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NOVEMBER/DECEMBER 2020 Official Publication of SDCMS

Celebrating 150 Years

TELEMEDICINE in Global Health

Contents NOV. / DEC.

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder


OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, 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 H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick 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: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, 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.]





Zooming Forward Advances With Telemedicine in Global Health By Srinivas Iyengar, MD


Briefly Noted: San Diego County Medical Society and CMA House of Delegates


Metabolic Health in the Time of COVID By Kristin Baier, MD

Finding Gratitude in Difficult Times By Helane Fronek, MD, FACP, FACPh



California’s Completely Unpredictable, Totally Chaotic Legislative Year By Janus L. Norman


More Than Skin Deep By Adama Dyoniziak



Physician Group Practice: Growth and Consolidation By Tal S. David, MD SanDiegoPhysician.org 1


San Diego Has Major Impact at CMA House of Delegates Session By Paul Hegyi, MBA AS YOU WILL NO DOUBT IMAGINE, CMA’S annual House of Delegates was an entirely different affair than past years. Normally a gathering of more than 500 physicians and trainees over an extended weekend, filled with delegation meetings, policy discussions and camaraderie, 2020’s House was a much more limited affair, held virtually. Realizing the impracticality of holding 16 hours of presentations and debate over a virtual platform, the policy agenda was curtailed to two major reports, containing 30 individual recommendations each. Testimony on each of these was taken in advance of the House on the CMA website, during a live town hall over Zoom the evening before the House, with additional questions taken after committee presentations. Our own Lase Ajayi presented the Future of Medical Practice Post-COVID-19 report as chair of the Council on Medical Services. The Council on Science and Public Health presented its recommendations in the Pandemic Response and Preparedness report. At the conclusion of the House of Delegates meeting Oct. 24, SDCMS Past President Robert Wailes took office as president-elect of CMA. Dr. Wailes’s ascension opened up one of the District I seats on the CMA Board of Trustees, which saw current SDCMS President Holly Yang elected, joining ongoing trustee William Tseng. The Board also established a new Governance Technical Advisory Committee chaired by Dr. Yang, assigned to review the seismic governance changes enacted six years ago and recommend updates that will ensure inclusive policy development. The 2020 House saw SDCMS Past President Susan Kaweski complete her term as chair of CALPAC, the political action committee for CMA. The House of Delegates has long been the single largest fundraising event for CALPAC, with delegations engaging in a friendly competition for bragging rights based on participation and donation totals. Early on, Dr. Kaweski recognized the challenges presented by a virtual meeting and worked with the CALPAC team to devise online

November/December 2020

tracking. Not only did fundraising meet past levels, they set an all-time record of $197,343 raised! Last year CALPAC established a perpetual trophy, the Victory Bell, to be held for a year by the delegation with 100% participation and highest average donation. I’m incredibly proud to report that District I was again awarded this honor. Please visit www.calpac.org/donate to contribute. Earlier in October, SDCMS member Vimal Nanavati was elected Development Chair of CALPAC. He added to his responsibilities during the House when he was elected Chair of the Organized Medical Staff Section (OMSS). Closing out the evening in a highly competitive race with four candidates, SDCMS PresidentElect Sergio Flores was elected vice-chair of the CMA Board of Trustees. Given our outstanding leadership, San Diego County Medical Society physicians are guaranteed to have a major policy setting and organizational impact on the California Medical Association and its direction for many years to come.

SDCMS Leaders in CMA Holly B. Yang I’m honored to represent District I (San Diego and Imperial Counties) on the California Medical Association’s Board of Trustees. My goal is to make sure that the voice of our local physicians is heard at the state level to help make decisions that serve CMA and its membership with our community in mind. I will do my best to represent our diverse needs and viewpoints as we continue to deal with the myriad issues our patients and physicians face, including health inequities and the COVID-19 pandemic. I am also taking on another role at CMA as the newly appointed chair of our second Governance Technical Advisory Committee. This is no small task, and I look forward to working with CMA staff and leaders across our state to iterate and improve our governance structure. My goals are to make sure the voice of our membership is heard, that we foster community and mentor leadership, and that we have effective, efficient policymaking — including an impactful House of Delegates.

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ZOOMING FORWARD Advances With Telemedicine in Global Health By Srinivas Iyengar, MD

Photo by Geoff Oliver Bugbee


o say 2020 was “atypical” in the medical lexicon would be a gross understatement. “Zoom” no longer implies you are talking about magnification optics, and “zooming” with colleagues has replaced grabbing a meal or toasting a beverage. In spite of taking every precaution we can think of, we all now know someone who has either overcome or succumbed to the effects of COVID-19 — physicians, families, and yes, even presidents. This particularly unique year in practicing medicine has had global repercussions as well. International NGOs (non-governmental organizations) have ceased many of their operations abroad, and medical volunteers have returned to their home countries. Individual patients in parts of the world where these organizations play a large role in the delivery of healthcare feel this burden the greatest.


November/December 2020

Acknowledging the good you have in your life is the foundation for all abundance.” — ECKHART TOLLE Orbis International, a global NGO based out of New York City, has been fighting avoidable blindness for nearly 40 years by training, mentoring, and inspiring eye care teams in places with the greatest need so they can save and restore vision in their communities for years to come. (In Latin, orbis means “of the eye,” and in Greek, it means “around the world.”) The flagship of Orbis is the world’s only Flying

Eye Hospital, once a DC-8, then a DC-10, and most recently, a renovated MD-10 airplane donated by FedEx. This unique airplane has a classroom in the front and, behind it, a state-of-the-art operating room. In non-pandemic times, the plane lands in airports around the world, and local eye care professionals come on board for ophthalmic training from Orbis’s staff and volunteer faculty. Cameras and microphones in the operating room allow training participants in the classroom to view the live surgery taking place and discuss surgical approaches. The plane also has cutting-edge simulation training technology — like virtual reality, artificial eyes, and life-like mannequins — so that eye care teams can safely build their surgical skills before progressing to real-life procedures. Orbis has a unique niche in global health, as it is focused on teaching other doctors, nurses, anesthesiologists, and

biomedical engineers. The concept is not based on the volume of surgeries performed but employs the classic “teach one to fish” philosophy of empowering others who might not have access to advanced training. The high costs of tuition and international travel prevent most eye care professionals in low- and middle-income countries — where the prevalence of vision impairment is estimated to be four times greater than in high-income regions — from advancing their skills. Since 1982, the Orbis Flying Eye Hospital has traveled around the world advancing the training of those delivering eye care. The Orbis team is generally in the country for a two-week program after significant advanced planning and logistics. The Orbis team consists of people from around the world, a United Nations of sorts. Just the coordination of visas and transport of medical equipment can provide unique challenges. Additionally, the challenges local doctors face in their daily lives is unimaginable to many of us here in San Diego. The start of a program begins with a screening day, followed by a week of surgery. The goal of screening day is to find the best teaching cases for the local surgeons, but inevitably includes the

selection of cases where a child’s life may be endangered from an intraocular tumor or blindness may be imminent without immediate intervention. In some cases, patients present with pathology that humbly teaches us that there are diseases that we have yet to even characterize here in the United States. Our team recently published an article about a new eyelid syndrome not seen in the ophthalmology

Vientiane, Laos. A patient with congenital ptosis deboards the Flying Eye Hospital after surgery.

textbooks here in the United States. While the Flying Eye Hospital is oneof-a-kind, over the years, Orbis has also added long-term in-country programs, hospital-based trainings and fellowships to provide additional skills-building opportunities for eye care professionals. Orbis currently has long-term country programs in 19 countries. Our permanent offices in eight of these countries, run

Dr. Iyengar teaching eyelid surgery in Kumasi, Ghana during an ORBIS program in 2019.

by local staff, develop and implement an array of multi-year projects to improve the quality and accessibility of eye care to residents, particularly in rural areas and low-resource urban communities. Many of these programs focus on the treatment and prevention of childhood blindness, cataract, trachoma, and corneal disease. Orbis’s award-winning telemedicine platform, Cybersight (www.cybersight. org), has become another critical resource for many eye care professionals around the world. This secure platform began nearly two decades ago, allowing doctors to share photographs of cases with their colleagues who might have been able to help diagnose and treat patients. Today Cybersight provides long-distance mentoring and education, online courses and lectures, and symposiums. Expert volunteers also provide on-demand advice for complex cases and remote surgical mentorship for local eye care pro-

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ORBIS Cybersight Usage in 2020

fessionals. Surgical training and lectures conducted on the Flying Eye Hospital are now broadcast live to eye care teams around the world via Cybersight. In 2019 alone, Cybersight trained more than 7,600 eye health professionals from 183 countries and regions. In 2020, Cybersight has seen a huge surge as eye care professionals around the world embraced remote learning during the COVID-19 pandemic and now has more than 30,000 registered eye care professionals across more than 200 countries and regions. Orbis has also used Cybersight to offer virtual Flying Eye Hospital programs — a safe alternative so that eye care professionals in the countries where the plane was due to visit this year can still receive training. As the entire world shifts toward online learning, Orbis is already poised to be a thought leader in this new approach to global health. VISION 2020 was a global initiative that aimed to eliminate avoidable blindness by the year 2020. It was launched in 1999 by the World Health Organization (WHO), together with more than 20 international NGOs involved in eye care and the prevention and management of blindness that comprise the International Agency for the Prevention of Blindness (IAPB). Twenty years later, organizations like


November/December 2020

At a time when other industries have been decimated from the effects of the pandemic, physicians here have the unique privilege to still apply an altruistic skill set, make a generous living, and enjoy the intellectual stimulation that comes from a career in medicine. Orbis have helped us make great leaps in the reduction of avoidable blindness, including the eradication of the world’s leading cause of infectious blindness (trachoma) in many countries. But there is still much work ahead. Experts have projected a tripling of global blindness by the year 2050, with the world’s most vulnerable communities — many of whom have been hardest hit by the pandemic — at greatest risk. At a time when other industries have been decimated from the effects of the pandemic, physicians here have the unique privilege to still apply an altruistic skill set, make a generous living, and enjoy the intellectual stimulation that

comes from a career in medicine. Every medical student, resident, or physician who has had the opportunity to use their skill set to help communities in resourcestrained areas abroad knows that particular satisfaction that comes from helping someone who might not otherwise get care. Finding volunteers willing to participate in international projects like Orbis and finding areas once again willing to embrace the American volunteer doctor will depend on the development, global efficacy, and swift administration of a vaccine. The end of the year is the time when most individual and corporate donors reflect on their year and make their social responsibility gifts. Organizations like Orbis have been able to provide reassurance that NGOs remain ready to quickly adapt to the post-pandemic era. That said, while some of us would say 2020 wasn’t so great, for many 20/20 still remains a dream. Dr. Iyengar is chief of ophthalmology at Scripps Encinitas Memorial Hospital and serves as its oculoplastic surgeon. He has been a member of SDCMS since 2014 and is owner of, and chief surgeon at, San Diego Eyelid Specialists. He also serves as a volunteer faculty member with Orbis International in Oculoplastic Surgery.

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our patient returns to clinic for his quarterly check to reassess his hypertension, dyslipidemia and type 2 diabetes mellitus (T2DM.) Over the last few years, you have observed his BMI slowly breaking the threshold into obesity, with an unfavorable waist circumference, hyperglycemia inching toward the need for insulin, triglycerides elevating while high-density lipoproteins stagnate, and blood pressure climbing to the verge of needing another pharmaceutical agent. All of this occurred despite his insistence on compliance with dietary guidelines and trying his best to incorporate more movement into his day through the aches and pains of osteoarthritis. This patient’s situation has become all too familiar for primary care providers and specialists. Despite their best efforts and medications at their fingertips, patients are slipping further into the despair of metabolic disease. Researchers at the University of North Carolina Gillings School of Global and Public Health examined National Health and Nutrition Examination Survey data from 8,721 people in the United States between 2009 and 2016. Data revealed 12.2% of American adults are metabolically healthy — defined as having optimal


November/December 2020

waist circumference, fasting glucose, high-density lipoprotein, triglycerides and blood pressure. This leaves the remaining 87.8% of the population more vulnerable to developing disease, including type 2 diabetes.1 While we are leading the world in many aspects of medicine, metabolic disease has become our Achilles heel. COVID-19 has brought renewed interest and urgency into successful treatment and prevention of metabolic syndrome. COVID statistics obtained from the CDC clearly show higher morbidity and mortality associated with metabolic disease, specifically diabetes and obesity. The CORONADO study demonstrates that being overweight and obesity are associated with poor early prognosis in patients with T2DM hospitalized for COVID-19.2 Ten percent of these hospitalized patients died within seven days. Sixty-five percent of diabetic patients with COVID-19 admitted to the hospital are men. Another study confirms patients with T2DM are prone to developing severe and critical COVID-19 with poor therapeutic effect.3 Complications of metabolic syndrome prior to COVID have been well established, yet barriers to successful, sustainable treatment and prevention

The “eat less, move more” campaign has been an epic failure as it fails to address the endocrine adaptations and satiety mechanisms that are crucial for weight loss.

persist. At the root of the problem is the failure to adequately address the decades of lifestyle choices that lead to insulin resistance. In our current healthcare system, physicians are burdened with time constraints imposed by hospital administrators and insurance companies as well as the pressure to be profitable. Treatment of metabolic syndrome and obesity becomes secondary to other quality control measures and comorbid conditions. Pharmaceuticals help treat lab values and symptoms but often neglect the underlying cause. This is a band-aid without stopping the bleeding. It takes

only minutes to order tests and write a prescription, maintaining the subpar standard of care. Additionally, inadequate nutritional training in medical school and residency, lack of insurance reimbursement for lifestyle interventions and misleading epidemiological studies have resulted in well-intentioned but flawed dietary guidelines. This has added to the frustrations of lifestyle counseling in a medical setting. The “eat less, move more� campaign has been an epic failure as it fails to address the endocrine adaptations and satiety mechanisms that are crucial for weight loss. As a society we

have prioritized financial gains from highly inflammatory processed food over nutrient-dense whole foods that would improve the health of the country. Attempts are being made to address the holes in metabolic and obesity training. The American Board of Obesity Medicine (ABOM) has recognized the challenges physicians face, and as a result created a certification focused on education pertaining to complexities of obesity management and associated comorbidities. As one of the few specialty board certifications that does not require a distinct residency, it has gained popularity in recent years as the obesity epidemic con-

SanDiegoPhysician.org 9

tinues to grow. From 1999–2000 through 2017–2018, the prevalence of obesity increased from 30.5% to 42.4% and the prevalence of severe obesity increased from 4.7% to 9.2%.4 Clearly a need for better management and education exists, but will this be enough to sufficiently address the obesity epidemic? As a diplomat of the ABOM, I can attest that antiobesegenic pharmaceuticals are encouraging, modestly effective, and considerably safer than surgical interventions in appropriate candidates. However, they don’t replace lifestyle and behavioral interventions needed to achieve long-term results. Having a team of obesity-certified physicians, bariatric surgeons, dietitians, and psychologists would provide comprehensive care but would also be time-consuming and costly for patients. At the forefront of ABOM training and the overall approach to treating metabol-

ic disease is the role of insulin resistance on recalcitrant weight loss. This is missing from the medical school curricula. Doctors correctly associate insulin with glucose homeostasis. As a result, we are taught to check glucose levels and assume insulin is within an acceptable range if serum glucose is between 70-100mg/dL and a hgbA1c is < 5.7%. By this assumption, we are missing a 10- to 15-year window of opportunity for intervention when we fail to routinely check a fasting insulin level. Euglycemic hyperinsulinemia is when an increase in visceral adiposity, hypertension, and unfavorable lipid patterns begin developing. As the main fat storage hormone, insulin is the driver of weight gain. When pre-diabetes develops, insulin is already detrimentally elevated and could have been for over a decade. Prevention and early intervention efforts at maintaining insulin sensitivity prior to hyperglycemia are critical. Discouragement over seeing patients

slip further and further into the wraths of their disease has created a need for a new branch of medicine: weight loss through metabolic health. Imagine a practice that is focused on reducing insulin levels and thus improving insulin sensitivity to ward off chronic modern disease — one that can cater to their patients’ desire to learn about proper human nutrition, physical conditioning, stress management, and psychological barriers to implementing change. With competent execution, medication deprescription becomes the norm. The patient’s vitality and energy returns. Healthcare costs decrease. Appointments become fewer and further between. Physician job satisfaction returns. LowCarbMD San Diego (www.LowCarbMDSanDiego.com) opened in July 2020 and is a membership-based model designed to combat the afflictions of metabolic dysfunction including obesity, dyslipidemia, T2DM, nonalcoholic fatty


Official Publication of SDCMS

Celebrating 150 Years

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November/December 2020

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NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

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TrusT liver disease (NAFLD), and hypertension. The medical weight loss programs offered emphasize nutritional interventions to reduce insulin resistance, inflammation, and energy toxicity for restoration of appropriate metabolic functioning. While metabolic health improves, weight naturally settles in a healthy range with preservation of muscle mass and lean tissue. Within a matter of a few week of therapeutic carbohydrate restriction, liver size decreases and blood glucose returns to normal levels. This type of practice is similar to a direct primary care or concierge structure but has a niche comparable to specialty care. It is designed to complement the primary care physician who doesn’t have adequate time or resources to address obesity or treat the underlying cause of metabolic syndrome which is insulin resistance. Surgeons have also found utility in this care model as a way of reducing surgical complications related to NAFLD and hyperglycemia. By utilizing a membership fee as opposed to insurance, requirements that limit doctors previously have been lifted. This allows for an increase in time spent with patients to provide education and address underlying impediments to weight loss. Patient rosters can be onethird the size of a traditional practice. Overhead costs are greatly reduced by eliminating the need for support staff to handle insurance claims and billing. Through remote monitoring and communication platforms, a partial or completely virtual experience is possible, which could further reduce overhead of a

brick-and-mortar location. In addition, metabolic health improvement has shown to increase survival in COVID-19 by improving insulin sensitivity. This is in addition to reducing exposure through customary hygiene and safety practices. True health extends beyond prescriptions to control symptoms and lab values. Innovative, progressive, and effective options exist as an adjunct to the care already being provided. Dr. Baier recently relocated to San Diego to open a metabolic health and medical weight loss clinic: LowCarbMD San Diego. She is a CMA-SDCMS member, double board certified in obesity medicine and family medicine, and has a passion for helping patients regain health through lifestyle modifications. References: 1. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009-2016.” Published online Nov. 28, 2019 in the journal of Metabolic Syndrome and Related Disorders. 2. Carious, B et al. Phenotypical characteristics and prognosis of inpatients with COVID-19 and diabetes: the CORONADO study. Diabetologia. 2020; 63(8.) 3. Wang, X et al. Impacts of Type 2 Diabetes on Disease Severity, Therapeutic Effect, and Mortality of Patients with COVID-19. J Clin Endocrinol Metab. 2020 Dec 1; 105(12.) 4. https://www.cdc.gov/obesity/data/ adult.html

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CALIFORNIA’S COMPLETELY UNPREDICTABLE, TOTALLY CHAOTIC LEGISLATIVE YEAR The California Medical Association’s 2020 Legislative Wrap-Up By Janus L. Norman


s 2019 concluded, reasonable assumptions about 2020 began to emerge. The year was expected to be busy and more polarizing due to the presidential election occurring in November. Large-scale, issue-based campaigns calling for new state programs supported by the expected state budget surplus were being announced. State legislators were finalizing their legislative packages. And lastly, the California Medical Association (CMA) was preparing to defeat yet another attempt to eliminate the cap on non-economic damages incorporated in California’s longstanding professional liability reform law, the


November/December 2020

Medical Injury Compensation Reform Act (MICRA). In March, the world changed, and California politics and the legislative process went through an unprecedented transformation. On March 19, Governor Gavin Newsom issued the nation’s first statewide stay-athome order in response to the arrival of the novel coronavirus (SARS-coV2) in California. All nonessential businesses, such as restaurants, entertainment centers/activities, etc., were immediately shut down until further notice. The state legislature was forced to take multiple extended recesses, and all in-person lobbying was

prohibited, leading to the cancellation of CMA’s annual Legislative Advocacy Day. The legislative process was completely upended. CMA staff worked diligently to adjust to ever-changing dynamics, as both houses of the legislature scrambled to implement social distancing guidelines and condense their calendars. In the end, CMA successfully maintained state funding for physician services, defeated proposals to increase or add new administrative burdens onto physicians, and secured a number of Executive Orders to protect medical practices as they faced a pandemic unlike any seen in the past century.

However, CMA did not escape the legislative session unscathed. The legislature passed, and the governor signed AB 890 (WOOD), which created two new classifications for nurse practitioners (NP). While this measure was passed into law, this matter is far from settled, as the fight to ensure patient safety now moves into the regulatory process. All of CMA’s advocacy centers have prioritized this issue, developed an action plan, and are coordinating with the American Medical Association (AMA) as well as various specialty associations to ensure the bill is implemented in a manner that protects patients and physician practices.


California began this year with a strong economy, historic reserves and a projected surplus of $5.6 billion. Due to the COVID-19 pandemic, the state’s economy took a significant hit, which meant the governor had to make several difficult decisions when revising his proposed budget in May. The governor’s May revision was a complete redrafting of the state budget proposal released on January 10, 2020. In January, the budget proposal increased our state’s investment in healthcare, which included growing California’s physician workforce. The May budget revision, however, sought to reverse course, proposing to cut Proposition 56 funding for increased physician reimbursements, reduce patient benefits in Medi-Cal and strike all investments seeking to expand the physician workforce. Through the budget process in the Legislature, CMA was able to protect: • $1.2 BILLION in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, non-emergency medical transportation, and value-based payments. This includes the continuation of all future cohorts of the Proposition 56 Physician and Dentist Loan Repayment Program (years 2–5 of the 5-year program). • $1.5 MILLION in General Fund monies to maintain the Proposition 56 Graduate Medical Education program

at an ongoing total of $40 million. • $33.3 MILLION in ongoing General Fund monies for the continuation of the Song-Brown Healthcare Workforce Training Program. • THE EXPANSION OF POSTPARTUM MENTAL HEALTH SERVICES for individuals diagnosed with a maternal mental health condition. Through the budget process in the Legislature, CMA was able to protect $1.2 billion in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, non-emergency medical transportation, and value-based payments. In addition, the revised budget proposal included a 47% increase to the Medical Board of California’s physician and surgeon licensing fee. Through CMA’s advocacy, the legislature rejected that proposal. Still, the legislature could revisit the discussion in 2021 when the Medical Board is subject to a review of all of its operations through the Sunset Review process. It is anticipated that the Medical Board will seek a license fee increase in the context of that process


Since the implementation of AB 72 (Bonta) related to surprise billing, CMA has been working with the legislature to mitigate the negative impacts on the physician community. This year, AB 2157 (WOOD) was introduced to address the issues surrounding the independent dispute resolution process (IDRP). Along with several specialty societies, CMA was able to secure amendments that allowed physicians to provide more substantial evidence to better defend their claims during an AB 72 payment dispute. Through CMA’s advocacy in the legislative process and with the Department of Managed Health Care (DMHC) directly, an IDRP determination has been in the physician’s favor, a first since the law became effective. However, our work on this issue does not end there. CMA continues to work with regulators and legislators to further ensure a process that is fair and accessible to any physician needing to use it.


Flavored tobacco products are often the entry point for young people who use tobacco. Over the last several years, a spike in e-cigarette use among the nation’s youth has been linked to targeted advertisements of flavored tobacco. Menthol cigarettes, sweet cigars, candy vapes, and other flavored tobacco products serve two purposes: to mask tobacco’s harshness and get users hooked to a dangerous, life-long addiction. In 2020, CMA combined forces with a large coalition of healthcare, youth and community organizations to support SB 793 (HILL), which prohibits tobacco retailers, or any tobacco retailers’ agents or employees, from selling, offering for sale, or possessing with the intent to sell or offer for sale, a flavored tobacco product or a tobacco product flavor enhancer. This ban includes e-cigarettes and vaping products, as well as traditional tobacco products. SB 793 crossed the legislative finish line and was quickly signed by Governor Newsom once it reached his desk. The new law will take effect on Jan. 1, 2021.


CMA worked with Assemblymember Lorena Gonzalez on AB 2257 to further address challenges for physician practices resulting from a bill passed last year (AB 5) that made significant changes to the definitions of independent contractors and employees, in an attempt to be consistent with the court decision in the Dynamex case. Last year, AB 5 included an exemption for physicians, but there continued to be a need to address business-to-business and referral agency arrangements. CMA successfully secured amendments to address those outstanding concerns, and the bill was signed into law. CMA also helped lead a coalition to defeat SB 977 (MONNING), which sought to expand the California attorney general’s existing authority related to mergers and acquisitions in the healthcare industry. Although CMA policy supports governmental actions designed to ensure hospital market competition, this broadly drafted legislation established a wide definition of healthcare transactions, which included leasing and other

SanDiegoPhysician.org 15

medical contracting arrangements. SB 977 ultimately failed to move off the assembly floor. CMA worked with Senator Dr. Richard Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability. In addition to the above, CMA worked with multiple legislative offices to stop the creation of new administrative burdens related to the COVID-19 pandemic. AB 685 (REYES) requires employers to provide written notification within 24 hours to their employees if they were potentially exposed, at the workplace, to a person who has COVID-19. As this would have required physician practices to report this information daily, CMA secured amendments that exempted employees who conduct COVID-19 testing or screening or that provide direct care to individuals known to have tested positive for COVID-19. This approach balanced CMA’s support for notifying employees of possible exposure and protecting physician practices from being overburdened. Senator Richard Pan, MD, introduced legislation requiring the state and healthcare employers to procure a stockpile of personal protective equipment (PPE) as a means of addressing future equipment shortages like the one experienced at the outset of the pandemic. As introduced, the bill would have created a significant burden on independent physician practices. CMA worked with Dr. Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability.


At the onset of the statewide public health emergency, CMA worked to build upon AB 744 (AGUIAR-CURRY, 2019), which required commercial health plans to implement payment parity for services provided via telehealth. An associationwide advocacy effort allowed CMA to secure widespread payer coverage across the entire healthcare system that required all commercial, Medi-Cal, and workers’ compensation payers to immediately


November/December 2020

cover telehealth services at the same rate as in-person services. To achieve this outcome, CMA worked with each independent agency and department to ensure consistency between the DMHC and the Department of Health Care Services (DHCS) as well as the California Department of Insurance (CDI) and employers under the Department of Workers’ Compensation (DWC). Each agency continued to post updated guidance consistent with CMA’s input, and often referenced CMA’s sponsored telehealth legislation (AB 744) as their models. CMA also advocated for the governor to waive existing laws requiring consent prior to providing telehealth services. During the COVID-19 state of emergency, these waivers ensure that no enforcement action would be authorized against covered healthcare providers providing telehealth services via remote communication technologies that may not fully comply with these privacy laws. CMA was successful in receiving these waivers at the state and federal levels.

on this bill can be found on the CMA website at cmadocs.org. Despite this setback, the fight to protect patient safety will now roll into the regulatory process. CMA will continue to work in tandem with AMA and our grassroots network to keep physicians engaged on this issue. CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice. In other scope developments, CMA and the American College of Obstetricians and Gynecologists (ACOG) resolved a longstanding issue with the certified nursemidwives (CNM) through SB 1237 (DODD). This bill creates a framework for CNMs to perform certain functions within the scope of midwifery independently while maintaining a collaborative relationship with a physician and surgeon. The measure also includes a requirement for informed patient consent as well as patient outcome reporting requirements.



CMA worked with a coalition of healthcare and other business organizations to defeat AB 2570 (STONE). This bill would have exposed physicians and their practices to frivolous lawsuits, making it more difficult for physicians to maintain the viability of their practices.


As discussed earlier, Assemblymember Jim Wood’s AB 890 creates two new categories of nurse practitioners, who would be allowed to provide services without standardized procedures. Despite the fervent work of CMA, the AMA, and numerous specialty societies, the bill passed the legislature and was enacted in law. The bill does not eliminate physician supervision and leaves room for interpretation regarding the role supervision can still play in the physician-NP relationship. It should also be noted that existing NPs are not impacted by AB 890 and must continue practicing under standardized procedures. In addition, the measure includes a delayed implementation of three years to allow for the completion of the regulatory process. A detailed factsheet

Although the 2019–2020 legislative session has finally concluded, uncertainty continues. In November, a new fiscal outlook will reveal whether the state budget is still facing a multibilliondollar shortfall. December will provide an idea of whether the legislature will reopen the Capitol and allow for inperson lobbying. The political process will continue to be uncertain. However, there will be a consistent truth among all the unpredictable chaos: CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice. For more details on the major bills that CMA followed this year, visit cmadocs.org/ leg-wrap-2020. Subscribe to CMA’s free biweekly Newswire, and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/subscribe. Janus L. Norman is CMA’s senior vice president of government and political relations.

Physician Group Practice: Growth and Consolidation By Tal S. David, MD Why are physician practices consolidating? Traditionally, solo and small-

group practices provided physicians with more autonomy, and less bureaucracy and politics, than large group practices. While this may still be true, many physicians feel that the advantages of largegroup practices far outweigh those available in smaller practices. Larger groups are able to afford staff and equipment that some smaller groups cannot. Consolidation provides a conduit through which physicians can provide their patients with comprehensive care. In a large orthopedic practice this might start with an office visit, progress to advanced imaging [e.g. MRI], and culminate at an affiliated surgical center or through the group’s physical therapy facility. Consolidation allows all of this care to be delivered through a single medical group. In the era of value-based medicine, the ability of a large-group practice to manage a patient’s care from start to finish can provide an opportunity to deliver turnkey, efficient care for a better price. The provider delivers service, the payer gets a better price, and the patient receives state-of-the-art care without referral-related delays and scheduling nightmares. Everyone wins.

What are the opportunities that large groups have over smaller groups or solo physicians? Perhaps the most obvious

advantage large groups have over small groups or solo physicians is financial stability. In no other time has this been more apparent than in 2020. The COVID-19 outbreak that began in the spring resulted in the closing of thousands of medical practices across the country due to financial stress. A disproportionate number of these practices belonged to small groups or solo practitioners. Other opportunities involve the economies of scale related to purchasing of ev-

erything from medical to office supplies, employee health insurance, computers, EHR and IT costs. These are all expensive items and can be more affordable when shared among a large group of physicians. Lease negotiations are easier and tenants have more leverage when the landlord identifies you as a large, high-revenuegenerating medical practice. Large groups can create protocols that, in turn, create standardization. Standardization can mean something different based on each group’s needs. It can mean standardizing processes, like clinicians do in operating rooms to maximize safety and efficiency. It can also mean standardizing products, such as using the same brand of surgical gloves across an entire health system. Standardization creates reliable data that can then be used to reduce costs and improve clinical outcomes.

Do you feel large groups have a seat at the table with payers and hospitals? Ul-

timately, payers want to share financial risk with the providers. If you are willing to do this, you will have a seat at the table. The payers don’t want to be the only ones on the financial hook when outcomes are sub-optimal and costs begin to climb. Providers have to deal with complications and poor outcomes — it happens to us all. But those practitioners who can consistently provide better outcomes will be rewarded by the payers. The trick is to demonstrate that your outcomes are better than the average. This goes back to data: How do you measure yourself? How do you demonstrate to the payer that your outcomes are worth paying for? You need the right instruments and the right dashboard to answer that question. Hospitals have to pass the same testing. There is a reason that hospitals spend hundreds of thousands of marketing dollars on billboards and banners that

let you know how highly they ranked in some recent magazine article: Outcomes matter in medicine. A large group that can demonstrate better outcomes will be welcomed at the hospital table as well.

Can solo physicians survive? If yes, how? I don’t know the answer to that

question. It is clearly getting more difficult. Perhaps in settings that are rural and underserved, the solo physician may always have value. These areas are not as likely to attract a large group or large hospital system due to the smaller populations to draw from. Growing up in rural Texas, our family’s primary care provider for decades was a solo physician who inspired me to go into medicine. I hate to think of a world where those relationships don’t exist anymore.

Do you have additional words of wisdom? Despite all of the economic

challenges that physicians continue to face year after year, we are still privileged to practice medicine. When I consider the trust that our patients put in us, it gives me pause. The patient and the doctor: It’s still a very personal and singular connection between two individuals, where one puts all of their trust in the other. And these days, trust is in short supply. Dr. David is a board-certified orthopedic surgeon who is president of Synergy Orthopedic Specialists Medical Group. He is a 17-year CMA-SDCMS member, past-president of the San Diego Orthopedic Society and a member of the board of directors for the California Orthopedic Association.

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Finding Gratitude in Difficult Times By Helane Fronek, MD, FACP, FACPh



of this year cannot capture the experience of living through it: The first pandemic of our lifetime; deaths of hundreds of thousands of Americans; fear, uncertainty, and suffering brought about by this novel virus; devastation of lives and livelihoods; strain on healthcare and providers witnessing death on an overwhelming scale; and the anguish of all involved. Add to that social unrest, the beginnings of what I hope will be a true reckoning with centuries of racism and injustice in our country; financial turmoil; widening political division; devastating fires and concerns about more to come; and a contentious election. To say it’s been a lot to contend with would be an understatement. If you’ve felt anxious, depressed, or just out of sorts, you are not alone. And still, our lives go on. We wake up each day and need to find the strength, will, and desire to work, care for our families, friends, and patients, and to make ourselves better people and the world a better place. 18

November/December 2020

Even if we have not lost someone close to us and still have a home, job, and income, this year has been one of loss for most of us. We miss being in the presence of others, free to laugh, smile, and bring our whole selves to our interactions. We miss traveling to see those living far away, to explore the world, or to attend a conference, where we are inspired and learn so much from the casual interactions in the hallways. We miss the freedom to pick up and go somewhere without worrying we will contract a deadly disease. We yearn for our old lives. As we approach Thanksgiving, some might wonder what we have to be thankful for, given the challenging times. Taking time to reflect on this is essential in times of distress, as gratitude builds our resilience. Fortunately, our lives abound in blessings and beauty. Many people

found that our constricted lives offered surprising benefits — a slower pace of life, more time with family, appreciation of nature. Online offerings have made conferences, concerts, museums, and other experiences available in the comfort of our homes and without the disruption or cost of travel. What changes have you found to be positive during this time? Even by reflecting on the losses we’ve felt, we begin to appreciate what we had, as we often don’t value things until they are gone. Most of those aspects of our lives will return; this practice can prevent us from taking them for granted in the future. Then, we can ask ourselves what is at the heart of all we are missing. Is it a feeling of connection? Freedom? Variety? Self-determination? Tranquility? Where else do you have those in your life now, or what opportunities do you have to create them? As we begin to focus on what we have or what we can design, we naturally feel gratitude — a more powerful, resourceful, and joyful place from which to fashion our lives. Dr. Fronek is a clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach.


More Than Skin Deep By Adama Dyoniziak INGREDIENTS: ONE WORLD TRAVELER.

International health interests. CDC epidemiology experience. Master’s degree in public health. Mix all ingredients vigorously, and liberally add vibrant watercolors. Let grow and flourish. Makes one Project Access volunteer dermatologist and watercolor painter: Dr. Paul Dean, of Grossmont Dermatology Medical Clinic. Dr. Dean knew he wanted to help people and to travel internationally. He dabbled in a dental track before going to University of California, San Francisco School of Medicine. He was an exchange student in Nigeria and Pakistan, and got hooked on international health. In his two years in the CDC Epidemic Intelligence Service, he went to Pakistan during a cholera epidemic after the country was hit by a typhoon and cyclone, killing 2 million people. After achieving his board certification from the American Board of Dermatology, he has served patients at Grossmont Dermatology Medical Clinic ever since. Dr. Dean was also the Medical Director for Project Concern International and a board member for the International Medical Corps (an organization that sends physicians to disasters and war zones). His experiences prompted him to complete the educational program at UCLA School of Public Health and receive a master’s degree in public health. Dr. Dean likes to treats each person holistically; he is concerned about their life. He wants to know how the patient and their family are handling their circumstances during the pandemic. “My four tips for a long and happy life: (1) Exercise and move any way you can every day. (2) Take high doses of Vitamin D. (3) Eliminate red meat from your diet. (4) Lower your stress levels — the best way to do that is to turn off the news,” Dr. Dean says. Grossmont Healthcare District had its

annual Grossmont Health Care Heroes Awards recognition event on Sept. 16, and we nominated Dr. Dean. He has been a volunteer dermatologist with Project Access since 2018, seeing patients for consultations, skin cancer screenings, and in-office procedures like biopsies and lesion removals. His patient-centered care approach ensures patients have better health outcomes. For example, he made sure a patient was referred to behavioral health because her dermatological complaints were tied more to her emotional and mental wellbeing. “When I work with Project Access patients, it reminds me of all the people I have met on my travels in the U.S. and abroad,” Dr. Dean says. “I enjoy being of service to others.” This healthcare hero is very humble, socially conscious, and wants to stay connected to his community. Besides see-

ing Project Access patients pro bono, Dr. Dean also sees more uninsured patients through another free clinic in the East County. He even designated one day a week to see his pro bono patients in his office. We also credit him with securing us with another volunteer MOHS surgeon. To keep balance in his life, Dr. Dean loves to travel with his wife and spend time with his five grandchildren. He is also a watercolor artist of 20 years with an art studio in Liberty Station. “Watercolor has always fascinated me because of its spontaneity,” Dr. Dean says. “It is quick and must be done in one sitting. There is no going back in watercolor. Watercolor is vibrant! The white paper of watercolor is what makes the painting sparkle.” Share your time and talent through Project Access and contact Adama Dyoniziak at adama.dyoniziak@championsfh.org or call (858) 300-2780. Also, help us help others by sharing your treasure and click on the donate button at www. championsforhealth.org. Adama Dyoniziak is executive director of Champions for Health. SanDiegoPhysician.org 19

CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or Sub-Investigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential. Our team of Clinical Research Professionals will conduct the clinical trials under your supervision. Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact jsaleh@ paradigm-research.com or anguyen@paradigm-research. com or Afalconer@paradigm-research.com PHYSICIAN OPPORTUNITIES SPANISH-SPEAKING FAMILY PRACTICE OR INTERNAL MEDICINE:Spanish-speaking family medicine or internal medicine physician for Borrero Medical Group located in South San Diego next to Chula Vista. The practice is growing and needs to hire a new physician. Borrero Medical Group is a well-established practice, 27 years in the community, exceptional office staff. Every member of our team plays an important role in improving the health of our patients. We offer an excellent comprehensive benefits package that includes Malpractice Coverage, Health Insurance, Competitive & Attractive Salaries, and Bonus. If interested, please submit inquiry and CV to rosa10borrero@att.net PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy and procedure, developing strategy, and overseeing quality assurance and quality improvement efforts for County of San Diego health services programs. Salary: $190-200,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. You may direct any questions regarding the application or selection process to Anna Lisa Acedo, Human Resources Services Manager, at AnnaLisa.Acedo@sdcounty.ca.gov 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?keywords=Deputy%20Public%20 Health%20Officer TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) 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. NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link below to be directed to our website to learn more about our organization and view our careers page. www.Nhcare.org PHYSICIAN WANTED: Samahan Health Centers is seeking


November/December 2020

a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at 844-200-2426, Ext 1046 or at crubio@samahanhealth.org 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?keywords=Deputy%20Public%20 Health%20Officer PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy and procedure, developing strategy, and overseeing quality assurance and quality improvement efforts for County of San Diego health services programs. Salary: $190-200,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. For more information click here. FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@gmail. com. Immediate opening. INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/ care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811. PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides family-focused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, upto 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds.sdcoxmail.com or 619-504-5830 with resume in .doc, .pdf or .txt. (Posted 12/4/19) GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069.

We are an equal opportunity employer and value diversity. Please contact Natalie Shields at 760-291-6637/nshields@ graybill.org. You may view our open positions at: https:// jobs.graybill.org/ BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@ grossmontdermatology.com PHYSICIAN CONSULTANT FULL-TIME: San DiegoImperial 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. (Posted 10/7/2019) PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCareaffiliated 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 PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowship-trained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position. Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 977-6300 or email Ngoc.B.Truong@dmu.edu PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only 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 31st, 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 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. 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


Looking for a retiring physician in an established Internal Medicine or Family Medicine practice who wants to transfer the patient base or sell the practice Please call 858-281-1588

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. OFFICE SPACE / REAL ESTATE AVAILABLE TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces.To inquire or to schedule a showing, please contact Jo Turner 619 733 4068. OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to pomerado hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914. KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@synergysmg.com for more information. SUBLEASE IN SHARP HOSPITAL: Sublease of a shared office space on the Sharp Hospital campus a small office on the third floor that is now shared with one other physician. Includes: two exam rooms, an office for the doctor, space for three employees, and a small amount of storage space. Please contact kspotz@synergysmg.com for more information. REDUCED PRICE - EL CAJON MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 3,700 square foot standalone medical building with 11 exam rooms & huge private parking lot available for sale or lease! Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $950,000. Asking Lease: $5,500/month + NNN. Terms are negotiable. Seller financing is available. Please contact: Dillon.Myers@ TonyFrancoRealty.com | (619) 738-2318 MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/ space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share part-time, half days or full days 4 exam rooms. Rent depends on usage. For more information, call 858-550-0330 extension 106. ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking . Contact Jean ( 858) 673-9991. MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease. The office is located in Imperial county and is approximately 910 sqft. Please email us at info@carlsbadimaging.com with any with further questions or needed details. (Posted 03/04/20)

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. MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call 858-430-6656 or text 619-417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at 858-622-9076 if you are interested. 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 hosptial between 1-5 and 1-805. 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. SHARED OFFICE SPACE: Office Space, beautifully decordated, 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 1/2 mile from Swami’s Beach. Contact Kristi or Myra 760-7538413. View Space on Website: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 useage. Contact Jo Turner (619) 733-4068 or jo@siosd.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact 858-633-6959. 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 OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi.eisenhauermd@yahoo.com, 760-753-8413

MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi. eisenhauermd@yahoo.com, 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at 760-730-3536 if interested in purchasing, pricing or have any questions. Thank you. NON-PHYSICIAN POSITIONS AVAILABLE PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@ steinermd.com PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@ steinermd.com EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486 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 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 |

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