March 2008 by San Diego Physician

Quality Improvement Deploying Proven Tactics to Get Us There

“ P H Y S I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”

Contents

VOL. 95 | NO. 3

QUALITY IMPROVEMENT PAGE 22

22 26 30 34

[ F E A T U R E S ]

[ O N L I N E ]

QUALITY IMPROVEMENT:

“DO HEALTH SYSTEM ERRORS CAUSE MEDICAL MALPRACTICE CLAIMS?”

The Sharp HealthCare Journey to Excellence: The Physician Role in Organizational Performance By STEPHEN C. BEESON, MD Making Strides in Quality Improvement in Both the Inpatient and Outpatient Arenas By ARTHUR M. FLIPPIN, MD What Business Are We Really In? Providing the Highest Quality of Care for Our Patients By A. BRENT EASTMAN, MD Sharp Rees-Stealy Medical Group: A Flexible, Learning Organization By JERRY PENSO, MD

By DAVID B. TROXEL, MD, MEDICAL DIRECTOR, THE DOCTORS COMPANY

VISIT SANDIEGOPHYSICIAN.ORG FOR THIS ARTICLE AND MORE.

[ D E P A R T M E N T S ]

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CONTRIBUTORS: This Issue’s Contributing Writers EDITOR’S COLUMN: Practicing Excellence SEMINARS: SDCMS’ 2008 Seminars and Events

COMMUNITY HEALTHCARE CALENDAR BRIEFLY NOTED: Medical Myth, Ask Your Advocate, and More…

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INTERVIEW: Richard Liekweg, CEO, UCSD Medical Center

POLITICAL ADVOCACY: No 10% Medi-Cal Cut THE PULSE: SDCMS Foundation Newsletter PHYSICIAN MARKETPLACE: Classifieds HISTORY OF MEDICINE: The “Sick Train”

Contributors STEPHEN C. BEESON, MD Dr. Beeson serves as physician coach for the Sharp Experience and full-time practicing physician for the Sharp Rees-Stealy Medical Group. Dr. Beeson’s patient satisfaction ranks him in the 99th percentile, and he is author of the bestseller, Practicing Excellence. Dr. Beeson has established a national reputation for coaching and training physician organizations across the country.

A. BRENT EASTMAN, MD Dr. Eastman is chief medical officer, Scripps Health, and N. Paul Whittier Chair of Trauma.

ARTHUR M. FLIPPIN, MD Dr. Flippin joined the Southern California Permanente Medical Group in San Diego in 1977 as a staff neurologist. He was appointed to the position of chief of neurology in 1991, a position he held until his appointment in 2000 to his current role as area medical director.

MARISOL GONZALEZ Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

WILLIAM P. HANEY, MD Dr. Haney, a retired ophthalmologist, has held a longtime interest in the history of medicine, often contributing articles to San Diego Physician.

KETTY LA CRUZ Ms. La Cruz is assistant editor of San Diego Physician.

RICHARD LIEKWEG Mr. Liekweg is CEO of the UCSD Medical Center.

JERRY PENSO, MD Dr. Penso is associate medical director, quality programs, for Sharp Mission Park and Sharp Rees-Stealy medical groups. Sharp is the largest integrated healthcare delivery system in San Diego. Sharp Mission Park, a primary care medical group, is located in northern San Diego County with 80 physicians and eight sites, serving more than 60,000 patients. Sharp Rees-Stealy, an affiliated, multispecialty medical group, has 13 sites throughout the county, more than 300 physicians, and serves 200,000 patients.

JOSEPH E. SCHERGER, MD, MPH Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

EAST COUNTY DIRECTOR HILLCREST DIRECTOR KEARNY MESA DIRECTOR EDITOR MANAGING EDITOR ASSISTANT EDITOR

Joseph Scherger, MD, MPH Kyle Lewis Ketty La Cruz

EDITORIAL BOARD

Adam Dorin, MD Robert Peters, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD Sandra Wilcox, MD

LA JOLLA DIRECTOR NORTH COUNTY DIRECTOR

SOUTH BAY DIRECTOR AT-LARGE DIRECTOR

YOUNG PHYSICIAN DIRECTOR RESIDENT PHYSICIAN DIRECTOR RETIRED PHYSICIAN DIRECTOR MEDICAL STUDENT DIRECTOR

Published by

PRESIDENT PUBLISHER DIR., BUSINESS DEVELOP. & MARKETING MARKETING & PRODUCTION MNGR.

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Tom McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steve Poceta, MD Wynnshang Sun, MD Robert Wailes, MD Douglas Fenton, MD Tony Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Lindsey Frost

Jim Fitzpatrick Maureen Sullivan Heather Back Jennifer Rohr

SDCMS EXECUTIVE COMMITTEE PRESIDENT PRESIDENT-ELECT PAST PRESIDENT SECRETARY TREASURER COMM. CHAIR DELEGATION CHAIR BOARD REP. BOARD REP. LEGISLATIVE CHAIR EXECUTIVE DIRECTOR

Albert Ray, MD Stuart Cohen, MD, MPH Theodore Mazer, MD Susan Kaweski, MD Lisa Miller, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Robert Wailes, MD Sherry Franklin, MD Robert Hertzka, MD Tom Gehring

SDCMS CMA TRUSTEES

Theodore Mazer, MD Albert Ray, MD Robert Wailes, MD

OTHER CMA TRUSTEES

Catherine Moore, MD Diana Shiba, MD

AMA DELEGATES

ALTERNATE DELEGATE

ACCOUNT EXECUTIVE PROJECT DESIGNER SENIOR DESIGNER COPY EDITOR

James Hay, MD Robert Hertzka, MD Albert Ray, MD

Dari Pebdani Jane Hughes Jessica Hedberg Adam Elder

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com 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 cpinfo@sandiegomag.com . 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. ]

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Editor’s Column By Joseph E. Scherger, MD, MPH

Practicing [ A Realistic Goal? ]

Excellence is a habit, not a single act. We are what we do repeatedly. — Aristotle xcellence in medical practice today goes beyond the comparison with pornography: I know it when I see it. Sure, a great patient visit or disease outcome gives the impression of excellence. But repeated and consistent excellence in medical practice is rare, even among the best physicians. What constitutes practice excellence? There are at least three dimensions. First, the patient must feel as if they received excellent care. The patient satisfaction score is all the way to the top. Secondly, what was done for the patient matches the highest current standards of care. Current best practice was delivered. Thirdly, the outcome of the care was optimal, given all realistic possibilities. Best outcomes are derived from consistently repeated best practices. How do we achieve such an ideal in medical practice? Is excellence a realistic goal and a consistently achievable outcome? Yes, according to Steve Beeson, Sharp-Rees Stealy physician leader of the

Sharp Experience and author of Practicing Excellence: A Physician’s Manual to Exceptional Health Care (1). His article in this issue tells the story of the Sharp Experience from the physician perspective. Steve Beeson does not just talk the talk of excellence. He walks the walk, both for himself in fulltime practice and for his group. Steve Beeson’s book is a wonderful read, and I recommend it highly to all physicians, regardless of specialty. After making the case for excellence, everything from improving patient compliance and building patient loyalty to reducing malpractice risk, he dissects the clinical encounter into detail most of us have never thought about. Did you know there are eight parts to each visit? They are: 1. The First Impression 2. Exam Room Preparedness 3. Techniques in History Taking 4. The Physician Exam 5. Providing Patient Information 6. Patient/Physician Collaboration 7. Patient Follow-up 8. Effective Appointment Closure

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Each of these has room for error or inadequate performance. Beeson gives pointers for excellence with each of these steps. He then provides pointers for difficult patient situations. The book then goes beyond the individual physician and staff to the medical group. How does an entire group achieve excellence? Beeson provides nine steps that were used at Sharp Rees-Stealy to accomplish its amazing turnaround. Steve Beeson was the keynote speaker at the Sharp Primary Care Conference in Hawaii. Fifteen of his colleagues were present. I enjoyed listening to the early skeptics — for example, the urgent care and occupational medicine physicians who felt that they were doing as well as they could under difficult circumstances. They are now doing incredibly better and look back on their past performance as an earlier time of substandard practice. Converting to consistent excellent practice is not easy. Physician coaching is often necessary, not something we in a traditionally autonomous profession are inclined to

“Privileged to Provide Care and Clinical Research Since 1975”

Osteoporosis,

admit that we need. Finding and developing coaches is an important and challenging process, but one that is necessary for group-wide excellence. Other companies known for consistent excellent service, such as Nordstrom or Starbucks, use coaching and development continuously. We need to also, and not just for our office staff. Steve Beeson’s keynote presentation highlighted nine essential elements of practice excellence. Everyone must be present for a group to sustain excellence. I find a list of

A SILENT EPIDEMIC With more than 1.5 million annual osteoporosis-related fractures, prevention, early detection, diagnosis and treatment are key

• About 55% of the US population over 50 or about 44 million men and women have osteoporosis or low bone mass (osteopenia) • 1 in 2 women and 1 in 4 men over 50 will have an osteoporosis-related fracture in their lifetime

Is excellence a realistic goal and a consistently achievable outcome? nine things intimidating, and I quickly wondered how realistic that could be. They are: Vision, Leadership, Passion, Relentlessness, Ownership, Recognition, Accountability, Measurement, and Execution. I could not think of any one of these to remove and still have excellence. It has been five years since I became the director of the San Diego Center for Patient Safety, an organization that is no longer active due to lack of funding. Benchmarks of quality of care in San Diego County revealed lots of gaps. One study on several common conditions even put us in the bottom 25 percent of major metropolitan areas! A lot has happened here since that time. I am convinced that San Diego County is now in the top 25 percent nationally. Every major hospital and medical group has had dedicated efforts to improve

• Women can lose up to 20% of their bone mass in the 5-7 years following menopause

quality, as this issue of San Diego Physician describes. Sharp’s recent Malcolm Baldridge Award is a crowning achievement. Steven Beeson has emerged as a major champion of physician excellence. We would all do well by following his teachings and example. AB O UT TH E AUTH O R : Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

• A DEXA (dual energy x-ray absorptiometry) Bone Mineral Density Test provides the ‘gold standard’ in detecting osteoporosis, determining rate of bone loss, predicting future fractures and monitoring the effects of treatment For FREE checklist pads of MAJOR RISK FACTORS to assess patients… Go to www.SDAMC.com and click on “Download PDF DEXA Exam Form” to print. Or order by phone: 619.287.9730 x 141 or email info@sdamc.com

San Diego Arthritis Medical Clinic 3633 Camino del Rio South, 3rd Floor (1.7 miles east of Texas Street) San Diego, CA 92108

R EF ER ENCE: Beeson SC. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. Gulf Breeze, FL: Fire Starter Publishing (Studer Group), 2006.

619.287.9730

In our January 2008 issue, we failed to include Harold J. Simon, MD, SDCMS-CMA member since 1969, in our list of longtime SDCMS-CMA members. Our sincerest apologies to Dr. Simon, and our appreciation for his many years of loyal membership!

Michael I. Keller, M.D., Director Puja Chitkara, M.D. Ara H. Dikranian, M.D. Oleg Gavrilyuk, M.D. G. Paul Ignat, M.D. Roger Kornu, M.D. Michael Meng, D.C. Patrick Astourian, P.A. Timothy F. Lazarek, F.N.P.

In our 2007 SDCMS directory, we failed to include Dr. Gregory M. Balourdas’ website: www.thehanddoctor.com. Please update your copy, and our sincerest apologies to Dr. Balourdas.

www.SanDiegoArthritis.com

ERRATA Anthony Blain, MD, and Robert Peters, MD, should have been included in our January 2008 issue as having volunteered their services during the October 2007 San Diego County wildfires. Our apologies to both Dr. Blain and Dr. Peters.

Offices: Mission Valley, Poway, Chula Vista, El Centro, & Yuma, AZ

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Seminars 2008 San Diego County Medical Society Seminars and Events MARCH

M AY EMR ROAD SHOW “To EMR or Not to EMR?” May 14 and 15 LEGAL SEMINAR “Contract Law” May 21, 6:30 p.m.– 8:30 p.m.

CERTIFIED MEDICAL CODER PREPARATORY COURSE

March 7, 14, 28, April 4, 11, 8:00 a.m. - 4:00 p.m. COLLECTIONS SEMINAR — OFFICE MANAGERS FORUM

For further information about any of these seminars or events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, call SDCMS at (858) 565-8888, or email us at SDCMS@SDCMS.org. Details may change as seminars approach — contact SDCMS to confirm. Thank you for your membership!

SDCMS NEW MEMBER SOCIAL

Aug. 29, 6:00 p.m. 9:00 p.m.

SEPTEMBER

LEGAL SEMINAR — OFFICE MANAGERS FORUM

March 20, 11:30 a.m. - 1:00 p.m. Along with its many social events held throughout the year, the SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) strives to build a robust schedule of free seminars for our physician members and their staffs (attendance rates for nonmember physicians and their staffs vary by seminar).

AUGUST

“HR Laws” May 22, 11:30 a.m. – 1:00 p.m.

APRIL

CMA CEO JOE DUNN DISCUSSIONS WITH PHYSICIANS May 27 and 28,

YOUNG PHYSICIANS SOCIAL

April 11, 6:00 p.m. – 9:00 p.m. CONTRACT NEGOTIATIONS SEMINAR April 16, 6:30 p.m. -

all day, both days at several different San Diego County hospitals

8:30 p.m.

JUNE

CONTRACT NEGOTIATIONS SEMINAR – OFFICE MANAGERS FORUM April 17, 11:30 a.m. - 1:00

PRACTICE MANAGEMENT SEMINAR “Financial Con-

p.m. RESIDENT AND NEW PHYSICIAN SEMINAR “Preparing to

Practice: What You Need to Know Before You Begin Your Practice” April 19, 8:30 a.m. 3:30 p.m.

tients Right: Tack, Courtesy, and Etiquette in the Medical Office,” June 19, 11:30 a.m. 1:00 p.m.

April 23, 11:30 a.m. - 1:00 p.m., 6:30 p.m. - 8:30 p.m., April 24, 11:30 a.m. - 1:00 p.m.

Sep. 6, 3:00 p.m. - 8:00 p.m.

OCTOBER LEGAL SEMINAR —

“HR Laws” Oct. 15, 6:30 p.m. - 8:30 p.m. LEGAL SEMINAR — OFFICE MANAGERS FORUM

“HR Laws” Oct. 16, 11:30 a.m. – 1:00 p.m.

trol for Physicians: Preventing Money Leaks,” June 18, 6:30 p.m. - 8:30 p.m. PRACTICE MANAGEMENT SEMINAR – OFFICE MANAGERS FORUM “Treating Pa-

RISK MANAGEMENT SEMINAR

YOUNG PHYSICIANS SOCIAL

OFFICE MANAGERS NETWORKING OPPORTUNITY Arrive 30 minutes before the beginning of our Office Managers Forums to network with other office managers!

SDCMS

Get In Touch ADDRESS: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123 TELEPHONE: Dareen Nasser, office manager, at (858) 565-8888 or at DNasser@SDCMS.org FAX: (858) 569-1334 CEO/EXECUTIVE DIRECTOR: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org COO/CFO: James Beaubeaux at (858) 300-2788 or at Beaubeaux@SDCMS.org DIRECTOR OF MEMBERSHIP AND MEMBER SERVICES: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org PHYSICIAN ADVOCATE: Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org

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OFFICE MANAGER ADVOCATE: Lauren Woods at (858) 300-2782 or at LWoods@SDCMS.org DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org SDCMS FOUNDATION EVP: Aron Fleck at (858) 300-2780 or at AFleck@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING: Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org ASSISTANT EDITOR AND WEBMISTRESS: Ketty La Cruz at (858) 565-7930 or at KLaCruz@SDCMS.org LETTERS TO THE EDITOR: Editor@SDCMS.org GENERAL SUGGESTIONS: SuggestionBox@SDCMS.org

Calendar

ISRAELI EMERGENCY MEDICINE CONFERENCE

COST: $325 physicians; $275 allied health professionals (RN, NP, PA); $100 medical students, interns, or residents CME: Up to 16 hours, Category 1 and Prescribe Credit INFORMATION: Call (559) 224-4224, ext. 118 or email csrau@fmms.org.

WHAT: The trip will include visiting all the

historic sites and tours of hospitals and disaster preparedness centers. WHEN: March 3-12, 2008 WHERE: Israel CONTACT: Roneet Lev, MD, tour leader, at roneet@cox.net.

INPATIENT GLYCEMIC MANAGEMENT CONFERENCE

TOPICS AND ADVANCES IN INTERNAL MEDICINE

WHAT: This conference will examine the various types of diabetes and how to manage hyperglycemia in the hospital through medical nutrition and insulin therapies, and will explore the diabetes resources available for patient care. WHEN: March 29, 2008 WHERE: Marriott San Diego Mission Valley COST: $100–$150 CME: Maximum 6.5 AMA PRA Category 1 Credits INFORMATION: Call (800) 82-SHARP.

WHAT: This program will feature presen-

tations of the latest information in virtually every area of medicine. The entire course is focused on a presentation of the evidence for or against diagnostic or therapeutic recommendations with an emphasis on evidenced-based decision-making in internal medicine. WHEN: March 6-12, 2008 WHERE: Hilton San Diego Resort CONTACT: Cheryl Featherstone at (888) 229-6263 or at ocme@ucsd.edu. 13TH ANNUAL PRIMARY CARE IN PARADISE

18TH ANNUAL NELSON BUTTERS’ WEST COAST NEUROPSYCHOLOGY CONFERENCE

WHAT: This four-day course will stress

preventive health issues and updates in general internal medicine and office family practice. WHEN: March 17-20, 2008 WHERE: Hapuna Beach Prince Hotel, Hawaii INFORMATION: Visit www.scripps.org/conferenceservices.

WHAT: Physicians and mental health providers of all specialties are invited to attend this conference. WHEN: April 3–6, 2008 WHERE: Hilton San Diego Resort INFORMATION: Contact Cheryl Featherstone at (888) 229-6263 or at ocme@ucsd.edu.

57TH ANNUAL YOSEMITE POSTGRADUATE INSTITUTE FOR PRIMARY CARE PHYSICIANS

23RD ANNUAL NEW TREATMENTS IN CHRONIC LIVER DISEASE

WHAT: Topics include dermatology, orthopedics, emergency preparedness, cardiology,sleeping disorders, COPD, ophthalmology, and diabetes. WHEN: March 28-30, 2008 WHERE: Yosemite Lodge, Yosemite National Park

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WHAT: A conference to review new hepatology medications that are or will soon be available, and to discuss their relative values. WHEN: April 5–6, 2008 WHERE: Hilton La Jolla, Torrey Pines

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INFORMATION: Visit www.scripps.org/conferenceservices.

FRESH START’S 2008 SURGERY WEEKENDS WHAT: Surgery Weekends happen seven times per year when more than 100 volunteers join together to provide free reconstructive surgery and related medical services to disadvantaged children with physical deformities. WHEN: April 12–13; June 7–8; July 26–27; Sept. 13–14; Nov. 1–2, 2008 WHERE: The Center for Surgery of Encinitas INFORMATION: Visit www.freshstart.org.

HEALING THE BEREAVED CHILD WHAT: This one-day interactive workshop will provide professional clinicians and counselors with useful information on how to support a child following the death of a loved one. WHEN: April 18, 2008 WHERE: Courtyard by Marriott (8651 Spectrum Center Blvd., 92123) COST: $100 INFORMATION: Call (800) 82-SHARP.

INAUGURAL SUDDEN CARDIAC ARREST: FROM AWARENESS TO PREVENTION WHAT: This educational activity will provide the attendee with the knowledge necessary to identify, treat, and/or refer patients to treatment in order to prevent SCA. WHEN: April 26–27, 2008 WHERE: Hilton La Jolla, Torrey Pines INFORMATION: Contact (858) 587-4404 or med.edu@scrippshealth.org.

Brief ly Noted MEDICAL MYTHS

Top Three Myths About Organ Donation By KETTY LA CRUZ | ASSISTANT EDITOR

history. In fact, organs from people well into their 70s and 80s have been successfully transplanted.

any people have made the selfless decision to become organ donors — the vast majority, however, have not. What’s keeping us from donating? Several myths abound that may diminish people’s enthusiasm for donating their organs.

MYTH 2: Donating my organs will damage my body. REALITY: The removal of donated organs is done surgically in a precise and routine manner by a medical professional. Once organs are taken, the skin is stitched back up much like it would be after surgery. Your body’s natural form will be maintained, and — since most bodies are clothed for funerals — the stitches will not be noticeable.

I’m too old and have a history of medical issues. My organs aren’t worth donating. MYTH 1:

REALITY: At your time of death, medical professionals determine the suitability of your organs. While some of your organs may not be suitable for transplantation, others may be. The decision by doctors to use your organs is based on specific medical criteria — not your age or medical

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MYTH 3: The rich and famous are given pri-

ority when they need a donor organ.

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REALITY: The United Network of Organ Sharing (UNOS), the organization responsible for maintaining the national organ transplant network, ensures fair distribution of donated organs. Age, race, gender, and income do not play a role in determining who gets a transplant and who does not. Instead, medical criteria such as blood type and severity of illness, as well as length of time spent on the waiting list, are taken into consideration.

R ESO UR CES: www.transweb.org www.mayoclinic.com www.unos.org www.healthatoz.com

Website Snapshots How Would You Like To… Increase Cash Flow? Reduce Expenses? Improve Billing Efficiency? Decrease Accounts Receivable?

INSTITUTE FOR HEALTHCARE IMPROVEMENT www.ihi.org

TSC Accounts Receivable Solutions, an innovative medical accounts receivable recovery company, has been providing our customers with personalized service since 1992. TSC offers:

■ Bad-Debt Collections ■ Self-Pay Clean-Up

■ Insurance Re-Billing & Clean-Up

■ Back-Logged Accounts Receivable Liquidation ■ System Conversion Clean-Up Endorsed by:

Contact us to see how you can benefit from the expertise of TSC Accounts Receivable Solutions. SDCMS Members qualify for reward incentives.

Catherine Sherman 888-687-4240, x14 csherman@tscarsolutions.com ■ www.tscarsolutions.com

Healthcare professionals and organizations interested in improving the way healthcare is provided are encouraged to visit the Institute for Healthcare Improvement’s (IHI) free website (www.ihi.org). The site provides programs, interactive tools, and links to books and articles designed to assist participants in measuring quality. Content advisors, academicians, and physicians who are experts in their respective fields review and identify content and contribute their knowledge and experiences regarding quality improvement. Visitors can also view improvement reports from other organizations, create their own projects, and join in group discussions.

NATIONAL QUALITY FORUM www.qualityforum.org

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ADVERTISE HERE The National Quality Forum (NQF) is a nonprofit organization created to develop a standardized method for measuring and reporting quality in healthcare. Nonmember visitors of NQF’s website (www.qualityforum.org) have access to information regarding ongoing and completed projects, publications of relevance, news releases, and upcoming forums. Healthcare leaders are afforded with survival guides on key topics like pay for performance to help them better understand each issue and the current and future impacts they have in healthcare. Healthcare stakeholders interested in improving the quality of healthcare should visit this site and take advantage of the many resources provided therein.

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY www.ahrq.gov

To run display advertising in San Diego Physician, please contact Dari Pebdani for information and rates. 619-744-0528 or darip@sandiegomag.com

Rosenberg, Shpall & Associates, APLC If your medical license or privileges are on the line…

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The Agency for Healthcare Research and Quality (AHRQ), an extension of the U.S. Department of Health and Human Services, has created a website (www.ahrq.gov) that provides healthcare organizations and practitioners with reliable quality measurement information. Visitors to the site can choose from an array of pertinent tools and resources located under the Quality Information and Improvement section that they can use to measure and compare their quality of healthcare. Research findings, data and survey results, links to other quality measuring websites, and case studies are also accessible.

• More than 50 years of combined experience in Medical License/Hospital Privilege Disputes • Medical Board accusations • Hospital privilege disputes • Wrongful termination • Civil actions/Independent counsel for medical malpractice claims • Provider Membership Disputes/Exclusion • Medical Corporations/Partnership Formation/Disputes

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Ask Your Advocate By Marisol Gonzalez

MA Scope of Practice, Opting Out of Medicare, Billing for Covered Services

UESTION: What is the legal scope of practice of medical assistants when it comes to renewing prescriptions?

MARISOL GONZALEZ

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ANSWER: A medical assistant cannot renew a prescription based on protocols. The Medical Board of California (MBC) believes this would constitute the unlawful practice of medicine. Medical assistants can, however, according to the MBC, call in routine refills that are exact and have no changes in the dosage levels. The refill

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must be documented in the patient’s chart as a standing order, patient specific. Medical assistants may not call in new prescriptions or any prescriptions that have changes.

UESTION: I am a physician at an outpatient clinic. I only see patients on a cash-paying basis. I do not contract with any healthcare plans, nor am I a participating provider in Medicare. Do I still need to take the formal step of “opting out” of Medicare even if I

have never been a participating provider? ANSWER: Yes, you must formally opt out of Medicare every two years by notifying them of your intent not to participate. The opt-out contract is for a two-year period from the date the physician files and signs an affidavit notifying Medicare that he or she has elected to “opt out.” After the two-year period is over, the physician could elect to become a participating provider during the provider enrollment period, or he or she may “opt out” again.

UESTION: If I am contracted with a non-Medicare insurance company, am I allowed to have

patients sign a waiver stating that we do not bill insurance companies for a flu vaccine and have the patients pay out of pocket? Can I have the patients pay the amount and have them attempt to get reimbursed directly from their health plan? ANSWER: Most health plans contractually prohibit billing patients for covered services, so, if you are contracted, be sure you are not violating such clauses. Flu vaccines are usually covered services. You can negotiate a new contracted rate for these services with the health plans you contract with. If you see any patients who have coverage with a plan that you are not

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contracted with, you are more than welcome to charge the amount and accept cash for it, and then have the patient bill their insurance company for reimbursement.

ABOUT THE AUTHOR: Ms. Gonzalez

is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

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Interview Richard Liekweg UCSD Medical Center CEO By SAN DIEGO PHYSICIAN

DP: WHAT IS THE DIFFERENCE BETWEEN UCSD’S MEDICAL CENTER AND THE OTHER HEALTHCARE SYSTEMS IN THE COUNTY?

RICHARD LIEKWEG: We have a commitment

to education — training the future supply of physicians, pharmacists, and other healthcare providers — and a passion for research — finding new ways to improve health and cure disease – while at the same time, providing exceptional patient care to our community and beyond. This triple mission of patient care, education, and research has allowed UCSD Medical Center to care for a broad spectrum of patients and offer a comprehensive system of services, from primary care to highly specialized care for complex cases. This includes a robust clinical research program, and several tertiary and quaternary referral centers found only at UCSD. This commitment is reflected in our vision, which is “Clinical Excellence…Through Service, Innovation, and Education.” Because we are part of UCSD, which is world-renowned for its educational and research excellence, we have the unique ability to collaborate across cam-

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pus in exciting biomedical research and educational programs that have local, national, and global impact. This synergy results in innovations in technology and treatment that can be homegrown right here in San Diego, as we’ve seen in the large number of successful start-up companies associated with discoveries coming out of UCSD. And through centers of excellence like the Moores UCSD Cancer Center, we integrate basic and clinical research and patient care on a major scale to accelerate advances in prevention, diagnosis, and treatment of disease. This means that patients can access the latest advances in the treatment of cancer that previously were only found at places like MD Anderson in Texas or Sloan Kettering in New York. Our commitment to education, research, and patient care benefits the entire region as we attract leading researchers and clinician scholars, and the best medical and pharmacy students. Many of these students ultimately choose to stay in San Diego and contribute to the region’s ability to care for its growing and aging population. SDP: WHAT DO YOU SEE AS THE BIGGEST CHALLENGES FACING UCSD MEDICAL CENTER TODAY AND IN THE COMING YEARS?

As with all hospital systems, our biggest challenge is maintaining financial solvency in the face of declining reimbursements, increasing costs, unfunded mandates, and growing numbers of uninsured patients. Almost 7 million people in California are uninsured, a number larger than the population of Massachusetts. UCSD has historically been a leading provider of care for the uninsured, and we are committed to continuing our role in the safety net, but we cannot take on more unfunded care than we already provide. We must generate adequate patient care revenue to cover escalating labor, pharmaceutical, and other costs; invest in facility improvements to maintain or expand access; replace or upgrade equipment and technology to deliver 21st-century medicine; install new information technology solutions to reduce human error and provide a safer environment for our patients, clinicians, and staff, and support important

regional services, like our Burn Center. In addition, as an academic center, we have some vital revenue streams supporting the university’s educational programs that are at risk at both the state and federal level. These are the direct and indirect graduate education funds that help support part of the cost of training over 500 medical and surgical residents and fellows each year. If these were to be cut, our education, research, and patient care programs would be severely impacted. Even with a positive operating margin, we have the challenge of accumulating enough capital to address our substantial facility needs to meet the state’s seismic mandate, but also because we have an aging hospital and infrastructure in Hillcrest that requires ongoing repair, renovation, and upgrades so we can provide safe, quality care for our patients. And, as our population grows and demand for services increases, we need to expand our facilities on both campuses. As construction costs skyrocket, we must generate the income to pay for these investments and rely on community philanthropy, while making strategic decisions in regards to program and facility growth.

MR. LIEKWEG:

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SDP: WHAT DO YOU SEE AS THE BIGGEST CHALLENGES FACING SAN DIEGO COUNTY’S PHYSICIANS? MR. LIEKWEG: At

the risk of sounding like a broken record, I would say it’s the reimbursement gap; it’s increasingly tough to run a successful practice when Medi-Cal, County Medical Services, and Medicare payments are inadequate to cover the significant costs of running a practice. As providers opt out of caring for Medi-Cal and unfunded patients in order to protect their income stream, those who continue to serve these populations are further impacted.

SDP: WHAT DO YOU SEE AS THE BIGGEST CHALLENGES FACING SAN DIEGO COUNTY’S HEALTHCARE SYSTEM? MR. LIEKWEG: The biggest challenge facing the county’s healthcare system is also

one of the biggest challenges for San Diego — that is, finding a way to take care of safety net patients across the continuum of care, including advocating together for better reimbursement for our region, so that no system or practice is overly burdened and access for all is preserved or enhanced. Coordination and collaboration among our hospitals, physician practices, and community clinics is vital so that we meet the needs of the underserved while ensuring that we maintain access to superb care for all patients throughout the county. The domino effect applies in healthcare. When more and more patients without insurance coverage use emergency rooms as their point of entry into the medical system, the results are overflow in the ERs and higher census in our hospitals. This creates access issues for all patients, and as we’ve seen around the state and the country, ultimately leads to financial crisis and closure for hospitals that are most impacted. Any curtailment of services by hospitals or physician practices, including the shrinking pool of specialty physicians willing to participate in the safety net, contributes

MR. LIEKWEG: I have great admiration for the practicing physician at a time when our healthcare delivery system is in peril and in need of reform. I grew up in a family of physicians. My grandfather was a general practitioner and the city coroner for Washington, D.C., in the early 1900s, my uncle was an obstetrician and an active leader of our community hospital’s medical staff, and my oldest brother is a retired cardiac surgeon who trained under some of the best academic heart surgeons in this country. You can only imagine the conversation at the family reunion when I announced I was going to be a hospital administrator. While working 16 years with the Duke University Health System, I also experienced firsthand the role that an academic medical center can play in support of our community physicians and hospital partners. At Duke, we partnered with physicians and hospitals across the state of North Carolina, outside the state, and even outside the country. We have the same opportunities here in San Diego. It’s important that many of our faculty physicians are members of the San Diego County

important partnership opportunities. Our mutual success depends on mutual understanding and support. My main message would be that UCSD Medical Center’s primary obligation and benefit to the community is as a premier academic medical center. This means we must maintain excellence in our patient care, research and teaching missions, invest in new technologies and programs, and recruit new faculty, in order to deliver on our commitment. I would seek support in this position from the physicians who understand the importance of making sure San Diego has a strong university medical system among its constellation of providers, as we build even stronger collaborations with community colleagues to advance patient care for our region. SDP: NOW THAT WE’VE DISCUSSED THE CHALLENGES FACED BY PROVIDERS, WHAT HEALTHCARE REFORM PROPOSALS OR CONCEPTS DO YOU FAVOR? MR. LIEKWEG: One thing is clear: the solution,

like the problem, will have to be multifaceted. There are many successful models worth discussion as we work to develop solutions. For example, I recently visited Singapore, where they spend 4–6 percent of their GNP on healthcare. The United States spends 16 percent, and we have similar life expectancy rates. Their Our commitment government subsidizes basic, affordable healthto education, research, and care at public hospitals patient care benefits the entire region and clinics, with conas we attract leading researchers and sumers required to pay clinician scholars, and the best some amount, based on medical and pharmacy their income level. Constudents. sumers can opt to pay more for higher levels of service, such as private or further to the crisis. semi-private hospital rooms We must collaborate on finding solutions. versus multi-bed wards. Those And, healthcare providers can’t solve who choose not to access the governMedical Society. this one alone. It will require county ment-sponsored care can purchase healthOur colleagues throughout the county support beyond what has been provided care through a smaller network of private participate in training our students and resto date, as well as a more rational state hospitals and providers. This model enidents, partner in providing care, and voland federal system of reimbursement. sures access to quality, no-frills medical unteer through our free clinics and other care for all Singaporeans, including lowcommunity outreach endeavors. We serve income groups, in an affordable governSDP: IF YOU HAD FIVE MINUTES ALONE WITH EVERY PHYSICIAN IN THE COUNTY, WHAT WOULD our colleagues with continuing education ment-subsidized model, with additional YOU WANT THEM TO KNOW? and professional training, and many other amenities available through the public or

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private sector for additional cost. I am optimistic that consumers are beginning to demand reform that protects their access to high-quality care, and our elected officials have taken this issue on as a priority. The proposals on the table today that appear to have the most traction are those that spread the cost of expanded coverage so everyone has skin in the game. A plan that provides coverage for primary and preventive services will be key to preventing ER overcrowding and costly interventions to treat advanced disease that should have been managed earlier. I expect that, ultimately, we will arrive at an approach that requires not only government but employers, insurance companies, consumers, hospitals, and providers to participate. This seems rational and equitable, since we will all benefit if we can assure at least some level of coverage for everyone. SDP: DO YOU THINK UCSD HAS A DISPROPORTIONATE SHARE OF UNDERFUNDED PATIENTS IN THE COUNTY? IS THERE A PROBLEM WITH OTHER SYSTEMS “DUMPING” ONTO UCSD? MR. LIEKWEG: Absolutely! It is a fact that UCSD Medical Center cares for a significantly disproportionate share of underfunded patients, relative to our size. We account for only about 8 percent of the region’s total inpatient discharges, but over 36 percent of the region’s unfunded and 13 percent of Medi-Cal discharges. Almost half of UCSD Medical Center’s patient discharges are undercompensated. Whenever colleagues in the community curtail access to MediCal and unfunded patients, many of these patients are told to go to UCSD as a last resort, which impacts our delicate financial balance and puts our system in jeopardy. We are seeing a greater number of underfunded patients arriving in our ERs or clinics after having been seen in another local hospital, stabilized, and discharged to get follow-up care by a physician on their medical staff. Unfortunately, many of these providers do not see Medi-Cal or unfunded patients, so they send them to UCSD. We are fortunate that the community clinics and others concerned about the

safety net are collaborating with us to help ensure these patients are getting the care they need, both primary and specialty care, through community providers, so that our hospitals and physicians are not adversely impacted. This effort takes ongoing dialogue, and a willingness by the community to participate at some level in caring for the uninsured. SDP: OTHER SYSTEMS SOMETIMES SAY THAT UCSD SHOULD BE THE SAFETY NET INSTITUTION SINCE IT RECEIVES PUBLIC FUNDS. WHAT PROPORTION OF THE UCSD MEDICAL CENTER’S OVERALL HEALTH SYSTEM BUDGET IS PUBLIC SUBSIDY? MR. LIEKWEG: This is one of the most frustrat-

ing myths that we have had to confront in recent years. UCSD Medical Center does not receive special funding, other than the less than 2 percent of our hospital budget that comes from the state via the University

of California to help offset the added costs of clinical teaching. The public funding we receive to help cover unfunded care is provided through the same contracts held by other hospitals and providers (such as MediCal and the county’s CMS program). I can assure you that the University of California expects its hospitals to maintain a positive margin so we can cover our operating budget, and pay for our capital investments. SDP: WHAT PROJECTS ARE ON THE HORIZON FOR UCSD MEDICAL CENTER? MR. LIEKWEG: Our strategic goals are to expand facilities and programs that best meet the needs of our growing, aging population, and to incorporate new technologies, including electronic medical records, telemedicine, and other advanced information technologies, into improving serv-

ice and quality of care. We are moving forward with expansion of the UCSD Medical Center campus in La Jolla. Construction is underway on the Sulpizio Family Cardiovascular Center, which will allow us to consolidate most of our programs in cardiovascular medicine and surgery in a state-of-the-art facility. This project will also expand our emergency department in La Jolla and provide us with additional intensive care beds and operating rooms. We have a number of projects underway in Hillcrest. Currently we are enhancing our Post-Anesthesia Care Unit, building a new inpatient MRI suite, and expanding our Neonatal Intensive Care Unit and our Labor and Delivery program. We are also planning a new inpatient bed tower in La Jolla, which will further improve access on both of our medical center campuses.

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The Sharp HealthCare Journey to Excellence The Physician Role in Organizational Performance By Stephen C. Beeson, MD

nstitutional culture change has certainly been tougher than originally anticipated. Perhaps our greatest challenge was the reality that we were good — some would even say we were very good. Status quo would have been sufficient and certainly a lot easier. The fuel that drives change can easily run dry in the face of resistance without the burning platform of poor performance. We had none of that. No one would have raised an eyebrow if we had collectively said, “If it’s not broken, don’t fix it.” To our good fortune, our leadership at Sharp had the foresight and clarity to realize that sitting idle in today’s healthcare marketplace was not only shortsighted, but could threaten the long-term

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viability of our organization. The reality of pay-for-performance was sponded to intensive outreach to improve, and a number of physicoming, and we had to position ourselves with growing regulatory cian contracts were not renewed based on performance measures. A pressures and rising patient expectations to improve the product we commitment without accountability carries little weight. delivered for our patients, staff, and physicians. We transitioned from opinion-based performance assessment to In 2001, a grassroots commitment was made to create the best measurement-based performance assessment. The change was an unplace to work, practice medicine, and receive care — one compocomfortable, pivotal, cultural shift, foundational to identifying opnent not less nor more important than the next. We called our comportunities to improve clinical and service measures. We created mitment the “Sharp Experience,” based on the premise that it is the dashboards of performance, reported results to physicians, and customer experience that drives consumer decisions coached and trained to improve outcomes. We measmore than anything else. We partnered with ured hemoglobin A1C control, mammograThe greatest the Studer Group, a healthcare consulting phy, cervical cancer screening, controller organization who had created dramatic use in asthmatics, vaccination rates, impact on front-line staff results in healthcare systems throughpatient satisfaction, patient combehavior was not necessarily out the country and had a tested and plaints, productivity, peer review, the training they had received, proven roadmap to improve operaformulary compliance, and generic but what they saw their tions and service to achieve tangible utilization. The director of quality, outcomes. Jerry Penso, MD, provided lists of paphysicians say My position as physician leader for the tients to our physicians needing mamand do. Sharp Experience began well after joining the mography, cervical screening, or improved Sharp Rees-Stealy Medical Group in 1994. In October diabetes control. Performance measurement was pro2001, I received a call from our medical director, Donald Balfour, vided to physicians, and training and support was deployed to asMD, asking if I would be interested in assuming the appointment of sure every physician had the resources and support to improve. physician “Fire Starter.” My role was defined as “bringing the Sharp Leaders were developed and trained to lead, and accountability Experience to the physicians of the Sharp Rees-Stealy Medical for performance was embedded at the highest levels of the organizaGroup.” tion. The effort to achieve outcomes intensified, painfully at first, My first several months were spent in training and learning about but as results in patient satisfaction and quality began to materialize, physician coaching and performance improvement. Fundamentally, even skeptics confessed that our roadmap, in order to work, had to I had to learn how to teach and train physicians and to create recepbe driven by expectations and payment for performance. Physician tiveness and enthusiasm for cultural and behavioral change. The vireimbursement in our employed physician model began to align a sion for what we were to become began to crystallize, but the portion of salary to clinical measure performance and patient satispathway to change and engage physicians across a large multi-spefaction. Recognition for high-performing physicians was profiled to cialty group spread over 12 sites and 50 miles was more challenging. thank the best for all they had done. We found recognition replicated We began our efforts with a system-wide training event for all behavior and took little time and money. Physician recognition was physicians to describe and define the physician’s role in the Sharp more important to the physician work experience than we realized Experience. We refined our training efforts by bringing one-hour and placed the Sharp Experience as a physician-friendly cultural shift. training sessions to the site level to assist physicians in improving the We began to tap engaged physician influence to drive the clinical patient experience and perception of care. We took a prescriptive work unit. We realized the greatest impact on front-line staff behav“how-to” approach: How to create a first impression? How to foster ior was not necessarily the training they had received but what they trust? How to improve compliance, drive loyalty, and improve outsaw their physicians say and do. A key organizational shift was to comes? Training efforts were repeated in electronic versions, promptcoach and train physicians to lead their clinical work unit. Physician ing and reminding physicians of important behaviors that matter. visibility and support for the Sharp Experience was a realized necesWe found that as performance improved and patient satisfaction sity to sustain change. Example is not the main thing in influencing began to rise, physicians who struggled became illuminated in our others — it is the only thing. evolving performance culture. Individual physician coaching was deOur quality and service continued to gravitate to the top of dataployed for those physicians that struggled. Not all physicians rebases. The better we became, the more we validated our efforts and 24

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believed in our mission. Constitutional alignment of large numbers of physicians is a challenge, but nothing made it easier than a proven roadmap to measurable performance excellence. By the end of 2007, the Sharp Rees-Stealy Medical Group had become the number-one-ranked medical group in the state of California in quality and service out of more than 170 medical groups by the Blue Cross Quality Report Card. We were the recipients of the 2007 AMGA Acclaim Award for Performance Excellence. Over the preceding five years, we had improved patient satisfaction with our physicians from the 17th percentile to over the 80th percentile. Physician satisfaction improved in each of the five measured years, and Sharp HealthCare was the recipient of the most coveted and prestigious award for organizational performance: the 2007 Malcolm Baldridge Award. At its core, the Sharp Experience is not about our objective measures of improvement, nor the awards on a national scale, or revenue

from pay-for-performance. The core of the Sharp Experience is about deploying proven tactics to change the culture of our organization. It is about succeeding by doing things better and providing every patient the care we would expect for our family. The Sharp Experience is about purpose, worthwhile work, and making a difference for those who have entrusted us with their care, and creating the sort of physician experience we hoped we would have when we joined this profession in the first place. It has become clear again, we best serve ourselves by our dedication to others. Every patient, every time.

ABOUT THE AUTHOR: Dr. Beeson serves as physician coach for the Sharp Experience and full-time practicing physician for the Sharp Rees-Stealy Medical Group. Dr Beesonâ&#x20AC;&#x2122;s patient satisfaction ranks him in the 99th percentile, and he is author of the bestseller, Practicing Excellence. Dr. Beeson has established a national reputation for coaching and training physician organizations across the country.

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It is critical that physician groups and care givers challenge the entire system process, stop what does not work, and not be afraid to try something new.

Making Strides in Quality Improvement [ In Both the Inpatient and Outpatient Arenas ] By Arthur M. Flippin, MD

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uality,” according to William Edward Deming, an icon of the quality movement, “is a never-ending cycle of continuous improvement.” Historically, quality improvements within healthcare have been attempted through many incremental efforts, in both the inpatient and outpatient arena, with mixed success. The Southern California Permanente Medical Group’s (SCPMG) experience, however, has shown that only when physician groups work every individual piece of the system can they achieve the dramatic improvements in healthcare that physicians desire for patients. It is critical that physician groups and caregivers challenge the entire system process, stop what does not work, and not be afraid to try something new. This article will look at several areas of quality improvement efforts by SCPMG including technological advances and patient care, as well as overall system challenges. The path to quality improvement is challenging, but required during this time of increasing demands for quality, affordable, and accessible healthcare. THE CHANGING FACE OF HEALTHCARE TECHNOLOGY

The most substantial quality improvement effort for SCPMG has come in the form of an organization-wide investment in healthcare information technology. Kaiser Permanente HealthConnect (KP HealthConnect) is a $4 billion information systems investment,

and is a critical foundation for improving the patient experience and effectiveness of care. KP HealthConnect helps ensure that caregivers, in both the ambulatory and inpatient setting, have the information they need to provide the right care at the right time. Evidence-based medical knowledge and best practices that address many of the key effectiveness of care measures are built in to provide clinicians with point-of-care decision support. The system makes it easy and convenient to connect patients to the people and services that they need to keep themselves and their families healthy. The system provides innovative tools that enable SCPMG physicians to deliver high-quality, safe, and efficient care in new and unique ways by integrating care across the continuum. With 24/7 access to information at every point of contact — in the appointment call center, exam room, pharmacy, hospital and even online — KP HealthConnect increases healthcare access, fosters more patient-centered care, and enhances staff and physician satisfaction. Alongside KP HealthConnect, SCPMG uses a robust disease management registry called POINT (Permanente Online Interactive Network Tools), which is a standalone system unique to KP Southern California. POINT is used in population-based medicine to assist physicians in providing evidence-based treatment. Within Kaiser Permanente’s integrated healthcare delivery system,

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POINT is a robust tool with access to information from the labs, pharmacy, and visit data. By mining POINT data, SCPMG is able to identify care gaps and conduct multi-tiered patient outreach to significantly improve outcomes. CHALLENGING SYSTEMS Technology is just a portion, albeit a critical component, of SCPMG’s overall quality improvement program. In addition, SCPMG maintains a system focus through the use of multidisciplinary team involvement within the inpatient setting. SCPMG’s multidisciplinary teams include hospital-based physicians, ED physicians, nurses, and pharmacy and quality improvement personnel. Quality reviews and interventions are performed prior to patient discharge, allowing physicians to identify issues and apply best practices in a timely manner. Additionally, SCPMG utilizes a rapid cycle improvement process in order to fast-track quality improvement efforts. This is the practice of breaking down complex systems and issues into smaller, more manageable pieces, and then focusing on the individual components. This approach offers an important tool for healthcare teams frustrated by the slow pace of other improvement methods. Using rapid cycle improvement, the team sets a global outcome measure based on the system’s goals. Improvement occurs through small, rapid PDSA (Plan, Do, Study, Act) cycles of change. At the completion of each PDSA cycle, a decision is made to adopt and implement the change, to adapt the change (as a result of conducting PDSA cycles under a variety of conditions), or to abandon the change. By emphasizing the testing of improvements on a small scale — identifying and focusing on one component of performance at a time — rapid cycle improvement enables a more expeditious completion of the overall strategy. CLINICAL STRATEGIC GOALS: 2007, A YEAR OF GREAT STRIDES Each year, SCPMG selects clinical quality goals to help improve care. The physician group designates a handful of the clinical strategic goals (CSG) as “imperatives,” the highest-priority goals for clinical improvement. In identifying specific clinical measures as imperatives, SCPMG is focusing on improving care in measurable ways that make a real difference to patients. Raising performance on quality measures like chronic disease management and cancer screenings, the physician group is improving health and saving lives. Through August 2007 (the most current data available), SCPMG has made improvements on almost all of its 2007 CSG imperatives, including cancer screening rates, blood pressure con28

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trol, lipid control, community-acquired pneumonia, smoking cessation, and hospital care for members with acute myocardial infarctions. Since the beginning of the year, SCPMG has shown strong improvements in the following areas: • Preventive cancer screenings. Colorectal cancer screening rates continue to improve significantly, rising 8.7 percent year to date. • Controlling blood pressure in members with hypertension. • Counseling members who smoke. Results from the SCPMG’s Ambulatory Satisfaction Questionnaire (ASQ) indicate improvements in patient perceptions that the physician group is advising them to quit (up 8 percent year to date) and offering strategies and/or medications to support them (up 7 percent year to date). • Hospital care for patients admitted with: • Pneumonia • Heart Failure • Heart Attack Among SCPMG’s successes during this past year, controlling blood pressure in members with hypertension proved to be a stand-out. The physician group has made considerable progress in this area over the last few years, helping patients with hypertension live healthier, longer lives. A recent study by Kaiser Permanente’s Care Management Institute (CMI) forecasts the number of strokes and heart attacks that can be prevented when patients and physicians maintain hypertension control. Based on this forecast, by improving the hypertension control rate to 80 percent from its current rate of 74.9 percent, and maintaining that improvement for five years, SCPMG could potentially prevent 650 strokes and 470 myocardial infarctions. One area that remains a challenge is helping patients with diabetes control their glycemic levels. Control rates have declined slightly since the beginning of 2007. In a recent SCPMG study, patients who attended one of the group’s “Living Well With Diabetes” health education courses improved their HBA1c levels by one or two percentage points within three months. Thus, indicating that health education may be an important part of the solution to improving outcomes and performance on this measure. PARTNERSHIPS FOR BETTER HEALTH Engaging patients to actively participate in their own healthcare is key to long-lasting, overall quality improvements. SCPMG clinicians identify and engage high-risk patients and those with chronic

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Engaging patients to actively participate in their own healthcare is key to long-lasting, overall quality improvements.

LOOKING FORWARD As the enormous pressure to rapidly improve healthcare systems continues to rise, SCPMG will push forward in its challenge of the status quo, in an effort to improve access and the effectiveness of care, and enhance physician and staff satisfaction. It is important to remember that successful quality improvement is dependent upon the ability to challenge oneâ&#x20AC;&#x2122;s own thinking about organizational processes, and challenge all parts of the current system. Quality takes time and an ongoing, sustained commitment.

illnesses in comprehensive disease management programs with strong outreach and health education. By emphasizing prevention and wellness, and by providing easy access to health improvement programs, education, incentives, and decision support tools, SCPMG creates the foundation necessary for physician/patient partnerships focused on achieving the best possible health.

ABOUT THE AUTHOR: Dr. Flippin joined the Southern California Permanente Medical Group in San Diego in 1977 as a staff neurologist. He was appointed to the position of chief of neurology in 1991, a position he held until his appointment in 2000 to his current role as area medical director.

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What Business Are We Really In? Providing the Highest Quality of Care for Our Patients By A. Brent Eastman, MD ach Scripps Health management meeting starts out by answering the question: What business are we really in? The meeting begins with a physician and a patient reliving a specific experience at Scripps to remind us all why we do the work we do. At Scripps, we believe the business we are in is to provide the highest quality of care for our patients.

BACKGROUND Scripps Health is a not-for-profit, community-based healthcare delivery network that includes four acute-care hospitals on five campuses, 13 clinic locations, an extensive ambulatory care network, home healthcare, and associated support services. Scripps Health now has approximately 11,000 employees, more than 2,600 affiliated physicians, and $1.9 billion in annual revenue. STRUCTURE FOR QUALITY At Scripps, quality denotes patient satisfaction, patient safety, and clinical outcomes. While it may sound unrealistic, Scripps considers every employee and physician to be on our Quality Committee. During a series of interviews conducted a couple of years ago, we asked numerous staff, managers, and executives, “Who is accountable for quality?” Each one of them said “I am.”

On a functional level, here are three key committees focused on quality throughout the organization. At the highest level, we have a Board Quality Committee. The Board Quality Committee is chaired by a board member and includes six of the 14 board members (43 percent), two former board member and the chairman of the board. The Board Quality Committee meets on a monthly basis to discuss performance metrics and share best practices. In addition, Chris Van Gorder, the CEO of Scripps Health, chairs an Executive Cabinet meeting with the chief executives at each of our business units as well as other corporate executives. There is a standing quality agenda item at each weekly meeting. As the chief medical officer, I have the executive accountability for quality. I chair the Joint Quality Leaders meeting, which includes an administrative quality leader and a physician quality leader from each of our hospitals, Home Health, and Scripps Clinic. One of the most important things we have done recently is hire an administrative counterpart to my position at the corporate office. I work with Mikele Bunce, PhD, who has a strong background in quality, performance improvement, and pay-for-performance. Mikele and I have no formal relationship with the quality leaders and the physician quality leaders throughout the system, but our Joint Quality Leaders meeting has created the crucible for the exchange of ideas across campuses. We understand that quality patient care occurs at our hospitals and clinics, and we see our role

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at the corporate office as support for the work done at the sites. This monthly meeting focuses on key quality metrics where our current performance is below our target (which we title The Red Zone), work done at system-wide quality subcommittees (e.g., Stroke Taskforce, Risk Managers Meeting), information systems for quality, culture change, and industry news/planning for the future. ACCOMPLISHMENTS

a Quality is bility of responsi . Quality everyone d supporte e b o t s ha st level e h g i h e h at t ization n a g r o e of th a priority g n i e b s a erall in the ov plan. strategic

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Over the past year, Scripps has made a number of changes, which we believe have been very successful. Of primary importance was the creation of a three-year corporate quality plan. Our plan is organized into sections: Strategic Planning; Competencies; Education/Communication; Measurement and Reporting; Quality Initiatives (Clinical Care, Patient Safety, Patient Satisfaction); Monitoring and Accountability; Reward, Recognition, and Reinforcement; and Industry Leadership and Innovation — all focused around quality. We looked at activities in each category along a spectrum from “meeting regulatory requirements” to “performance excellence,” rated our current performance, and then analyzed the gap between current performance and performance excellence. Our plan was developed to close that identified gap and move our organization along the continuum towards performance excellence where needed. This was the first year that Scripps had a Success Shares plan. Scripps bases 25 percent of management incentive compensation on quality metrics, but for the first time ever, all staff had an opportunity to receive a significant monetary incentive payment based upon financial performance and patient satisfaction scores. By meeting our goals, we just paid out approximately $8 million to employees, exemplifying our belief that everyone in the organization is responsible for quality. We have developed a number of educational events for our employees and physicians. On November 30, 2007, we had our Inaugural Quality Summit, which focused on surgical patient safety. We also have a performance improvement training scheduled for our whole management team on January 30, 2008, as well as a five-day “master’s level” program for those interested in more detailed knowledge and skills beginning spring/summer 2008. Scripps created a new quality award, which is a recognition program for multidisciplinary teamwork on projects developed from evidence-based medicine. Awards were presented at the Quality Summit. Each facility had a team winner and the perpetual award is hanging in a place of prominence at each facility.

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Scripps continues to work on its information systems for quality. We have completed phase one, stage one of an enterprise data warehouse, which we call our Quality Data Management System (QDMS). QDMS will support our efforts in quality as well as clinical research, and then expand to other areas such as finance. In addition, we have continued to work toward deployment of an electronic medical record. Our chief nurse executives have taken this project to another level by standardizing workflow across campuses to decrease variation, which, in turn, improves patient safety and clinical outcomes. Scripps Healthâ&#x20AC;&#x2122;s promise to our board of trustees are the performance metrics tied to our strategic plan. We create one-year objectives to meet our three-year goals as we believe that culture change is a multi-year process. In 2007, Scripps Health met our Quality Strategic Objective targets for patient satisfaction, patient safety, and clinical process measures. In addition to clinical process measures, we monitor outcome measures of interest to our patients. Our Medicare mortality rates continue to be some of the best in the nation. Most recently, Scripps was named as one of Fortune 100â&#x20AC;&#x2122;s Best Companies to Work For 2008 (#56). We believe it is a truism that the more satisfied your employees are, the more satisfied your customers will be.

ported at the highest level of the organization as being a priority in the overall strategic plan. Learn from the best. Internally, we learn from each other through the sharing of best practices. Externally, we learned from a pilgrimage we took to Intermountain Health, where we heard that two of the keys to their success were developing a quality education program and creating an enterprise data warehouse, both of which have been incorporated into our quality plan. Quality/performance excellence requires a culture change. We do not consider our job one of quality management (i.e., maintaining the status quo), but quality improvement. Improvements require change and change can be met with hesitation and anxiety. To change our culture, we set long-term goals and short-term objectives, and communicate both to staff to motivate as well as to set attainable outcomes. Multidisciplinary team efforts are essential to success. One cannot improve patient care without engagement and support of physicians and without the input of all affected parties.

WHAT HAVE WE LEARNED? Quality is a responsibility of everyone. Quality has to be sup-

ABOUT THE AUTHOR: Dr. Eastman is chief medical officer, Scripps Health, and N. Paul Whittier Chair of Trauma.

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Sharp Rees-Stealy Medical Group A Flexible, Learning Organization By Jerry Penso, MD

harp Rees-Stealy Medical Group, the region’s oldest multispecialty medical group, is committed to providing the finest in personalized healthcare. We provide care at 19 locations with 1,600 employees and more than 340 physicians representing virtually every medical specialty. In 2007, we had more than 1 million patient visits, with nearly 70 percent of the population covered by one of several managed-care arrangements. Since our medical group’s founding more than eight decades ago, the philosophy has always been to place the well-being of the patient first, followed by what is best for the medical group, and then the individual physician. This is one of the cornerstones of our mission, and it is deeply embedded in our organizational culture. It drives our desire to provide an optimal healthcare experience for patients in terms of quality, service, and access. The aim is to offer quality services that set community standards and exceed expectations. We have designed a quality improvement program to optimize preventive, acute, and chronic care in addition to providing an outstanding patient experience. The initiatives have included: • Implementing a comprehensive electronic health record (EHR) system • Building the IT infrastructure to produce the data needed to determine our outcomes

• Creating multidisciplinary teams to engage physicians and staff to design and implement quality and service initiatives • Implementing point-of-care alerts to notify physicians when patients require additional services • Building a diabetes registry to track diabetic patients • Improving scheduling to increase patients’ ability to see their primary care physician on the same day they call for an appointment • Implementing outbound phone calls to reach out to patients due for services • Implementing physician report cards for quality and service measures • Establishing a physician incentive program based on quality and service • Developing, reviewing, and setting performance targets • Tying manager performance reviews to achievement of strategic targets

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We apply quality improvement resources toward projects that will clearly create better health for patients and community. Two projects illustrate our ability to achieve dramatic improvements in patient outcomes: blood sugar control in high-risk patients with diabetes and breast cancer screening.

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The blood sugar control program (called “DM-9”) focuses on patients whose last HbA1c was nine or above. We initiated the “planned visits” model in which patients follow a pathway that includes physician or staff interventions prior to, during, and after the office visit. Lists of qualifying patients are provided to individual physicians who proactively schedule a visit dedicated to helping the patient attain better diabetes control. Staff then calls patients one week prior to the visit to remind them of their appointments and their need to bring their medications, the blood sugar log book, and to have their laboratory tests done. Physicians developed an evidencebased algorithm that guides treatment, and on-site nurses have been trained to provide insulin teaching for new starts, when necessary. Finally, diabetes case managers follow-up telephonically with each patient after the visit. Since the inception of the program in January 2007, DM-9 has resulted in a 15 percent reduction in the number of patients with HbA1c level nine or above. Breast cancer screening was a focus of an extensive, multidisciplinary team review. The goal was to increase mammography screening rates by improving access, customer service, and physician office efficiency. The team instituted centralized radiology scheduling, with a single number to call. A system of standing orders and self-referrals allows women to call the central scheduling office directly to schedule their mammograms. To improve compliance, a computerized automated reminder system notifies women when they are due for a mammogram and offers the option of scheduling a Pap smear and mammogram on the same day for convenience and dramatically reduced wait times. Most sites at Sharp Rees-Stealy now offer same-day mammograms and breast cancer screening rates have improved from 73 percent to 85 percent in the past four years.

American Medical Group Association’s Acclaim Award honoree, an award recognizing organizations that embrace the Institute of Medicine’s aims for an ideal healthcare system. We achieved another milestone in 2007, when Sharp HealthCare was awarded the Malcolm Baldrige National Quality Award, the nation’s highest Presidential honor for quality and organizational performance excellence. With patients/consumers and employer groups demanding transparency in healthcare costs, quality and service, Sharp ReesStealy began to strategize early to align the structure, culture, and processes to support the effort and achieve success. We learned data is the key for successful quality improvement efforts. Accurate, high-quality data is critical because without it, it is impossible to create feedback reports and point-of-care tools and to understand if changes result in true improvement outcomes. The adoption of an electronic health records system will allow us to continue our efforts toward providing efficient, high-quality care. Above all, it is our physicians who make the difference. Their skill, dedication, and commitment to excellence position Sharp Rees-Stealy Medical Group well for ongoing quality and service improvement.

We set high expectations for our physicians and staff, knowing that our patients and community will benefit from the improvements. These and other quality improvement projects have fostered the creation of a flexible, learning organization. We set high expectations for our physicians and staff, knowing that our patients and community will benefit from the improvements. Transparent goals and feedback drive accountability throughout the medical group. Multidisciplinary teams facilitate open communication and reduce barriers based on tradition or hierarchy. Rounding by top leadership (sites visits and problem-solving at the local level) creates trust and helps maintain momentum. Incentives, both financial and non-financial, create alignment between strategic quality and service goals and performance. We are proud of the recognition our quality efforts have received, both within California and nationally. For the second year in a row, Sharp Rees-Stealy Medical Group has earned the title of top performing physician organization in Blue Cross of California’s Quality Scorecard. Also in 2007, Sharp Rees-Stealy was selected as the

ABOUT THE AUTHOR: Dr. Penso is associate medical director, quality programs, for Sharp Mission Park and Sharp Rees-Stealy medical groups. Sharp is the largest integrated healthcare delivery system in San Diego. Sharp Mission Park, a primary care medical group, is located in northern San Diego County with 80 physicians and eight sites, serving more than 60,000 patients. Sharp Rees-Stealy, an affiliated, multi-specialty medical group, has 13 sites throughout the county, more than 300 physicians, and serves 200,000 patients.

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Political Advocacy

No10% Medi-Cal Cut The following letter was sent to California state Senators Ducheny and Hollingsworth on February 20, 2008, imploring them to rescind the 10 percent Medi-Cal provider rate cut.

February 20, 2008 cheny, Chair, Budget and The Honorable Denise Du State Capitol Building Sacramento, CA 95814

Fiscal Review Committee

view Committee e Chair, Budget and Fiscal Re Vic h, ort gsw llin Ho is nn De The Honorable State Capitol Building Sacramento, CA 95814 Hollingsworth: Dear Senators Ducheny and

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ty, cians in San Diego Coun enting the over 8,000 physi res s rep on S), ati CM ific (SD ram s ty rou cie dical So tially disast The San Diego County Me budget experts, the poten ior sen s e’s thi g tur din isla cin leg a res rni er , the Califo , and consid wants to emphasize to you physician reimbursement l Ca diMe to s cut r yea rent fiscal of the recently passed cur trol. health care is the responsi con t cos to te draconian rou lth care for patients whose hea on t ms pac roo y im ve enc ati erg em neg in waits nificant lifornia through increased These cuts will have a sig l impact all patients in Ca wil and a, rni lifo Ca of te bility of the sta elcosts. ion, will dramatically acc ong the lowest in the nat and increased pass-through am y ead alr es, rat l Ca dician Me n groups from Medi-Cal. A 10 percent cut to physi with s of physicians and physicia du exo al nti sta e to afford to see patients sub a y ead erate what is alr practice find they are abl e vat pri even in to ns fail cia es ysi rat ph nt ’s Diego di-Cal payme • Fewer than half of San the pre-10 percent-cut Me es, cas se of ny rea ma dec in t, ady fac ste in a — cument these low reimbursements CMS has been able to do SD rs, ups yea e gro n fiv cia er ysi Ov ph e. car ysicians and cover the cost of rendering ses in the percentage of ph rea y dec e ead Th alr ts. are ien es pat rat l e Ca dil, acceptanc physicians willing to see Me and specialty, but, in genera ce cti pra of de mo by ies var willing to take Medi-Cal en three years ago. m fro t to see Medi-Cal patients giv cen per 5 –2 down 10 ed if they would continue ask s, re up we ns gro cia all ysi sm ph of t ’s cen ego Di ns, 81 per • In a late 2007 survey, San 93 percent of solo physicia g rin or gge ts sta ien A pat l nt. Ca me dipay Me in s stated they would reduce a hypothetical 5 percent cut ed for your 83 percent of large group and s, up gro m diu me g with Medi-Cal is attach of lin t dea vey 56 percen sur the of n tio di-Cal. The entire sec completely cease taking Me ect, they soon as the cuts go into eff as t tha us ed staff ’s review. tifi no y ead alr encies Medi-Cal patients have new Medi-Cal patient emerg • Several physicians seeing e patients, and will send any rvic l to r-se Ca -fo difee l Me Ca dider un Me e new routine car will refuse all non-emergent rring new patients seeking refe be l der wil ren ey to Th g m. lin roo wil y r enc m a docto directly to the hospital emerg legislative office to find the t’s ien pat the ing ask s, tor their California state legisla cuts. ns, se unfair and unreasonable the der s or primary care physicia un e car sed mi state-pro able to see either specialist un is t on ou lati ing pu po cel t can ien se, pat l rea Ca didget deficit to inc bu the se cau If even a fraction of the Me l wil is Th . ms . care from emergency roo nificantly more expensive they will get their health| M A R C Hred2 in y room is nearly always sig enc erg em the O P H Y S I C I A N . o r ghealth 0 0 8 ive care del any savings because

Page 2 In addition to raising cos ts for the state, which wil l have to pay for more em for the treatment of an illn ergency room care — and ess made more severe by having to pay delayed care — the longer will affect all patients seekin emergency room waits and g care in the emergency roo disruptions m. We understand that Califo rnia has a budget deficit, and we want to be constr fornia Medical Association uctive. In conjunction wit (CMA), we would be del h the Caliighted to discuss options save Medi-Cal dollars, inc with you and your staff on luding but not limited to: wa ys to really • Offering generic drugs whenever possible, at mu ch lower cost. • Assigning all Medi-Cal patients a primary care me dical home and requiring there. The cost savings wo them to get all but true em uld be enormous. ergency care • Care management that cou ld save as much as 30 percen t of health care costs and im Physicians accepting Mediprove quality and appropria Cal have stayed in this pro teness. gram out of compassion and strained to the breaking po good will. That good will int after years, if not decade has been s, of underpayment. The straw that will break the cam cuts imposed by this legisla el’s back, resulting in the ture are the disruption of an already fra creased costs to the state of gile safety net, with a likelih California and potential hea ood of inlth consequences to patien And we fear that once docto ts who get delayed care, or rs leave Medi-Cal, where no care at all. they have served out of com never return to seeing Me passion rather than profit, di-Cal patients. The Medithey will Ca l infrastructure, once destro to be reestablished. Acces yed by these cuts, may nev s for Medi-Cal patients to er spe be able cialists will likely disappear We stand ready to discuss . the importance of this pro blem with you and your sta devastating cuts. ff, and implore you to res cind these California’s low-income con stituents, the most vulnerabl e patients in your districts, With deep concern for the are the ones who will truly future of California’s health suffer. care, Sincerely,

Albert Ray, MD President

Sincerely,

Theodore Mazer, MD Immediate Past President

Cc: Office of Governor Arn old Schwarzenegger Assembly Speaker Fabian Nu ñez Senate President Pro Tempor e Don Perata Senator Mark Wyland Senator Christine Kehoe Assemblyman Kevin Jeffries Assemblywoman Mimi Wa lters Assemblyman Martin Garric k Assemblyman George Plescia Assemblywoman Lori Saldañ a Assemblyman Joel Anderson Assemblywoman Shirley Ho rton Assemblywoman Mary Salas Joe Dunn, CEO, Californi a Medical Association Richard Frankenstein, MD , President, California Medic al Association

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Stuart Cohen, MD, MPH President-elect

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building a healthier San Diego by addressing unmet healthcare needs for all patients and physicians through education, innovation and service

The

Pulse

No 37

Supporting Your Foundation DECEMBER 2007

I want to send a heartfelt thank-you to the following supporters who donated to the SDCMS Foundation in December 2007. Every dollar is a dollar closer to our goal of eliminating gaps in healthcare in San Diego County. – Carol L. Young, MD, President, SDCMSF Board of Directors NEW CORPORATE, GOVERNMENT, AND FOUNDATION PARTNERS FOR SDCMSF INITIATIVES Alliance Healthcare Foundation (Project Access San Diego) Grossmont Healthcare District (Project Access San Diego) Kaiser Permanente, Local Office (Project Access San Diego) Molina Healthcare (Web Portal Project) Sepracor, Inc. (Web Portal Project) Supervisor Greg Cox (Project Access San Diego) Supervisor Ron Roberts (Project Access San Diego) INDIVIDUAL DONORS: FOUNDER’S CLUB ($25,000 AND ABOVE) Robert Hertzka, MD, and Roxanna Fox (2)

GRAND BENEFACTOR’S CLUB ($10,000–$24,999) Ralph Ocampo, MD, and Mrs. Ocampo (4) CENTURY CLUB ($100–$999) Robert Rubenstein, MD* Sandra Wilcox, MD FOUNDATION FRIEND (UP TO $100) Andrew J. Accardi, MD (2) Behrooz A. Akbarnia, MD Kousay Abdullah Al-Kourainy, MD Steven Ronald Andree, MD (2) Jorge T. Arce, MD (4) Ramin Bagheri, MD (2) Scott Logan Brown, MD (2) Michael John Brucker, MD Robert A. Bullock, MD (2) Kimberly J. Butterwick, MD (3) Kenneth W. Carr, MD (3) John C. Carson, MD (2)

William T. Chapman, MD (4) Cesar T. Chavez, MD (3) Van Le Cheng, MD Peter Colaprete, MD (2) Marcus Contardo, MD (2) Sheryl O. Cramer, MD Frederick James De La Vega, MD (2) Jorge M. Del Aguila, MD (4) Frantz J. Derenoncourt, MD (2) Taddese T. Desta, MD (3) Steven R. Drosman, MD (2) Mohammad Sadi Erfani, MD Richard L. Fassett, MD (2) William E. Friedel, MD (3) Jerrold Glassman, MD (4) Irwin Goldstein, MD Galen H. Hansen, MD (3) Brian P. Harney, MD (3) William P. Hitchcock, MD (3) Mylien V. Ho, MD (3) Robert D. Jacobs, MD (3) Serge Charles Kaska, MD

Karen E. Kohatsu, MD Jason R. Kornberg, MD Eric S. Korsh, MD (3) Mauricio Levine-Kogan, MD (2) Julian P. Lichter, MD (3) Robert M. Malkus, MD (2) Allan E. Mallinger, MD (2) Joseph M. Mann, MD Michael H. Michalski, MD (3) Howard G. Milstein, MD (2) Gustavo A. Mondragon, MD Leonard M. Okun, MD Robert T. Reid, MD (2) Denise Rubino, MD (2) Cynthia Lynn Schaeffer, MD (2) Bradley John Schnierow, MD (2) Craig M. Sclar, MD Joseph A. Scoma, MD Christopher M. Uchiyama, MD Leticia M Uwedjojevwe, MD (3) Keith D. Vrhel, MD (2) Robert L. Warner, MD

Note: (#) indicates number of years of gifts to SDCMSF. * indicates Retired Physicians Society Membership

SDCMS FOUNDATION ADVISORY COUNCIL James Lewis Bowers, PhD, Consultant for Philanthropy Steven A. Escoboza, President/CEO, Hospital Association of San Diego and Imperial Counties Ronne Froman, RADM, USN Retired, Chief Operating Officer, City of San Diego Richard S. Ledford, President, Ledford Enterprises Michael I. Neil, BGN, USMC Retired, President, Neil, Dymott, Perkins, Brown and Frank

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thank you

SDCMS FOUNDATION BOARD OF DIRECTORS Carol Young, MD, President, Rheumatology, Escondido David Priver, MD, Vice President, Obstetrics and Gynecology, San Diego Ralph Ocampo, MD, Secretary/ Treasurer, General Surgery, Retired James Hay, MD, Immediate Past President, Family Medicine, Encinitas Sarah Aghassi, Esq., Director, Office of Strategy and Intergovernmental Affairs, County of San Diego

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Gabriel Arce, CEO, Retired, Community Health Group Ellen Beck, MD, Family Medicine, San Diego John Berger, MD, Family Medicine, San Diego Edgar D. Canada, MD, Anesthesiology, San Diego Judy Forrester, Consultant, Forrester Enterprises Tom Gehring, CEO, San Diego County Medical Society Theodore M. Mazer, MD, Otolaryngology and Head and Neck Surgery, San Diego

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Albert Ray, MD, Family Medicine, San Diego

SDCMS FOUNDATION STAFF Aron R. Fleck, MBA, Executive Director Stephen H. Carson, MD, Chief Medical Officer, Pediatrics, San Diego Claudia Gastelum, Care Coordinator, PASD

A CURTCO MEDIA PUBLICATION

Improve the health

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San Diego County Medical Society Take Advantage of These SDCMS-CMA Benefits! EMR SOFTWARE: SDCMS has partnered with Allscripts to provide special preferred early adopter pricing and discounts for SDCMS members on their HealthMatics EHR and practice management solutions. Contact Jamie Smolin at (310) 490-9711 or at Jamie.Smolin@Allscripts.com. INSURANCE PRODUCTS AND SERVICES: SDCMS has partnered with Alliant Insurance Services, Inc., to provide SDCMS members with discounts on a comprehensive portfolio of insurance products and services. Contact Franco Ganino (619) 849-3794 or at fganino@alliantinsurance.com. PRACTICE MANAGEMENT CONSULTING: Practice Performance Group has signed an agreement to offer SDCMS members practice management consulting discounts (equal to 10% or $500, whichever is larger), free half-day seminars at SDCMS (watch your faxes and emails), and a free one-year subscription to their newsletter. Call (800) 452-1768 or visit www.PPGConsulting.com.

SDCMS PICTORIAL MEMBERSHIP DIRECTORY: Appear in CMA REIMBURSEMENT HOTLINE: (888) 401-5911 — Free SDCMS’ annual pictorial membership directory. Receive a free directory each year and a 50% discount on any addi- CMA LEGAL INFORMATION HOTLINE: (415) 882-5144 — Free tional directories purchased. Contact SDCMS. CODING HOTLINE: Access a coding hotline free of CMA LEGISLATIVE HOTLINE: (866) 462-2819 — Free charge (provided by CHMB Solutions. Email your coding CMA PHYSICIAN CONFIDENTIAL LINE: A free, 24-hour question(s) to SDCMS at Coding@SDCMS.org. phone service for physicians, dentists, medical students, SAN DIEGO PHYSICIAN MAGAZINE: Receive a free sub- residents, and their families and colleagues who may have scription to the voice of San Diego County’s physicians. an alcohol or other chemical dependence or mental/bePlace free classified ads and discounted display ads. Con- havioral problem. Completely confidential. Using it will not result in any form of disciplinary action or referral to any tact SDCMS. disciplinary body. Call (213) 383-2691. SAN DIEGO MAGAZINE: Receive a gift subscription (active physician members) or a discounted subscription (res- LOCAL, STATE, AND FEDERAL PHYSICIAN ADVOCACY: ident physician members). To sign up, contact SDCMS. To SDCMS-CMA continue to be vigilant in our protection of update your subscription address, contact San Diego Mag- MICRA, in fighting against nonphysician scope of practice expansions (all scope bills in 2006–07 were killed!), in workazine at (888) 350-0963 or at sdgm@kable.com. ing closely with our political representatives and other SDCMS EMAIL NEWSLETTER, “NEWS YOU CAN USE”: healthcare stakeholders to fix our broken healthcare fiReceive, free of charge, the latest in medical, local, state, nancing system, and in doing everything we need to do to and federal news critical to your practice … free of adver- protect physicians’ interests wherever they are challenged. tising. Contact SDCMS. Contact SDCMS.

CONTRACT ANALYSIS: Coastal Healthcare Consulting Group has signed an agreement to offer SDCMS members a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts! Call Kim Fenton at Coastal SDCMS SEMINARS: SDCMS member physicians and their Healthcare Consulting Group at (714) 544-5488 or visit office staff attend free of charge all SDCMS seminars (inwww.healthcareconsultant.org. cluding Office Managers Forums), covering legal issues, COLLECTIONS SERVICES: Receive a 10% discount on HIPAA, risk management issues, how to begin your practice, monthly charges with TSC Accounts Receivable Solutions. contract negotiations, getting paid, billing, and much more. Contact SDCMS. Call Catherine Sherman at (888) 687-4240, ext. 14.

FULL-TIME SDCMS PHYSICIAN ADVOCATE: Have a question? Don’t know where to begin? Contact your full-time, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at MGonzalez@SDCMS.org.

FULL-TIME SDCMS OFFICE MANAGER ADVOCATE: Let CORPORATE LEGAL SERVICES: Receive a free consulta- HIPAA COMPLIANCE: Receive a discount on a complete, your office manager and staff know that they have a fulldo-it-yourself HIPAA privacy and security compliance toolkit tion and discounts on corporate legal services. Call Ladd time office manager advocate on staff at SDCMS ready to (CD ROM). Call David Ginsberg at PrivaPlan at (877) 218-7707. Young Attorneys at Law at (619) 564-6696. help them with any questions they may have, free of CALIFORNIA EMERGENCY DRIVING EMBLEM: Receive charge. Contact Lauren Woods at (858) 300-2782 or at BILLING SOLUTIONS: Receive a 50% discount on your first California physician emergency driving emblem LWoods@SDCMS.org. startup fees and a $33 per physician per month services free of charge, and any additional emblems at the discredit. Contact Ron Anderson (CHMB Solutions) at (760) 520 SDCMS NEWS ALERTS: Stay informed of the news that counted price of $10 each. Contact SDCMS. 1340 or at randerson@chmbsolutions.com. affects your bottom line and your patients’ health with EPOCRATES CLINICAL REFERENCE GUIDES: Receive a faxed and emailed alerts sent by SDCMS to you, free of PROFESSIONAL LIABILITY INSURANCE: Most SDCMS 30% discount off of a one-year subscription and a 35% charge … and free of advertising! Contact SDCMS. members who use The Doctors Company for their profesdiscount off of a two-year subscription to Epocrates’ clinsional liability insurance receive a 5% discount on their ical reference guides. Students and residents receive a 50% SDCMS AND CMA WEBSITES: Access, free of charge, the professional liability insurance. Contact SDCMS. discount. Contact Epocrates at (800) 230-2150 or visit “Member Physicians” section of SDCMS’ website and the members-only section of CMA’s website to find valuable re SAN DIEGO COUNTY PHYSICIAN MAILING LISTS: Receive www.cmanet.org. one free physician mailing list annually and a discount on CMA ON-CALL DOCUMENTS: You can access, free of sources, such as a list of San Diego County physician NPIs, all additional mailing lists requested in the same year. Con- charge, thousands of pages of medical-legal, regulatory, and updated weekly. Contact SDCMS. tact SDCMS. reimbursement information, through CMA’s online library. ENGAGEMENT IN HEALTHCARE ISSUES: Be a part of the SDCMS MEMBERSHIP CERTIFICATE: Receive a free Contact CMA at (415) 882-5144, at legalinfo@cmanet.org, solution! Become involved in any of a broad spectrum of or visit www.cmanet.org. opportunities both SDCMS and CMA afford their member SDCMS membership certificate. Contact SDCMS. physicians, including joining an SDCMS or CMA committee AUTO INSURANCE: Along with your spouse, receive dis- CMA’S WEEKLY NEWSLETTER, “ALERT”: Delivered di- or becoming a physician leader. Contact SDCMS. rectly to you, free of charge, via email or fax. Contact counts of 4.5% to 14% on all lines of coverage from the AuKatherine Gallia at CMA at (916) 551-2074 or at tomobile Club of Southern California. Contact SDCMS. kgallia@cmanet.org. TAMPER-RESISTANT PRESCRIPTION PADS: Receive dis CONTRACT ANALYSIS: Receive free access to CMA’s counts on tamper-resistant prescription forms. Contact Model Managed Care Contract and objective written analySDCMS. ses of major health plan contracts. As well, receive from INVESTMENTS: Invest with Dunham & Associates and CMA-contracted attorneys a 15% discount on other con(858) 565-8888 • SDCMS@SDCMS.org discount your SDCMS dues by $150. Call Jeff Dunham (Dun- tract analysis services. Call CMA at (415) 882-3361 or visit www.cmanet.org. ham & Associates) at (619) 308-9700.

CONTACT SDCMS TODAY

Classifieds DONATED ITEMS FREE CPAP MACHINE: This is an opportunity to obtain a used CPAP machine in excellent condition for a deserving patient or institution. Call Irv Sherman at (858) 487-6370. [548]

OFFICE SPACE

LEASING, RENEWALS AND SALES: Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in San Diego County. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase agreement to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at (858) 677-5329; e-mail chris.ross@colliers.com. 3998 VISTA WAY, SUITE 100 IN OCEANSIDE: Two medical office spaces (approximately 2,312ft2 and 3,999ft2 contiguous) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and ground floor access. Lease price: $2.75/ft2+NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [556] MEDICAL/DENTAL SPACE FOR LEASE: Excellent opportunity for a medical/dental office with the best exposure in the largest home development in San Diego County. Great location: 5,000–6,000ft2 of divisible space! There are 13 dental specialty offices within the building complex. The building is exposed to 44,000+ vehicles a day and 5,800 patients per month. Excellent exposure will increase your clientele! Call Dr. Underwood at (619) 948-8932. [550] BEAUTIFUL OFFICE SUBLEASE IN DEL MAR: New office space available to share (sublease): 1,100ft2. Includes your own one- or two-treatment rooms, shared waiting room, staff lounge, short-/long-term lease, no utilities, rent negotiable (depends on space and days needed in office). (858) 342-3104 [426] OFFICE TO SHARE: Office available in desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior designer renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom (including shower), and kitchen. Contact us at San Diego Vein Institute at (760) 944-9263. [546] COSMETIC OFFICE AVAILABLE TO SHARE: East County location with accredited operating room. Ideal for facial or general plastic surgeon for satellite office. Central location with ample parking. For more information, please contact (619) 701-4786. [542]

psychiatrist, podiatrist, etc. One mile from new SR125 exit. Call (619) 216-0400 or email drsable@eastlakeeye.com. [538] OFFICE SPACE FOR SUBLEASE: Office available part time for Scripps doctor in desirable Scripps/Ximed building in La Jolla. Share elegant office; available full day Mondays and Friday afternoons. Includes consultation office, two exam rooms, front desk, common waiting area, staff bathroom, and kitchen. Use of operating suite or use on other days negotiable. Contact Cindi at (858) 452-6226. [535] BEAUTIFUL NEW MEDICAL OFFICE CONDOS: Own your medical office space for effectively less than the cost to rent. Build wealth and save money. 1,200ft2 suites to 14,000ft2 suites available in the new North County Regional Medical Center next to the intersection of Rancho Santa Fe Road and San Elijo Road Carlsbad/San Marcos border. Expected occupancy is summer of 2008. Call American Real Estate Development at (858) 550-0670 for more information. [534] ACROSS FROM SHARP AND CHILDREN’S HOSPITAL: Beautifully furnished 2,000ft2 office; fully equipped; five exam rooms. Share with part-time physician. Please call (619) 823-8111 or (858) 279-8111. [385] SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MIDWAY): Share fully furnished, six-exam-room/twooffice suite with internist. Ample free parking, great location. Contact Elaine Watkins at (858) 945-3813 or at ejwatkins@gmail.com. [527] MEDICAL SPACE FOR LEASE: 2,350–11,761ft2 completed shell building on Highway 86 in Imperial County for $2.05ft2/month. Please contact Dr. Maghsoudy at (760) 730-3536 or at afsaneh_maghsoudy@hotmail.com. [525] PREMIUM HILLCREST OFFICE SPACE: 800ft2 office space available immediately. Includes 200ft2 waiting room/ balcony; great location next to Mercy Hospital. Competitive pricing: opportunity to share office staff and resources. hillcresteyecare@yahoo.com. [524] OFFICE SPACE TO SHARE (SOUTH COUNTY): Chula Vistaarea family practice office to sublease at 340 4th Ave., Suite 10, just north of Scripps Mercy Chula Vista Hospital. Office includes three exam rooms and one treatment room, and is 1,700ft2. Supporting staff available. Contact Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521] SUBLEASE BEAUTIFUL, NEW MEDICAL OFFICE IN SAN MARCOS: Premium, class-A medical office space in San Diego County’s fastest growing city! All or part of an approximately 1,850ft2 newly constructed suite in San Marcos’ city hall building. Spacious reception area, large procedure room with hardwood floors, four exam rooms, two restrooms, doctor’s office with large window, and reserved parking. Easy access to I-78. Ample patient parking. Contact Kristina at (760) 942-9028 or at Kristinasm@yahoo.com for more information. [520]

OFFICE BUILDING FOR SALE: Kearny Mesa medical suites for sale or lease. Address: 8910-12 Clairemont Mesa Blvd. (off Highway 163). Ground and/or second floor: 12,312ft2. X-ray and physical therapy on ground floor. Price: $4,300,000 or $1.80 NNN. 6.5/1,000 parking. Call Shauna at CB Richard Ellis at (858) 546-2606. [540]

MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscale medical spa in Eastlake available to sublet a portion of the facility to a specialist. Ideal for plastic surgeon or aesthetic physician performing minimally invasive procedures. Also open to acupuncturist or wellness/anti-aging physician, which complements the spa and noninvasive aesthetic services currently being offered. Call (619) 228-4483 for more information. [519]

EASTLAKE: Prime location in new medical office building: 1,000ft2 office (shell condition). Tenant build-out credited in reduced rent. Basic office infrastructure already provided. Ideal for neurologist,

MEDICAL OFFICE AVAILABLE TO SHARE: Primary care office available to share. Store-front building with great visibility and recently updated interior. Current physician has been in practice for 10 years and

wants to cut down on hours. Lots of opportunities for a starting physician or a specialist. Office staff available to share if needed. Call (619) 575-4442 or fax letter of interest to (619) 575-1297. [518] OFFICE SPACE AVAILABLE: Office space in a desirable location directly across the street from Scripps Mercy Hospital. The office is currently occupied by a well-established internal medicine practice. Inquiries: call Connie at (619) 718-9440 or email to sdmg@covad.net. [515] OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501] AVAILABLE OFFICE SPACE: For an updated list of available offices, please visit www.sandiegohealthcareproperties.com. [495] MEDICAL OFFICE SPACE FOR LEASE (ENCINITAS): Share suite with three established physicians. On second floor with ocean view and convenient location. Features include: ample free parking, private entrance, roomy front desk area, private bathroom, and a spacious waiting room. In a multi-specialty medical building located minutes from Scripps Encinitas. Perfect for outpatient consultation. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, or Deeann Wong, MD, at (760) 753-7341 or at WendyKMD@AOL.com. [487] MEDICAL OFFICE SPACE: Two medical suites (approximately 2,500ft2 and 1,300ft2) available for lease. Building located about one mile from Tri-City Hospital; easy access from Freeway 78. For further details, please contact Aruna Garg, MD, at (760) 724-8562, Wendy Shumate, MD, at (760) 9402268, or call (760) 630-4715. [478] MEDICAL OFFICE SPACE AVAILABLE: Medical office space located in convenient Hillcrest location available. The space is approximately 4,500ft2 with several advantages for a group of one to four surgical specialists. There is ample parking, full outpatient surgical center on first floor of the building, and a therapy area on the second floor. Ample medical records storage space and phone and computer wiring already installed. For more information, please contact (619) 299-0007. [462] OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one parttime physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 432-6644 or at EIM2006@sbcglobal.net. [459] SPACE FOR LEASE (CORONADO): Brand new building in Coronado. Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435]

MEDICAL OFFICES FOR SALE FROM 1,500 SF: OWN FOR LESS THAN LEASING! 10—building medical campus. Suites from 1,500 -6,300 sq. ft. Strategically located between TriCity Medical Center & Scripps Encinitas. Purchase your office. Prices starting about $650,000. Outstanding signage available on Melrose Dr. and Sycamore Ave. For information call: Jon Walters, Colliers International at (760) 438-8950; John Hoffmann, Cushman Wakefield at (760) 929-2000. www.premiercrossing.com

TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at SDCMS at KLaCruz@SDCMS.org. SDCMS members place classified ads free of charge (excepting services-offered ads); all others pay $100 for the first 75 words and $0.50 per word thereafter. Ads will also appear on SDCMS’ website at www.SDCMS.org.

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Classifieds MEDICAL OFFICE SPACE FOR LEASE: La Jolla medical office in convenient location for solo spine surgeon, psychiatrist, or pain management specialist. Contact Jo Turner at (858) 587-0773, at (619) 7334068, or at jturner@spondylos.com. [416] UTC: Full-time windowed office and part-time inside office in 8th-floor suite with established psychologists and psychiatrist in class-A office building available. Features include private entrance, staff room/kitchen facilities, professional collegiality and informal consultation, private restroom, spacious penthouse, exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Available now! Contact Christine Saroian, MD, at (619) 682-6912, or Jody Saltzman, PhD, Tom Wegman, PhD, or Manny Tobias, PhD at (858) 455-5252. [404] NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, accredited surgery office available, 3,000ft2, includes exam room, dexa scanner, and physical therapy. Ideal for a wide range of healthcare practitioners. Call John at (619) 549-8870 for more details. [398] LARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2, adjacent to Scripps Hospital, includes large reception and front office, audiology lab, private office space as well as three large area rooms, many built-in storage cabinets, and staff lounge. Previous tenant was Children’s Hospital. Contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [389] CHULA VISTA: Several suites available now at Bay Medical Plaza. We are conveniently located near Scripps Hospital, major freeways, and many restaurants and retailers. There’s an onsite pharmacy, a good parking ratio, and building is secure. This is a great opportunity to expand or relocate your medical practice in Chula Vista. For more information, contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [387] BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE: Located in Hillcrest/Uptown San Diego. Physician with large suite seeking physician/healthcare professional or other business professional to share offices and/or exam rooms and receptionist. Parking spaces available for rent (off street, covered). Call (858) 354-9833 for further information. [346] PART-TIME OFFICE SPACE: Available for sublease in 502 S. Euclid medical building, across from Paradise Valley Hospital emergency room, in National City. Nice office with four exam rooms ideal for sub specialist. Supporting staff available. Contact Iman Mikhail, MD, at (619) 470-2300. [328]

PHYSICIAN POSITIONS AVAILABLE P MEDICAL DIRECTOR, PART TIME: Interested in clinical research? Accelovance, Inc., conducts clinical research for pharmaceutical and biotech companies with its primary focus on vaccine and general health conditions. Accelovance is seeking a medical physician as part-time medical director for our research clinic located at 5920 Friars Road in San Diego. The medical director will interface with patients, conducting physical exams and providing general research program oversight. Prior clinical research experience a plus. Submit cover letter and CV to: Accelovance, Inc., 2275 Research Blvd., Ste. 700, Rockville, MD 20850; email: careers@accelovance.com; fax: (240) 238-4901. [551] RARE INTERNAL MEDICINE OPPORTUNITY: Alvarado Medical Group, consisting of five highly respected internists, is seeking a BC/BE general internist to take over the mature, fully scheduled, PPO and feefor-service, private medical practice of a departing partner. The practice involves office and hospital care, one-in-six easy weekend call schedule, no

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HMOs/MediCal, and multiple benefits. The group has an in-house, fully certified complex laboratory, cardio and vascular echos, stress echo capability, and a bone densitometer. Partnership expected with one year. Please contact Charlynn Case, business manager, at (619) 229-5055. [549]

time BC/BE neurologist, pulmonologist, and occupational therapist. Flexible hours, excellent pay with possible profit sharing. Please send your resume either by fax at (619) 393-0830 or email at harmonymedicalgroup@yahoo.com. No phone calls. [523]

FAMILY PRACTICE PHYSICIAN: Immediate opening in community clinic located in the Linda Vista area. 28–32 hours per week. Great hours: 8:30 a.m. – 5:30 p.m. No call. Email awalton@mcccsd.com. [544]

VOLUNTEER FP/IM PHYSICIANS NEEDED: Camp Pendleton Family Practice Residency is looking for a few enthusiastic volunteer family practice or internal medicine physicians interested in teaching to help preceptor residents and medical students in our outpatient family practice clinic. Please contact CAPT John Holman at (760) 725-1398. [511]

OB/GYN NEEDED: Full-time OB/GYN is needed in a busy private practice. Every four- to five-night call. Beautiful San Diego lifestyle. State-of-the-art office practice and excellent hospital with Level III nursery. Please fax CV to (858) 277-9370, attn: Katy Scheneberg, office manager; call (858) 277-9378; or email westcoastobgyn@yahoo.com for more information. [541] PRIMARY CARE PHYSICIAN WANTED: Caring and compassionate part-time/full-time physician for a traditional internal medicine office in La Mesa/El Cajon. Basic computer skills are necessary. One or two weekend calls per month is expected. Call Dr. Prabaker at (619) 698-0606 or email vprabaker@yahoo.com. [536] PSYCHIATRIST NEEDED: San Diego Family Services is hiring newly licensed or licensed psychiatrists for its Kearny Mesa location. We are looking for a skilled provider to accommodate all SDFS clients. Great supportive team atmosphere and flexible part-time hours. Plenty of growth opportunities. Please send resume to hr@sdfamilyservices.com, or, for more information, please visit our website at www.sdfamilyservices.com. [532] URGENT CARE (EAST COUNTY): Busy practice established in 1982 seeks a full-time or part-time physician. Fax CV to (619) 442-2245. [479] NAVAL HOSPITAL CIVILIAN POSITION: Naval Hospital Camp Pendleton has an immediate opening for one full-time civilian faculty for its 12-12-12 family practice residency program. This opportunity includes precepting residents, inpatient/outpatient care (including ICU and maternity care), and educational responsibilities. Must be residency trained and board certified. Previous teaching experience preferred. A competitive compensation package is available as a GS-15 with bonuses. If you are interested, check our website at www.cpen.med.navy.mil. Send your CV to or contact Jim La Joie, business manager, Department of Family Medicine, Naval Hospital Camp Pendleton, CA 92055, by email to jim.lajoie@med.navy.mil, by fax to (760) 725-1101, or call (760) 725-1398. [530] FAMILY MEDICINE OPPORTUNITY: Seeking a BC physician in family medicine, full-time position, call responsibilities include telephone triage, minimal inpatient care, no OB, competitive salary and excellent benefits package. Please submit CV to: Vivian Hudson, Physician Resource Manager, Sharp Mission Park Medical Group, 2201 Mission Ave., Oceanside, CA 92054, call (760) 901-5259, fax (760) 901-5242, or email Vivian.hudson@sharp.com. [529] FAMILY PRACTICE POSITION: Join a growing family practice office in the Carmel Valley area of San Diego. The practice is professional, caring, delivers outstanding primary care, and is PPO and fee-for-service ONLY with NO HMO care! Generous starting salary with production bonus, malpractice, pension plan, health benefits, and vacation. Easy call every 3–4 weeks, with no OB, and hospital care is optional but not required. Send resume to DelMarFamilyPractice@earthlink.net, or fax to (858) 793-2650. Call Dr. Schlitt at (858) 793-2727. [526] BC/BE NEUROLOGIST, PULMONOLOGIST, OCCUPATIONAL THERAPIST: Harmony Multi Specialty Group has the following immediately available positions: part-

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PHYSICIAN NEEDED: Board-certified/board-eligible, full-time family practice physician needed for a busy North Inland County physician-owned-and-directed group. One hundred percent outpatient based, guaranteed first-year salary, excellent benefit package. Email CV to jshaw@pennelm.com or fax to (760) 745-0451, attn: Judy. [510] POSITION AVAILABLE: Per diem openings for urgent care center at Cassidy Medical Group located in Vista. Hours are 5pm–9pm, M–F, 9am–5pm, Sat., and 10am–4pm, Sun. Competitive salary. Malpractice insurance provided. Please send CV to judy@cassidymg.com or fax to (760) 477-7881. For additional information on our group, please visit www.cassidymg.com. [508] FAMILY PRACTITIONER: Cassidy Medical Group in Vista is searching for a family practitioner for their department. The group is comprised of 16 primary care physicians, including family practice, internal medicine, pediatrics, and obstetrics/gynecology. Outpatient hours only as the group uses hospitalists for all inpatient care. Competitive salary and benefits. For more information on the group, visit www.cassidymg.com. If interested, please send CV to judy@cassidymg.com or fax to (760) 477-7881. [507] NORTH COUNTY MEDICAL GROUP: Graybill Medical Group, a 35-physician medical group with offices in Escondido, San Marcos, and Fallbrook, is actively recruiting physicians in family medicine, internal medicine, and several specialties including ENT and OB, as well as other surgical specialties. The practice openings involve both office practice and inpatient hospital care. Hospitalist-only positions are also available. Our group is well established with an integrated EMR. Physicians interested in discussing positions available should contact Floyd Farley, CEO, at ffarley@graybill.org or via fax at (760) 737-7324. [498] POSITION AVAILABLE: Four-partner internal medicine practice in Chula Vista seeking BS/BE internist to replace one or possibly two retiring partners. Quality group, well-recognized for excellence throughout the South Bay and San Diego. Partnership status or initial employee relationship is available. Call (619) 421-4000 or (619) 787-6948. [483] PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60–$100+/hour), flexible hours, choose your own days (full or part time). No weekends, no call, transportation and personal assistant provided. Contact Chris Hunt, MD, at (858) 2791212. [458] TRADITIONAL INTERNAL MEDICINE OPPORTUNITY: Seeking full-time, CA-licensed, BC/BE internist to join our three-clinician private practice group in Escondido. Inpatient/outpatient care. Competitive salary, malpractice, benefits, and partnership potential. Please send CV to EIM2006@sbcglobal.net. [456] FAMILY PRACTICE (CHULA VISTA): Seeking a family practice physician to cover solo physician practice one week every two months. Contact Ann at (619) 4221324 or at doctorwp@pacbell.net. [451]

Classifieds FAMILY PRACTICE DOCTORS NEEDED: Full time and part time; days, nights, and weekends available. Fax CV to La Costa Urgent Care at (760) 603-7719. [449]

NONPHYSICIAN POSIT IONS AVAILABLE N MEDICAL ASSISTANT/BACK OFFICE: Busy OB/GYN practice needs experienced medical assistant. Competitive wage and benefits. Spanish a plus but not required. Fax resume to (619) 298-4250. [547] NURSE PRACTITIONER: Immediate opening in community clinic located in the Linda Vista area. 28–32 hours per week. Great hours: 8:30 a.m. – 5:30 p.m. No call. Email awalton@mcccsd.com. [545] MEDICAL RECEPTIONIST: New practice opening in Solano Beach looking for an experienced, bright, and well-organized person with knowledge in insurance billing (or at least willing to learn). We offer excellent salary and room for career advancement. Please fax your resume to (858) 653-0105, attn: Van Cheng, MD, or email us at vacheng@ucsd.edu. [537] PT ECHO TECH NEEDED: Flexible hours, ideal for parent with child responsibilities. Minimum two years experience, required RDMS, and experience in stress echo. Contact Marybeth at (760) 940-1982. [528] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER WANTED: Part-time/full-time physician assistant or nurse practitioner wanted for internal medicine practice located adjacent to Scripps Mercy Hospital in a well-established office. Experience required. Competitive pay and benefits. Fax resume to Connie at (619) 718-9440 or email to sdmg@covad.net. [514] PRACTICE MANAGER: Retiring practice manager seeks individual with five years of full-charge experience managing a medical office of 15–25 employees. Competencies: financial oversight, HR management, monitoring general practice systems, and reporting within a computerized medical environment. Well-respected, growth-oriented clinical and surgical practice. Good benefits package. Fax resume with salary experience to (858) 552-2182. [512] MEDICAL OFFICE MANAGER: Busy six-physician internal medicine group looking for experienced office manager. We are located in the College area, adjacent to Alvarado Hospital. Communication and organizational skills are essential and experience with accounts payable, accounts receivable, electronic billing, collections, and payroll are needed. A working knowledge of medical manager, QuickBooks, and general computer experience is preferred. Excellent compensation package. Fax resume to (619) 2870833. [509] PHYSICIAN ASSISTANT WANTED: To assist busy cardiologist in Chula Vista. Must be fluent in Spanish and English; experienced; dedicated; and honest individual; full time or part time. Office hours are from 9 a.m. to 6 p.m., Monday thru Friday. Please fax resume to (619) 656-5250. [504] NURSE PRACTITIONER: Fast growing interventional pain practitioner seeking a part-time nurse practitioner. This position will provide medical care under the supervision of a board-certified physician providing assistance and support to the physician in patient care. Experience preferred; competitive compensation available. Fax resume to Jenny at (619) 3982988 or by email at jenny@integratedpain.com. [503] MEDICAL RECEPTIONIST WITH MANAGEMENT SKILLS: Position available, full or part time, in a family practice office located in Scripps Ranch. Fax resume to (858) 271-5327, attn: Dr. Wasserman. [494] NURSE PRACTITIONER: Four-physician internal medicine practice in Chula Vista seeks part-time/full-

time nurse practitioner. Work with a quality group; reasonable hours. Previous experience is preferable; salary negotiable depending on experience. Call (619) 421-4470 or (619) 421-4000. [488] PHYSICIAN ASSISTANT: Fast-growing interventional pain practice looking for a full-time physician assistant. This position will provide medical care under the supervision of a board-certified physician, providing assistance and support to the physician in assessing, planning, and providing patient care. Experience desired, but we will train the right person. Competitive compensation and benefits package are available. Fax resume and cover letter to Jenny Reyes, office manager, at (619) 398-2987 or by email at jenny@integratedpain.com. [482] NURSE PRACTITIONER WANTED: Part-time/full-time nurse practitioner wanted for internal medicine practice in Escondido. Previous experience is desirable. Call (760) 432-6644. [455]

PHYSICIAN POSITIONS WANTED P CARDIOLOGIST SEEKING EMPLOYMENT: Noninvasive cardiologist wants to join IM or cardiology practice (office based). Board eligible. Experienced in echo, stress test, nuclear, and CT. Call (858) 922-8354 (cell), (760) 633-3044, or email cvshah@aol.com. [558] INFECTIOUS DISEASE LOCUM TENENS: Board-certified ID physician available for weekends, vacations, and sick leave. Please call (619) 869-1296. [552] GERMAN DOCTOR SEEKS EXTERNSHIP: Experienced German internist and family physician looking for fourweek externship in a family doctor’s or internist’s practice in preparation to take USMLE practical exam in April. I will be arriving in San Diego March 12. Email fmeierkord@yahoo.de. [543] PEDIATRIC LOCUM TENENS: Board-certified pediatrician is available to do pediatric locum tenens work. Call (619) 425-3951. [421]

PRACTICES FOR SALE P SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small investment for 51 percent ownership. Looking for new medical director. Contact Leonard Schulkind at (619) 807-5485. [539] DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast-growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

MEDICAL EQU IPMENT M MEDICAL EQUIPMENT FOR SALE: From Advanced Dermatology and Cosmetic Surgery: 1) Surgical chair/table. Ritter electric procedure table with controls on the table and also as foot pedals; in excellent condition. Has elevation, tilt, back, and foot controls. Patient can be put in supine and Trendelenberg positions. Price normally $2,000, will sell for $900. 2) Flat exam table. Back can be raised and there is a foot rest. Table has drawers and an electric outlet: $200. Call Mike at (760) 436-8700 or at (619) 261-8063. [553] ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vascular, abdominal, small parts, five transducers: $6,000. Quinton 4000 monitor with Q55 treadmill, recording paper, electrodes, crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619) 460-0083 or (619) 518-9542. [513]

furniture inventory list is available upon request. Email kwahl@san.rr.com. [506]

SERVICES OFFERE D S PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent financing available for physicians! Includes purchase of a practice, equipment, partner buyout, working capital, and real estate. Call Dan Fencyk at CBN Financial: (619) 231-1590 or dfencyk@communitybanknv.com. [522] BILLING, CONSULTING, OUTSOURCING: We are committed to maximizing your bottom line! Our billing service uses state-of-the-art technology to ensure charge capture, code validation, electronic submission and remittance, payment postings, patient statements, structured follow-up and appeals, electronic document storage and meaningful reporting. Supplemental services include online appointment scheduling, automated call reminders, scan systems, and other technological advances. Consulting services include accounts payable, auditing, business development, electronic medical record selection and implementation, credentialing, contracting (payor, physician, and staff), executive assistant, financial management, information systems, operational management, practice assessment, practice management, relocation management, and other technological advances. Contact us today for your free consult! Contact Kena Galvan (619) 326-0700 or kena.galvan@abs-sol.com. [452] RMC VINYL REPAIR PLUS: Medical equipment upholsterer. Expert in repair and replacement of medical fixture upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service! Call (619) 443-4060. [400] R REAL ESTATE

HOUSE FOR RENT: Fish/Hike/Bike Mammoth! Large rustic family home; four bedrooms plus loft (2K, 3Q, 4S beds), three baths, gourmet kitchen, three fireplaces, decks, and mountain view. Visit www.mammothevents.com for activities from Motocross, July 4 festivities, and Mammoth Festival of Wine, Music, and Food, to life and wellness conference: $400/night plus cleaning fee, fourth night free. Ask for ski season rates. (858) 7937938; email for photos mgharris@michaelgharris.net. [485] MISCELLANEOUS M REIMBURSEMENT TROUBLES: Problems with payments from United Healthcare? Call (619) 442-9896, ask for Jeff. We are a doctor’s office, not a feeseeking service. [533] 2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT: Excellent condition; 2K in recent/routine maintenance, new front eisenglass, 3.5 years remaining on full-warranty ($6,000 value), only a paltry 100 hours for two pristine 220-hp engines, GPS, generator, TV/DVD/stereo/air/heat and much more. Exact boat with less features costs $150K; $98,000 (firm) to first buyer. (858) 254-0202. [454] 2003 BMW M3 (RED, MANUAL, CONVERTIBLE): Very good condition, low miles, and new tires: $33,750. (858) 254-0202. [453]

RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICAL EQUIPMENT: Perfect for plastic surgery/oral surgery. Endoscopy, cameras, loupes, tools. Waiting room

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History of Medicine

The “Sick Train”

[ Paris to Lourdes ]

By WILLIAM P. HANEY, MD very day a train leaves Paris for the nine-hour journey to Lourdes. Most of the passengers are pilgrims of one sort or another. Many suffer from illnesses or ailments that may not be apparent to the casual observer. All are seeking some sort of spiritual renewal, and many are hoping for alleviation of a physical problem that has not responded to conventional medical therapy. Every hour on the hour, the train stops at an important historic site that is involved in some way with the Christian faith, including Orléans for Joan of Arc, Tours for St. Martin, and Poitiers for Charles Martel. The travelers are part of an annual migration numbering in the millions, all bound for the tiny town of Lourdes, population 15,000, nestled deep in the rugged Pyrénées Mountains of southern France. One hundred years ago the trip was not so easy. The train left Paris at 5:30 a.m. and arrived at 3:40 a.m. the following day, some 22 hours later. “Make way for the sick” was a cry heard at all the stops. Each car was divided into several compartments with wooden benches lining the sides. Stretchers could be put down for the gravely ill. Nurses and doctors were in attendance, but, in spite of care, death on the train was not uncommon. Pilgrims brought on board their own food and chamber pots so that in time each compartment became its own little “fetid fellowship.” Wealthy and poor

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rode side-by-side, shedding inhibitions about contamination, waste disposal, etc. As class distinctions disappeared, a peculiar type of devotion developed out of helping and caring for others. The pilgrims were on their way to pray at the site of the miraculous visions experienced by the little peasant girl, now saint, Bernadette Soubirous. During a two-week period in 1858, Bernadette saw a vision of the Virgin Mary eighteen times in a niche of a cave along the Gave du Pau River near her home. A succession of endorsements, witnesses, and testimonials followed, leading to the site’s becoming a pilgrimage destination associated with miraculous healing. Most of us are skeptical, some are interested, and some a bit enchanted. Indeed, among us there is no lack of scoffers. In 1903, one such skeptical physician was invited to ride the train. Alexis Carrel, a 29-year-old faculty member at the medical school in Lyons, decided to accept the invitation and “see for himself.” Dr. Carrel was a brilliant young physician, a talented researcher, and a doubting observer. He grabbed his notebook and boarded the “Sick Train.” As the train hurtled south, Dr. Carrel made rounds asking questions and taking notes. One traveler, 22-year-old Marie Bailly, lay on a makeshift mattress stretched across two benches. She suffered from tuberculous peritonitis. Flushed, feverish, emaciated, spitting

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blood, and ashen in color, she lay at death’s door. Dr. Carrel was so alarmed he demanded to know how anyone so ill could be put aboard a train. The story of Marie’s recovery at Lourdes was recorded in detail in his little notebook. She died 35 years later at the age of 57. Dr. Carrel presented his findings to the French medical community. The reaction was so hostile that he was forced to leave the country, planning to “give up medicine and take a farm in Canada.” Fortunately, his research results had preceded him. The Rockefeller Institute in New York City offered him a position and a laboratory. In 1912, Dr. Carrel was awarded the Nobel Prize in Medicine for his development of methods for suturing small blood vessels. Some of his techniques are used to this day. But he never forgot his night with little Marie on the “Sick Train.” Her recovery before his very eyes so astonished him that he wrote, “There are certain links, as yet unknown, between psychological and organic processes. There is some objective value in spiritual activity.” In addition, he felt that “scientists should not deny what they themselves have not seen!” Such statements seem reasonable enough, yet…

ABOUT THE AUTHOR: Dr. Haney, a retired ophthalmologist, has held a longtime interest in the history of medicine, often contributing articles to San Diego Physician.

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