an MRI.” By explaining the steps to be taken to patients and caregivers, he is now able to reassure them when appropriate, and to take the steps necessary to rule out reversible factors more quickly. It has been predicted nationally that 50% of people with dementia do not have a diagnosis, due to a variety of reasons. National research has shown that screening adoption by health systems leading to appropriate diagnosis can reduce unnecessary emergency department visits, allow patients and their family members to make critical decisions while the patient still has mental capacity, and improve patient compliance for other health issues. Furthermore, earlier diagnosis paves the way for sooner access to support services in the community. There are numerous organizations in San Diego County that can help improve the quality of life for patients. “Life does not end with an Alzheimer’s diagnosis,” says Eugenia Welch, president/CEO of Alzheimer’s San Diego. “We know how this disease ends, and are painfully aware there is still no effective treatment or cure. But we passionately believe people can live well with dementia, and that with proper planning and care, each remaining day can be a good one.” With the rapidly increasing number of older patients experiencing memory and cognitive issues, the burden of Alzheimer’s disease and other dementias in San Diego County may become catastrophic. Therefore, this article is written as a call to arms. We will need all hands on deck. It will take a collaborative effort between primary care doctors and specialists to address this epidemic. It will take healthcare systems making responsible decisions in developing the infrastructure to meet the needs of this growing patient population. It will take government officials allocating funds to programs that support the patients and their families. This is not going to be an easy problem to solve. However, with all of us working together I remain optimistic that each and every person with concern for memory impairment in San Diego County will get the medical care that they need. To download the clinical guidelines and for other resources, visit ChampionsforHealth.org/alzheimers. Dr. Chyung is a neurologist at Scripps Clinic and a member of the executive team of the Alzheimer’s Project Clinical Roundtable.

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STUDY FINDS PUBLIC SUPPORT FOR HEALTHCARE PROVIDERS TALKING ABOUT GUN SAFETY BY CALIFORNIA MEDICAL ASSOCIATION STAFF

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new study out of the University of California, Davis, Firearm Violence Research Center shows that Californians find gun safety conversations that take place in the exam room appropriate if a patient has access to a gun and the patient — or someone in the patient’s home — is at increased risk for firearmrelated harm, such as trouble with drug or alcohol misuse. The study was published Oct. 7 in Health Affairs’ special issue on Violence and Health. While previous studies have found public support for health professionals talking with patients about gun safety in general, this study is the first to ask about appropriateness of these conversations in specific risk scenarios. “Healthcare providers have unique potential to recognize risk for firearm injury and — when risk is elevated and there’s access to a gun — to talk with patients about safe gun practices,” says lead researcher Rocco Pallin. “But providers infrequently assess risk and engage with patients in these conversations in part because they think patients won’t be receptive or that such discussions may alienate them. Our results suggest that these conversations are broadly acceptable, and that patients may find them most appropriate when there is specific risk.” Over the past 10 years ending in 2017, fatalities from firearm violence among civilians in the U.S. exceeded combat fatalities

PREVENTION in World War II. Firearm homicides have increased by 32% since 2014, suicides by 41% since 2006, and the number of nonfatal crime victims by 37% since 2013.

Interventions for Patients at Acute Risk Four out of five respondents, regardless of gun ownership status, said it was at least sometimes appropriate for a physician to intervene to reduce firearm injury when a patient with access to a gun had thoughts of self-harm or harming others. Suggested interventions included counseling the patient to have someone else keep the gun and informing the patient’s family. This study is the first to gauge public opinion on the appropriateness of temporary transfer when someone with access to a gun is in crisis. The high level of support for this intervention, regardless of firearm ownership status, suggests this may be a reasonable risk reduction strategy. “When someone is suicidal, reducing access to lethal means can be lifesaving, and temporary transfer is one option,” Pallin says. The authors recommend that providers be informed about relevant statutes, which vary by state, in order to make lawful and realistic recommendations. Increased attention has been given to the role of healthcare providers in reducing firearm injuries in the last two years, but Pallin

suggests more work needs to be done. “Clinicians, firearm owners, safety instructors and researchers need to work together to develop and evaluate approaches to assess patient risk, counseling on gun safety when clinically relevant, and intervening in emergency situations,” he says. “We need to understand what works best for certain types of risk, certain types of providers, and certain types of patients in order to educate providers to most effectively and efficiently work to prevent firearmrelated harm.” The state of California recently appropriated funds to develop clinician training on strategies for firearm injury prevention, which has the potential to become a national model. For an overview of the study results, see the “Opinions on Health Professionals Talking About Gun Safety” factsheet. The full study is available to Heath Affairs subscribers.

Additional Resources The California Medical Association (CMA) Firearm Violence Prevention Technical Advisory Committee has identified opportunities and resources that may aid physicians in addressing firearm violence as a public health issue. In addition to a policy statement, the committee compiled a number of ways physicians can help prevent firearm violence.

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CELEBRATED! Produced in partnership with the San Diego County Medical Society, San Diego Magazine’s Top Doctors Celebration was held at the Intercontinental San Diego to honor the 2019 Top Doctors featured in the October issue. A highlight of the event was a chef’s competition while guests also enjoyed a walkabout dining experience paired with craft cocktails, San Diego beers, fine wine, and live music and dancing.

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Illustration by Ricardo Gonzalez NOVEMBER /DECEMBER 2019

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4 1. In alphabetical order: Lase Ajayi, MD, Julia Beauchamp, MD, Laurie Bernard, MD, Melissa Cameron, MD, Ami Doshi, MD, Michelle Edmunds, MD, Maria Huang, MD, Manaswitha Khare, MD, Begem Lee, MD, Aarti Patel, MD, Heather Pierce, MD, Tiranun (Jane) Rungvivatjarus, MD. 2. Jon Kistler, MD, and Steve Koh, MD. 3. Lase Ajayi, MD, Kim Bui, MD, Kyle Edmonds, MD, and Sandip Patel, MD. 4. Kelly Parsons, MD, Genevieve Parsons, MD, and Tom Savides, MD. 5. Alan Shahtaji, DO, Rebecca Rosen, MD, Divya Reddy, MD, and Michelle Johnson, MD. 6. Jan Fronek, MD and Helane Fronek, MD.

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R E G E N E R AT I V E M E D I C I N E

Stem Cell Therapy: What Your Patients Need to Know By Christopher J. Rogers, MD, and Mary A. Ambach, MD

KAREN IS AN ACTIVE 58-year-old avid traveler who presented to our clinic with bilateral knee arthritis. She had difficulty walking and sleeping due to pain, stiffness, and swelling. Radiographs revealed moderate joint space narrowing. Physical therapy, steroid injections, and repeated hyaluronic acid gel injections offered temporary relief, but her condition continued to worsen. Her primary physician had advised her to consider knee replacement, but she was concerned about the potential for complications with surgery and wanted to pursue other options. An online search revealed many clinics that promote stem cell therapy. She attended a seminar given by healthcare providers that use umbilical cord blood stem cells, but was disappointed by their lack of scientific evidence. She eventually consulted our clinic to learn more about cell-based therapies. Karen is not alone. There are more than 30 million Americans who suffer with arthritis. Currently, no cure exists and standard medical care often does not sufficiently meet their needs. More than 600,000 patients per year undergo total knee replacement surgery after having failed conservative care. Although most patients are satisfied with the results of surgery, complications and adverse events can occur such as infection, deep venous thrombosis and persistent chronic pain. Many patients are not good candidates for surgery because they are too young or are medically unfit. Orthobiologics are cells and substances produced by cells that are used for the treatment of osteoarthritis, tendon tears, degenerated discs, and other orthopedic

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conditions. They promote the body’s intrinsic capability to heal and offer a viable option for patients who have failed conservative care or are not appropriate surgical candidates. Commonly used orthobiologics include platelet rich plasma (PRP), bone marrow aspirate concentrate, and minimally manipulated adipose tissue derived from a patient’s own (autologous) tissues. Decreased inflammation and tissue healing have been demonstrated in multiple clinical trials. These autologous cell-based therapies contain mesenchymal, adipose, or hematopoietic stem cells, which play a key role in the clinical benefits. However, they also contain many other cells, cytokines, proteins, and growth factors that may contribute to clinical improvement. What Is Regenerative Medicine? Regenerative medicine is a new medical specialty that uses advancements in cell biology, immunology, genetics, and tissue engineering to understand how the body heals itself. What Is Platelet Rich Plasma (PRP)? Platelet rich plasma is formed when a patient’s own highly concentrated blood derived platelets are suspended in plasma. Platelet rich plasma contains a high concentration of growth factors, cytokines, and other substances that promote tissue healing and immunomodulation. It is useful for the treatment of tendon, ligament, cartilage, disc, and joint injuries. Is Platelet Rich Plasma Therapy Safe and Effective? There are several randomized controlled

trials that demonstrate the safety and efficacy of PRP for the treatment of knee osteoarthritis, tennis elbow, patellar tendinopathy, rotator cuff tendinopathy, plantar fasciosis, and other orthopedic conditions. A list of scientific studies can be found at www.sdomg.com/prp and www.sdomg.com/endoret-research. What Are Adult Stem Cells? Stem cells have the capacity to differentiate into other cell lineages or self renew. Adult stem cells are found among differentiated cells in tissues and can generate different cell types for the specific tissue in which they live. A unique population of adult stem cells, mesenchymal stem cells (MSCs), were discovered to have an active role in connective tissue repair and have the capacity to differentiate into bone, cartilage, tendon, or adipose cells. They have colony forming capacity and have a characteristic set of cell surface markers. Significant progress toward safe and effective clinical applications of MSC mediated therapy has been made and continues to evolve rapidly. The best studied sources of MSCs include adipose tissue, which contain a heterogenous mixture of reparative cells. Is Autologous Stem Cell Therapy Safe and Effective? Several randomized controlled trials exist for bone marrow-derived cell therapies for knee osteoarthritis and hip osteonecrosis

and adipose-derived cell therapies for knee osteoarthritis and achilles tendinopathy. High quality clinical trials have been published regarding treatment of tendon tears, partial ACL tears, bone injuries, joint osteoarthritis, and lumbar disc degeneration. Published scientific studies for orthopedic applications can be found at www.sdomg. com/fat and www.sdomg.com/bma. Are Stem Cell Therapies Regulated by the FDA? The U.S. Food and Drug Administration (FDA) regulates the use of stem cells as Human Cells, Tissues, and Cellular and Tissue Based Products (HCT/Ps) under Title 21 Part 1271. Therapies that use a patient’s own bone marrow aspirate concentrate or minimally manipulated adipose tissue are compliant with current FDA regulatory guidelines. Stem cell based products that do not satisfy specific FDA guidelines are regulated under Section 351 as a biological drug. These products require safety and efficacy clinical trials. Products that contain umbilical cord blood, amniotic tissue cells or exosomes require FDA approval of a Biologics License Application (BLA) before they are allowed to be marketed to patients. The FDA has issued warning letters to manufacturers who are not in compliance or make unproven claims of safety or efficacy. Are Umbilical Cord Blood, Amniotic Tissue Cells And Exosomes Safe or Effective? Some clinics promote using these products for the treatment of multiple medical conditions and make unproven claims about safety and efficacy. At this time, there are no studies for safety or efficacy for the products offered at these clinics. In fact, last year more than 17 cases of bacterial infections were reported in patients who had received umbilical cord blood injections. Further testing of these products at Cornell University confirmed that they do not contain any live stem cells at all. We advise patients and physicians to avoid the use of these products until

further testing for safety and efficacy have been conducted. Avoid Clinics That Make Unproven Claims or Use Products That Are Not FDA Compliant. The best way to protect yourself is to stay informed by visiting these sites: https://www.fda.gov/consumers/consumer-updates/fda-warns-about-stemcell-therapies https://www.closerlookatstemcells. org/stem-cells-medicine/nine-thingsto-know-about-stem-cell-treatments/ You can obtain a free copy of our booklet, “A patient’s guide to stem cell therapy,” at www.sdomg.com. Last year, Karen received a single treatment using her own blood and minimally manipulated adipose tissue. At three-month follow-up, she no longer has knee pain, stiffness, or swelling. Twelve months later, she is able to hike and travel without the need for pain medications. We have treated hundreds of patients like Karen, and will continue to share our clinical outcomes in published textbooks, at medical conferences, and in peer-reviewed medical journals. Cell based treatments are investigational and should only be performed by physicians who have advanced training in regenerative medicine. Such physicians practice evidence-based medicine, use FDA complaint therapies, and provide informed consent. They maintain a registry of clinical outcomes, such as DataBiologics, a regenerative medicine registry cofounded by Dr. Rogers. This registry is used by physicians all over the world to track patient outcomes so that they may make informed medical decisions and help move the field of regenerative medicine forward. San Diego Orthobiologics Medical Group is one of just 10 clinics in the U.S. selected to participate in an FDA approved clinical trial of adipose derived stem cells for the treatment of knee osteoarthritis. If you are interested in participating in this clinical trial or would like to obtain more information about cell therapies, visit www.sdomg. com or call (760) 909-2355.

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CLASSIFIEDS PHYSICIAN OPPORTUNITIES

OUTPATIENT PRIMARY CARE PHYSICIAN Located in Vista/Oceanside, Vista Community Clinic is a private, nonprofit outpatient community clinic with 5 locations in North San Diego County, serving people who experience social, cultural or economic barriers to health care. Position: Full-time, Part-time and Per Diem FM/IM Physicians. Responsibilities: Provide outpatient care. No hospital call. Malpractice coverage provided. Requirements: California license, DEA LICENSE, CPR CERTIFICATION AND BOARD CERTIFICATION. Visit us at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled PHYSICIAN CONSULTANT FULL-TIME: San Diego-Imperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application. DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https:// www.governmentjobs.com/careers/sdcounty/ jobs/2359704/deputy-public-health-officer19092204u?keywords=Deputy%20Public%20 health%20&pagetype=jobOpportunitiesJobs TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MDS) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj. Bhatia@sdcounty.ca.gov or call (619) 542-4008.

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BOARD CERTIFIED NEUROLOGIST POSITION AVAILABLE: Seeking a Board Certified Neurologist based in the San Diego region. Opportunities available on a part-time or full time basis for a prominent multi-specialty medical group practice. Candidates should have interest in management of traumatic brain injury, postconcussive symptoms, medical legal evaluations including IME, and EMG. Competitive salary. Please send letter of interest and CV to admin@ pacificmedicalllc.com. SAN DIEGO COUNTY EMPLOYMENT OPPORTUNITY: The County of San Diego has a current employment opportunity for MD-Chief, TB Control & Refugee Health (Public Health Medical Officer). Please see the link for more information: MD-Chief, TB Control & Refugee Health (Public Health Medical Officer-19412807UTB 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 parttime/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 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. PHYSICIAN POSITIONS WANTED RESEARCH PHYSICIAN (NO CLINICAL PRACTICE) PHYSICIAN: Provides medical leadership, oversight, and management of human clinical trails while ensuring the integrity of the studies and the safety and well-being of human subjects. Performs duties in accordance with company’s values, policies, and procedures. On call responsibilites: shares in rotation of weekly call schedule. Please email resumes to tabitha. alvarado@prosciento.com PRACTICE FOR SALE COASTAL NORTH COUNTY PRACTICE FOR SALE: Established 5-star Urgent Care office in affluent coastal North County. Fully furnished & ‘turn-key’. Prominent building signage on busy thoroughfare ¼ mile from I-5. 2000sf. 4 exam rooms + procedure room. Low overhead. 1 year left on lease ww/option to renew. Asking $250K. Serious inquiries only. Reply in confidence to: asapuc@cox.net. PRACTICE FOR SALE IN ENCINITAS: A GYNonly practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31, 2019. Please call Mollie for more information at (760) 943-1011. CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research. Contact E-Mail: CL9636750@gmail.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.

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hospital between I-5 and I-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

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 OFFICE SPACE / REAL ESTATE AVAILABLE ENCINITAS OFFICE SPACE TO SHARE/SUBLEASE: Longstanding (38 years) allergist in Encinitas has a 3000 square foot office space available to share/sublease. Six exam rooms and a permanent private office/consultation room. Office is available Tuesday morning and all day Wednesdays and Fridays. Office located on El Camino Real in Encinitas. Please contact wwpleskow@sbcglobal.net or call (760) 436-3988 LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee (Poole Bldg) between I-5 and I-805. Sublease full or part of office with 5 plus rooms, bathroom/ shower. Excellent referral situation. (Interested in all specialties in particular, a Psychiatrist.) (If interested, may participate in multiple research projects) Call (858) 344-9024 or (858) 320-0525 MEDICAL/OFFICE SPACE AVAILABLE: Beautifully decorated, new office space 2000 sq feet located at 6125 Paseo Del Norte in Sunny Carlsbad , CA. This unique office offers great visibility off interstate 5 and close to Carlsbad Outlet Mall. This medical office consists of 3 exam rooms, 1 big procedure room, and a large nurse’s station. To view the space, contact Katia at (760) 352-4103 or email: Feminacareo@gmail.com MEDICAL OFFICE SPACE SUBLET AVAILABLE: San Diego Eye Professionals, 5965 Severin Dr. La Mesa, CA 91942. This office is close to Sharp Grossmont Hospital and Grossmont Out Patient Surgery Center. A newly renovated beautiful 2,000 sq. ft office space with 6 exam rooms and 3 exam rooms available for sublet. Office has 2 bathrooms, laboratory, large reception office area with brand new lighting and hard wood floors throughout the office, handicap compliant office and reception with wheel chair access. Lots of free parking directly in front of office. Single story building. Optometrist/ Ophthalmologist practice but all practices OK.

Please contact Dagmar or Tami at (619) 5834295 or sandiegoeyeprofessionals@gmail.com 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 half a mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space at www. eisenhauerobgyn.com. Looking for compatible practice types. 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. 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 FOR SALE MEDICAL EQUIPMENT AVAILABLE IN ENCINITAS: GYN-office closing in Encinitas and has medical equipment for sale or take away. Available equipment: exam tables, chart racks, autoclave, ultrasound machine, credenza for supplies, Berkley suction machine. Call Mollie for information at (760) 943-1011 NON-PHYSICIAN POSITIONS AVAILABLE FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time 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 PHYSICIAN ASSISTANT/NURSE PRACTITIONER: Our growing Neurosurgery office in Chula Vista is looking for a part-time Nurse Practitioner/Physician Assistant. The job requires running clinic two days per week and possible hospital rounds/surgical assist in the future. We are looking for an efficient, hardworking team player with communication skills, caring and ability to adequately document is expected. Must have a current CA (PA or NP) license. We are willing to train the right candidate. For more information, fax resume to (619) 476-7963 Attn: Office Manager. 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]

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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 Grief and Loss Can Teach Us About Gratitude By Helane Fronek, MD, FACP, FACPh

RECENTLY, OUR 34-YEAR-OLD nephew died. His wife is expecting their first child, so the tragedy feels magnified. Besides our own loss, we are also aware of our nephew’s loss of the joy and opportunities of raising his child, our niece’s loss of her beloved partner, and their son’s loss of knowing, learning from, and being loved by his father. At times of loss, we often don’t know what to say to ease the grief of those suffering. One of our niece’s friends attempted to comfort her by saying, “Don’t

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worry. You’ll meet someone else and have more children.” While the intent was kind, her words had the opposite effect. These comments, in which what we have lost is trivialized and devalued by suggesting it is easily replaced, fail to honor what we had. Our nephew and his wife had a special, loving friendship and marriage. Each had commented how lucky they felt to have met and to be loved by the other. When a person has lost a loved one, it is far more helpful to share what we also valued about this person, or the ways in

which they touched our lives. In this way, we honor the loss and let the bereaved take comfort in knowing that others understand its significance. It is true that we often don’t appreciate what we have until it is lost. We take many things for granted, expecting they will be there for us forever. When they disappear, we are surprised at how much they added to our lives, and how our lives suddenly seem bereft or less joyful, interesting or safe than before. A clever medical student shared that he had started to preemptively grieve some of the important people in his life, to imagine they were no longer alive, so he would be able to understand the many things he appreciated about them. While this may seem morbid, it gives us an opportunity to bring into focus what we value in our relationships. What we learn from these experiences is the value of recognizing the good in our lives. By consciously paying attention to everything you appreciate in one hour of your life, you may be surprised at the many things that contribute to your happiness and sense of wellbeing. You may notice the color of the walls or a piece of art in your home brightens your mood, the new foliage outside gives you a sense of rebirth and hope, the beauty of the sunrise or sunset fills you with awe, a journal article or book stimulates your curiosity or provides a new perspective for you to consider, the people you encounter superficially or those most important in your life bring innumerable benefits to your life. When we fail to notice these things, we deprive ourselves of an important source of happiness: gratitude. Providing opportunities to experience gratitude helps protect against burnout and enriches our lives, as they show us the richness that already exists. 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.

PREVENTION

ONE-THIRD OF BREAST CANCER DEATHS COULD BE PREVENTED 4 LOCAL RESOURCES THAT REMOVE BARRIERS TO CARE FOR YOUR PATIENTS

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ne week after being laid off from her job as a paralegal, Hillary Condon of Ocean Beach was in an unimaginable position: Her insurance would be terminated at the end of the month, and she had to figure out how she would pay for her $1,300 biopsy that would determine if she had breast cancer. “I was freaking out,” Condon says. “I was told that once I was diagnosed, I could start Medi-Cal, which would help pay for my treatment, but I couldn’t get diagnosed until I got that biopsy.” Susan G. Komen San Diego works to remove barriers to breast cancer treatment for women and men who are uninsured and underinsured, including covering diagnostic costs. Komen San Diego stepped in and paid for Condon’s biopsy. “I was unemployed and there’s no way I could have afforded that. Plus, if I waited any longer, my diagnosis could have been worse. I believe if Komen San Diego hadn’t stepped in, I wouldn’t be alive today.” Susan G. Komen’s Scientific Advisory Board, led by George Sledge, Jr., MD, Professor and Chief of the Division of Oncology in the Department of Medicine at Stanford University, estimates that about one-third of all breast cancer deaths could be prevented without a single new breakthrough in research, just by ensuring people receive (and stay with) the care they need. These findings underscore the importance and impact of local services and positive patientprovider communication in developing treatment plans. Here are four local resources that can help remove barriers to care for your patients and increase access to early detection and quality treatment. Komen San Diego’s Financial Assistance Fund provides financial assistance for breast cancer patients during treatment, including: co-pays, childcare,

rent/mortgage, utilities, transportation, food assistance, breast prosthetics, lymphedema sleeves, post mastectomy bras, and any breast-cancer-related medical device. Komen San Diego’s Breast Cancer Screening & Diagnostic Fund is for women and men who are under-insured, uninsured and do not qualify for the state-funded program, Every Woman Counts. Komen San Diego will cover the cost of clinical breast exams, screening and diagnostic mammograms, surgical consultations, MRIs, breast biopsies, and ultrasounds. Komen San Diego’s Care Coordination has Care coordinators who develop personalized care plans to decrease barriers to treatment and provide linkages to support services. This program prioritizes metastatic breast cancer patients, low-income, uninsured and underserved patients, as well as breast cancer patients facing physical or transportation barriers. Susan G. Komen’s Helpline is a tollfree line whose staff provides patient information about breast health or breast cancer, support groups and counseling, or additional financial assistance. They can call the breast care helpline to speak with a trained specialist or oncology social worker. The toll-free helpline also provides patients with information and resources to make an educated decision about clinical trial enrollment. 877-Go-Komen (877465-6636) helpline@komen.org. For more resources and suggested questions to ask a doctor, please direct patients to www.KomenSanDiego.org.

Hillary Condon

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