May 2008

THE RISE OF THE SMART PATIENT At the Crossroads of Evidence-based Medicine and Consumer-directed Healthcare “ 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 ”

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Contents

VOL. 95 | NO. 5

THE RISE OF THE SMART PATIENT PAGE 24

VISIT SANDIEGOPHYSICIAN.ORG

[ F E A T U R E S ] EVIDENCE-BASED MEDICINE:

24 30

The Rise of the Smart Patient: At the Crossroads of Evidence-based Medicine and Consumer-directed Healthcare By DANIEL FRIEDLAND, MD “Evidence-based”: A Term in Search of a Definition

By BRIAN S. ALPER, MD, MSPH

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

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CONTRIBUTORS: This Issue’s Contributing Writers EDITOR’S COLUMN: Times Are Tough: You’ve Got a Friend SEMINARS: SDCMS’ 2008 Seminars and Events

COMMUNITY HEALTHCARE CALENDAR BRIEFLY NOTED: SDCMS Reference Guide to Health Plan Obligations, and More…

WORKERS’ COMPENSATION 101: Overcoming Perceived Misunderstandings

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23 34 35 36 39 44

TAKING IT OUT OF THE OFFICE: Recreation Prescriptions for the Underserved THE COUNCIL OF COMMUNITY CLINICS FAMILY HEALTH CENTERS OF SAN DIEGO

NEW STROKE CARE SYSTEM: Coming Soon…

PHYSICIAN MARKETPLACE: Classifieds CHRONIC CARE MADE EASIER: Taking Action on Many Fronts

Contributors BRIAN S. ALPER, MD, MSPH Dr. Alper is the founder and manager of DynaMed, a point-of-care reference resource designed to provide doctors and medical researchers with the best available evidence to support clinical decision-making.

FRAN BUTLER-COHEN

Ms. Butler-Cohen is CEO of Family Health Centers of San Diego.

DANIEL FRIEDLAND, MD Dr. Friedland is the author of Evidence-based Medicine: A Framework for Clinical Practice and founder of SuperSmartHealth.com, which incorporates the principles of EBM into a vision of optimal health and well-being.

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.

EVALYN GREB

Ms. Greb is a retired licensed clinical social worker.

BRUCE E. HAYNES, MD

Dr. Haynes, an emergency medicine physician, is the medical director for the Emergency Medical Services Branch in the Division of Public Health Services of the County of San Diego Health and Human Services Agency, a position he has held since February 2006.

STEPHEN R. O’KANE

Mr. O’Kane is CEO of the Council of Community Clinics.

LAWRENCE S. POHL, MD, MPH

Dr. Pohl received his medical degree from the University of Buffalo and his master’s degree in public health from the Medical College of Wisconsin. He is board certified in both family and occupational medicine.

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.

CHRIS SEARLES, MD

Dr. Searles is a family physician and a psychiatrist who works primarily with the underserved and uninsured of San Diego County. He is on the clinical faculty at UCSD’s Department of Family and Preventive Medicine and is the co-director of the UCSD Combined Family Medicine and Psychiatry Residency Program.

WILMA WOOTEN, MD

Dr. Wooten is San Diego County’s public health officer.

Send your letters to the editor to Editor@SDCMS.org

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 ADVERTISING ART DIRECTOR COPY EDITOR

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

Dari Pebdani Jane Hughes Geneen Montgomery 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

Times Are Tough do not need to say much about how tough being in medical practice is these days. Medicare cuts, Medi-Cal cuts, difficult insurance reimbursement, new reporting requirements that would challenge an MBA, and a looming recession with more people having less money to spend on healthcare. And the overhead costs of practice continue to rise relentlessly. How do physicians survive tough times? In situations like this, I am reminded of a line from The Beatles: “I get by with a little help from my friends.”

When it comes to helping physicians with medical practice issues, friends can be hard to come by. This is where the San Diego County Medical Society (SDCMS) comes in. SDCMS is here for you, especially in tough times. Mem-

bership definitely has its benefits. Here are some real examples of SDCMS helping members. These come from Marisol Gonzalez, the full-time helper of SDCMS member practices (her title is physician advocate): A pediatrician is starting up a new practice. She has questions about many things: the legalities of rest periods for employees; information about sole proprietorships; incorporation; and her business license. Using CMA’s ONCALL documents as a resource, Marisol is able to guide her through the maze of starting and running an independent practice. She also connects her with endorsed business partners at a discount, such as CHMB billing services.

An internist is having reimbursement problems with health plans. He needs an advocate to understand the billing

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policies and critical information to negotiate timely payment. Again, the CMA ON-CALL documents come to the rescue, and having a local resource like Marisol saves countless hours and provides the reassurance of not being alone working with large payers.

The office manager of a family practice group calls or emails about three times a week with questions about medical practice issues. These range from how physicians should report domestic violence to what physicians can charge when they receive a subpoena or are giving testimony in a deposition. Marisol is able to research these subjects and provide up-to-date answers to her questions.

SDCMS staff helps small and large practices alike. Recently, one of San Diego County’s largest medical groups faced a very expensive litigation action

by the state. SDCMS teamed up with CMA to help the group right from the beginning. SDCMS and CMA were able to provide the attorneys defending the group with critical documents and guidance that helped result in a successful defense. And remember, with professional liability insurance, The Doctors Company gives a 5 percent discount to physicians who are SDCMS members.

Unfortunately, some physicians or office staff call SDCMS for help and are not members. They may decide to join only when they are in a crisis.

ADVERTISE HERE 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…

A P R O F E S S I O N A L L A W C O R P O R AT I O N

When it comes to helping physicians with medical practice issues, friends can be hard to come by.

Since membership dues are used to employ Marisol and the other great SDCMS staff, only members can be helped in this way. Save yourself the embarrassment of waiting to join SDCMS until you are in crisis. You don’t buy fire insurance when the house is burning.

If you are not a member, join now and take advantage of the many benefits of a staff ready and waiting to help you. As Carole King and James Taylor sang, “Ain’t it good to know that you’ve got a friend?”

ABO UT THE 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.

Members Of The Firm: David Rosenberg, J.D. Tomas A. Shpall, J.D. Annette Farnaes, J.D. Steven H. Zeigen, J.D. Corey Marco, M.D, J.D. Jason L. Nienberg, J.D.

Wells Fargo Bank Plaza 401 “B” Street, Suite 2209 San Diego, California 92101 Telephone: (619) 232-1826 Facsimile: (619) 232- 1859 Email: RSALAW@yahoo.com

• 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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Seminars 2008 San Diego County Medical Society Seminars and Events AUGUST

M AY “WHAT IS/ISN’T EHR/EMR?”

May 14, 4:00 p.m. - 8:00 p.m.; May 15, 9:00 a.m. - 1:00 p.m.

LEGAL SEMINAR “Contract Law” May 21, 6:30 p.m.– 8:30 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.

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!

LEGAL SEMINAR — OFFICE MANAGERS FORUM

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

CMA CEO JOE DUNN: DISCUSSIONS WITH PHYSICIANS

May 27 and 28, all day, both days at several different San Diego County hospitals

JUNE PRACTICE MANAGEMENT SEMINAR “Financial Con-

NOVEMBER

SDCMS NEW MEMBER SOCIAL

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

RISK MANAGEMENT SEMINAR

Nov. 13, 11:30 a.m. - 1:00 p.m., Nov. 14, 11:30 a.m. - 1:00 p.m.; Nov. 14, 6:30 p.m. - 8:30 p.m.

SEPTEMBER RESIDENT AND NEW PHYSICIAN SEMINAR “Preparing

YOUNG PHYSICIANS SOCIAL

to Practice: What You Need to Know BEFORE You Begin Your Practice” Nov. 22, 8:30 a.m. – 3:30 p.m.

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

OCTOBER SEXUAL HARASSMENT TRAINING

DECEMBER

Oct. 15, 6:30 p.m. - 8:30 p.m.

YOUNG PHYSICIANS SOCIAL

SEXUAL HARASSMENT TRAINING — OFFICE MANAGERS FORUM Oct. 16, 11:30

Dec. 5, 6:00 p.m. 9:00 p.m.

a.m. – 1:30 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-

tients Right: Tact, Courtesy, and Etiquette in the Medical Office” June 19, 11:30 a.m. 2:30 p.m.

Announcing Allscripts as a Preferred Vendor of the San Diego County Medical Society

Coastal Healthcare Consulting Group, Inc. Would You Like To Get Paid What You Are Worth?

Allscripts is pleased to announce that it will offer preferred pricing to SDCMS members on the award winning HealthMatics® Office Practice Management and Electronic Health Records solution.

This integrated PM and EHR solution offers state of the art technology that includes:

CONTRACTING AND NEGOTIATION SERVICES FOR PHYSICIANS AND MEDICAL GROUPS • Medical Group Contracting and Negotiation • Health plan Contracting • Revenue Enhancement • Contracts Review • Staff Training

• • • •

Reasonable Rates, Great Results!

Kim Fenton, President 714-544-5488

www.HealthcareConsultant.org • KimF@HealthcareConsultant.org

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Complete work flow management P4P, clinical and financial reporting Advanced Scheduling Comprehensive Claims management

• • • •

E-prescribing with formularies Electronic orders and results Automated Health Maintenance Online Patient Portal

For more information please contact Jamie Smolin at 619.955.6929 or at jamie.smolin@allscripts.com. Visit us online at www.allscripts.com/healthmatics.

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Calendar

ESSENTIAL TOPICS IN PEDIATRICS 2008: EXPLORING THE DEVELOPMENTAL SPECTRUM

DELIVERING SAFE AND OPTIMAL CARE THROUGH EFFECTIVE TEAMWORK AND COMMUNICATION

WHAT: Experts in the field of autism will update participants on early diagnosis and management of this disorder through several lectures and an intensive workshop (designed with the generalist in mind).

WHEN: May 15 WHERE: Catamaran Resort Hotel and Spa, San Diego COST: $250 CME: 24.5 AMA INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

WHAT: This seminar is ideal for anyone interested in better teamwork and communication in their healthcare setting. Organizations are encouraged to send groups of people who work together in high-risk service lines, such as the operating room, intensive care unit, emergency department, and labor and delivery.

WHEN: June 10–11 WHERE: La Costa Resort and Spa, Carlsbad CME: Available INFORMATION: Visit www.ihi.org (click on “Programs”).

GLUCOCORTICOIDS MOOD: CLINICAL MANIFESTATIONS, RISK FACTORS, AND MOLECULAR MECHANISMS

ALZHEIMER’S DISEASE: UPDATE ON RESEARCH, TREATMENT, AND CARE WHAT: Expert faculty will address how we handle psychiatric and behavioral issues, what medications we see on the horizon, how we can help improve the quality of life for the Alzheimer’s disease patients and caregivers, and much more.

WHEN: May 22–23 WHERE: The Westin Horton Plaza Hotel, San Diego INFORMATION: Visit http://cme.ucsd.edu/alzheimers.

FRESH START’S 2008 SURGERY WEEKENDS WHAT: Over 100 volunteers join together to provide free reconstructive surgery and related medical services to disadvantaged children with physical deformities caused by birth defects, accidents, abuse, or disease.

WHEN: June 7–8; July 26–27; Sept. 13–14; Nov. 1–2 WHERE: The Center for Surgery of Encinitas INFORMATION: Visit www.freshstart.org.

WHAT: This conference will encompass many aspects of the clinical effects of glucocorticoids in a variety of illnesses and in health. The topics addressed will be of relevance to many medical specialties in which glucocorticoid therapy is widely used.

WHEN: June 20 WHERE: San Diego Marriott Del Mar COST: $425 CME: 10.75 AMA INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

25TH ANNUAL SUPERFICIAL ANATOMY AND CUTANEOUS SURGERY WHAT: This program is designed to provide the basic information and principles of superficial head and neck anatomy and surgery for those interested in dermatological surgery.

WHEN: July 14

WHERE: San Diego Marriott Del Mar COST: $2,795 CME: 44 AMA INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

25TH ANNUAL PRIMARY CARE MEDICINE: A PRACTICAL APPROACH WHAT: The course will emphasize the practical aspects of clinical practice.

WHEN: August 1–3 WHERE: Marriott Hotel and Marina, San Diego INFORMATION: Call (858) 587-4404 or email med.edu@scrippshealth.org.

19TH ANNUAL CORONARY INTERVENTIONS WHAT: This conference will discuss the state-ofthe-art concepts and techniques of interventional cardiology.

WHEN: September 17–19 WHERE: Hilton La Jolla Torrey Pines INFORMATION: Call (858) 587-4404 or email med.edu@scrippshealth.org.

ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATION COURSE WHAT: Four-day CME and certification course in advanced wilderness life support and wilderness medicine. This course is designed to further educate medical professionals in outback safety, survival, diagnosis, and treatment.

WHEN: November 12–15 WHERE: Carlton Oaks Country Club, Santee CME: Available INFORMATION: Visit familymedresidency.ucsd.edu/awlsconference.shtml.

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

fly Noted e i r B

Reference Guide to Health Plan Obligations Free SDCMS Members-only Benefit he San Diego County Medical Society (SDCMS) is pleased to provide our members with a reference guide to health plan obligations. This guide represents another example of the benefits and advocacy that members of SDCMS-CMA receive to help them successfully practice medicine and meet the needs of their patients. It provides essential information to assist physicians when dealing with payment disputes and contract issues with health plans. Moreover, its very content exists because of successful CMA advocacy on behalf of physicians in the promotion of new laws, precedent-setting court actions, advocacy with regulatory agencies, and the classaction federal anti-racketeering (RICO) lawsuit against major health plans filed

by CMA.

T

The guide comprises several sections: A quick reference to health plan obligations. Each obligation is described and identified as a state law, court decision, or a provision of the RICO settlement, and accompanied by a listing of the recourse physicians can utilize when the obligations are not met as well as the source for further information.

SECTION 2: Contact information for SDCMS and CMA if assistance is needed in dealing with health plans as well as listings of the sources for further information cited in Section 1.

SECTION 3: Guidance for pursuing recourse against health plans through the appropriate regulatory agency if obligations are established by state law.

SECTION 4: Guidance on seeking recourse if the obligations are established pursuant to the RICO settlement terms.

SECTION 1:

SECTION 5: Model letters developed by CMA to send to health plans when they fail to meet their obligations.

SDCMS-CMA members can access this guide in the “Member Physicians” section of SDCMS’ website at www.SDCMS.org.

Please contact Marisol Gonzalez, your physician advocate at SDCMS, if you have any questions regarding the information contained in this guide or if you need any assistance in dealing with a health plan. As you use this guide, reflect on the fact that it is made possible by the collective support that physicians provide as members. And if you encounter colleagues who do not have a copy because they are not a member, you might tell them how valuable you find such membership benefits and that their support would enable SDCMS and CMA to do even more on behalf of the medical profession.

NOTE: Thank you to the Alameda-Contra Costa Medical Association (ACCMA) and the California Medical Association for compiling this amazing member benefit!

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fly Noted e i r B Welcome New and Rejoining SDCMS-CMA Members!

Nonmembers: Join Today at www.SDCMS.org New SDCMS-CMA Members NATASHA PRAKASH CHANDANANI, MD Anesthesiology San Diego • (858) 565-9666 JOEL C. DIAMANT, MD Internal Medicine La Jolla • (858) 554-7809 PHILLIP WILLIAM DICKINSON, MD Surgery La Mesa • (619) 464-4469 LAURA NORTON FAGERLUND, MD Internal Medicine and Pediatrics Coronado • (619) 435-2234

CHRISTINE CYN NIEMAN, MD Pediatric Anesthesiology San Diego • (858) 565-9666

SARA ELIZABETH STEWART, MD Anesthesiology San Diego • (858) 565-9666

PATRICIA E. PARDO, MD Anesthesiology San Diego • (858) 565-9666

DANIEL VERNON WHITE, MD Neurological Surgery Chula Vista • (619) 476-7958

SISSELA SAYEUN PARK, MD Cardiac Anesthesia San Diego • (858) 565-9666

ALICIA COLLINS BENJAMIN, MD Internal Medicine San Diego • (619) 699-1645

CARL A. POWELL, DO Surgery Cardiff • (760) 635-7507

BRUCE LEIGH BOWER, MD Internal Medicine and Diagnostic, Vascular, and Interventional Radiology San Diego • (858) 565-0950

XING-JIAN REN, MD Internal Medicine and Geriatric Medicine La Jolla • (619) 245-2350

LAURIE ANN FRAKES, MD Internal Medicine, Medical Oncology, and Hematology Encinitas • (760) 452-3340

Rejoining SDCMS-CMA Members

BRIDGETTE BOGGESS FRANEY, MD Family Medicine Poway • (858) 675-3210

CHANDRAKANT V. SHAH, MD Cardiovascular Disease Cardiff by the Sea • (760) 633-3044

CHARLES IRVING KNOLL, MD Physicial Medicine and Rehabilitation San Diego • (619) 516-3992

DEAN EDWARD SIDELINGER, MD Pediatrics San Diego • (619) 685-2539

MARK CUTLER NELSON, MD Orthopedic Surgery and Spine Surgery San Diego • (858) 571-0606

ANTHONY JAMES STANZI, MD Pediatric Anesthesiology San Diego • (858) 565-9666

CARLOS M. GARCIA, MD Pediatrics Chula Vista • (619) 271-4059 JIM RAYBURN HARLEY, MD Pediatrics and Pediatric Emergency Medicine San Diego • (858) 966-8005 STEVEN A. ORNISH, MD Psychiatry and Forensic Psychiatry San Diego • (619) 692-3222 EUGENE MICHAEL TACHUK, MD Family Medicine San Diego • (619) 222-5433

SDCMS Physicians Honored As Health Heroes!

On March 20, 2008, San Diego’s Combined Health Agencies (www.combinedhealth.org) recognized three SDCMS members at its 14th annual Health Hero Awards, where each of the 25 member agencies honors a local business, media professional/celebrity, medical/health professional or scientific researcher who has contributed to the local health industry through their community activism. The honorees, whose unique stories demonstrate what it means to go above and beyond in their respective fields, stand out in the San Diego County community by volunteering their time and talents on top of the pressures of a demanding career. The SDCMS physicians honored this year are Mitsuo Tomita, MD, M. Sandra Norton, MD, and Holly Yang, MD. Congratulations!

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ADVERTISE HERE To run display advertising in San Diego Physician, please contact Dari Pebdani for information and rates.

619-744-0528 or darip@sandiegomag.com

San Diego Physician Editor Appointed to Medical Economics Editorial Advisory Board Leslie Kane, editor of Medical Economics magazine, informed her readers in March that our own Joseph Scherger, MD, San Diego Physician editor since 2004, had been added to the Medical Economics editorial board: Joseph Scherger, MD, a family physician in San Diego, has joined our Editorial Board. Scherger, a nationally recognized healthcare IT expert, has recently focused on using technology tools and quality improvement methods to redesign the medical office. In addition to being in the forefront of information technology developments and having an impressive resume of published articles, books, and speaking engagements, Scherger has been recognized as Family Physician of the Year (AAFP, 1989); received the Thomas Johnson Award for family medicine education (1994); and served on the IOM (Institute of Medicine of the National Academies) Committee on the Quality of Health Care in America (1998-2001). We are delighted to have Scherger’s guidance in informing our coverage.

Congratulations, Dr. Scherger!

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fly Noted e i r B Robert Wailes, MD North County Director, SDCMS Board of Directors SDP: HAVE YOU ALWAYS WANTED TO BE A PHYSICIAN? DR. WAILES: Ever since high school. During my

studies require a large number of participants, and it’s just not practical to get the research done. So, while I’m a big believer in evidencebased medicine, I also know there are very severe limitations in its application.

senior year, I joined a group called Medical Explorers, which allowed me to follow a doctor around for a day. He was a neurosurgeon, and I just thought it was the coolest thing in the world. From that point on, I was pre-med.

EXPERIENCE IN YOUR PRACTICE?

SDP: WHAT IS YOUR SPECIALTY AND MODE OF PRACTICE?

DR. WAILES: The

DR. WAILES: I’m

a pain medicine specialist. I’m part of a small group called the Pacific Pain Medicine Consultants, located in North County. Our practice consists of three physicians and two physician assistants. We do a full range of services dealing with pain management. We like to think of ourselves as a multidisciplinary program that treats just about any type of pain problem.

SDP: WHAT IS YOUR OPINION ON EVIDENCE-BASED MEDICINE?

It’s a wonderful concept, but evidence-based medicine only covers a fraction of the choices we have in our day-to-day practices. It’s a shame, but it’s a reality that we don’t have good research outcome data on most of what we do. In my field, many of the things I come across are extremely difficult to study. It is nearly impossible to do double-blinded research on topics like spine fusion. Also, many

DR. WAILES:

SDP: WHAT ARE THE CHALLENGES OR FRUSTRATIONS YOU

biggest challenge is having to deal with insurance companies. Oftentimes, we are limited in the care we want to provide our patients because it conflicts with the insurance companies’ guidelines. This has to do with everything from the selection of medications to certain procedures that are chosen. It’s frustrating because we want to do the best for our patients with the least harm, but we can’t always practice that way because of insurance restrictions. We see examples where insurance companies opt for the bigger, more expensive, more complicated, and frequently less-satisfying procedures that are the least cost-effective, but have been around for a long time.

SDP: WHEN DID YOU JOIN SDCMS-CMA AND WHY? DR. WAILES: I joined SDCMS-CMA in 1993. I joined for one big reason: The fact that organized medicine is our only hope to produce change. I wanted to be a contributor, and I knew that I needed to be a part of the team.

I’ve always been interested in the economics

and finance of healthcare and in the politics of healthcare legislation. After a while of being involved on the county level as I have been, it just tends to grow on you.

SDP: WHY SHOULD OTHER DOCTORS BECOME INVOLVED WITH ORGANIZED MEDICINE? DR. WAILES: I believe it’s our responsibility as physicians to support our patients and our chosen profession. It’s only through organized medicine that we have the format and ability to make effective change in the quality of care and access to care for our patients. It is also our responsibility to promote a supportive career path for the providers that give patients care.

SDP: WITH WHAT THOUGHTS WOULD YOU LIKE TO LEAVE YOUR CONSTITUENTS IN THE ENCINITAS/CARLSBAD AREA? DR. WAILES: Be part of the team; be part of the solution. I hope you’re all concerned about the issues that confront us every day. You can rest assured that there are a number of organizations, from the county to the state to the national level, that are working to improve the issues that trouble most physicians. Organized medicine is the best format to present your opinions, to be persuasive, and to work for your goals. What better way to achieve your goals than with the support of an entire medical association behind you. That’s why it’s important for all doctors to be part of the team.

PROJECT ACCESS SAN DIEGO (PASD) Connecting Uninsured and Underinsured San Diegans With Volunteer Physicians

PHYSICIANS WANTED: • Primary care physicians to provide a “medical home” for one or more people.

• Specialty care physicians to provide one or more specialty consult(s) and procedure(s).

For more information about PASD or to let us know how you would like to help, contact Aron Fleck, SDCMSF executive director, at (858) 300-2780 or at AFleck@SDCMS.org.

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Ask Your Physician Advocate!

By Marisol Gonzalez

How Long to Keep Medical Records?

Can I Charge to Copy Medical Records?

How Can I Place a Classified Ad?

Your Physician Advocate Has the Answers! tion, the records of pregnant women should be retained long enough to assess the effects of medication or treatment received on the fetus, requiring retention at least until the child reaches the age of majority.

Q

UESTION: A private attorney representing one of our patients is requesting a copy of the patients’ medical records for a Social Security benefits trial. This attorney has stated that because it’s for a trial regarding Social Security benefits, they are entitled to these records for free. Is this true?

MARI SO L G O NZALE Z

Q

ANSWER: Yes, but they are only allowed one free copy. California Health & Safety Code §123110 (d) (1) states: “Any patient or former patient or the patient’s representative shall be entitled to a copy, at no charge, of the relevant portion of the patient’s records, upon presenting to the provider a written request, and proof that the records are needed to support an appeal regarding eligibility for a public benefit program.” Although a patient shall not be limited to a single request, the patient or patient’s representative shall be entitled to no more than one copy of any relevant portion of his or her record free of charge. (Health & Safety Code

UESTION: I am a pediatrician; how long do I need to keep my medical records?

ANSWER: CMA ON-CALL document #1160 gives three different recommended retention periods. Under option two, it is recommended that physicians retain records for at least 10 years after the last date a patient is seen, with exceptions.

Minors’ records should be kept longer in those cases where the 10 years elapse before the minor has reached the age of 18.

In no event should a minor’s records be destroyed until at least one year after the minor has reached the age of 18. In addi-

§123110 (d) (2)) This subdivision shall not apply to any patient who is represented by a private attorney who is paying for the costs related to the patients appeal, pending the outcome of that appeal. For purposes of this subdivision, “private attorney” means any attorney not employed by a nonprofit legal services entity.

(Health & Safety Code §123110 (d) (3))

Q

UESTION: I would like to place a classified ad in San Diego Physician as well as on SDCMS’ website. What is the cost and how can I do this?

ANSWER: SDCMS members can place a classified ad in San Diego Physician and on www.SDCMS.org free of charge. For nonmembers, the charge is $100 for the first 75 words and $0.50 for every word thereafter. Contact Ketty La Cruz at (858) 5657930 or at KLaCruz@SDCMS.org.

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.

DOES YOUR OFFICE MANAGER HAVE A QUESTION TOO? Lauren Woods, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions they may have! Feel free to contact Lauren at (858) 300-2782 or at LWoods@SDCMS.org, and make sure your office manager is signed up to receive SDCMS’ new office manager e-newsletter.

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Workers’ Compensation 101 Overcoming Perceived Misunderstandings and Stereotypes

By LAWRENCE S. POHL, MD, MPH

he topic of workers’ compensation has different connotations to the employer, the injured employee, and the doctor. Many doctors attribute a negative feeling toward this discipline, and this is often due to misunderstanding and stereotypes that are perceived.

Early workers’ compensation laws were a trade-off between employer and employee. The laws provided benefit to the injured worker, regardless of fault, in exchange for the employer’s limited liability.

The employer could no longer use traditional defenses, while the worker gave up his or her right to sue for potentially large pain and suffering damages. Providing workers’ compensation benefits by the employer has become mandatory and is a significant cost and responsibility of conducting business in California. Employers may purchase workers’ compensation in-

T

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surance through a private insurance company or elect to be self-insured if they meet certain qualifications. The employee does not contribute to the cost. The Division of Workers’ Compensation, within the California Department of Industrial Relations, regulates the California Workers’ Compensation System. The California Workers’ Compensation Appeals Board (WCAB) is the judicial body that makes rulings for disputed issues within the system.

Treating patients with work-related injuries can be challenging, given the various rules within the system, but can be very rewarding as we see an injured worker return to his or her usual and customary duties. Work-related injuries can be specific or acute, such as a lumbosacral strain, or cumulative, such as tendonitis or carpal tunnel syndrome. There also may be a work-related illness, such as a

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hypersensitivity pneumonitis from inhalation of dust particles, tuberculosis, from work exposure to active TB, or diseases such as asbestosis or pleural mesothelioma, which often can have a latent period of 30 or more years.

When the injured worker presents to the physician, the first priority is to determine if the particular injury is work-related. For an injury to be considered work-related and thus fall under the jurisdiction of the California workers’ compensation laws, the injury must arise out of and in the course of employment (legal abbreviation is AOE/COE). There must be a causal relationship between the employment and the injury sustained. There also must be a relationship of time and place between the injury and employment — that is, while the employee was performing an activity related to his or her job.

Sometimes, the injury is straightforward and clearly work-related, such as a patient bending over at work and, in the process of lifting a heavy item, straining his or her back. Other instances are not as clear, such as a mechanic who lifts, bends, and stoops at work on a regular basis, but cannot remember a specific incident leading to this injury. Another example is if a worker suffers a myocardial infarction while at work, he or she has suffered an injury in the time and place of employment, but for there to be compensation, the heart attack would have to be caused by the work. In our state, for firefighters and police officers, there is a presumption within the law that the heart attack is work-related. This is not the case in most other occupations, and causation must be proven.

When the doctor determines that the injury or illness is work-related, he or she must fill out a Doctor’s First Report of Injury Form. In this form, the doctor must describe the injury, present the subjective and objective findings, the impression, whether he or she feels it is work-related,

The modalities available for treatment are not different from treating other patients with private insurance plans, and include medication, physical therapy, chiropractic, acupuncture, diagnostic studies, injection therapy, surgery, and many others.

From a physician’s standpoint, one has to walk the fine line between the needs of the patient, the employer, and the insurance company. The key to facilitate efficient resolution of work-related injuries is prompt treatment and communication between the injured worker, the employer representative, and the insurance adjuster.

There are some differences in the workers’ compensation system from the private arena. These include the concepts of apportionment, TTD (total temporary disability) payments, firm guidelines for utilization review, the ACOEM (American College of Occupational and Environmental Medicine) guidelines, qualified medical evaluations (QME), and use of the AMA Guides to Impairment, when a patient has reached a period of maximal medical improvement (MMI), also called

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From a physician’s standpoint, one has to walk the fine line between the needs of the patient, the employer, and the insurance company.

and if there are other factors that would inhibit healing or if there were prior similar injuries that have not resolved at this time. The doctor also must document a treatment plan, estimate when the patient would be cured of his or her injury/illness, and make a determination if the patient may return to regular duties, be on modified duty with specific restrictions, or be off work on what is called in the workers’ compensation system total temporary disability (TTD). It is to the benefit of the employer and the employee that the patient be returned to modified, then regular duty as soon as feasible. This can be accomplished in the vast majority of cases, ensuring efficient resolution of the case, and avoiding the development of the “disability mentality” and becoming deconditioned.

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permanent and stationary (P and S).

Apportionment is the legal concept that the causation of an injury may be apportioned, percentage-wise, to several different etiologies. For example, let us take the case of a 60-year-old male with a history of significant degenerative arthritis of his lumbar spine, who has had several previous back surgeries from which he has never fully recovered, but has been able to work as a mechanic. Suppose he has an acute injury to his lower back when he slips and falls at work, sustaining a lumbosacral strain. At the point that he reaches a point of MMI, the treating physician must make a determination about apportionment — that is, what portion of the back condition was preexisting to the acute injury, and what portion was attributed to the recent fall? This

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determination has legal and financial ramifications.

In the workers’ compensation system, not only are all medical costs paid for the injured worker, with no deductible or copay, but the injured worker is also entitled to total or partial temporary disability payments if he or she is not able to work, or if there is no appropriate modified duty available from the employer. The worker, while on TTD, receives up to two-thirds of his income, up to approximately $700 per week. This differs from the private arena, where, if the patient cannot work he may be entitled to State Disability Insurance (SDI), but this amount is much less. Parenthetically, the injured worker may apply for SDI in addition to his workers’ compensation payments.

Several years ago, workers’ compensation costs were rising at an alarming rate and were costing employers more and more money, and forcing some out of business or out of the state. Part of these runaway costs was due to overutilization of services, such as physical therapy and chiropractic. In 2004, due to the efforts of Governor Schwarzenegger and the legislature, in an effort to stem these rising costs, and loss of companies to other states, a sweeping legislation was passed: SB-899. One of the most important aspects of this legislation was the institution of stringent utilization review requirements. Each workers’ compensation insurance company was required to have a utilization review program, with physicians doing a large portion of the reviews, covering topics such as PT, chiropractic, MRIs, surgery, epidural steroid injections, facet injections and the like.

A cap was instituted for chiropractic and physical therapy of 24 per year, at the most.

Along with these changes, there was the adoption of the American College of Environmental and Occupational Medicine Guidelines (ACOEM) to be presumed correct, from a legal standpoint.

Generally, the ACOEM guidelines stress functional restoration as indicative of reasons for approving further treatment, such as PT, or chiropractic; there needs to be shown subjective and/or objective

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improvement from a treatment modality if further treatment was to be recommended. Physicians all over the state are making peer-to-peer telephone calls to determine and understand their colleague’s rationale for a particular treatment plan.

When a patient has reached a period of maximal medical improvement (MMI), physicians or other providers are required to do a permanent and stationary report, and determine factors such as apportionment (see above), appropriate future medical care, and, most recently, impair-

No, it is not a perfect system, but with the cooperation of the main players, a fair shake is possible for all involved. ment rating; this rating must be done using the AMA Guides to Impairment Rating, fifth addition. Depending on the body part, there are various measurements of ROM, presence of spasm, and objective findings of radiculopathy or neuropathy that translate into, first, a local impairment rating, for example the hand, and are then converted into a whole-body impairment rating. This rating is used by California’s disability rating system and takes into consideration factors such as future earning capacity, type of occupation, and age to convert to a disability rating. This disability rating translates into a monetary payment, if impairment and therefore disability is found, for the injured employee.

Qualified medical examiners (QMEs) are certified by the state to give a second opinion if either the injured worker (or his attorney, if he is represented) or the employer disputes any aspect of the permanent and stationary determination.

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How does this look from a physician’s standpoint? The physician who is willing to treat injured employees can build a close relationship with both the injured employees and groups of employers. As the injured worker moves through the system and observes that you have treated him or her efficiently and in a caring manner, he or she may choose to refer friends or relatives to you. As employers have watched you treat their employees appropriately, they may choose to send other employees to you, both workers’ compensation and private patients.

How does the system work from an injured worker’s standpoint? The injured employee is treated appropriately for his or her injury and is kept working, albeit with certain specific restrictions. He or she is paid for all medical care and does not have to worry about high deductibles, copays, and high hospital bills. In more than 95 percent of cases, the injured worker is able to return to his or her livelihood of gainful employment. If the injured worker is one of the unfortunate employees who must be off work for a period of time, he or she is reimbursed to some extent for time off work. If he or she cannot return to his or her usual and customary duties, employers are given incentives to create a permanent modified duty position for the employee. If the injured worker is determined unable to return to full duty or a modified duty position, he or she usually receives a lump sum payment, sometimes payment for vocational rehabilitation costs, and continued payment of his medical costs.

No, it is not a perfect system, but with the cooperation of the main players, the doctors, therapists, insurance companies, nurse case managers, employers, and the patients, a fair shake is possible for all involved.

ABOUT THE AUTHOR: Dr. Pohl received his medical degree from the University of Buffalo and his masters degree in public health from the Medical College of Wisconsin.

He is board certified in both family and occupational medicine.

Public Health Taking It Out of the Office Recreation Prescriptions for the Underserved in Chula Vista

By Chris Searles, MD s every kid I see today going to be obese?” a frustrated colleague asks me. “I feel like that’s all I’m seeing in the office!” Whatever your specialty and wherever your practice, whether you see children or their grandparents, chances are you’re seeing your patients get heavier. In Chula Vista, as in other communities, underserved patients present to their doctors not only with high rates of obesity, but also shouldering the highest burden of preventable diseases such as diabetes and hypertension.

We know that exercise is an important part of the solution, and our patients know it too. But for our patients who live and work below the poverty line, getting out to walk for exercise in their neighborhoods may not be easy. Poorly lit streets, no sidewalks, and community violence can keep even the most motivated family indoors.

Finding affordable, safe, and structured exercise programs can be a challenge. How do we encourage exercise in these high-risk communities in a way that brings reality into the equation?

The answer to this question is certainly not in the office. Part of my colleague’s frustration comes from knowing that physicians and patients just don’t have enough time together. A typical office visit today takes 15–20 minutes, and community clinics in underserved areas can be even busier.

Patients can be frustrated as they try to communicate “just one more thing” to their physicians, and doctors have the impossible task of delivering important preventive care messages in their brief time together.

One study at Duke found that it takes an average of 7.4 hours to deliver preventive messages to an average patient panel and an additional 10.6 hours for patients with chronic disease. After seeing more and more underserved patients in my practice who desperately needed to exercise, I began to wonder: Even if I deliver a message that

“I

sticks with patients, how do I identify and minimize those barriers to exercise that may be specific to my lower SES patients?

In Chula Vista, I’ve begun to answer this question by finding a perfect partner for public health: the Chula Vista Parks and Recreation Department. The Chula Vista Physicians Winning with Recreation (CV PoWeR!) program is the result of a partnership between the department and area physicians that is designed to provide reliable, safe, and structured physical programs to children, adults, and seniors through a point of care “recreation prescription” that allows them to exercise for free. Whether it’s swimming or after-school programs for the kids, a walking club for adults, or chair yoga and tai chi for seniors, there is something for everyone.

When I presented the idea to Parks and Recreation Director Buck Martin and Assistant Director Ed Hall, there was no hesitation. We sat down and looked over the recreation brochure and put together several age-group-specific activities that could be represented on the “recreation prescription.” While there was some initial concern about costs to the city having an increased number of nonpaying participants, it soon became apparent that we could create this program without raising the city’s overhead. For instance, who is using the other half of the pool when the high school water polo team is practicing in the deep end? The city is paying to heat the pool and provide a lifeguard, so why not offer self-directed water aerobics in the shallow end for free to Dr. Smith’s group of patients with osteoarthritis who can’t bear weight without pain?

As we went through the recreation brochure, we all began to realize that by matching a knowledge of recreation programming with the insight of a physician partner who can talk about the health needs of the community in a meaningful

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way, something special can happen. The CV PoWeR! program has opened access points for the underserved in new and exciting ways, and, though additional study is needed, we hope that community members at the highest risk for preventable disease are getting healthier.

Our success in Chula Vista encouraged me to start www.RecreationRx.org to help promote partnerships between physicians and recreation organizations working in areas of unmet need throughout California.

The website is designed to be informative, but also to be used as a tool to help new programs manage themselves. The site has a “Program Forum” that can serve as the administrative home to new programs. “Program Champions” can receive orders for new prescription pads, get and receive feedback, place important files (orientation guides for participating doctors, etc.), and moderate a discussion board specific to their program. By housing this resource for new programs, my hope is to facilitate new program development and to make it easy for programs to share their experiences.

In the summer of 2008, the County of San Diego will pilot a recreation prescription program modeled after CV PoWeR! that will be the first regional program of its kind. As city, county, and state budgets shrink, the need to address health disparities among the underserved is increasing.

By finding community partners with similar goals, physicians can maximize their efforts in the office and help patients tackle the barriers they face as they strive to live longer and healthier lives.

ABOUT THE AUTHOR: Dr. Searles is a family physician and a psychiatrist who works primarily with the underserved and uninsured of San Diego County. He is on the clinical faculty at UCSD’s Department of Family and Preventive Medicine and is the co-director of the UCSD Combined Family Medicine and Psychiatry Residency Program.

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With more than two million articles published each year and the emergence of thousands of health-related websites, we are in the midst of an unprecedented information explosion, which can make it very challenging for the patient to find reliable information.

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evidence-based medicine

The Rise of the Smart Patient At the Crossroads of Evidence-based Medicine and Consumer-directed Healthcare

By Daniel Friedland, MD

I

NTRODUCTION: THE RISE OF THE SMART PATIENT

How often does this happen in your practice: You enter the room to meet your patient, who presents you with a stack of literature she has downloaded off the Internet, self-diagnosing her perceived medical condition. You walk into the next room and a patient states that he wants a prescription for a new drug after reading information contained on that drug’s website, which he saw advertised on TV. Like it or not, patients are searching the Internet to find healthcare information. At latest count, more than 113 million individuals in the United States have searched for healthcare information online. They are finding answers to almost any health concern, creating personal health records, finding doctors, hospitals, and clinical trials, and managing insurance-related concerns. We are witnessing the rise of the smart patient, driven by the availability of 24/7 health information, reduced time for office visits, rising premiums, and the emergence of high-deductible health plans, all of which press patients to find their own answers to maintain both physical and financial health.

With more than two million articles published in the literature each year and the emergence of thousands of health-related websites, we are also in the midst of an unprecedented information explosion, which can make it very challenging for the patient to find reliable information. And while being more informed is good, if the information is neither relevant nor reliable, then it’s distracting, time consuming, and potentially frustrating to both the physician and the patient. So the issue is, how can we, as physicians, help guide our patients at the crossroads of information overload and economic concerns to find more reliable information online?

For more than 10 years, physicians have been using evidence-based medicine (EBM) to sort through the overwhelming amount of information. However, due to time constraints, this is often challenging to do in daily practice. On the other hand, many patients have

the time, interest, and willingness to perform research online, but they don’t have a systematic way of doing this. This article presents an EBM-aligned strategy to empower physicians to take an active role in enabling these patients to make wise use of online resources to support their quest to become smarter and healthier patients.

HARNESSING EBM TO SUPPORT THE RISE OF THE SMART PATIENT

Most clinicians do not have the time to educate patients on the intricacies of EBM. But, if we can identify and invest our patients with the most basic principles of EBM, and offer appropriate evidenced-based resources, it will likely result in their bringing higher quality information to the visit, open new lines of communication, and strengthen a shared decision-making bond that may even save time in the patient encounter.

The Evidence-Based Medicine Resource Center at SuperSmartHealth.com provides a free resource that teaches patients the basics of EBM and also provides links to many of the resources mentioned below.

EBM teaches patients to think about their health decision-making as a four-step process that supports them to: 1) Frame their questions properly; 2) Find the best evidence to answer their questions; 3) Evaluate what they find to ensure it’s relevant and reliable; and 4) Apply the evidence to the particulars around their care.

STEP 1: FRAMING THE QUESTION

The problem with much of the information patients bring to providers is that it does not answer the right question to begin with.

For example, let’s return to the patient with Internet research supporting his request for the drug he saw advertised on TV. While the patient might initially believe he is the perfect candidate for the medication, reframing the question using the EBM PICO model (Patient, Intervention, Comparison intervention, Outcome) helps M AY

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evidence-based medicine

to clarify crucial gaps in the information required to make a fully informed decision.

Introducing and using the PICO format with such a patient invites a discussion about whether the patient population (P) in the study is indeed similar to the patient; the intervention (I) is available on his health plan; the benefit of this particular therapy was found not only more effective than placebo, but also more effective when compared (C) against the current best available regimen; and that the outcomes (O) of benefit demonstrated in the research are truly meaningful to the patient’s quality and length of life, rather then simply a change in some laboratory test value.

This format saves everyone time by streamlining the discussion and increasing the likelihood patients will find the right answers to the right questions when they proceed to search for information on the Internet.

STEP 2: FINDING THE EVIDENCE

When it comes to guiding our patients to help them find better information on the Internet, it’s important to recognize where they are searching and to direct them to high-quality resources that may be underappreciated.

According to the Pew Online Health Search Survey (2006), 66 percent of individuals begin their health inquiry at a search engine such as Google. This returns an overwhelming amount of information, although Google now enables one to refine the search by categories such as treatment, test/diagnosis, symptoms, causes/risk factors, and alternative medicine.

Another 27 percent start at a health-related website. The top trafficked websites according to Compete.com are listed in Table 1 below. The quality of these health-related websites has improved dramatically over the years. It is worth surfing these top 10 sites to explore some of the information they provide.

Table 1. Top Trafficked Websites RANK

WEBSITE

VISITORS/MONTH in Millions*

1

WebMD.com

15.1

2

NIH.gov

8.2

3

RevolutionHealth.com

6.1

4

RightHealth.com

5.6

5

everydayHealth.com

5.0

6

MayoClinic.com

5.0

7

MedicineNet.com

4.2

8

RealAge.com

3.0

9

Drugs.com

2.8

10

Healthline.com

2.4

*January 2008

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Of the top commercial websites, WebMD.com and RevolutionHealth.com include comprehensive coverage of health conditions, drugs, assessment of symptoms, screening, risk assessment tools, discussion boards with physicians and fellow patients, personal health records, and directories for healthcare providers and hospitals.

The top nonprofit health site, NIH.gov, the medical research agency for the United States, acts as a clearinghouse for the 27 institutes and centers that make up the NIH. It provides access for consumers to high-quality information on a comprehensive A-Z list of health topics, as well as newsletters, and a helpful list of tollfree hotlines to health organizations across the country.

Beyond the websites ranked most popular are other quality resources too numerous to mention in the space of this article.

However, you can find links to many of them through The Consumer and Patient Health Information Section (CAPHIS) of the Medical Library Association’s “Top 100 List” of “Health Websites You Can Trust” at http://caphis.mlanet.org/consumer/ generalhealth.html.

One resource worth mentioning is the first referenced on the CAPHIS list: MedlinePlus.gov from the National Library of Medicine. Drawing approximately 200,000 visitors per month (according to Compete.com in January 2008), it is relatively underappreciated when compared with the most trafficked websites listed in Table 1. MedlinePlus is one of the best patient education resources you will find, with extensive information on 750 health-related topics, the latest health news, a comprehensive resource on drugs and complementary alternative medicine supplements, an illustrated medical encyclopedia, interactive patient tutorials, a medical dictionary, and physician and hospital directories. One of its most useful resources is an extensive list of organizations by health topic (www.nlm.nih.gov/medlineplus/organizations/orgbytopic_a.html), which have been pre-screened for quality, authority, and accuracy of health content, thus enabling the patient to efficiently identify the top few websites related to his or her particular health condition.

A few other resources referenced by CAPHIS also bear mention: Healthfinder.gov developed by the Department of Health and Human Services, MayoClinic.com (one of the top 10 most popular sites listed in Table 1 and contributes information to Revolution Health), the ClevelandClinic.org/health (which contributes information to WebMD), and FamilyDoctor.org, produced by the American Academy of Family Physicians.

The strong point of many of these resources is that they cater to the health literacy of the average Internet user. For select patients with high health literacy (or for their designated “EBM champions” who search on their behalf ), the following threestep drill down strategy may also be offered as an efficient and rigorous way to find high-quality, evidence-based information.

First, these patients may begin searching the same online medical textbooks healthcare providers search, such as those at Emedicine.com and UpToDate.com. Many chapters of both resources

According to the Pew survey, almost three-quarters of health seekers do not consistently check the sources and date of the health information they find online.

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The problem with much of the information patients bring to providers is that it does not answer the right question to begin with.

provide links to free consumer information. The health professional information of UpToDate requires a subscription, but motivated patients may pay $20 per week or $45 per month for full access.

Next, patients can drill down further looking for high-quality, evidence-based information on focused clinical questions in the form of systematic reviews or practice guidelines. The Cochrane Collaboration (www3.interscience.wiley.com/cgi-bin/mrwhome/ 106568753/HOME) publishes some of the highest quality reviews around and provides free abstracts with easy-to-read plain language summaries for patients. The National Guidelines Clearinghouse (NGC) (www.guidelines.gov) is the single best resource to find practice guidelines from hundreds of institutions and affiliated organizations. Links are provided to the major recommendations and, where available, to the full text of each guideline and handouts for patients.

Finally, patients who want to drill down even further to search for the latest studies on their specific questions of interest can search the U.S. National Library of Medicine’s MEDLINE database at Pubmed.gov. PubMed currently searches more than 17 million records from more than 4,800 journals. A helpful tutorial is available to guide individuals in using its powerful search tools, including the “Clinical Queries” link that has filters for searching on questions of therapy, diagnosis, etiology, and prognosis. Abstracts can be downloaded for most articles and some have links to free full-text articles. For those that don’t, one can try retrieving the full text article through freemedicaljournals.com, which provides free access to more than 430 journals.

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STEP 3: EVALUATING THE EVIDENCE

According to the Pew survey, almost three-quarters of health seekers do not consistently check the sources and date of the health information they find online. In partnering with patients to improve healthcare, it’s essential to highlight the importance of evaluating the reliability of online information.

There are two key steps to evaluating information online: First, evaluate the reliability of the website searched, and second, evaluate the quality of the research that the website ideally references.

MedlinePlus has a great section on “Evaluating Health Information Online” at www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html. It leads off with a flash tutorial at www.nlm.nih.gov/medlineplus/webeval/webeval.html, which goes through four key considerations, including who authored and funded the site, how to determine quality, and issues of privacy.

The big issue for patients evaluating the quality of research referenced on websites involves them recognizing a hierarchy of evidence: how randomized controlled trials (and systematic reviews they contribute to) provide more reliable information than observational studies, which provides superior information to anecdotal evidence. Healthcare providers and patients can find more information on this and on how to tell whether evidence is relevant, believable, and meaningful at the EBM Resource Center at SuperSmartHealth.com.

STEP 4: APPLYING THE EVIDENCE

Once patients identify more reliable information, they will be more

evidence-based medicine

prepared to engage in the final step: discussing how the evidence applies to them and sharing in the decision-making process.

This step involves a consideration of the best options, extrapolating from the evidence the likelihood of the key outcomes for each option, and weighing the patients’ preferences for those outcomes.

In deciding whether one approach is a step better than another, physicians can outline several factors the patient may consider by using the pneumonic STEPC (Safety, Tolerability, Efficacy, Price, and Convenience). This pneumonic may help the patient remember the key outcomes to be weighed and frame subsequent discussions with healthcare providers.

In addition, great resources are available to help prepare patients in advance for decision-making discussions with their providers. The Foundation for Informed Medical Decision Making (informedmedicaldecisions.org) and its partner Health Dialog (healthdialog.com) work with health plans and employers to provide shared decision programs that help patients clarify their options and the risks, benefits, and preferences associated with each. The Ottawa Health Research Institute (http://decisionaid.ohri.ca/index.html) provides one of the best free resources for patient decision aids. In addition to providing generic forms to help patients structure their decisions, they provide an extensive A-Z list of disease-specific decision aids, all of which have been graded according to the International Patient Decision Aid Standards to ensure they incorporate valid information.

As patients become more informed about their options and empowered to make decisions, we also need to be mindful of the con-

text in which decisions are made. Optimal health is more than treating disease. Any decision may also be influenced by patients’ socioeconomic circumstances, cultural context, spiritual values, and their personal vision and goals for optimal health and well-being.

CONCLUSION

By working with our patients, we can play an active role in supporting the rise of the smart patient. In teaching patients EBMaligned strategies, which enable them to frame questions properly, find evidence in more reliable databases, and become more critical in the way they evaluate information, patients will bring more reliable evidence to their office visits. If they also have the ability to recognize the factors that contribute to the decision-making process, they will come to the visit prepared to discuss their various options. It’s a vision to the future — a partnership between physician and patient, leveraging the skill set and time of both parties — that may not only save time but result in more fulfilling encounters and smarter, healthier, and more satisfied patients.

ABOUT THE AUTHOR: Dr. Friedland is the author of Evidence-based Medicine: A Framework for Clinical Practice and founder of SuperSmartHealth.com, which incorporates the principles of EBM into a vision of optimal health and well-being. For the past 10 years, Dr. Friedland has trained thousands of physicians and allied health-related professionals in EBM across the United States.

Dr. Friedland now also provides EBM programs for patients to facilitate their partnership with healthcare providers to better health.

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When clinical reference content is accurately and consistently derived from the best available research using transparent methodology, then the “evidence-based� approach allows clinicians to make informed decisions that enable them to provide the best care to their patients at the point of care.

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evidence-based medicine

“Evidence-based” A Term in Search of a Definition

By Brian S. Alper, MD, MSPH he term “evidence-based” is as misused and misidentified as politicians’ quotes. It has been used to denote systematic evaluation of research, but has also been used to confuse and “sell” concepts without providing comprehensive evaluation of the evidence supporting the concepts. When clinical reference content is accurately and consistently derived from the best available research using transparent methodology, then the “evidence-based” approach allows clinicians to make informed decisions that enable them to provide the best care to their patients at the point of care.

Evidence-based, in any field, means that conclusions are based on the best available evidence. This doesn’t mean that the evidence will never change or be altered; to be consistently reliable, evidence must be continuously and consistently and systematically identified, evaluated, and selected.

For evidence-based medicine (EBM) content to correctly, accurately, and reliably be labeled as evidence-based, the following steps are required: 1) Systematically identifying all applicable evidence 2) Systematically selecting the best available evidence from that identified 3) Systematically evaluating the selected evidence (critical appraisal) 4) Objectively reporting the relevant findings and quality of the evidence 5) Synthesizing multiple evidence reports 6) Deriving overall conclusions and recommendations from the evidence synthesis 7) Changing the conclusions when new evidence alters the best available evidence Editors use these seven steps to consider medical literature for inclusion in DynaMed, an online clinical EBM resource for clinicians at the point of care. But simply stating that seven steps are needed isn’t enough to be assured that the best available evidence is being presented. Each step needs definition, clarification, and process. Outlining the editors’ process through these steps will help illustrate what is required behind the scenes for clinicians to practice EBM.

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To systematically identify all applicable evidence in Step 1, an extensive set of current literature is monitored daily. Systematic literature surveillance (SLS) is conducted using more than 500 journals directly or indirectly through many journal review services and other sources of systematic evidence evaluation.

For each source monitored, each issue is reviewed cover to cover.

All entries are considered because information in letters to the editor, editorials, and “reporting from the literature” pages may contain reports of new research that would be otherwise unidentified if relying exclusively on abstracts posted with traditional research articles.

When adding a new topic or critically revising an existing topic, PubMed Clinical Queries is used to provide systematic searches for identification of the best available evidence. In addition, numerous sources are searched for evidence-based reviews (such as Cochrane Database of Systematic Reviews), for guidelines (such as National Guideline Clearinghouse), and for traditional reviews.

Editors then move to the second step in the process. Each article is assessed for clinical relevance and each relevant article is further assessed for validity relative to existing content. The most valid articles are summarized, the summaries are integrated with content, and overview statements and outline structure are updated based on the overall evidence synthesis.

Determining clinical relevance is the first consideration in systematically selecting the best available evidence from that identified. The relevance of medical information is different for every user. DynaMed is used in clinical care by practitioners with a wide range of experience and interests, and is also used in medical education. When adding information, the editors consider several questions to determine relevance.

DOES THIS INFORMATION HAVE A DIRECT BEARING ON PATIENT-ORIENTED OUTCOMES? Patient-oriented outcomes are outcomes that affect quality

of life without extrapolation. Examples include mortality, incidence of myocardial infarction, and presence and severity of pain.

These are also called clinical outcomes. Disease-oriented outcomes are used as surrogate markers for monitoring the effects of interventions ultimately intended to affect patient-oriented outcomes.

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evidence-based medicine

Examples include cholesterol concentration, blood pressure, and bone mineral density. Patients are only interested in these outcomes as a means for affecting clinically significant outcomes such as mortality or fracture incidence. Because DynaMed is primarily a clinical tool for use during patient care, patient-oriented outcomes information is considered relevant and included. Patientoriented evidence is given priority over disease-oriented evidence, with disease-oriented evidence entered only if it adds substantially new information.

IN THE ABSENCE OF PATIENT-ORIENTED EVIDENCE, MIGHT THIS INFORMATION BE USEFUL IN CLINICAL DECISION-MAKING? Much of medical knowledge is

still lacking in terms of patient-oriented outcomes research. Clinical decisions based on extrapolated disease-oriented evidence are not proven to be appropriate. However, clinicians still need to make decisions in situations where patient-oriented evidence is not yet available. Disease-oriented evidence is considered relevant for inclusion in situations where patient-oriented evidence is lacking. Individual clinicians will have to determine if this information is considered relevant within their practice. When disWhile it is true that the ease-oriented evidefinition of “evidence-based” dence is not presented can be confusing and is often as such in the supporting reference, commisused, when the term is mentary will be added correctly used, and the evidence and may appear as in an EBM content source is accurately and consistently derived “patient-oriented outcomes not assessed,” from the best available evidence, “clinical outcomes not clinicians can use that content assessed,” or specific source to make decisions that commentary pointing enable them to provide the out problems with exbest care to their patients at trapolating the inforthe point of care. mation to clinical care.

IS THIS INFORMATION PART OF A CLINICAL CONTROVERSY? In situations where the evidence does not clearly support or refute a clinical fact, opposing views are presented. DynaMed is not designed to resolve clinical controversies and strives to present information with as little “inappropriate” bias as possible. The inherent bias towards patient-oriented outcomes is considered appropriate. Information that questions “standard” approaches and has a potential bearing on patient-oriented outcomes is considered relevant for inclusion.

IS THIS INFORMATION THAT IS OF UNIQUE INTEREST DUE TO POPULARITY? Some medical information is not clinically relevant but widely publicized. Summarization of this type of information (often with commentary) is relevant to users if it is likely that clinicians will be asked about it during clinical encounters. It is important for physician and patient education to point out where this type of information is not clinically applicable.

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Clinically relevant articles must be assessed to determine the scientific validity of conclusions and facts presented before consideration for use. Conducting critical appraisal for all articles would be wasteful if these articles did not make a change to the existing knowledge base.

Easily identifiable study features (e.g., study method, sample size) are compared with existing studies in current content to determine if new articles potentially represent the best available evidence. Articles that do not provide relevant information with validity that meets or exceeds the existing content are excluded at this stage.

In Step 3, editors have found that abstracts in research publications often do not accurately reflect the methodologic quality and results found in full-text articles. Article summaries in other publications also often do not accurately reflect the methodologic quality and results found in full-text articles.

Full-text evaluation of articles is required for: • Any article rated as Level 1 [likely reliable] evidence or Grade A recommendation [consistent high-quality evidence] (1) • Any article potentially ratable as Level 1 or Grade A based on abstract-only information; full-text evaluation is necessary to provide lower levels or grades • Any article for which definition of absolute magnitude of effect and/or detailed description of interventions or exposures are necessary, regardless of level of evidence • Any article which represents the most important guidance for a topic, regardless of level of evidence Reports used for updating content represent the best available evidence for the specific content under consideration. Evidence may be labeled in one of three levels: Level 1 (likely reliable) Evidence; Level 2 (mid-level) Evidence; Level 3 (lacking direct) Evidence (1). Articles that potentially warrant the highest evidence ratings undergo complete critical appraisal using methods established in the Users’ Guides to Evidence-based Practice from the Evidence-Based Medicine Working Group (2). If serious methodological shortcomings are discovered (sufficient to affect clinically relevant results), then the evidence is labeled as mid-level evidence and the shortcomings are described.

When reporting the evidence, editors consider all of the following as they go through Step 4: • Were all relevant outcomes reported in the original article?

• What are the most relevant outcomes to report in the topic?

• For relevant outcomes, what is the magnitude of effect? This may be represented by absolute rates and number needed to treat (NNT) or harm (NNH) abbreviations, or by absolute differences in continuous variables (e.g., mean decrease in 1.3 points on 0–10 visual analog pain scale).

• Were the findings clinically significant?

• In the case of no statistically significant differences, were the findings robust enough to rule out clinically significant difference?

• Are there any methodologic limitations sufficient to alter reliability of clinical conclusions?

In Step 5, evidence-based summarization of articles is necessary, but insufficient for a point-of-care reference. Evaluating individual evidence reports requires synthesizing multiple evidence reports.

Addition, deletion, and organization of information within content is done with consideration of levels of evidence. When multiple articles are present on the same topic, preference for inclusion and organization is based on the quality of methodology, e.g., preference given to data derived from randomized controlled trials over data from prospective observational studies, which is given preference over retrospective studies, which is given preference over anecdotal reports. When data of lesser quality does not add any substantially new or different information, this data is then deleted from content.

Moving to Step 6, deriving overall conclusions and recommendations from the evidence synthesis is required for a comprehensive point-of-care reference. Multiple evidence reports of similar quality are organized such that the overall conclusions quickly provide a synthesis of the best available evidence.

In DynaMed, treatment overviews (the ultimate synthesis of evidence for a clinical topic) are based upon all of the available evidence in the treatment section, and selection of the most important concepts. As new topics are created and existing topics are critically revised, treatment overviews are explicitly linked directly to the supporting evidence synthesis.

The final step in DynaMed’s evidence-based methodology is changing conclusions when new evidence alters the best available evidence. This step is crucial because new evidence is published every day. Having new evidence summaries handled separately from reviewed content in a manner requiring the clinician to search in two locations to synthesize the entire story would make finding the best available evidence more difficult.

As soon as new evidence is evaluated using the six steps governing systematic processing, it is added to the appropriate topic(s) in context. This process allows immediate and comprehensive access to the best available evidence as it occurs.

In conclusion, while it is true that the definition of “evidencebased” can be confusing and is often misused, when the term is correctly used, and the evidence in an EBM content source is accurately and consistently derived from the best available evidence, clinicians can use that content source to make decisions that enable them to provide the best care to their patients at the point-of-care.

ABOUT THE AUTHOR: Dr. Alper is the founder and manager of DynaMed, a point-of-care reference resource designed to provide doctors and medical researchers with the best available evidence to support clinical decision-making.

Visit DynaMed Online DynaMed, a leading point-of-care clinical reference tool, is available to all healthcare professionals at www.ebscohost.com/dynamed. Subscribers to the site are provided with the most up-to-date, evidence-based information gathered from more than 500 medical journals and evidence review databases that will assist them in making the best clinical decisions when it is needed most.

Updated daily, the data presented on DynaMed’s website is thoroughly reviewed for scientific relevance and validity, and then integrated with existing content to produce the best available evidence on various healthrelated topics. Residents, medical students, practicing physicians, and medical scholars looking for answers to complex clinical questions are invited to subscribe to this site.

RESOURCES: (1) Definitions and sources available at www.ebscohost.com/dynamed/levels.php.

(2) Available from the Centre for Health Evidence at www.cche.net/usersguides/main.asp.

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Safety Net The Council of Community Clinics Stephen R. O’Kane, CEO, Council of Community Clinics ince 1977, the Council of Community Clinics (CCC) has provided a wide array of support services to community clinics and health centers in their efforts to provide quality care to diverse communities, particularly those with low income and uninsured populations. In 1980, CCC member health centers served a total of 103,800 patients, which accounted for 200,000 patient visits. In 2006, CCC member health centers served a total of 500,000 patients in 1,400,000 patient visits representing a 280 percent growth. In 2006, more than half (61 percent) of these patients were Hispanic, 17 percent white, 4 percent black, 5 percent Asian, and 1 percent American Indian. Ninety-five percent of the CCC’s clinic population is below 200 percent federal poverty level.

Through local, state, and national advocacy efforts, the CCC works to continually keep important issues facing community health centers in front of public and private decision makers. This is extremely important, as more than 600,000 people in San Diego County alone have no health insurance, and it appears that state healthcare reform proposals, which were a large focus of 2007, will not happen in 2008.

Our commitment to the community is unwavering. In the last year alone, the CCC has secured funding for health centers to expand mental health services to the uninsured and manage specialty treatment pools for breast cancer, HIV/AIDS services, asthma, and dental care.

The CCC used its experience in emergency preparedness to support community health centers during the October 2007 firestorm by mobilizing and coordinating the delivery of supplies and equipment. The Community Clinics Health Network (CCHN), a subsidiary of the CCC, supported quality-improvement initiatives, and health centers exceeded national benchmarks in diabetes care. The CCHN provided information technology services to health centers, including leading a collaborative process to evaluate electronic health record software, and working with health centers to select and implement pharmacy management software. Council Connections (CC), a subsidiary of the CCC, is the largest clinic-based national group purchasing organization in the United States and has expanded to 30 states and 500 healthcare organizations with more than 2,500 member sites. It held a successful and well-received annual conference with attendees from throughout the nation.

The CCC has accomplished a great deal during the past year alone.

We worked in partnership with community health centers statewide through the California Primary Care Association, which uses a collaborative process to identify priorities and move them forward in the legislative process. Every April, the CCC, along with health center leadership and physicians, visit the San Diego and Imperial counties contingent of state legislators to educate them about health center issues. In addition, the CCC works with the National Association of Community Health Centers and visits Washington annually in March for the Policy and Issues Forum. Visits to local members of Congress

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take place at the same time to educate them on the importance of federal health center funding and other issues.

We also work closely with the County of San Diego to assure health services to our community. Key among these services is a contract for the Mental Health and Primary Care Services Integration Project that enables our member clinics to receive reimbursement to care for uninsured individuals with serious mental illness. In 2007, the project’s first year, a total of 638 patients were served. Almost 70 percent of these patients had not received county-funded mental health services previously, demonstrating the need for programs to be delivered in the community health center setting and meeting the MHSA mandate that counties identify underserved and unserved individuals.

In addition, the CCC managed contracts with close to 100 specialists (e.g., pathologists, periodontists, radiologists, surgical facilities) throughout San Diego County to provide treatment services. The CCC staff determined patient eligibility and authorized treatment procedures for 2,225 patients in 2007. The CCC managed specialty treatment pools covering the following types of services: • Breast cancer screening and diagnostic services • Medical, dental, and home health/home hospice services for patients with HIV/AIDS • Asthma treatment for children and youth ages 0–17 • Dental Services for children ages five and under One of our key responsibilities to the San Diego community is to serve as the safety net for essential health services. Our training and experience in emergency preparedness in support of community health centers positioned us as a major health resource during the October firestorm. The CCC Emergency Preparedness Coordinator, together with other CCC employees, staffed the Clinic Liaison position at the San Diego County Medical Operations Center during the first 108 hours of the wildfires. The clinic liaison served as the hub for clinic communication and fielded multiple medical resource requests from the clinics. In coordination with the San Diego County Office of Emergency Services and international relief organizations, critical medications, N-95 particulate masks, respiratory inhalers, and evacuation shelter supplies were mobilized to the clinics to serve their patients and community members. CCC also polled clinic sites daily to identify their operational status and shared this information with several media outlets to help inform patients in need of care.

At the end of the day, we remain dedicated to our mission and vision: to represent and support community clinics and health centers in their efforts to provide access to quality healthcare and related services for the diverse communities they serve with an emphasis on low income and uninsured populations; and serve as the common voice for these entities by building and strengthening relationships with strategic public and private partners resulting in sustainable resources and healthier communities.

Safety Net Family Health Centers of San Diego Fran Butler-Cohen, CEO, Family Health Centers of San Diego oday’s Family Health Centers of San Diego (FHCSD) evolved from a single, small clinic, the Chicano Community Health Center, established in 1970 and tucked under the Coronado Bridge in Barrio Logan, to 25 sites where more than 700 employees and approximately 100 providers are engaged in the mission of community medicine. In the absence of a national healthcare plan, FHCSD made a commitment more than two decades ago to create a comprehensive healthcare organization where patients could obtain low- or no-cost medical care, physicians could practice medicine without administrative burden, and national quality goals would drive the operations of its clinics. The early successes prompted the board of directors to expand the mission and scope of FHCSD into all San Diego communities that lack affordable, accessible, quality medical care.

The physicians who currently work in the Family Health Centers of San Diego system appreciate the opportunity to practice medicine without the responsibilities of practice overhead: workers’ compensation premiums, personnel management, rent payments, billing, and claims management, to name a few.

The FHCSD system also ensures the physicians have the supportive services needed to promote optimal patient care. For example, a team of health educators are scheduled at each clinical site; case management is provided in all clinical departments; needed equipment is procured through a team of grant developers; appointments and reminder calls are capably handled by a centralized call center; and licensed nurses in every clinical department provide nursing services and education support.

Years ago, FHCSD developed its own software — a sophisticated patient tracking system capable of features such as on-demand reporting and electronic prompts to remind physicians the date and value of their patient’s last lab test. Monthly medical staff forums offer the opportunity to connect with other physicians who serve at the various FHCSD locations.

Quality is the act of continually striving to be the best, and at Family Heath Centers of San Diego, the physicians have a voice in the development of new programs and services. For example, a high-complexity lab was established in 2006 to provide faster lab results to physicians, and program grants are written to establish needed services such as a free immunization program, no-cost cancer screening programs, and sliding-scale medical care. Family Health Centers of San Diego is not mandated to have national accreditation, yet FHCSD has been accredited by The Joint Commission for more than a decade.

This is another testament to the quality goals of FHCSD. FHCSD offers the capability for many in-house referral services for physicians. These include podiatry, speech therapy, health education, nutrition, dental, mental health counseling, and many more. Programs are conceptualized and developed based on input from the FHCSD physician partners. These physicians represent such disciplines as internists, pediatricians, ob-gyns, family practice physicians, and a host

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of specialists, including endocrinology, neurology, ENT, cardiology, and orthopedics.

FHCSD is proud of the growth and expansion into needy communities throughout San Diego County. Each year, FHCSD has experienced a significant increase in patient volume. Now the second largest-volume community health center in the nation, FHCSD provides more than 450,000 healthcare encounters each year.

In addition to freestanding clinics, for more than a decade the organization has provided needed medical care to homeless shelters, batteredwomen’s shelters, elementary schools in disadvantaged neighborhoods, and other community settings utilizing three 40-foot mobile medical units. The KidCare Express program, as the mobile medical unit project is known, provides more than 25,000 visits each year.

Through years of focused grant writing, the following programs were created to enhance the services of FHCSD: pediatric speech, occupational, and physical therapies; the most comprehensive HIV services in San Diego; a Health and Developmental Services Program for screening young children; vision care clinic; specific programs for asthma prevention, teen pregnancy prevention, lead screening, and diabetes management; dedicated walk-in clinics and a dedicated teen health center, to name a few. These programs enhance the delivery of medical care services throughout the network of FHCSD clinics.

Physician practice at Family Health Centers of San Diego has changed from its early beginnings almost 40 years ago. Volunteers represent the past. Today, all physicians are on-staff at the health center.

Wages are competitive and benefits are excellent — certainly a far cry from the days when physicians finished a busy day at their private practice or at the hospital and then ran down to the Barrio to volunteer until late in the evening. Today’s physician makes a career commitment to community medicine. In addition to the competitive salary and benefits package, the physicians at FHCSD derive satisfaction from knowing that the healing arts are never enjoyed more than when they are provided to those with the highest need.

FHCSD chief medical officer Mark Bulgarelli, MD, states, “As an FHCSD physician, I am honored to be of service and to be a part of the rich history of this community. Each day we deal with patients with few resources and we face those challenges together. We at FHCSD have found innovative ways to provide high-level services. I am part of a team of caregivers that is touching lives in a positive way every day.”

Where else in San Diego can physicians practice medicine their way, not worry about the overhead of a group and know deep in their hearts that they are helping those who need care and help the most? The answer is in a community health center.

Family Health Centers of San Diego invites physicians to take a tour and see firsthand the wonderful world of community medicine. Call us at (619) 515-2301. We would enjoy showing you healthcare — our way!

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Public Health

New Stroke Care System Coming Soon‌

By Bruce E. Haynes, MD

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new system of stroke care for patients with acute stroke symptoms is on the verge of starting in San Diego. This system will help assure patients with acute stroke receive rapid, appropriate care. Physicians are an integral part of this new effort, and this article outlines changes you may see in hospitals, and enlists your support for the system.

In 2005, The Board of Supervisors directed the Health and Human Services Agency (HHSA) to look at ways to improve stroke care in the county. As a result, a Stroke Task Force was formed to address this issue. The Task Force divided the approach to the solution into an educational component and an examination of care component.

The education component developed a media program to educate the public about stroke symptoms and encourage individuals with stroke symptoms to seek care rapidly. This has been used in a number of low cost media and is available.

The next phase and the second component identified by the task force to improve stroke outcomes in the county will focus on acute stroke care. This will seek to assure the identification of acute stroke patients in the field by paramedics, and transporting patients to hospitals with procedures in place to rapidly assess and treat acute stroke. The guidelines are modeled on the criteria for hospital certification as a Primary Stroke Center by the Joint Commission.

HHSA’s Emergency Medical Services developed the criteria in concert with the Stroke Task Force. The criteria will be implemented in the summer of 2008.

Patients with symptoms of an acute stroke starting in the previous three hours will be transported to hospitals that either are certified as Primary Stroke Centers, or are surveyed by the Emergency Medical Services and found to meet similar criteria in the county policy.

Hospitals are required to have staff to coordinate stroke care activities, with appropriate input from neurologists and other members of the medical staff. A team will respond to acute stroke patients, using protocols to deliver rapid, evidence-based care. The facility will obtain CT head scans rapidly, to facilitate use of thrombolytic therapy using Tissue plasminogen activator (tPA), if indicated.

Just as important, care pathways will encourage use of important measures, such as swallowing tests before oral intake, cardiac rhythm monitoring, blood pressure monitoring and treatment, and others. Similar protocols already exist in many or most of local hospital facilities.

An important component will be performance measures for stroke care, accompanied by a quality improvement system to improve use of 36

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important care measures. A patient registry will facilitate this. Early measures will mirror those recommended by the American Stroke Association. These include deep vein thrombosis prophylaxis for admitted patients, patients discharged on antithrombotics, those with atrial fibrillation receiving anticoagulation therapy, and thrombolytic therapy considered for administration when the patient arrived. Other standardized measures considered important are antithrombotic medication within 48 hours of hospitalization, a lipid profile obtained during hospitalization and discharge on cholesterol reducing medication, the screen for dysphagia, stroke education, smoking cessation, and consideration of a plan for rehabilitation. Local providers should check with their respective hospital to understand the measures in effect.

The program’s goal is to help assure that patients with acute stroke receive rapid, coordinated, and currently accepted care to lower mortality and reduce disability from stroke. Physicians will play the key role in achieving these goals. Medical staff members are encouraged to check with their facilities about implementation plans for this stroke care initiative.

Hospital surveys will be disseminated in early summer, with system implementation beginning sometime during the summer of 2008. Please contact Bruce Haynes, MD, medical director of the HHSA Emergency Medical Services, at (619) 285-6429 if you have questions or comments.

ABOUT THE AUTHOR: Dr. Haynes, an emergency medicine physician, is the medical director for the Emergency Medical Services Branch in the Division of Public Health Services of the County of San Diego Health and Human Services Agency, a position he has held since February 2006.

San Diego County Health Statistics • In 2004, there were 1,423 deaths due to stroke in San Diego County, with almost 90 percent among residents ages 65 and older. Of the total deaths, 1,087 were white and 863 were female. (1) • In 2004, among San Diego County residents, the rate of stroke death was 53 percent higher for females than for males (57.1, 37.3 per 100,000), while the 2005 rates for stroke hospitalizations was only 15 percent higher for females than for males (224.6, 196.1 per 100,000). (1) To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends, and comparisons to national targets, please call the county’s Community Health Statistics Unit at (619) 285-6479. To access the latest data and data links, including the Regional Community Profiles document, go to www.sdhealthstatistics.com.

RESOURCES: 1) Community Health Statistics Unit online Community Profiles: Death Statistical Master Files (CA DHS), County of San Diego, Health & Human Services Agency, Community Epidemiology; SANDAG, Current Population Estimates, 9/27/2006.

STEMI Receiving System Update You may be interested in an update on the STEMI receiving system that began in January 2007. In this effort, paramedics obtain a 12-lead EKG in the field on patients who appear to be experiencing a myocardial infarction. If the EKG shows an acute myocardial infarction, designated on the EKG as ***Acute MI*** or similar interpretation, the patient is transported to a hospital identified as a “STEMI Receiving Center,” a facility that offers emergent cardiac catheterization and angioplasty/stent placement.

In the first year, 330 STEMI patients had a “field activation,” or notification and response of the cardiologist and catheterization laboratory personnel before the patient arrived in the hospital, and underwent an angioplasty or stent placement. The median door-to-balloon time in these patients was 62 minutes. This is well below the door to balloon times reported before the STEMI system. The rapid door to balloon time should translate into lower mortality and improved outcomes among STEMI patients. The County of San Diego would like to thank all of the physicians who have been so dedicated to providing these low door-to-balloon times.

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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 MEDICAL JOURNALS: Retired neurologist has several neurological medical journals that range from 1960 to present. Some are bound. Please contact Dr. Levine at (619) 588-4929 if interested. [562] 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

LEAS ING, RE NE WALS A ND SA LES : 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) 6775329; e-mail chris.ross@colliers.com.

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] SUBLEASE 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 1,950ft2 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 by email at Kristina@sdsleepclinic.com for more information. [520] SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA IN CARMEL VALLEY: A portion of an upscale, 4,000ft2 medical spa available for sublease. Ideal for an ophthalmologist, plastic surgeon, ENT, and cosmetic dentist. Sublease includes a spacious reception and waiting area, six exam/procedure rooms, surgery suite, two dental chairs, three doctor offices, and consultation room. Easy access to I-5, 805, 56, and I-15. Located inside a medical and dental office building within a retail center. Contact Janice at (858) 481-7701 or janice@laser-clinique.com for more information. [561]

exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door.

Free parking. Perfect for low-volume hospital campus consultations one to five half-days per week.

Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557] 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 shamshoian@coveycommercial.com. [556] OFFICE SPACE AVAILABLE: Office space at the corner of 8th Avenue and Washington Street in Hillcrest.

Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555] OFFICE TO SHARE: Office available in desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior design 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 to use as satellite office.

Central location with ample parking. For more information, please contact (619) 701-4786. [542] 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] 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, 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]

MEDICAL OFFICE AVAILABLE TO SHARE: Beautifully remodeled, state-of-the-art office in Chula Vista conveniently located across from Sharp Memorial Hospital campus. Terrific opportunity to share office with a respected dermatology/cosmetic surgeon who has been well established for over 20 years in the community. Lots of potential for a new physician beginning his or her own practice, or a well-established specialist. Included are several exam rooms with a procedure room, spacious reception area, office staff, and a computerized, paperless medical records system. Office open Monday thru Friday. Contact Michele, office manager, at (619) 421-9332. [560]

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]

MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS): OB/GYN-type consultation room and one to two

PREMIUM HILLCREST OFFICE SPACE: 800ft2 office space available immediately. Includes 200ft2 waiting

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]

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. Support staff available. Contact Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521] 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] 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 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. Office situated 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 multispecialty 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 Hillcrest available. The space is approximately 4,500ft2 with several advantages for a group of one to four surgical specialists. There is ample parking, a 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) 2990007. [462]

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 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

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 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) 733-4068, 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): Inhouse, 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 builtin 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]

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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.

Support staff available. Contact Iman Mikhail, MD, at (619) 470-2300. [328] P HYSICIAN POSITIONS AVAILABLE P PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR: Temecula Independent Diagnostic testing facility seeks physician to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month, typically scheduled for nine-hour shifts. Candidates must have California license. Please contact Lynn at (619) 819-6530 for more information, or fax your CV to (619) 2417790 for immediate consideration. [572] STAFF PHYSICIAN/STUDENT HEALTH CENTER (JOB #51380): Responsibilities include providing patient care to students of the University of San Diego at the Student Health Center (SHC). Under the direction of the SHC director and/or AVP of student affairs for student wellness, may collaborate to develop and implement wellness area and campus-wide educational and health promotion projects and programs. Must be knowledgeable of principles of general preventive medicine and use those skills for individual and group counseling, collection and analysis of health behavior data, and work with the campus community to improve the health and wellness of students. There will be general guidance and direction from the SHC director and supervising physician. Requirements include board certification/ board eligible in general preventive medicine, pediatrics, adolescent medicine, family medicine, or other primary care specialty. Candidate must have current, active California medical license and DEA. Possession of a current, valid CPR certificate is also required. Current knowledge of drug and treatment protocols common to ambulatory care, and one year of outpatient primary care experience that demonstrates evidence of ability to work independently is mandatory. Prior experience or specialty training in college health is preferred. Candidate must perform all duties in an accurate, thorough, and efficient manner, and will perform other duties as required.

Candidate must be able to organize workflow to meet the needs of the patient flow, and should be able to adjust the workflow to meet the most critical needs first. Candidate must understand and follow policies as outlined in the office manual, understand and display good, general medical knowledge, has excellent interpersonal skills, and is able to communicate effectively at all times. Candidate must work well with family members, patients, and other nonmedical personnel, and adhere to the highest medico-legal standards of nursing practice. Works as a team member and demonstrates excellent interpersonal and communication skills with the SHC team. Upholds the mission of University of San Diego at all times and shall maintain a clean, neat, and professional appearance at all times. Consistently meets assigned work schedule, observes appropriate conduct standards, is motivated, and shows ambition in performing job duties. Recognizes and completes needed projects, uses information systems to solve problems and answer questions.

Shows emotional stability, deals with difficult situations in a calm and effective manner, and knows when to bring a medical problem to the attention of the medical director. Hours are Monday thru Friday, 8:30 a.m. – 5:00 p.m. Call human resources at (619) 260-4594 or at (619) 260-4626 (24-hour job line), or visit www.sandiego.edu/hr. [568] PHYSICIAN FOR ADDICTION TREATMENT CLINIC: Opiate addiction center located in central San Diego is looking for a CA-licensed physician with a non-restricted DEA license. Office is on El Cajon Blvd., one mile west of the I-15 exit, which is one mile or so

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south of I-8. In need of a physician with at least a basic understanding of substance abuse. Work hours are flexible as our business is open from 5:30 a.m. – 1:30 p.m. We currently have a total of 8-12 weekly hours available for the position. Please fax resume to (619) 286-0060, or call Justin at (619) 286-4600 (office) or (619) 869-2466 (cell). [566] PARTNERSHIP OPPORTUNITY: ENT position available immediately in an existing La Jolla practice. Partnership may be quickly achievable. Please call (858) 458-1287 for details. [564] PER DIEM RESEARCH PHYSICIAN: Profil Institute for Clinical Research, Inc., a private research institute located in Chula Vista, CA, is currently seeking a part-time research physician to support recruitment, screening, and clinical study activities in both inpatient and outpatient settings. At Profil, we are focused on early-phase investigations of potential new treatments for diabetes and other metabolic diseases. This position requires some availability on weekday mornings, but offers flexible hours. Visit our website at www.profil-research.com. Please submit CV to hrpicr@profil-research.com. [554] 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 HMOs/ Medi-Cal, 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] 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@lvhcc.com. [544] 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] 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,

Classifieds 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 three to four 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-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] 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] 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 5:00 p.m. to 9:00 p.m., M thru F, 9:00 a.m. to 5:00 p.m. Sat., and 10:00 a.m. to 4:00 p.m. 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 and outpatient care. Competitive salary, malpractice, benefits, and partnership potential available. 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] 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] NON-PHYSICIAN POSITIONS AVAILABLE N MEDICAL RECEPTIONIST: Full-time, front office position with solo family practice in La Mesa. Experience in scheduling appointments, referrals, insurance, accounts payable, accounts receivable, billing, and collections required. Knowledge of Medical Manager and Quick Books needed. Fax resume to (619) 6672688. [567] PHYSICAL THERAPIST: Part-time or full-time PT needed for group orthopedic practice. Great opportunity, benefits. Please fax CV to (619) 229-3933. [565] MEDICAL RECEPTIONIST/FRONT OFFICE: We are looking for a front office receptionist for a busy OB/GYN practice. Bilingual in Spanish and OB/GYN experience is a must! Resumes can be faxed to (858) 5650033. [563] 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@lvhcc.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.

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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 positions available.

Office hours are from 9:00 a.m. to 6:00 p.m., Monday thru Friday. Please fax resume to (619) 6565250. [504] 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/fulltime 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] 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] P PHYSICIAN POSITIONS WANTED MEDICAL OPHTHALMOLOGIST (PER DIEM): Board-certified medical ophthalmologist available two days per week for per diem or locums work in the San Diego or nearby areas. Highest ethical standards. Experienced and skilled in therapeutic and cosmetic Botox and dermal fillers. Also experienced in clinical trials.

Email bshaw1@san.rr.com. [569] 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] PRACTICE FOR SALE P

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]

UROLOGY PRACTICE FOR SALE (SAN DIEGO): Practice opportunity in San Diego. Busy solo practitioner to retire in October 2008. Thriving practice; multiple contracts; turnkey operation with Spanish language and laparoscopy skills. Can’t miss. Interested applicants email rvsmith13@san.rr.com. [571]

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 available. Fax resume to Connie at (619) 718-9440 or email to sdmg@covad.net. [514]

SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small investment for 51 percent ownership. Looking for a new medical director. Contact Leonard Schulkind at (619) 807-5485. [539]

PRACTICE MANAGER: Retiring practice manager seeks individual with five years of full-charge experience managing a medical office of 15–25 employees.

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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.

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EXAM TABLE FOR SALE: Full-functioning, electric exam table. Includes drawers, storage area, and elevation and tilting capabilities. $100 OBO. Call Pam at (858) 456-2114. [559]

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. Contact Monica Coburn at CBN Financial: (702) 310-7111 or mcoburn@communitybanknv.com. [522]

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] RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICAL EQUIPMENT: Perfect for plastic surgery/oral surgery.

Endoscopy, cameras, loupes, tools. Waiting room furniture inventory list is available upon request.

Email kwahl@san.rr.com. [506]

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]

upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service! Call (619) 443-4060. [400] MISCELLANEOUS M 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 paltry100 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 CONVERTIBLE (RED, MANUAL): Very good condition, low miles, and new tires: $33,750. (858) 254-0202. [453] C CME/CERTIFICATION COURSES ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATION COURSE: Offered through UCSD and AWLS, this fourday CME and certification course is designed for medical professionals who are interested in outback adventure. Course includes didactics, workshops, and surfing/hiking/kayaking/climbing adventures. Dates are November 12 to 15, 2008. Please visit familymedresidency.ucsd.edu/awlsconference.shtml for further information. [570]

RMC VINYL REPAIR PLUS: Medical equipment upholsterer.

Expert in repair and replacement of medical fixture

CALL TODAY TO RESERVE YOUR ADVERTISEMENT

SAN DIEGO COUNTY MEDICAL SOCIETY

2008-2009

MEMBERSHIP DIRECTORY

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DARI PEBDANI SAN DIEGO MAGAZINE 619.744.0528 darip@sandiegomagazine.com

Discover Your Website! www.SDCMS.org Access SDCMS Members-only Resources, Including Webcasts, NPI lists, a Bulletin Board, and Much More…

Member physicians can access the “Member Physicians” section using their name and birthdate. For assistance, email Webmaster@SDCMS.org.

Renew Your 2008 SDCMS-CMA Membership

Check Out the Latest SDCMS Seminars and Community Events Read and Post Classified Ads Join SDCMS-CMA Online

Search for a Physician

Learn About the SDCMS Foundation, Its Initiatives, and How You Can Get Involved!

Read Current and Past Issues of San Diego Physician, Including “Web Exclusives”

If you have any questions or suggestions, contact SDCMS at (858) 565-8888 or at Webmaster@SDCMS.org.

Public Health Chronic Care Made Easier Taking Action on Many Fronts to Make a Difference

By WILMA WOOTEN, MD AND EVALYN GREB

ver wonder if your Alzheimer’s patient and her husband follow the treatment plan you suggested after they leave your office? Ever ask your staff to make a referral for your elderly female patient who is losing weight to a meal program for seniors, knowing it may be a difficult task for a very busy staff person? Ever wish there were more supports in the community to help provide services and monitor the health status of your frail diabetic once he/she leaves the office?

Based on national prevalence rates, one in two San Diegans has one or more chronic conditions and accounts for 83 percent of our local healthcare dollars (1).

With the “age wave,” it is predicted that persons 60 years plus with chronic conditions will increase 69 percent between 2005 and 2020 (2).

A physician survey by Mathematica shows that they are dissatisfied with current health policies, including public reimbursement (3). And while 54 percent reported being “very satisfied” with care for general patients, only 38 percent re-

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ported this for patients with chronic conditions. The physicians in the study cited lack of training in several important areas, such as coordination of in-home and community services, patient education on chronic illness, managing psychological and social aspects of chronic care, providing effective nutritional guidance, and managing chronic pain.

The County of San Diego Health and Human Services Agency, in conjunction with its many community partners, is taking action on many fronts to make a difference in chronic care delivery by supporting physicians and patients with prevention, education, and communication initiatives. Funding for these various projects comes from a variety of federal, state, local, and foundation resources. The success depends on all of us, but most importantly, support from the physician is crucial.

Team San Diego is a joint project between the County’s Long Term Care Integration Project, University of California at San Diego (UCSD) Extended Studies, and Mark Meiners, PhD, at George Mason University. This initiative is preparing to launch its online training for community health and social service providers in July 2008 through UCSD Extension Summer courses. The eight one-hour, online modules are designed to prepare providers of mutual patients with chronic care needs to create a “virtual team” around each patient, in support of the primary care physician.

After completing the eight modules, a six-hour, in-class training will put the new skills into action as providers come face to face, by neighborhood, for team building and development of a communication protocol. The goal is to improve care coordination across settings and providers and increase patient engagement to become active members of that team. An introductory module is designed for physicians to present the business case on

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the advantages to your practice and how to support your office staff in participating in this training.

The full training will provide health and social service providers with basic information on working successfully with elderly and disabled persons, how to create a “team” when no one has time to be in the same room for each patient, how to see diversity as opportunity for developing professional relationships, legal and ethical issues with sharing information among team members, and tools and techniques for empowering patients to manage their own care better through taking increased responsibility.

Some of these tools will include sample personal health records, medication lists, transition checklists, and training on use of the county’s rich resource databank on www.sandiego.networkofcare.org/aging, where you can find aging and disabled community resources, a large bank of healthcare literature, a “virtual” long-term care options counselor, fall prevention safety tools, and more. To receive information or sign up for the introductory module (1 CME), call Jackie Kuhn at (858) 964-1059.

Other county initiatives will be described in more detail in future articles and include preventing diabetes in Hispanic elderly, falls prevention, childhood and elderly obesity programs, smoking cessation, feeling fit clubs for the elderly, chronic care self-management (Stanford Model) training, oral health, and Medicare senior risk reduction.

ABOUT THE AUTHORS: Dr. Wooten is San Diego County’s public health officer.

Ms. Greb is a retired licensed clinical social worker.

R ESO UR CES: 1) Medical Expenditure Panel Survey, 2001 2) Department of Rehabilitation, Laurie Dickinson, December 2007 3) National Public Engagement Campaign on Chronic Illness — Physician Survey, Mathematica Policy Research, Inc. 2001

We proudly announce our 2008 member dividend. We set a higher standard. We ensure that members benefit from our strength. We embrace opportunities to recognize and reward physicians. We exceed expectations. We offer tangible benefits to those who join us. We stand behind the promises we make.

We are The Doctors Company.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

We are on a mission to relentlessly defend, protect, and reward doctors who advance the practice of good medicine.

We act with single-minded determination to reward our members and to ensure that they share in the company’s financial strength. In 2007, our members received a dividend of between 5 and 7.5 percent. For 2008, our members will receive a dividend distribution at the same level. That’s $44 million returned to members in two years. To learn more about our medical professional liability program for SDCMS members, call (858) 452-2986.

Endorsed by

$5.95 | www.SANDIEGOPHYSICIAN.org

SAN DIEGO COUNTY MEDICAL SOCIETY 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

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