June 2008 by San Diego Physician

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY

Medical Staff

RELATIONS A Practicing Physician’s Perspective Why Hospitals Oppose it “ 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 ”

JUNE 2008

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Contents

VOL. 95 | NO. 6

MEDICAL STAFF RELATIONS [ F E A T U R E S ] MEDICAL STAFF RELATIONS

24 34

Medical Staff Relations: A Practicing Physician’s Perspective BY KENNETH COHN, MD, MBA

[ W E B

E X C L U S I V E ]

Dangers of Working With a Bare Doctor or Going Without Liability Insurance Coverage BY MARK GORNEY, MD

Medical Staff Self-governance: Why Hospitals Oppose It BY TOM CURTIS

VISIT SANDIEGOPHYSICIAN.ORG FOR THIS ARTICLE AND MORE

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

4 6 8 10 12 2

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CONTRIBUTORS: This Issue’s Contributing Writers EDITOR’S COLUMN: Smart Reductions in Medi-Cal Costs SEMINARS: SDCMS’ 2008 Seminars and Events COMMUNITY HEALTHCARE CALENDAR ASK YOUR ADVOCATE & BRIEFLY NOTED: SDCMS Member Spotlight, and More...

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18 20 22 41 44

LEADERSHIP: Contextual Decision-making RISK MANAGEMENT: Getting Sued for Breast Cancer PUBLIC HEALTH: Hot Topics in Communicable Reportable Disease PHYSICIAN MARKETPLACE: Classifieds HISTORY OF MEDICINE: A Bullet in the Coffin

Contributors RICHARD E. ANDERSON, MD

Dr. Anderson is chairman and CEO of The Doctors Company.

KENNETH COHN, MD, MBA Dr. Cohn is a practicing general surgeon and a director at Cambridge Management Group, which specializes in resolving physician-physician and physician-administration communication issues. TOM CURTIS

Mr. Curtis, who is a partner with Curtis Green and Furman LLP in Pasadena, focuses on representing physicians and physician organizations in healthcare litigation, medical staff issues, peer review, and disciplinary and licensing matters.

TOM GEHRING

Mr. Gehring is the executive director and chief executive officer of the San Diego County Medical Society.

MICHELE GINSBERG, MD Dr. Ginsberg is trained in internal medicine and infectious diseases and has been with the County for more than 30 years. She is chief of the Community Epidemiology Branch in the Public Health Services Division of the Health and Human Services Agency and medical director for the County Public Health Laboratory. MARISOL GONZALEZ Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership. WILLIAM P. HANEY, MD

Dr. Haney, a retired ophthalmologist, has held a longtime interest in the history of medicine, often contributing arti-

cles to San Diego Physician.

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.

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

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 Jessica Hedberg 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

Smart Reductions in Medi-Cal Costs In reality, this simple-minded slash in the Medi-Cal program is likely to increase costs and make a bad program worse.

JOSEPH SCHERGER, MD, MPH

likely to increase costs and make a bad program worse. We can do better. Sometimes budget cuts end up costing a program more, and this is certainly what will happen with a 10 percent cut in payments to physicians who see Medi-Cal patients. SDCMS’ 2007 Physician Workforce and Compensation Survey shows that fewer than half of physicians in private practice currently see Medi-Cal patients, an amount that is 10–25 percent lower than three years ago, depending on the size of the group. Medi-Cal reimbursement to private physicians is among the lowest in the nation for Medicaid programs. When asked if they would continue to see Medi-Cal patients with even a 5 percent cut in payment, large percentages of the physicians said no. With a 10 percent cut, there will be a great exo-

he state’s budget deficit seems to be growing every week. When the $14 billion deficit was discovered this year, a 10 percent cut in provider reimbursement across the Medi-Cal program was quickly proposed and is moving through the legislature. Being the largest line item in the state budget — and not protected by legislative mandates — the Medi-Cal program is the obvious target in the state budget. The total Medi-Cal budget is about $33 billion. $14 billion are state dollars, and the rest comes from federal matching funds. Cutting the program 10 percent will save (on paper) the state budget about $1.4 billion, while losing more than that in federal matching funds. In reality, this simpleminded slash in the Medi-Cal program is

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dus of private physicians from Medi-Cal. If not physicians in private practice, where will Medi-Cal patients go? The community clinics in San Diego County are already at capacity with the number of patients they can see. The increasing uninsured population is severely impacting this source of care. That leaves emergency rooms (ERs), where 4–6 hour waiting times are now the norm. If the bulk of the Medi-Cal population must get their needed healthcare from ERs, the costs to the state go up, not down. When simple primary care problems are seen in the ER at higher costs, wasteful spending occurs. Medi-Cal is more than knee deep in wasteful spending. PricewaterhouseCoopers recently came out with a report that as much as 50 percent of healthcare spending is waste, money

spent for no benefit. Fifty percent! I think that number is extreme, and most health policy analysts today agree on a 30–35 percent figure for waste. That is still huge. Thirty-five percent of our national $2.3 trillion health spending is more than $800 billion! Thirty-five percent of the $33 billion Medi-Cal program is $11.55 billion. A huge chunk of our state deficit could be reduced by cutting Medi-Cal waste, not cutting reimbursement that drives patients to more expensive places for care. Much has been learned in the last 15 years about reducing healthcare costs while improving quality. Some of these changes can be done quickly and could save the state billions of dollars. Here are four ways to save Medi-Cal dollars smartly: 1) SUPPORT PRIMARY CARE MEDICAL HOMES. If every Medi-Cal patient had a primary care medical home and was required to use it, the cost savings would be enormous. Common acute problems would be taken care of inexpensively rather than in ERs. Chronic illness care makes up more than 75 percent of healthcare costs (Rand Corporations studies funded by the IOM), and managing chronic illnesses at the primary care level, such as diabetes, hypertension, and asthma, save massive dollars. Studies show that for every 1 percent reduction in the HbA1c value, the measure of diabetes control, a thousand dollars a year per diabetic is saved in overall costs. Given the current obesity and diabetes epidemic, the costs of poorly controlled patients getting complications are huge. Asthma patients on Medi-Cal crowd our ERs every day at great cost. Good primary care asthma management almost eliminates ER visits and hospitalizations. Assign all Medi-Cal patients to a primary care medical home, and require them to get all but true emergency care there. Referrals to specialists would be done based on real need rather than patients using their Medi-Cal card to shop for doctors. I know this sounds like managed care. Done right, managed care works! California leads the nation in population examples of such savings and efficiency. Medi-Cal groups in California are succeeding with pay-for-performance and quality improvement programs, while our Medi-

Cal program lumbers along in wasteful care lacking any coordination. A minority of Medi-Cal patients already have a primary care home through Medi-Cal managed care plans. The same concept could easily be expanded to all Medi-Cal patients and existing Medi-Cal groups. Paying reasonable rates to primary care and specialty physicians saves money in avoiding unnecessary, more expensive care elsewhere.

health plans are saving money while improving outcomes through personalized care management. 4) PRACTICE COMPASSIONATE LONG-TERM CARE.

Thirty to 40 percent of Medi-Cal costs are in long-term care. In most skilled nursing facilities (SNFs), the majority of patients are on Medi-Cal. For the seniors, most have some degree of dementia. Few have advanced directives or a family willing to do compassionate decision-making. How many SNF beds are hospice beds? Many in long-term care are at the end of their lives, yet curative care is routinely practiced, creating a state of “Medi-Cal captivity” that goes on indefinitely at great cost. Who benefits? Growing up Catholic, I often wondered, “Where is purgatory?” I now know that we create purgatory on Earth with many patients in long-term care. Most long-term care patients should receive proactive compassionate care that recognizes the realities of appropriate care at the end of life. Just think of the savings to Medi-Cal and Medicare.

2) HAVE A COST-EFFECTIVE DRUG FORMULARY.

Amazingly, Medi-Cal takes pride in offering brand name drugs when generic drugs are available at much lower cost. For example, cholesterol lowering with a statin medication is one of the most common medications used in society. Brand name Lipitor dominates in the Medi-Cal program while most private health plans have patients using generics such as simvastatin, pravastatin, or lovastatin. Even at a deep discount, more than $50 a month is spent on Lipitor, while the generic drugs can be gotten for $4 to $6 a month at Wal-Mart and most other pharmacies. Big pharmaceutical companies walk away with large sums of Medi-Cal dollars while the physician providers of care cannot afford to see the patients. I wonder how much the pharmaceutical company lobbyists work to keep their big piece of the Medi-Cal pie intact while the state has great deficits? MediCal should cover essential drugs in the most cost-effective way possible. Put intelligent leadership here without pharmaceutical company influence.

The proposed 10 percent cut in physician reimbursement will have disastrous consequences to the Medi-Cal program. This is not just crying wolf or hyperbole. The private community of healthcare providers is already saying enough, and the exodus from Medi-Cal by the majority of physicians still seeing these patients will push these patients onto systems that are already overloaded. When will we bring intelligence into public healthcare programs and reduce the waste that is all around us? Our legislature should not act mindlessly or at best simplistically with Medi-Cal. Use this budget crisis to begin changing the program for the better. Proven methods for doing that are readily available.

3) REDUCE WASTEFUL CARE. Any physician who works in a hospital sees Medi-Cal dollars wasted every day. There are no bestpractice guidelines. There is no proactive care management. Anything goes. Tests, surgeries, and other procedures are done indiscriminately without attention to the patient’s ultimate outcome. For many patients on Medi-Cal, their social situation is the root cause of their Medi-Cal problems. We repeat cycles of expensive care while the social problems go unaddressed. Sixty percent of premature disease and death are due to lifestyle factors, and Medi-Cal does little to work with patients who become very expensive at no benefit down the road. Other

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ABOUT THE AUTHOR: 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.

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Seminars 2008 San Diego County Medical Society Seminars and Events JUNE

SEPTEMBER

PRACTICE MANAGEMENT SEMINAR

YOUNG PHYSICIANS SOCIAL

“Financial Control for Physicians: Preventing Money Leaks” June 18, 6:30 p.m. - 8:30 p.m.

13, 3:00 p.m. 8:00 p.m.

RISK MANAGEMENT WEBINARS

Nov. 13, 11:30 a.m. - 1:00 p.m., Nov. 13, 6:30 p.m. - 8:00 p.m.; Nov. 14, 7:30 p.m. - 9:00 p.m.

OCTOBER

PRACTICE MANAGEMENT SEMINAR

RESIDENT AND NEW PHYSICIAN

– OFFICE MANAGERS FORUM

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

Sep.

NOVEMBER

SEXUAL HARASSMENT

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

TRAINING — FOR PHYSICIANS

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

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

TRAINING — OFFICE MANAGERS FORUM

Oct. 16, 11:30 a.m.

– 1:30 p.m.

AUGUST

DECEMBER YOUNG PHYSICIANS SOCIAL Dec. 5, 6:00 p.m. - 9:00 p.m.

SDCMS NEW MEMBER SOCIAL

Aug. 8, 6:00 p.m. 9:00 p.m.

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

SDCMS

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 OFFICE MANAGER ADVOCATE: Lauren Woods at (858) 300-2782 or at LWoods@SDCMS.org

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DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org SDCMS FOUNDATION EXECUTIVE DIRECTOR: Aron Fleck at (858) 300-2780 or at AFleck@SDCMS.org SDCMS FOUNDATION ASSISTANT EXECUTIVE DIRECTOR: Tana Lorah at (858) 300-2779 or at TLorah@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

Community Healthcare Calendar

FRESH START’S 2008 SURGERY WEEKENDS WHAT: More than 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.

DELIVERING SAFE AND OPTIMAL CARE THROUGH EFFECTIVE TEAMWORK AND COMMUNICATION WHAT: Seminar ideal for anyone interested in better teamwork and communication in their healthcare setting. 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 WHAT: Conference that encompasses many aspects of the clinical effects of glucocorticoids in a variety of illnesses and in health. 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.

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.

CRITICAL CARE SUMMER SESSION 2008 WHAT: Summer session designed to provide the latest cutting-edge information to critical care practitioners. WHEN: July 24 WHERE: Catamaran Resort Hotel, San Diego COST: $375 CME: 15.25 credits INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATION COURSE

WHAT: Three-day course focusing on those patient situations requiring your urgent attention: hypertension, gynecology, ENT, ophthalmology, and cardiovascular urgencies. WHEN: August 1–3 WHERE: San Diego Marina Marriott COST: $395 CME: 12 credits INFORMATION: Call (858) 652-5400 or email med.edu@scrippshealth.org.

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.

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: • • • •

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

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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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Submit Your Community Healthcare Event at

WWW.SDCMS.ORG

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

WHAT: Three-day CME program with topics of interest to primary care providers, held on the water at the newly renovated San Diego Hilton Resort. WHEN: June 27–29 WHERE: San Diego Hilton Resort CME: Up to 32.5 credits INFORMATION: Visit www.sandiegoafp.org.

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19TH ANNUAL CORONARY INTERVENTIONS WHAT: Discussions around state-of-the-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.

PRIMARY CARE SUMMER CONFERENCE: OFFICE URGENCIES EMERGENCIES

SAN DIEGO ACADEMY OF FAMILY PHYSICIANS’ 51ST ANNUAL POSTGRADUATE SYMPOSIUM

NEW ADVANCES IN INFLAMMATORY BOWEL DISEASE WHAT: Conference intended for physicians, nurses, social workers, and others involved in the care of patients with Crohn’s disease or ulcerative colitis. WHEN: September 13 WHERE: La Jolla Sheraton Hotel COST: $125 INFORMATION: Call (858) 652-5400 or email med.edu@scrippshealth.org.

Ask Your Physician Advocate! By Marisol Gonzalez How Long Before a Physician-Patient Relationship Is Terminated? How Far Back Can Health Plans Go to Collect for Overpayments? How Long Is a Contact Lens Prescription Good for?

cialist for future unrelated problems that fall within the specialist’s area of expertise. If the physician has any doubt as to whether or not the physician-patient relationship has in fact been terminated, the physician would be well advised to provide care to the patient. After treatment, the physician can then send the patient a letter notifying him or her that the physician is terminating the relationship and will not provide care after a reasonable period of time.

ON-CALL document #0152, “Medicare Managed Care/Medicare Advantage,” states, “Despite the plethora of physician and patient protections contained within California law, generally speaking, these laws have no application to plans offered by Medicare Advantage organizations.” It goes on to say that Medicare Advantage standards supersede all state law and regulation, with the exception of state licensing laws and laws relating to plan solvency.

UESTION: A health insurance company sent me to collections for an amount they claimed was an overpayment to me for a patient that I saw four years ago. This company claimed that the patient was not covered by them and that the patient was in fact a Medicare Advantage enrollee. When I verified eligibility for the patient at the time of treatment, I used the insurance company’s online eligibility verification service. I printed a snapshot of this verification as proof of eligibility. I’m glad that with the help of SDCMS-CMA, I was able to get this situation resolved, but doesn’t California law state that health plans can only go back as far as 365 days for overpayments?

MARISOL GONZALEZ

UESTION: I have not seen one of my patients for two to three years. Is it safe to say that my relationship with this patient has been terminated? ANSWER: No. According to CMA ONCALL document #0805, “Termination of Physician/Patient Relationship,” the passage of time alone does not necessarily establish that a patient has terminated the physicianpatient relationship. A physician should not assume that because a patient has not made an appointment with the physician for a year or more, the patient does not expect to receive further services from that physician. A patient may still anticipate that the physician, particularly a primary care physician, will be available to treat the patient for future problems. In addition, a patient who visits a specialist for a particular disorder may expect to be able to return to that spe-

ANSWER: Yes. Licensed Knox-Keene plans and insurers are precluded from pursuing overpayments more than 365 days after the original payment, unless the overpayment was caused in whole or in part by provider fraud or misrepresentation. If the patient was in fact a Medicare Advantage enrollee, this California law would not apply. CMA

UESTION: Once we do an eye exam on a patient for a contact lens prescription, how long is it good for?

ANSWER: According to Business and Professions Code 2541.2, the expiration date of a contact lens prescription should not be less than one to two years from the date the patient receives a copy of the prescription. Reexamination of the patient should be done earlier than one year if the patient’s history or current circumstances establish a reasonable probability of changes in the patient’s vision of sufficient magnitude or the presence of probability of visual abnormalities related to ocular or systemic disease indicate the need for reexamination.

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. 12

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PHYSICIANS needed in greater Rancho Bernardo & Scripps Ranch*

Cardiologists Dentists Family Practice Physicians Internists

Ob/Gyn’s Oncologists Ophthalmologists Physical Therapists

Surgeons * Underserved Specialties Data Sources – Solucient Market Planner Plus; US Census Bureau; Claritas, Inc.; American Medical Association Physician Masterﬁle —April 2006

Lease New Class `A´ Medical Ofﬁce Space at

Pinnacle Medical Plaza 10672 Wexford, San Diego 92131 Leasing: Paul Braun 858.677.5324 paul.braun@colliers.com

Chris Ross 858.677.5329 chris.ross@colliers.com

www.pinnaclemedicalplaza.com

Tom Mercer 858.677.5388 tom.mercer@colliers.com

Our Knowledge is your Property

fly Noted e i r B Margaret E. McCahill, MD

By SAN DIEGO PHYSICIAN

SDP: WHY DID YOU CHOOSE THIS PARTICULAR MODE OF PRACTICE? DR. MCCAHILL: I think it chose me. For over 28 years, I have cared for patients who are medically underserved. Many people do it for a few years, which is wonderful, but for those who do it as a career, I believe the vocation just chooses you.

SDP: ARE YOU DOING WHAT YOU THOUGHT YOU WOULD BE DOING IN THE HEALTHCARE INDUSTRY?

nursing trainees, marital and family therapy trainees, and chaplain trainees — we have five different professional disciplines training together in our team. In between a morning and afternoon of clinic, there will be more meetings, credentials applications to review, correspondence to answer, and grants to write and/or review. There will be tours of St. Vincent de Paul Village coming through, and some visitors may want to stop to ask questions, which we are always pleased to answer. After leaving the

We just go into each exam room and do the best we can for that patient. I think that is the biggest thing that makes it easy for me to say I am the happiest physician I know.

argaret E. McCahill, MD, founding director of the UCSD Combined Family Medicine and Psychiatry Residency Program, current medical director of St. Vincent de Paul Village Family Health Clinic, and 15-year member of SDCMS-CMA, is the proud recipient of the 2008 Physician Humanitarian of the Year Award presented by the Medical Board of California. She was honored for her many years of providing outstanding care to medically indigent patients and her dedication to training and enlisting future healthcare providers of varying disciplines to continue to care for the underserved. Congratulations!

SDP: HAVE YOU ALWAYS WANTED TO BE A PHYSICIAN?

DR. MCCAHILL: I have been very fortunate to

be able to do more than I ever thought possible to help those who have no access to healthcare. This can only happen if one is fortunate enough to be able to join a team that does what your passion is. When I was able to bring together the teaching mission of UCSD Family Medicine with the service mission of St. Vincent de Paul Village and its outreach programs, much more has happened than I could ever have done by myself. We are able to care for thousands of uninsured San Diego-area residents, and to teach hundreds of our community’s future healthcare professionals while providing that care. It is really the team that makes it happen, and it doesn’t get any better than that. SDP: DESCRIBE A TYPICAL DAY.

Yes. When I was growing up, women were strongly discouraged from entering medical school, so I went to a nursing school first and then changed my major to pre-med before graduating. I have always been grateful for the nursing training I received, however.

DR. MCCAHILL:

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DR. MCCAHILL: I may have a 7 a.m. meeting somewhere, or I may go to the clinic first. There will be patients to be seen, and there will be trainees who have questions about their patients: the resident physicians, clinical pharmacy trainees, medical students,

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clinic, there will be evening meetings at the university, then home to care for grandchildren. When the little ones are in bed, there are administrative matters to complete, and there will be emails from medical students and others who just found our program on the website and need to hear back from us in this moment of enthusiasm. The work stops by midnight, most of the time. SDP: WHAT CHALLENGES OR FRUSTRATIONS DO YOU EXPERIENCE THAT KEEP YOU FROM BEING 100 PERCENT SATISFIED WITH YOUR CHOSEN CAREER PATH? DR. MCCAHILL: I am one of the happiest physicians I know. Because our clinics don’t care for patients with insurance (all services are free, and we refer those with insurance to clinics that do bill it), we have no worries with billing, managed care, or any of that. Precepting residents is very simple when there are no insurance companies involved. In fact, everything about the practice is much simpler: We just go into each exam room and do the best we can for that patient. I think that is the

If your medical license or privileges are on the line… biggest thing that makes it easy for me to say I am the happiest physician I know. SDP: WHEN DID YOU JOIN SDCMS-CMA AND WHY?

Rosenberg, Shpall & Associates, APLC 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

DR. MCCAHILL: I was encouraged to join organized medicine by my colleagues and decided to join in 1985. Altogether, I have been a member for over 15 years.

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. Amy C. Lea, J.D.

SDP: WHY DO YOU THINK DOCTORS SHOULD BECOME INVOLVED IN ORGANIZED MEDICINE? DR. MCCAHILL: The thing that seems to make most of my colleagues miserable is the interface between medicine and the whole business of billing and insurance issues. Prescription callbacks alone drive many of my colleagues crazy. We would all just like to practice medicine and get that third party (the payers) out of the room. A physician fighting that alone will not get very far, but working together, maybe physicians can maintain some control over their practice.

SDP: WHAT THOUGHTS WOULD YOU LIKE TO LEAVE US WITH? DR. MCCAHILL: It seems to me that the key to

a satisfying medical practice is to be doing that which is truly your passion. When we can do that, it is possible to put up with a lot of flack. If you can’t do the work that you’re passionate about all the time, try to carve out a part of your workweek so you can do it for at least that part of your time. Then make that part grow over the years.

For more information on Dr. McCahill and the programs in which she is involved, visit www.combinedresidency.org, www.sandiegohealthandfaith.org, www.neighbor.org, or email her at mmccahill@ucsd.edu.

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

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

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fly Noted e i r B

Covering for Another Physician By THE SCPIE COMPANIES

(

)

pletely with a covering physiovering for another Patients who have not been forewarned may cian before he or she fills in physician is a combe anxious and concerned that their “real” helps reduce the risk of liabilmon activity, but it doctor is not there for them in a time of need. ity. Consider the following: can increase liability risks for the physicians involved. These their “real” doctor is not there for them k Agree on limitations for prescribing risks can be reduced by being aware of in a time of need. The goodwill and and refilling medications. A good some of the problems that could result rapport you have with your patients in malpractice claims. The following rule is to refill only enough medwill not automatically transfer to a recommendations may help when signication to carry the patient through covering physician. ing out to someone else: until the next appointment with k Take the lead: Telephone the coveryou. ing physician and provide details. Ink Choose a covering physician who is k Agree that the covering physician form him or her about special reliable and trustworthy, preferably will not prescribe any new medicapending cases or difficult patients. one who has comparable or equivation without first examining the paMost patients feel that no one underlent training and experience. For extient. stands their problem as well as their ample, an internist would normally k Ask the covering physician to proown doctor. Colleagues may be at a not cover for a surgeon, yet a family vide prompt documentation of all significant disadvantage if they are practitioner could usually cover for an patient contacts. not advised of a highly charged situENT specialist. ation with an apprehensive or even k When feasible, notify patients well in Taking precautions and discussing hostile patient or family. advance of any prolonged absence. Pawith colleagues the full range of on-call tients who have not been forewarned may be anxious and concerned that

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Communicating clearly and com-

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coverage responsibilities can help reduce your liability exposure.

Quote

Know Your

MEDICAL STAFF’S RIGHTS

The protection of the medical staff’s right to selfgovern and the rights of individual physicians to due process are essential to ensure the very best patient care. — Stephen T. House, MD, Chair of the American Medical Association Organized Medical Staff Section

Q CMA ON-CALL Documents

ANSWER: This law provides legal protection for six key principles of medical staff self-governance that are essential for the professional teamwork of the medical staff. 1 Creating and amending medical staff bylaws. (Although all bylaws changes are subject to approval by the hospital governing body, the governing body cannot unreasonably withhold its approval.) 2 Establishing and enforcing criteria for medical staff membership and privileges. 3 Establishing and enforcing quality of care and utilization review standards, and overseeing other medical staff activities, such as medical records review and meetings of the medical staff and its committees. 4 Selecting and removing medical staff officers. 5 Collecting and spending medical staff dues. 6 Hiring independent legal counsel, at the expense of the medical staff. (This bill also gives the medical staff the right to expeditiously seek resolution of self-governance disputes through the court system.)

SDCMS-CMA members can access an array of information relevant to medical staffs at the members-only section of CMA’s website at www.cmanet.org. For assistance in logging onto CMA’s website, contact your SDCMS physician advocate, Marisol Gonzalez, at (858) 300-2783 or at MGonzalez@SDCMS.org.

CMA ON-CALL DOCUMENTS: • “Bylaws Analysis Service” (#1703) • “CMA-sponsored Medical Staff Self-governance Bill: A Primer on SB 1325 (#1218) • “Disruptive Behavior Involving Members of the Medical Staff” (#1241) • “Economic Credentialing and Exclusive Contracts” (#1212) • “Exclusive Contracts” (#1211) • “Guidelines for Physician Wellbeing Committees Policies and Procedures” (#1240) • “Hospital Medical Staff Incorporation” (#1219) • “Legal Counsel for the Medical Staff Consistent or Conflicting Interests” (#1281) • “Medical Staff Applicants in MBC Diversion Program” (#1210) • “Medical Staff Membership for Physician Excluded From Any Federally Funded Healthcare Program” (#1207) • Medical Staff Self-governance Policy and Law (#1280) • “Sexual Harassment in the Medical Staff Context” (#0837)

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UESTION: WHAT IS THE MEDICAL STAFF SELF-GOVERNANCE ACT (SB 1325)?

(Source: www.calphys.org/ html/bb693.asp)

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Leadership

Contextual Decision-making What Do You Know? Known Knowns:

Simple Context

Known Unknowns:

Complicated Context

Unknown Unknowns:

Complex Context

Unknowables:

Chaos

By TOM GEHRING cle as “the simple context — the domain of best practice” (“A Leader’s Framework for Decision Making” by David Snowden and Mary Boone, Harvard Business Review, November 2007). Since I don’t want to focus on medical decision making, let’s try another example: executing a budget. The facts are (usually) clear, and the actions to be taken if off budget are (usually) clear. We adhere to best practices. What should the leader do in this context? Avoid micromanaging, make sure people don’t become complacent by ensuring every anomaly is investigated, and make sure processes are adhered to. What happens if there are multiple right answers? This is the realm of “known unknowns.” Rather than make a simple causeeffect decision, we need to investigate multiple options and choose between them. There is often incomplete and even con-

n previous issues of San Diego Physician, I’ve written about decisionmaking, assuming that all decisions are made in essentially the same manner. In this article, I’ll discuss why decisions need to be made in context. Let me start with an example: A patient comes into the ER with severe trauma. While the outcome may not be pre-ordained, the protocols are clear — the decision-making is (nearly) straight line, i.e., cause and effect, because in this case we are dealing with (mostly) “known knowns,” and there is usually one “right” answer. This in no way diminishes the skill necessary to do the right thing — becoming an effective trauma surgeon takes decades. However, the process of making decisions in this case is referred to by David Snowden and Mary Boone in their Harvard Business Review arti-

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flicting information. Experts are often helpful in providing the information necessary to make decisions. What must the leader do? Investigate all the options, ensure that all the experts are heard from, make sure the “wild and crazy” ideas of the non-experts are considered, avoid analysis paralysis, and, in the end, as all leaders must do, make the decision. The best medical example would be a patient who comes in with multiple, undifferentiated symptoms. In this case, the

treating physician must marshal all of the relevant experts to come up with a diagnosis, often in the face of incomplete information and multiple strong opinions. Snowden and Boone refer to this as the “complicated context — the domain of experts.” What happens if there is no right answer? If the decision-making context is filled with unpredictability, incomprehensible change, and often a complete lack of understanding (except in retrospect) of what is going on? Then we are in the domain of “unknown unknowns” — the most challenging decision-making environment for a leader, and the context in which we more and more find ourselves. Consider two problems: repairing a Prius and building a power line through a desert preserve. A Prius is a complicated machine and takes an expert to fix, but there are technical manuals, there are a finite number of parts, and, in the end, the Prius is the sum of its parts. The ecology of the desert preserve, on the other hand, is never the same: There is constant change, there are many stakeholders, and there is conflicting science, i.e., the whole is more than the sum of the parts. Snowden and Boone refer to this as the “complex context — the domain of emergence.” For leaders used to the dictum “don’t just stand there, make a decision,” the complex context is nerve racking because it calls for the leader not to make snap decisions, not to try to impose order (or a tried-and-true model) on a situation that is oh-so-unclear, to foster creativity and experimentation, and to be patient. Finally, we have a “chaotic context — the domain of rapid response.” Quoting Snowden and Boone, “In a chaotic context, searching for the right answer would be pointless. The relationships between cause and effect are impossible to determine because they shift constantly, and no manageable patterns exist, only turbulence. This is the realm of the unknowables. The events of September 11, 2001, fall into this category. The leader’s task is obvious — and the exact opposite of the complex context — communicate and direct in a “top-down” manner (there is no time for input or committee meetings) to establish order. Paradoxically, the leader must look and listen for signs that

stability is emerging and then revert to the leadership styles of the complex context. Having reviewed the four basic contexts of decision making — simple, complicated, complex, and chaotic — the single most important message for the reader is to understand which context you are in and then apply the appropriate decision-making

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style. Applying the right decision-making style for the given context is just using the right tool for the task!

Mr. Gehring is executive director and CEO of the San Diego County Medical Society.

ABOUT THE AUTHOR:

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Risk Management

Getting Sued for Breast Cancer

WAYS TO PRODUCE LITIGATION

By RICHARD E. ANDERSON, MD, THE DOCTORS COMPANY uits involving breast cancer are the most common cause of malpractice litigation in the United States. This is true despite the fact that breast cancer is relatively common, diagnostic pathways are well established, patients often request breast cancer-specific evaluation, and there is clear benefit to early diagnosis. The vast majority of cases allege delay in diagnosis. These claims may, in turn, be divided into those involving diagnostic error and those involving poor communication. Additional claims arise from therapeutic acts of omission or commission. Without much difficulty, I have put together a list of 39 ways to get sued for breast cancer. Undoubtedly, you will not agree with every item or its categorization, and you may want to add others. A number of these examples could have been listed in more than one category. I encourage your participation in adding to future versions of this material. Nonetheless, the ways I have listed here have proven to be regrettably effective in precipitating malpractice litigation, an outcome all of us wish to avoid.

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NINETEEN WAYS TO GET SUED FOR BREAST CANCER INVOLVING THE HISTORY AND PHYSICAL EXAMINATION

Assume that a mass in a young woman is not cancer. 2 Ignore a breast mass in a pregnant woman. 3 Ignore a breast mass in a lactating woman. 4 Ignore a breast mass in an elderly woman. 5 Allow a negative physical examination to delay biopsy in a patient with a suspicious mammogram. 6 Believe that the absence of grave signs of breast cancer is evidence against the presence of breast cancer. 7 Assume a nipple discharge is just hormonal. 8 Assume the presence or absence of breast pain is an important determinant of cancer. 9 Fail to document history, physical examination, and plan for follow up. 10 Order a diagnostic study and fail to assure it is completed.

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11 12 13 14

15 16 17

18 19

Allow a patient with a known lesion to be lost to follow up. Tell a patient not to worry about a mass she brings to your attention. Fail to suggest breast cancer screening in appropriate patients. Fail to assure that breast cancer screening includes both a physical examination and a mammogram. Fail to take an adequate family history. Fail to discuss breast cancer prevention in high-risk patients. Fail to discuss family screening for a patient with a strong family history of breast cancer or who is known to carry BRCA 1 or 2. Dismiss palpable axillary lymph nodes as simply normal. Tell a patient she would have been cured if only we had found the lesion earlier.

TEN WAYS TO GET SUED FOR BREAST CANCER INVOLVING MAMMOGRAMS

Allow a negative mammogram to delay biopsy of a suspicious mass.

Allow an indeterminate mammogram to delay biopsy of a suspicious mass. 3 Allow a negative breast ultrasound to exclude cancer in the face of an indeterminate mammogram. 4 Read a technically inadequate mammogram. 5 Fail to compare current mammograms to prior studies. 6 Fail to personally inform the referring physician of suspicious findings. 7 File an abnormal mammogram report without contacting the patient. 8 Fail to obtain a specimen or postbiopsy mammogram in a patient with diffuse microcalcifications. 9 Perform a mammogram on a self-referred patient without assuring clinical follow up. 10 Tell a patient that with the benefit of hindsight, a nonspecific finding on a prior mammogram was actually cancer.

10 1

These 39 ways of getting sued for breast cancer are not exhaustive, but every one has, in fact, produced litigation in our experience. The last one is particularly troublesome because it says our system does not reward even the responsible exercise of clinical judgment unless the outcome is perfect. No physician believes good clinical practice is possible without good clinical judgment, and no one wants to practice purely defensive medicine. Nonetheless, in the current

medico-legal environment, anything other than the earliest possible diagnosis of breast cancer may produce yet another malpractice claim. Weighed against a diagnosis of cancer, retrospective arguments concerning cost, patient anxiety, or low probability may not be satisfactory defenses. ABOUT THE AUTHOR: Dr. Anderson is chairman and CEO of The Doctors Company.

Endorsed by

TEN WAYS TO GET SUED FOR BREAST CANCER INVOLVING BIOPSY AND TREATMENT

Issue a pathology report without reviewing prior biopsies. 2 Issue a pathology report without understanding the clinical context. 3 Fail to personally inform the referring physician of a suspicious finding on a biopsy. 4 Allow a negative fine-needle aspiration to exclude a diagnosis of breast cancer. 5 Perform definitive breast surgery relying on an outside pathology report from a pathologist you do not know. 6 Perform definitive breast surgery without waiting for a definitive pathology report. 7 Fail to offer breast conservation therapy to appropriate patients. 8 Treat inflammatory lesions of the breast with antibiotics without assuring complete resolution. 9 Treat enlarged axillary lymph nodes with antibiotics without assuring complete resolution. 10 Assume a patient will be grateful because your decision to delay biopsy of a lesion, which proved to be malignant, was based on sound clinical judgment.

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www.CHMBSolutions.com

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Public Health

Hot Topics in Communicable Reportable Disease By MICHELE GINSBERG, MD, AND MEMBERS OF THE COMMUNITY EPIDEMIOLOGY BRANCH

here are currently more than 80 diseases that are reportable to the local public health officer. This article highlights investigations of two rare diseases conducted by the Community Epidemiology Branch (CEB) of HHSA and surveillance of a common condition. A complete list of communicable diseases reported in San Diego County from 1996 to 2007 is available at www.sdepi.org. VECTOR-BORNE ILLNESSES

During 2006, two patients were admitted to local hospitals after being exposed to vector-borne diseases elsewhere.

A Two-year Review (2006–2007)

was supple, and no lymphadenopathy was noted on physical exam. There was a questionable infiltrate noted on her chest X-ray. WBC: 28,600 shift to left. Platelet: 36,000. Blood cultures: Gram-negative rods. CEB was contacted, and public health laboratory performed PCR test on the isolate and identified Yersinia pestis. Sputum cultures were negative for plague, and the patient was diagnosed with septicemic plague. Public Health follow-up with original hospital staff and air flight crew was undertaken. This case was attributed to Inyo County and will not be listed in San Diego list of reportable diseases. CASE 2: In early November, a 55-year-old fe-

CASE 1: A 70-year-old female resident of Inyo

County, California was admitted to a hospital near her home with altered mental status and pneumonia. She had two free-roaming dogs, and rodents were found in her house. The patient was airlifted to a San Diego hospital. On admission, the patient was responsive only to pain. Her neck

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male was admitted to a local hospital. She was evaluated for dehydration secondary to vomiting and SOB, fever, and chills. A petechial rash was observed on her thighs, shoulders, and back. Initial blood tests — platelet count: 24,000; hematocrit: 53.5 percent. The woman returned to San Diego a week before hospitalization after conclud-

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ing a six-month trip in her camper. She camped throughout the Western states, including Wyoming, Utah, and California. County Vector Control examined the camper, which contained rodents and animal skins. A deer mouse trapped in the camper tested positive for hanta virus, as did a blood sample from the patient. The patient expired. Obtaining a travel history and area of residence were key in making the diagnosis of both these vector-borne illnesses. Public Health can assist with animal surveillance information, laboratory testing for plague, hanta virus, West Nile virus, and assure that appropriate environmental evaluation and mitigation are taken. In 2007, San Diego experienced a record high of West Nile virus cases — 225 patient specimens were tested at the San Diego Public Health Lab. Sixteen cases of West Nile disease were diagnosed; 15 people were exposed in San Diego County. Twelve were neuroinvasive, and four were West Nile fever. In a future article, San Diego County

Vector Control will discuss the vector control activities related to West Nile. FOOD-BORNE OUTBREAKS

When you evaluate a patient with gastrointestinal symptoms and obtain a stool culture, the clinical laboratory is encouraged to submit salmonella, shigella, Enterotoxigenic E. coli, and listeria to the public health laboratory. All patients reported with enteric infections are interviewed. Identification of common exposures at restaurants or consumption of common products results in further investigation, correction of problems at facilities, and removal of the implicated product from further sale. During 2006, 31 food-associated outbreaks were identified in San Diego County. When a case investigation identifies an eating establishment that may be the source of exposure, Environmental Health sanitarians inspect restaurants and review food handling practices as well as the facility structure and source of foods served. During 2006, investigations conducted in San Diego were instrumental in the recall of unpasteurized milk and colostrum associated with E. coli O157:H7 infection, salmonella associated with Easter chicks and pet lizards, and Vibrio vulnificus infection associated with raw oysters. During 2007, there were 21 food-associated outbreaks and a case of botulism associated with a nationwide recall of a canned chili product.

aged to report positive influenza detections to the public health laboratory at (619) 692-8500 or by fax at (619) 692-8558. Additional information about disease reporting is available by calling (619) 515-6620. San Diego County Community Epidemiology Branch thanks you for prompt disease reporting. It facilitates the investigation and overall reduction in disease.

ABOUT THE AUTHOR: Dr. Ginsberg is trained in internal medicine and infectious diseases and has been with the County for more than 30 years. She is chief of the Community Epidemiology Branch in the Public Health Services Division of the Health and Human Services Agency and medical director for the County Public Health Laboratory.

INFLUENZA SURVEILLANCE IN SAN DIEGO COUNTY

San Diego County conducts influenza surveillance year-round. Effective public health intervention is dependent on early detection of circulating strains and monitoring the disease impact on the community. Influenza surveillance includes: • Influenza virus detection and characterization, laboratory confirmation. • Reporting of severe pediatric influenza cases. • Surveillance of emergency department visits and school absence for “flu-like illness.” • Review of death certificates and syndromic surveillance. Physicians and laboratories are encour-

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Medical Staff Relations

A Practicing Physician’s Perspective By KENNETH COHN, MD, MBA PART 1

e teach residents how to practice but not how to live life as a physician. A national survey of 1,205 physicians documented burnout in 66 percent, depression in 32 percent, and suicidal ideation in 4 percent. Physicians are experiencing 11 distinct losses, including losses of financial security, status, independent clinical decision-making, collegiality, freedom of choice of specialty and practice location, and power in hospital governance. This article describes different ways that physicians and hospital leaders can work together to improve the practice environment and reconnect with the values that attracted them to healthcare careers in the first place.

STRUCTURED DIALOGUE

“Structured dialogue” (Figure 1) is a process that helps a group of practicing physicians articulate their collective, patient-centered self-interest. Structured dialogue can help physicians improve physician-physician communication, understand more fully the complexity of hospital operations, and articulate clinical priorities for their communities. Unlike hospital-centric change efforts, the structured dialogue process is led by a medical advisory panel (MAP) of highperforming, well-respected clinicians, who are asked as experts

Note: For a copy of this article with complete references, including reprint permissions and further resources, please email Editor@SDCMS.org or visit www.SDCMS.org.

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to take a community-wide view of health delivery. Based on presentations by physicians in the major clinical sections and departments, the MAP recommends clinical priorities in a report to hospital management and the board. The panelâ&#x20AC;&#x2122;s report contains a statement of the direction in which the hospital and medical staff should be heading, rather than a list of capital-intensive budget items. In return for giving physicians a say in clinical priority setting, the hospital is able to enlist physicians to attend meetings and outline priorities. continued on page 27

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Medical Staff Relations

Unlike hospital-centric change efforts, the structured dialogue process is led by a medical advisory panel (MAP) of high-performing, well-respected clinicians, who are asked as experts to take a community-wide view of health delivery.

CRITICAL STEPS IN IMPLEMENTING THE STRUCTURED DIALOGUE PROCESS Over 30 hospitals and hospital systems in the United States have successfully undertaken a structured dialogue process by pursuing the following specific steps:

• • • • • • • • •

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The hospital CEO and practicing physicians engage in a discussion of issues affecting care at their hospital. Practicing physicians agree to participate in the structured dialogue process in return for assurance that the CEO and the board make every effort a priori to implement the physicians’ recommendations. The CEO appoints two co-chairs who are outstanding clinically, respected by their peers, flexible in their outlook, and willing to invest time to improve care processes. The co-chairs pick a panel of 5–14 similarly talented physicians from different clinical areas who have earned the respect of their peers. The panel hears presentations from physicians in all major clinical areas after being briefed by administrators, including the CEO and vice presidents of finance, nursing, and information technology. The chief medical and nursing officers attend MAP meetings to listen to the presentations and serve as resources. A talented administrative assistant assists with scheduling, room reservations, and other aspects of communication, on average five hours per week in the beginning of the process. Identified “quick-fixes” are addressed and solved, giving the process increased credibility. MAP members compile a data-driven, consensus-based report that outlines the top three to four major clinical initiatives (based on recommendations that presenters from multiple sections raise repeatedly) and lists the top

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•

five recommendations of every physician presenter, which they discuss with physician colleagues, administrators, and the board. A joint task force of physicians, nurses, and administrators implements the major MAP recommendations in a timely fashion within two years.

In general, hospitals of varying size have used the time-tested, structured dialogue process successfully by meeting the following three prerequisites: 1) Physicians and hospital executives must be interested in exploring how they can work together to improve care for their community. 2) Practicing physicians must recognize the benefit of making time to prepare for and attend meetings based on their need to use their time better, improve processes of care, and/or leave a lasting legacy. 3) Hospital administrators and the board must agree a priori to make every effort to implement the physicians’ carefully thought-out recommendations, even if the physicians’ suggestions represent a change in the hospital’s business model. This step may be frightening to hospital leaders who are comfortable with a top-down approach and view physician-led clinical priority setting as a loss of control; a trained facilitator can reassure hospital leaders that by surrendering control, they will achieve increased influence and improved standing with their boards. Trust may be fragile in the beginning but increases as communication improves, hospital processes become more transparent, and physicians begin to appreciate the complexity of healthcare where they work.

Medical Staff Relations continued from page 25

CASE STUDY: CLINICAL PRIORITY SETTING RESULTS

A West Coast nephrologist who served as co-chair of the MAP at his hospital summarized the process as follows: Our report, presented to the hospital board of directors in September 2003, represented the first time that the hospital received a consensus report from practicing physicians about what the hospital should do in the future. Before, the process involved physicians pursuing individual (and sometimes selfish) agendas. We evolved from a self-interested view of what the hospital should do for us as physicians to a more empowered view of how the

CLINICAL PRIORITY SETTING PROCESS Hospital Management Board of Trustees

Medical Advisory Panel prioritized recomendations

set guidelines; appoint presenters

Clinical Presenters

written documents; oral presentations

Medical Staff

Clinical Presenters and peer participation in sections/services

FIGURE 1: The Structured Dialogue Process for Clinical Priority Setting

hospital could employ limited resources to improve care for our community. Through the process of discovery, we began to think and act more as long-term partners and co-owners than short-term customers and renters. The MAP process allowed us to evolve beyond maintaining a level playing field for all physicians to leveraging hospital resources to meet community needs. That clinicians who prided themselves on patient care could come to consensus on long-term priorities gave the board and hospital administration the confidence to accept the MAP recommendations. On this journey, a number of quick fixes were identified and corrected. Seeing nagging irritations suddenly solved — such as making sure that the physician on-call rooms had clean linens daily — lent excitement and credibility to the process. Although the report recommended the immediate establishment of a palliative care program, the creation of an acute stroke center and much greater emphasis on improvement of throughput in the operating room and emergency departments, which are in the process of implementation, subsequent accomplishments that occurred after the report writing are equally significant: • During the implementation phase, the MAP encouraged orthopedists to consolidate vendors, which they accomplished. This resulted in a $4.2 million savings over the following three years and brought the average implant cost down from $11,000 to $4,200. • In addition, the MAP spearheaded an ambitious program to limit sepsis mortality by accelerating identification of septic patients, decreasing laboratory test turnaround times, administering antibiotics more rapidly, and taking measures to curtail ventilator-associated pneumonia. This multipronged approach resulted in a 50 percent decrease in hospital sepsis mortality, from 46 percent to 23 percent in the first year of the program. The MAP has continued as an advisory body, meeting monthly with members of the administration and leaders of the medical executive committee and reporting to the board of directors annually. This direct line to the board assures the physicians that there will be no immediate veto of the physician-generated recommendations. Previous service on hospital committees felt like wasted time because I did not feel that anyone with the power to do anything was listening, and nothing was implemented in a timely fashion. No one person seemed accountable, and the communication loop rarely was closed. The reason for my change in behavior stems from the feeling that I am making my time count and that we are truly making a difference. The MAP process has reinvigorated physician communication and patient care and made me realize the value of pooling ideas and talent. Previously, I did not realize how often we were talking at each other rather than to each other. Through the processes of dialogue, active listening, and discovery,

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I am dealing with some of the complexities in healthcare administration and have begun to think, work, and act more interdependently than independently. CASE ANALYSIS

The structured dialogue process creates a safe environment in which to explore differences and use reflection and feedback to improve hospital processes and physician-physician communication. As communication improves and recommendations are implemented in a timely fashion, transparency and trust build, which improves the practice environment, expands service lines, and results in better care for the community. Physician satisfaction impacts the satisfaction of other team members, making it easier to recruit and retain talented healthcare professionals. The most fundamental lesson is that, through the processes of reflection, dialogue, and discovery, physicians who are not employees of a hospital can become motivated to act like stewards and owners of a valuable community resource. Many practicing physicians are skeptical of the value of attending hospital meetings because their income depends on seeing patients, they lose income when they are not providing direct patient care, and they feel that they rarely see evidence that their input influences decision-making in a timely fashion. Physicians can bring focus to decision-making with a data-driven, fix-it-now approach, just as administrators can prevent costly errors by wanting to understand contingencies affecting multiple stakeholders before making major decisions. THE ROLE OF PHYSICIAN CHAMPIONS

Physician champions, such as those who serve on the MAP, help to create a safe environment for learning and leave a lasting legacy through improved communication, proactive clinical priority setting, and improved processes and programs. Cultural transformation embodies personal change, as illustrated in the case presentation. CONCLUSION

Active physician participation that leads to timely changes in the practice environment gives physicians a feeling that their time is well spent and facilitates finding physicians who are willing to participate in medical staff task forces. By sharing timely information about hospital operations with physicians, the structured dialogue process enables physicians to understand the complexity of running a contemporary hospital, improves physician-hospital communication and collaboration, and serves as an effective training environment for new physician leaders. In part II, I will discuss two additional frameworks that allow physicians to build on success (appreciative inquiry) and find practitioners in their own communities who are doing great work and incorporate their ideas (positive deviance).

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PART 2 In part I, I discussed the self-fulfilling prophecy of medical staff relations, that if you treat physicians as adults, you receive adult behavior. In part II, I will illustrate how physicians can build on success (appreciative inquiry) and find practitioners in their own communities who are doing great work and incorporate their ideas (positive deviance). APPRECIATIVE INQUIRY

Appreciative inquiry (AI) is based on the premises that people respond favorably to positive reinforcement and that sharing stories of past successes generates more energy and less defensiveness than analyzing problems and attributing blame. AI may be helpful when root-cause analysis becomes mired in finger pointing. Physicians and hospital leaders can use AI to overcome defensiveness, turf battles, negativism, change fatigue, and slow response time. Physicians can encourage healthcare leaders to incorporate AI into their daily practice by making rounds and giving positive reinforcement to other healthcare professionals when patients express satisfaction or

The most fundamental lesson is that, through the processes of reflection, dialogue, and discovery, physicians who are not employees of a hospital can become motivated to act like stewards and owners of a valuable community resource.

delight, and by asking people, â&#x20AC;&#x153;What is going well for you?â&#x20AC;? rather than making problems the focus of rounds. The following case study demonstrates the relevance of AI in a healthcare setting. CASE STUDY: PHYSICIANS AND HOSPITAL LEADERS BUILD ON SUCCESSFUL CRISIS MANAGEMENT

When the CEO was out of town, a hospital noted contamination of its water supply. Routine testing showed small quantities of a microorganism capable of causing systemic illness in immuno-compromised patients arising from an old shower head. Rapid repeat testing confirmed that the contamination was not a result of laboratory artifact and raised the question that the hospital water supply might be contaminated. Physicians and management representing infectious diseases, oncology, pediatrics, and the offices of the vice president for medical affairs (VPMA) patient care services, operations, and public relations cleared their schedules and formed a command post from which to receive and communicate information rapidly and often. They shut off the existing water supply and made arrangements for an emergent resupply of fresh water while they researched ways to determine the extent of the contamination, remove

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the source(s), and purify their water delivery system. They calmly briefed the CEO and board of directors and then medical staff, employees, the press, and local community agencies to offer assurance that they had identified a problem and were in the process of remedying it. In addition, they stepped up monitoring of susceptible patients. Within three days, the team had replaced the old shower heads and purified the water system. No patient morbidity or mortality occurred as a result of the contamination. In discussion of the situation afterward, some participants felt that the departmental culture and the annual process of budgeting created silos that made it difficult to obtain interdepartmental cooperation except in times of crisis; however, all agreed that the shared values, camaraderie, and pride they felt from their rapid and effective handling of a potentially lifethreatening contamination episode gave them a sense of accomplishment on which they built during future challenges.

CASE ANALYSIS

Professionals prefer being inspired to being supervised. Generally, it is quicker and easier to build on small wins than to tear down perceived weaknesses. Storytelling, which is an integral part of AI, decreases the inhibiting effects of hierarchy on an organization, uses metaphors to summarize important points and make them vivid, and provides vignettes that are remembered more readily than facts. POSITIVE DEVIANCE

Positive deviance (PD) is a bottom-up The silo mentality approach to organizational change, based on the premise that soluembodied in â&#x20AC;&#x153;Let the docto problems already exist tors and nurses deal with pa- tionswithin the community. It encompasses intentional tient care and leave finance and behaviors that depart operations to the administrators,â&#x20AC;? is from the norms of a in honorable destined for failure in a rapidly changing group ways. PD seeks to environment. identify and op-

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timize existing resources and solutions rather than obtaining external resources to meet those needs. Keys to the positive deviance method include: • self-identification as a community by members of the community; • people see themselves as working toward the same goal rather than conflicting goals; • mutual designation of a problem by community members, rather than identification through a top-down approach; • inclusion of community members on the leading edge who have managed to surmount a problem; • an analysis of meritorious behaviors that enable outliers (positive deviants) to achieve success; and • the introduction and adoption of meritorious behaviors elsewhere in the organization. The following case study shows how a community hospital applied the principles of positive deviance to improve communication and collaboration. CASE STUDY: WRESTLING WITH READMISSIONS

Waterbury Hospital Health Center is a 234-bed Connecticut community teaching hospital that invited Jerry Sternin, the

founder of the positive deviance approach, to speak at grand rounds in autumn of 2004. As the staff discussed the application of PD to healthcare settings, they identified communication as their most pervasive challenge. Dr. Anthony Cusano and nurse Bonnie Sturtevant designed a telephone survey to learn whether recently discharged patients were following their prescribed regimens successfully. To their surprise, 80 percent of patients were taking their medications incorrectly. For example, one patient, told to take a pill every other day, took it only Tuesday and Thursday, incorrectly assuming that weekends did not count. Another patient, sent home with a variety of new prescriptions, did not take a necessary medication he already had at home because he did not receive a new prescription for it. Additional patients did not fill a prescription because of expense, but did not inform their physicians and thus never learned of more affordable alternatives. The investigators analyzed the 20 percent who exhibited no medication errors and learned that patients who were taking their medications correctly received an educational call from a nurse shortly after discharge. Nurses who were making the phone calls found the results so startling and the corrective process so satisfying that they told colleagues, who volunteered to make phone calls to recently discharged patients. Within a few months, they had

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The silo mentality embodied in Physicians can “Let the doctors and nurses deal encourage healthcare with patient care and leave finance and operations to the leaders to incorporate administrators,” is destined for failure in a rapidly appreciative inquiry (AI) into Prior to the intervention, changing environment. A their daily practice by making Waterbury Hospital readmore suitable approach mitted two patients per appears in the report by rounds and giving positive reinmonth on average for failand colleagues forcement to other healthcare pro- Malcolm ure to adhere to post-dis(2003) on cultural concharge medication plans. vergence. They wrote fessionals when patients express that Dr. Cusano noted, “The a key reason that satisfaction or delight, and by patients getting the calls New Zealand had imlove to know that someone proved healthcare outasking people, “What is going cares about them, and it comes was that integrated makes the staff feel good about district health boards have well for you?” rather than what they are doing. We realized encouraged managers to shift making problems the that people who were getting the from a preoccupation with recalls were close to 100 percent on source management to improving focus of rounds. doing the right things. It turns out that clinical outcomes and physicians and reached over 150 patients and had expanded the calling process to include new interns and residents. CASE ANALYSIS

the phone call itself is the solution. So we had to find a way of getting it done for everyone: If everyone on staff makes one phone call a month, we can contact every discharged patient. If communication is the issue, positive deviance showed us that it is also the answer.” The power of PD lies in its bottom-up process. Frontline care providers rather than the CEO determine where to direct their efforts. They invest effort in figuring out which approaches will yield the best results. Sternin felt that organizational resistance to identifying and following other institutions’ best practices was similar to transplant rejection in that it stimulated more conflict than collaboration. What healthcare professionals discover for themselves, they own. DISCUSSION

Improved communication and collaboration will not erase physicians’ current frustration over increased workload and decreased reimbursement or hospital leaders’ concerns over razor-thin clinical operating margins. However, both groups share a passion for caring for patients and a desire to improve clinical outcomes that can transcend differences in outlook and training. As the case presentations showed, healthcare professionals do not need external supervision to become inspired and empowered owners who promote trust and goodwill. Instead, we need to stop the destruction of internal motivation, so that we can achieve outstanding outcomes in difficult situations. Physicians, nurses, and hospital leaders generally agree on the “who,” since they live in the same communities and share the same patients; they also generally agree on the “why,” when they choose healthcare careers to make a difference in patients’ and their families’ lives. The “how” is the basis of dynamic interchange and lifelong learning.

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nurses to embrace a clear role in stewarding resources to achieve the board’s goals. That people have minimized the gap between physician, nursing, and managerial cultures and moved to a more Copernican view that puts patients and families at the center of the universe should give us hope that transformative cultural change is possible, with dividends for physicians, administrators, nurses, hospital employees, and especially patients and families. CONCLUSION

All parties feel squeezed by rising consumer expectations despite stagnant or decreasing reimbursement, rising expenses, and staffing shortages. Physicians may attribute their declining state to local incompetence rather than global economic challenges. Collaboration, though difficult because of differences in background, outlook, and training, can help all parties survive and thrive in the future as it fosters improved care for our communities.

Kenneth Cohn, MD, MBA, is a practicing general surgeon and a director at Cambridge Management Group, which specializes in resolving physician-physician and physician-administration communication issues. He is the author of two books, Better Communication for Better Care: Mastering Physician-Administrator Collaboration and Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Dr. Cohn is the editor of The Business of Healthcare and Improving Physician-Hospital Relations: A Field-Tested System. His website is www.healthcarecollaboration.com. His email address is ken.cohn@collaborateforsuccess.com.

ABOUT THE AUTHOR:

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Medical Staff Relations

MEDICAL STAFF SELF-GOVERNANCE

Reprinted with permission from the October 2007 issue of Southern California Physician (www.socalphys.com). 34

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WHY HOSPITALS

O POSE P D uring decades of experience as an independent counsel to medical staffs, I have often been struck by the scope and intensity of hospital opposition to the efforts of medical staffs to become self-governing. That opposition has included interference with medical staff elections, preclusion of elected officers from performing their duties, appointment of â&#x20AC;&#x153;alternativeâ&#x20AC;? executive committees, interference with meetings of standing medical staff committees, interference with medical staff retention of independent counsel, refusal to allocate medical staff treasury funds as directed by the medical staff, absconding with the medical staff treasury, refusing to permit the medical executive committee to sit in executive session, unilateral amendment of medical staff bylaws, and unreasonable refusals to accept amendments to medical staff bylaws adopted by the medical staff. In some instances, opposition to self-government has manifested itself in even more egregious ways. Notably, there have not only been threats but actual instances of retaliation against medical staff leaders. Financial punishment has been directed toward medical directors, hospital-based physicians, and in academic institutions, faculty members, who, in their capacity as medical staff members, have supported the concepts of self-governance. In rare instances, acts of intimidation have been directed at staff members whose vulnerabilities have been revealed in what they thought were confidential well-being committee meetings.

IT By TOM CURTIS

The link between opposition to self-governance and economic fear cannot be overestimated.

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It might be useful to start a discussion of medical staff self-goveconomically beneficial relationship with its medical staff. As obvious ernance by considering the reasons why such strenuous opposition as that might seem, opposition to self-governance is alive and well. exists. In 2002, a strategy analysis by the Voluntary Hospital AssoPerhaps another explanation for the opposition is a hospital’s culciation identified the domination of the medical staff as a viable ture, particularly in a multi-hospital chain. Complex administrative strategy to protect the economic base of the hospital. The link bechains of command are not designed to recognize the decision-maktween opposition to self-governance and economic fear cannot be ing role of the medical staff. The medical staff is something “to be overestimated. Such fear has been articulated in different ways, but managed” so that it might act “harmoniously,” which means “in the essence is simply this: To permit a harmony with the decisions of the hosmedical staff to be self-governing is to pital administration.” It doesn’t require an advanced permit it to influence hospital decisions There also exists a more abstract obmade on matters such as patient care, jection to self-governance: The hospital degree in economics to recog- board of directors has a fiduciary duty utilization, hospital contracts with servnize that a cooperative and to protect the hospital, and since the ice providers, hospital exclusive contracts and, in the end, hospital strategic policy. board of directors must exercise harmonious relationship be- hospital Giving such power to the medical staff “ultimate authority” on hospital matters, tween a medical staff and its there is no room for self-governance. presents the risk that the medical staff may “interfere” with the “proper” runalong the line, the concept hospital tends to serve the Somewhere ning of the hospital. of “ultimate authority” has been taken hospital’s economic interests. Recent history demonstrates the onto mean “unlimited authority” and “ungoing effort of the hospital industry to fettered decision-making” and, in the further maximize control over medical end, “absolute power.” staffs. The use of hospitalists, vice presidents of medical affairs, This assertion is not legally correct. However, there seems to be board-level “quality” committees, and economic credentialing a common strategy among administrators that if they tell a medical have added to the control that hospitals already exert over exclustaff often enough that it has no power, and if they prevent the medsive contract providers and medical directors. ical staff from obtaining independent advice on that issue, it will Is the fear that prompts these activities well founded? I have yet believe that it has no power and act accordingly. to see a hospital demonstrate that its fears of economic losses flowing from self-governance have actually occurred. The battles fought IS THE OPPOSITION WORKING? over economic credentialing are illustrative. Hospital demands for “loyalty” — commitments that staff members not practice at other The short answer to the question of whether opposition to self-govhospitals or ambulatory surgery centers — are predicated solely on ernance is working is “yes and no.” Let’s examine both sides. the need to protect the hospital from economic loss. In instances Opposition to self-governance is extremely successful at hospiwhere economic credentialing has been struck down by the courts, tals with medical staffs that have little or no knowledge of their statudid economic disaster result? Of course not. tory responsibilities and powers; that cannot maintain cohesiveness; It doesn’t require an advanced degree in economics to recognize that that lack economic resources to act independently; and that lack a cooperative and harmonious relationship between a medical staff and sufficient will to endure protracted controversy. The principles established in Medical Staff of Community Memoits hospital tends to serve the hospital’s economic interests. By encourrial Hospital of San Buenaventura vs. San Buenaventura Community aging self-governance, rather than opposing it, a hospital can build an 36

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Memorial Hospital have been codified as a California statute (Business and Professions Code § 2282.5) since 2004. Yet these principles are still not well understood. I am often invited to speak to medical executive committees. It is not surprising to learn that medical staff leaders are unaware of the rights of the medical staff and the mechanisms that exist to enforce those rights. There is a general awareness of the right to set the criteria and standards for membership and privileges, and to enforce those standards. However, few medical executive committees are aware that the medical staff has the power to establish clinical criteria and standards to oversee and manage quality assurance, utilization review, and chart review. Similarly, many medical staff leaders think that the hospital administration has some role to play in selecting and removing medical staff officers and determining how medical staff dues are to be used. Of course, Business and Professions Code §2282.5 (a)(3) and (4) provide just the opposite. Most medical staff leaders are aware of their right to retain independent legal counsel, but unaware of the implications of that right as it relates to the ability of the medical staff to meet confidentially with an attorney and to maintain privileged attorney-client communications. This fact alone compels the conclusion that there is a right to meet in executive session, a point often contested by administrators. Perhaps most importantly, many medical staff leaders are not familiar with the dispute resolution provisions of Business and Professions Code §2282.5 and the process by which a medical staff can go to court after reasonable efforts have been made to resolve differences with a hospital governing board. Even fewer leaders appreciate the importance of the statement of legislative intent that precedes Business and Professions Code §2282.5. The relationship between medical staffs and hospitals is determined to be one of “mutual accountability, interdependence, and responsibility of the medical staff and the hospital governing board for the proper performance of their respective obligations.” In other words, the governing board must be accountable to the medical staff for the proper performance of its responsibilities in the same way the medical staff must be accountable to the board for the proper performance of medical staff responsibilities. This extraordinarily important language is often overlooked. When medical staff leaders are not fully conversant with the rights and powers of the medical staff, hospital opposition to self-governance can succeed by simply telling medical staff leaders that they have no power. This message is frequently communicated both by hospital leaders and by attorneys hired by the hospital to provide legal services to the medical staff. In essence, the message is that the hospital’s “ultimate authority” trumps whatever the medical staff might wish to do, so it’s pointless for the medical staff to do anything! Opposition to self-governance also succeeds in the absence of medical staff cohesiveness. Hospital administrators have long known that the easiest way to control a medical staff is through a strategy of “divide and conquer.” A common method of controlling the medical staff is to establish relationships with a few key medical staff members, who are told that their “help” is needed by an administration simply trying to “get things done.” In the past, hospital-sponsored leadership retreats have been a fertile area for developing such relationships. More powerful still are the economic ties that a hospital administration can establish with medical staff members, not just in the

realm of exclusive contracts and medical directorships, but also in terms of preferential treatment in staffing and equipment purchases, operating room scheduling or patient flow from hospital-controlled IPAs. For-profit institutions have extended this strategy even further by encouraging medical staff members to invest in the hospital itself, thereby strengthening the argument that medical staff self-governance will cause economic injury to the hospital. It’s not easy to vote against one’s own economic interest, and these strategies are often successful in fragmenting the medical staff and developing medical staff opposition to self-governance. Opposition to self-governance also succeeds when a medical staff lacks sufficient economic resources and sufficient will to engage in protracted battles. For example, consider something as simple as implementing amendments to medical staff bylaws. When those amendments articulate principles of self-governance, hospital administrators and boards of directors often oppose them. In such cases, the hospital’s argument to the chief of staff has been: “Why don’t you drop these amendments? You are wasting your money because we will prolong the controversy until you are out of resources.” (This is, in fact, a real quote.) Clearly, administrators know that while Business and Professions Code § 2282.5 has a dispute resolution process that ultimately entitles a medical staff to go to court to defend its rights, that process is expensive and, in the absence of sufficient economic resources and sufficient will, medical staffs will be unable to complete the process.

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WHERE HAVE MEDICAL STAFFS PREVAILED?

Now let’s look at the other side. There are many instances in which opposition to medical staff self-governance has failed. Some of these events have achieved recognition in California and, on occasion, throughout the nation. In 2002, the Ventura case established the right of medical staffs to go to court to protect and preserve their authority and powers over quality assurance, to protect their own medical staff treasury, and to ensure their ability to freely elect their own leaders. During 2003 and 2004, the medical staff of Western Medical Center, Santa Ana successfully opposed the acquisition of its hospital by one entity and then successfully negotiated an agreement with the corporation that ultimately acquired the hospital. That agreement, among other things, established the right of that medical staff to review and approve certain contracts with “related parties” that were linked economically to the hospital owner. The agreement further established the right of the medical staff to elect representatives to the governing body of the hospital, to participate in the selection of key administrative officials, to participate in decisions regarding the allocation of the hospitals resources, and to ensure adequate capitalization for the hospital. Thus, after the Ventura case established the rights of the medical staff over traditional areas related to quality care, the Western Medical Center case expanded the realm of medical staff interests to include economic issues, which relate to quality of care. The following year, the medical staff of Alvarado Medical Center in San Diego successfully established its right to participate in the selection of the purchaser for the hospital. Following an Office of Inspector General order mandating that Tenet Healthcare sell the hospital as part of a settlement agreement in a criminal prosecution, the medical staff used §2285.5 to gain participation in the selection of the new owner. Thus, the medical staff’s interest in economic issues affecting quality of care extended to the ultimate issue of who would own the hospital. In all of these examples, the medical staffs in question were knowledgeable, cohesive, and in possession of sufficient economic resources to maintain a battle for a protracted period of time. In the last of these cases, Alvarado, an important lesson was illustrated. There, no protracted battle was necessary. The mere fact that the medical staff demonstrated that it knew its rights and was prepared to fight for them, including going to court if necessary, was sufficient to produce a prompt resolution. There are many other examples that have taken place below the radar, in which medical staffs have successfully negotiated disputes with hospitals and their governing boards. In each of those cases, the fact that the medical staff was knowledgeable, cohesive, and adequately funded was instrumental in producing a resolution of the issue.

pated in the struggles at Community Hospital, Western Medical Center, and Alvarado, you would likely be told that those struggles were worth it because those medical staffs gained greater influence over matters affecting quality of care. That influence is critical in many respects. Medical staffs are the principal advocates for quality of care in a system in which many decisions are predicated upon financial considerations. A study released in the May 2007 issue of the journal Medical Care found that hospitals are pushing too hard to streamline and cut costs and are putting patients at risk for medication errors, nerve injuries, infections, and other preventable mistakes by doing so. If we have a system of mutual accountability as the legislative intent in Business and Professions Code § 2282.5 states, hospitals should not be allowed to “push too hard to streamline and cut costs” without someone pushing back. That’s the function of the medical staff. Of course, it is not fair that medical staff leaders, who are paid little if anything for their time, must divert attention away from their practices to serve as advocates for quality of care against competing forces that are, by comparison, extremely well staffed, well funded, and in control of the battlefield. And it is even more unfair that medical staffs should have to fund battles to establish their rights to be advocates for quality of care. However, when quality of care hangs in the balance, what is the alternative? WHERE DO WE GO FROM HERE?

When I speak at large gatherings of medical staff leaders, there are always some leaders who tell me that my presentation does not reflect what’s going on at their hospitals. They have enlightened administrators who work cooperatively with them every step of the way, recognize their authority, and facilitate their actions. My response is always the same: I am delighted and I wish it could be so everywhere. But just in case things change, I advise them to memorialize their successful system in their medical staff bylaws. And for those not so fortunate, why not learn from the successes of other medical staffs? First, become knowledgeable about your rights and powers. This is not accomplished by going to hospitalsponsored seminars, but rather through your national, state, and local medical associations, through independent legal analysis of your current situation, and through your own leadership retreats. Then, make medical staff cohesiveness a goal. Strive for consensus and for internal decision-making that places quality of care above all other considerations. Next, marshal your resources. Establish a treasury, sufficient to enable a defense of your positions in court if necessary. Finally, be willing to assert your rights. Demonstrate your knowledge, your cohesiveness, and your willingness to fight, and it’s likely that you will not have to do so.

WHY FIGHT FOR SELF-GOVERNANCE?

When medical staffs know their rights and powers, exercise them, and if opposed, demonstrate cohesiveness and staying power, the end result is a change in the environment of the hospital and a change in the relationship between the hospital and its medical staff. If you were to consult with the medical staff leaders who partici38

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ABOUT THE AUTHOR:

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

The

Pulse SAVE THE DATE!

•

No 39

Wednesday, June 11, 2008 San Diego County Medical Society Foundation DONOR APPRECIATION NIGHT!

Robert Dubac’s Male Intellect: The 2nd Coming is the hilarious and provocative sequel to Robert Dubac’s wildly popular one-man show: The Male Intellect: An Oxymoron? Dubac is once again featured in a tour-de-force performance, playing a crazy cast of characters, and this time taking on society’s hypocrisies along with the age-old question: “What do women want?” For more information on the show, go to www.miracletheatreproductions.com.

Private Donor Reception: 6:45 p.m. Showtime: 8:00 p.m.

The Lyceum Theatre 79 Horton Plaza San Diego, CA 92101

THE FIRST 100 DONORS TO RSVP WILL RECEIVE ONE FREE TICKET TO THE SHOW!

For event details or to purchase tickets, please contact: Tana Lorah at (858) 300-2779 (tlorah@sdcms.org) www.sdcmsf.org

Additional Tickets Available for $35!

This show is open to the general public, and $5 from each ticket purchased directly benefits the San Diego County Medical Society Foundation and its mission “to address unmet San Diego healthcare needs for all patients and physicians through innovation, education and service.”

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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.

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

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.

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) 4876370. [548]

"DEAR EDITOR:

I wanted to formally thank you for helping me find employment through your magazine, San Diego Physician. I will be joining a family medicine practice, and found the ad in the classifieds. I really appreciate the services SDCMS provides, and I plan to be an even more active member in the organization as I begin my practice. Thanks!" - SDCMS Member Physician

OFFICE SPACE OCEANSIDE OFFICE: Office with ocean view available in 1,000ft2 suite. Prefer full time, but part time is available. Share suite with psychologist. Includes furnished waiting room, lots of storage, locking file cabinets, and receptionist area. Currently furnished, but unfurnished is an option. Available immediately. Contact Michael Samko, PhD, at (760) 721-1111 or at michael@michaelsamko.com. [580]

PRIME OFFICE SPACE TO SHARE: Office currently occupied by orthopedic surgeon situated in highly desirable location in a beautiful new building at 7910 Frost Street. The new hospital under construction (Sharp Memorial) is directly across the street. Digital X-ray, MRI, fluoro, CT Scan, pharmacy, PT, and other in the building. Wired for and using EMR. Please call (858) 220-0700 or email dglosrsc@mac.com. [579] 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, or 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 at janice@laser-clinique.com for more information. [561]

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 through Friday. Contact Michele, office manager, at (619) 421-9332. [560]

low-volume hospital campus consultations 1–5 half days per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557]

cony; great location next to Mercy Hospital. Competitive pricing. Opportunity to share office staff and resources. hillcresteyecare@yahoo.com. [524]

3998 VISTA WAY, SUITE 100, IN OCEANSIDE: Three medical office spaces (approximately 2,000ft2 each) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and ground floor access. Lease price: $2.40/ft2+NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [556]

OFFICE SPACE TO SHARE (SOUTH COUNTY): Chula Vista-area family practice office to sublease at 340 4th Ave., Suite 10, just north of Scripps Mercy Hospital, Chula Vista. Office includes three exam rooms and one treatment room, and is 1,700ft2. Support staff available. Contact Drs. Jenkin or Tetteh at (619) 804-7252. [521]

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]

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) 5754442 or fax letter of interest to (619) 575-1297. [518]

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]

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

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 SR-125 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]

OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished

SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MIDWAY): Share fully furnished, six-exam-room/two-office

medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501]

suite with internist. Ample free parking, great location. Contact Elaine Watkins at (858) 945-3813 or at ejwatkins@gmail.com. [527]

MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS):

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]

OB/GYN-type consultation room and 1–2 exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door. Free parking. Perfect for

PREMIUM HILLCREST OFFICE SPACE: 800ft2 office space available immediately. Includes 200ft2 waiting room/bal-

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 multi-specialty medical building located minutes from Scripps Encinitas. Perfect for outpatient consultation. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, or Deeann Wong, MD, at (760) 7537341 or at WendyKMD@AOL.com. [487]

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 (limit 100 words).

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Classifieds 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) 940-2268, or call (760) 630-4715. [478]

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]

OB/GYN NEEDED: Full-time OB/GYN is needed in a busy pri-

PHYSICIAN POSITIONS AVAILABLE 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 call (619)

LEASING, RENEWALS AND SALES: Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in San Diego County. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase agreement to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at (858) 6775329; e-mail chris.ross@colliers.com. 299-0007. [462]

INTERNAL MEDICINE/PEDIATRICS PHYSICIAN: Sharp ReesStealy Medical Group, a 375+ physician multi-specialty group in San Diego, is seeking a full-time BC/BE internal medicine/pediatric physician to join three internal medicine/pediatric physicians. We offer a competitive compensation package, excellent benefits, and shareholder consideration after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax to (619) 233-4730 or email to lori.miller@sharp.com. [582]

SPORTS MEDICINE/FAMILY PRACTICE POSITION: Seeking board-eligible/certified family practice physician with an interest in musculoskeletal and sports medicine for a busy multidisciplinary pain management practice located in Kearny Mesa across from Sharp Memorial Hospital. The office is state-of-the-art, complete with procedure room. Part-time or full-time opportunities are available. No afterhours calls. Fax CV to Hjordis Williams, office manager, at (858) 565-4146, email to hjordis.williams2@sharp.com, or call (858) 565-4117. [578] PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR:

OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one part-time physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 432-6644 or at EIM2006@sbcglobal.net. [459]

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) 819-6577 for more information, or fax your CV to (619) 241-7790 for immediate consideration. [572]

SPACE FOR LEASE (CORONADO): Brand new building in Coron-

PHYSICIAN FOR ADDICTION TREATMENT CLINIC: Opiate addic-

ado. Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435]

tion center located in central San Diego is looking for a California-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 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) 2864600 (office) or at (619) 869-2466 (cell). [566]

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]

NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, accredited surgery office available. 3,000ft2 includes exam room, dexa scanner, and physical therapy. Ideal for a wide range of healthcare practitioners. Call John at (619) 549-8870 for more details. [398]

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]

LARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2, adjacent to Scripps Hospital, includes large reception and front office, audiology lab, private office space as well as three large area rooms, many built-in storage cabinets, and staff lounge. Previous tenant was Children’s Hospital. Contact Sammye at (619) 342-7207, ext. 8, or at baymedical@ smiser.net. [389]

CHULA VISTA: Several suites available now at Bay Medical Plaza. We are conveniently located near Scripps Hospital, major freeways, and many restaurants and retailers. There’s an onsite pharmacy, a good parking ratio, and building is secure. This is a great opportunity to expand or relocate your medical practice in Chula Vista. For more information, contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [387]

BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE: Located in Hillcrest/Uptown San Diego. Physician with large suite seeking physician/healthcare professional or other business professional to share offices and/or exam rooms and receptionist. Parking spaces available for rent (off street, covered). Call (858) 354-9833 for further information. [346]

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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]

PER DIEM RESEARCH PHYSICIAN: Profil Institute for Clinical Research, Inc., a private research institute located in Chula Vista, 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]

vate 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]

FAMILY MEDICINE OPPORTUNITY: Seeking a BC physician in family medicine, full-time position, call responsibilities include telephone triage, minimal inpatient care, no OB, competitive salary and excellent benefits package. Please submit CV to: Vivian Hudson, Physician Resource Manager, Sharp Mission Park Medical Group, 2201 Mission Ave., Oceanside, CA 92054, call (760) 901-5259, fax (760) 9015242, 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] 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] 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 prac-

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 fee-for-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]

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tice 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) 279-1212. [458]

Classifieds TRADITIONAL INTERNAL MEDICINE OPPORTUNITY: Seeking full-time, CA-licensed, BC/BE internist to join our threeclinician 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

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) 287-0833. [509]

recording paper, electrodes, crash cart, defibrillator:

PHYSICIAN ASSISTANT WANTED: To assist busy cardiologist

doscopy, cameras, loupes, tools. Waiting room furniture inventory list is available upon request. Email kwahl@san.rr.com. [506]

physician to cover solo physician practice one week every two months. Contact Ann at (619) 422-1324 or at doctorwp@pacbell.net. [451]

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 through Friday. Please fax resume to (619) 656-5250. [504]

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]

MEDICAL RECEPTIONIST WITH MANAGEMENT SKILLS: Position

$2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619) 460-0083 or (619) 5189542. [513]

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

SERVICES OFFERED HOUSEKEEPING: Seeking weekly/bi-weekly housekeeping position in San Diego County. Bilingual. Twenty years experience. Honest! Call (619) 787-8257 and ask for Carmen. [xxx]

NONPHYSICIAN POSITIONS AVAILABLE

available, full or part time, in a family practice office located in Scripps Ranch. Fax resume to (858) 271-5327, attn: Dr. Wasserman. [494]

REGISTERED NURSE: Family medicine office in Torrey Hills

NURSE PRACTITIONER: Four-physician internal medicine prac-

seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email resume to admin@torreyhillsfamilymedicine.com. [577]

tice in Chula Vista seeks part-time/full-time nurse practitioner. Work with a quality group; reasonable hours. Previous experience is preferable; salary negotiable depending on experience. Call (619) 421-4470 or (619) 4214000. [488]

care, the most important aspect of your business is your billing. MBC provides full-practice management to ensure your billing and collections are optimal. With MBC, expect great services and great results! The difference is our service … let MBC make the difference for you. Call (800) 980-4808, ext. 102. [575]

NURSE PRACTITIONER WANTED: Part-time/full-time nurse prac-

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent fi-

titioner wanted for internal medicine practice in Escondido. Previous experience is desirable. Call (760) 432-6644. [455]

nancing available for physicians! Includes purchase of a practice, equipment, partner buyout, working capital, and real estate. Call Monica Coburn at CBN Financial: (702) 310-7111 or at mcoburn@communitybanknv.com. [522]

MEDICAL BILLING CONNECTION (MBC): After your patients’

PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit resumes via email to dlpotter22@hotmail.com. [576] WOMEN’S HEALTH NURSE PRACTITIONER: Progressive Mission Valley office looking for a part-time nurse practitioner with strong GYN experience including HRT. Fax resume to (619) 220-8567. [573] 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) 667-2688. [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) 565-0033. [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. [537]

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 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] SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small investment for 51 percent ownership. Looking for a new medical director. Contact Leonard Schulkind at (619) 8075485. [539]

PRACTICE MANAGER: Retiring practice manager seeks individual with five years of full-charge experience managing a medical office of 15–25 employees. Competencies: financial oversight, HR management, monitoring general practice systems, and reporting within a computerized medical environment. Well-respected, growth-oriented clinical and surgical practice. Good benefits package. Fax resume with salary experience to (858) 552-2182. [512]

MEDICAL OFFICE MANAGER: Busy six-physician internal medicine group looking for experienced office manager. We are located in the College area, adjacent to Alvarado Hospital.

RMC VINYL REPAIR PLUS: Medical equipment upholsterer. Expert in repair and replacement of medical fixture upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service! Call (619) 443-4060. [400]

MISCELLANEOUS 2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT: Ex-

DEL MAR-AREA GENERAL PRACTICE: Prime location, huge

MEDICAL EQUIPMENT

cellent 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]

MEDICAL EQUIPMENT FOR SALE: From Advanced Dermatol-

2003 BMW M3 CONVERTIBLE (RED, MANUAL): Very good con-

ogy 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]

dition, low miles, and new tires: $33,750. (858) 2540202. [453]

potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

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]

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 followup 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]

ULTRASOUND, STRESS, ECG: HP 2000 ultrasound, cardiac, vascular, abdominal, small parts, five transducers: $6,000. Quinton 4000 monitor with Q55 treadmill,

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CME/CERTIFICATION COURSES ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATION COURSE: Offered through UCSD and AWLS, this four-day 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

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History of Medicine

A Bullet in the Coffin A Testimonial

By WILLIAM P. HANEY, MD hysicians make daily decisions that alter people’s lives. However, the consequences of these decisions do not often change the fate of nations. When they do, the doctor is frequently forgotten in the subsequent train of events. James Monroe, our fifth president, was a key figure in the Louisiana Purchase. In addition, he authored the “Monroe Doctrine,” which declared the sovereignty of the independent American states in both North and South America. It stated that any colonization or invasion in the New World by European powers would be regarded by the United States as an “unfriendly act.” The principles of this doctrine have been applied again and again by succeeding presidents, including President Polk in 1845 over the Oregon Territory, President Lincoln in 1860 over Mexico and the Dominican Republic, President Cleveland in 1895 over Venezuela, President Teddy Roosevelt over unpaid debts in the New World, and President Franklin Roosevelt in 1929 as part of his “Good Neighbor” policy. The Monroe Doctrine is better known than the man who penned it. Even less well known is the story of Dr. John Riker of Trenton, New Jersey, who saved James Monroe’s

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life, thereby enabling both the Louisiana Purchase and the Monroe Doctrine. In the spring of 1776, Monroe was a law student at William and Mary College in Williamsburg, Virginia. He was a tall, rawboned youth of 17 and a bit bored with his studies. Seeking some adventure and relief from the tedium, he enlisted in the Virginia militia, preparing himself to do battle with the British and their Hessian allies in the Revolutionary War. So it was that he found himself on the outskirts of Trenton, New Jersey on a bitterly cold Christmas night. He was in command of a small group of ragged American soldiers, whose clatter awoke a nearby homeowner. Out came Dr. John Riker in robe and slippers, sloshing through the snow and demanding that the troops get off his property. Dr. Riker was an ardent patriot and had been chasing foraging Hessians off of his property for weeks. When he found that these were American troops, he brought out hot drinks and food. In addition, he offered his services and joined the company on its way to attack the Hessian outpost in downtown Trenton. The attack on the Hessian barracks was not a complete surprise. German mercenaries had managed to mount two cannons at the foot of Queen Street, planning to sweep

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the area with grapeshot. Monroe led his men down the street to silence the artillery. Hit in the shoulder by musket fire, Monroe went down, bleeding badly from a “severed artery.” Out from the shadows came Dr. Riker to stanch the bleeding and clamp the artery. For the remaining sixtysix years of his life, Monroe claimed that he would have died on the spot but for the quick action of Dr. Riker. In John Trumbull’s famous painting, “The Battle of Trenton,” Monroe’s badly wounded body lies in the arms of his doctor near the mortally wounded Hessian commander, Colonel Johann Rall. Years later, in seeking to honor Riker, President Monroe was unable to find any trace of the doctor or his descendents. Of medical interest is the fact that the bullet in his shoulder was never removed. It lies today at the bottom of Monroe’s coffin in Richmond, Virginia, a silent, inaccessible testimonial to a distant colleague, all but forgotten in the history of medicine.

ABOUT THE AUTHOR: Dr. Haney, a

retired ophthalmologist, has held a longtime interest in the history of medicine, often contributing articles to San Diego Physician.

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