July 2008

2008 MAGGIE AWARD WINNER

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY

“ 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 ”

JULY 2008

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Contents

VOL. 95 | NO. 7

[ F E A T U R E S ] PAIN:

24 26

To Suffer or Not? OK, We Know the Question — So What’s the Answer?

BY ROBERT E. WAILES, MD

Persistent Pain: Its Management Remains an Elusive and Frustrating Goal

BY BILL MCCARBERG, MD

30 34

Interventional Therapies for the Treatment of Chronic Pain

BY MARK S. WALLACE, MD

It Hurts: Managing the Pain Patient

BY SUSAN SHEPARD

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

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CONTRIBUTORS: This Issue’s Contributing Writers EDITOR’S COLUMN: How to Save Medicare (and America) SEMINARS: SDCMS’ 2008 Seminars and Events COMMUNITY HEALTHCARE CALENDAR ASK YOUR PHYSICIAN ADVOCATE: Second Opinions, Bad Payments, and More...

BRIEFLY NOTED: New and Rejoining Members, SDCMS 2008–09 Board of Directors, and More …

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18 20 22 38 41 44

TIPS FOR FINDING THE BEST EVIDENCE FIGHT THE BITE!: What WNV Illness Means to You SEXUALLY TRANSMITTED DISEASES: Quarterly Report THE PULSE: SDCMS Foundation Newsletter PHYSICIAN MARKETPLACE: Classifieds

SAN DIEGO PHYSICIAN: 2008 Maggie Award Winner!

Contributors MICHAEL DORSEY

Mr. Dorsey is the chief of the Community Health Division for the San Diego County Department of Environmental

Health.

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.

KAREN HESKETT

Ms. Heskett is an instruction coordinator at the UCSD Biomedical Library.

BILL MCCARBERG, MD

Dr. McCarberg, founder of the Chronic Pain Management Program for Kaiser Permanente in San Diego, is on the

board of directors of the American Academy of Pain Medicine, is president of the Western Pain Society, and is adjunct assistant clinical professor at the UCSD School of Medicine.

PAT SARCHET

Ms. Sarchet is a clinical outreach librarian at the UCSD Biomedical Library.

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.

SUSAN SHEPARD, MSN, MA, RN ROBERT E. WAILES, MD

Ms. Shepard is director of patient safety education for The Doctors Company.

Dr. Wailes is medical director of Pacific Pain Medicine Consultants, SDCMS secretary for 2008–09, and a

current CMA trustee.

MARK S. WALLACE, MD

Dr. Wallace is professor of clinical anesthesiology and program director of the UCSD Center for Pain Medicine.

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, MPH

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 Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, 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 Geraldine Kang

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

Stuart Cohen, MD, MPH Lisa Miller, MD Albert Ray, MD Robert Wailes, MD Susan Kaweski, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Sherry Franklin, MD Robert Peters, 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

How to Save Medicare (and America) Tough Love

T

he conservative, market-oriented chairman of the Federal Reserve Bank, Alan Greenspan, stated on his retirement that his greatest fear for America was the cost of the Medicare program.

With 78 million baby boomers turning 65 and older, twice the number as today, the unfunded Medicare mandate for this generation is estimated at $67 trillion! What is a trillion dollars? To put that into perspective, one million seconds ago was last week. One billion seconds ago was the early 1970s when Nixon left the White House. One trillion seconds ago was 30,000 BCE! The current federal deficit is approaching $10 trillion. A doubling of the Medicare population, and business as usual, will certainly bankrupt America for our children.

Medicare is already in crisis. Current estimates show that Medicare will run out of money in 2019, just 11 years from now.

Reimbursement cuts are being proposed, a mindless method of reducing costs that will certainly be counterproductive. Most hospitals are already losing money on patients who only have Medicare. Physicians are in the same situation and are fleeing from taking Medicare patients. Further reimbursement cuts will make this access even worse as emergency rooms, not

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equipped to manage the chronic diseases of seniors, face further overcrowding.

Healthcare researchers estimate that medical waste makes up 30–35 percent of healthcare costs. PricewaterhouseCoopers recently estimated this at 50 percent! Medical waste is expenditures that provide no benefit to the patient. Even using the lower 30 percent figure, for the $500 billion Medicare program, the waste is $150 billion! Add the $300 billion Medicaid program, and we have about $250 billion of taxpayer-funded medical waste in this country. Saving the Medicare program should begin with reducing medical waste.

How much money will we keep borrowing to pay for unnecessary and overpriced tests, procedures, and medications?

party pays the bills, what happens in the patient-physician relationship becomes unrestrained. Restraint must come before we bankrupt America and leave a problem for our children that is beyond solution.

When Ronald Reagan took office in 1981, he appointed the 34-year-old David Stockman as federal budget director. Stockman’s job was to apply “tough love” to the federal budget and reduce spending by 30 percent. The government should only pay for socially necessary programs. No frills, no fat, and no payment to compensate for poor human behavior. Stockman did just that, although what finally passed Congress were lesser savings. Unfortunately, Medicare was considered untouchable during the Reagan years, and the escalation in costs rivaled the

I know about the cost-effectiveness data supporting bariatric surgery, but come on, would entitlement to this procedure using taxpayer dollars pass a voter referendum?

Medical care is a dance among people, the medical profession, and the overall healthcare system. This dance has become overly expensive as we have medicalized normal parts of living, such as aging and death, and have made common health problems overly expensive. When a third

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rate of today and the federal deficit tripled.

Will Durant, in his 11-volume Story of Civilization, states that one factor in the decline of ancient Egypt was that healthcare became “overspecialized.” The Greek and Roman civilizations declined in part due to slothful human behavior and a sense of en-

titlement to its maintenance. America is already the most overweight developed country in the world, and Medicare is planning for 3 million bariatric surgeries a year! I know about the cost-effectiveness data supporting bariatric surgery, but come on, would entitlement to this procedure using taxpayer dollars pass a voter referendum?

If your medical license or privileges are on the line…

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

For the $500 billion Medicare program, the waste is $150 billion! Add the $300 billion Medicaid program, and we have about $250 billion of taxpayer-funded medical waste in this country.

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. Wells Fargo Bank Plaza

It is time to apply “tough love” to Medicare. If we provided only healthcare that was evidence-based, cost-effective and necessary for health, we would save hundreds of billions of dollars. We could provide that for everyone, the foundation of a healthcare system, and let people pay for or buy supplemental insurance for everything else they want.

None of the candidates for president is expressing anything close to this bold vision for fixing Medicare. They only want to tweak our current failing system. Cut reimbursement but still provide for almost everything under the sun. How stupid.

This is a recipe for continued social decline.

The richest country in the world with the best medical schools and higher education can do better. We can provide necessary healthcare for all Americans (not just senior and disabled Americans), be affordable, and have the best healthcare in the world.

Right now we need to focus primarily on reducing the waste in the system and a lot of tough love.

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.

ABOUT THE AUTHOR:

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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Seminars 2008 San Diego County Medical Society Seminars and Events OCTOBER

AUGUST SDCMS NEW MEMBER SOCAL

SEXUAL HARASSMENT

RISK MANAGEMENT WEBINARS

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

TRAINING — FOR PHYSICIANS

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

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

SEXUAL HARASSMENT TRAINING —

SEPTEMBER YOUNG PHYSICIANS SOCIAL

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).

NOVEMBER

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

OFFICE MANAGERS FORUM

RESIDENT AND NEW PHYSICIAN

Oct. 16, 11:30 a.m. – 1:30 p.m.

SEMINAR

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

– 3:30 p.m.

DECEMBER YOUNG PHYSICIANS SOCIAL

Dec. 5, 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 SPECIALTY SOCIETY ADVOCATE: Karen Dotson at (858) 300-2787 or at KDotson@SDCMS.org LETTERS TO THE EDITOR: Editor@SDCMS.org GENERAL SUGGESTIONS: SuggestionBox@SDCMS.org

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The nurse from VITAS suggested we give pet therapy a try.

I was a little surprised, but said, “Sure.”

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When she saw the pup, my mother smiled.

I hadn’t seen that smile for so long. She even began to talk of her childhood, of the dog she had as a little girl, as if it were yesterday.

VITAS gave me a little more time with the mother I once knew. I’ll never forget …

Serving the San Diego area since 1995 For information, please call 1.800.93.VITAS www.VITAS.com

Community Healthcare Calendar

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.

WHEN: July 14 WHERE: San Diego Marriott Del Mar COST: $2,795.00 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: $375.00 CME: 15.25 credits INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

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

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

PRIMARY CARE SUMMER CONFERENCE: OFFICE URGENCIES EMERGENCIES 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: $395.00 CME: 12 credits INFORMATION: Call (858) 652-5400 or email med.edu@scrippshealth.org.

MEDICAL SPANISH COURSE WHAT: The goal of this conference is to teach basic to intermediate medical Spanish language skills in the classroom and to implement the usage of these skills with native Spanish speakers in an immersion setting. Presented by Medical Studies Abroad.

WHEN: August 16–23 WHERE: Catamaran Hotel and Resort, San Diego COST: $795 physicians CME: 20 AMA INFORMATION: Visit www.medicalstudiesabroad.com for details.

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: $125.00 INFORMATION: Call (858) 652-5400 or email med.edu@scrippshealth.org.

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.

THE CALIFORNIA HEART RHYTHM SYMPOSIUM WHAT: Conference highlighting what is known about basic arrhythmia mechanisms, how our clinical therapeutic strategies are driven by science, and how observations from clinical therapeutics have created new avenues for research.

WHEN: October 2 WHERE: Manchester Grand Hyatt, San Diego COST: $300.00 CME: 15.5 AMA INFORMATION: Call (858) 534-3940 or email at ocme@ucsd.edu.

DESTINATION HEALTH: RENEWING MIND, BODY, AND SOUL WHAT: Luxury vacation combined with lectures,

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workshops, and activities designed to empower you on your personal journey toward health and education.

WHEN: October 12–17 WHERE: Kauai Marriott Resort and Beach Club in Kauai, Hawaii COST: Reduced rates for attendees: Garden View: $195; Pool View: $220; Renovated Rooms: $245; Run of Ocean: $245 INFORMATION: Visit www.scrippsintegrativemedicine.org.

3RD ANNUAL HEART FAILURE AND ARRHYTHMIAS: FROM PREVENTION TO CURE WHAT: Conference offering practical, up-to-theminute advice on management of both inpatient and outpatient heart failure and arrhythmia patients while offering a glimpse into what the future may hold.

WHEN: November 1 WHERE: Paradise Point Resort INFORMATION: Call (858) 652-5400 or email med.edu@scrippshealth.org.

THE SCIENCE AND CLINICAL APPLICATION OF INTEGRATIVE HOLISTIC MEDICINE WHAT: Educational experience that includes an upto-date review of integrative medicine science and research, as well as an opportunity for personal renewal. This program also features an optional ABHM board certification exam.

WHEN: November 17–21 WHERE: Paradise Point Resort, San Diego CME: Available INFORMATION: Visit www.scripps.org/conferenceservices.

NATURAL SUPPLEMENTS: AN EVIDENCE-BASED UPDATE WHAT: Clinically relevant overview of the latest information on natural supplements and nutritional medicine with an emphasis on disease states.

WHEN: January 22–25, 2009 WHERE: Paradise Point Resort, San Diego CME: Credits available.

INFORMATION: Visit www.scripps.org/naturalsupplementsCME.

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Ask Your Physician Advocate!

By Marisol Gonzalez Second Opinions Patients Who Make Bad Payments Paying Marketing Agents

Q

UESTION: When a patient obtains a second opinion, where does the responsibility lie in notifying the patient of the results? Would it be the responsibility of the initial physician or the physician who provided the second opinion?

ANSWER: After evaluating the patient, a second-opinion physician should provide the patient with a clear understanding of the opinion, whether or not it agrees with the recommendations of the first physician.

(their insurance coverage or other billing and demographic information that can assist the new physician in having their services paid), you can share this information with the new treating physician and not violate HIPAA. You should not instigate the contact because this disclosure has nothing to do with treating the patient, and, unless this information is requested by the new physician, this disclosure could be a violation if the patient found out and complained.

Also, physicians could face a patient civil action for defamation of character or other related causes and should not take this unnecessary risk.

Q

UESTION: We have a patient who has a history of making bad payments. This patient currently has outstanding bills with us and is trying to see a new physician without paying for the amounts that are owed to our practice. Can I tell the new physician about this patient’s bad payment history?

ANSWER: You should not instigate a call to the new treating physician to warn them about the patient’s financial status; however, if the new physician asks for the financial information on the patient

Q

UESTION: I am thinking about contacting some patients whom I haven’t seen for a few years to tell them about some new techniques and procedures we are doing. The method I plan on using is paying a marketing agent a percentage in relation to the patients that come in. Is there anything unethical about this?

ANSWER: CMA ON-CALL document

#0205, “Physician Advertising,” states that a marketing agent can be used but only if you carefully set up your arrangement. In addition to confirming that the advertising by the marketer complies with all of the aforementioned limitations on physician advertising, you must be sure that your payment is strictly for the fair market value of advertising or promotional services of the marketing agent. Any payment in excess of that fair market value would appear to constitute an illegal payment for referrals. Payment cannot be based on the number of referrals received.

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.

MARISOL GONZALEZ

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

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

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

Renew Your 2008 SDCMS-CMA Membership

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

Search for a Physician

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

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

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

y l Noted f e i Br

American businesses lose

$60 billion annually in lost productivity

28%

from workers who suffer from pain.

of the U.S. population is in pain at any given moment.

(National Pain Foundation)

(National Pain Foundation)

WELCOME NEW AND REJOINING SDCMS-CMA MEMBERS! PHILLIP MICHAEL CACHERIS, MD Anatomic Pathology and Clinical Pathology Carlsbad • (760) 268-6211

New SDCMS-CMA Members!

PATRICIA GAIL ANDERSON, MD Psychiatry Chula Vista • (619) 656-1010

WUN-LING CHANG, MD Internal Medicine • Infectious Disease San Diego • (858) 202-1736

BRETT JUSTIN BERMAN, MD Cardiovascular Disease • Clinical Cardiac Electrophysiology San Diego • (619) 299-2570

JAY JOSEPH DOUCET, MD Surgery • Surgical Critical Care San Diego • (619) 543-7200

JENNIFER MICHELLE BLACK, MD Internal Medicine San Diego • (800) 290-5000

GIOVANNI ELIA, MD Obstetrics and Gynecology San Diego

KIMBERLY ANN BOWER, MD Family Medicine San Diego

DANIEL JONATHAN FRIEDLAND, MD Internal Medicine San Diego • (858) 481-2393

PAMILA KAUR BRAR, MD Internal Medicine La Jolla • (858) 554-5195

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SILVIA GARCIA, MD Family Medicine San Diego

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KRISTEN LYNN GUY, MD Emergency Medicine San Diego • (619) 287-3270 EDIT ELISABETH HEGYI, MD Hematology Carlsbad • (760) 268-6211 SCOTT WHITTAKER HELMERS, MD Orthopedic Surgery San Diego • (619) 532-8427 SANJA JAREBICA, MD Family Medicine • Obstetrics and Gynecology San Diego • (619) 278-3360 JIE-GEN JIANG, MD Anatomic Pathology and Clinical Pathology Carlsbad • (760) 268-6200 ANURADHA KANUNGO, MD Anatomic Pathology and Clinical Pathology Carlsbad • (760) 268-6211

PAIN MANAGEMENT EDUCATION WEBSITES: AMERICAN ACADEMY OF PAIN MEDICINE: www.painmed.org AMERICAN ACADEMY OF PAIN MANAGEMENT: www.aapainmanage.org AMERICAN PAIN SOCIETY (APS): www.ampainsoc.org AMERICAN SOCIETY OF ADDICTION MEDICINE: www.asam.org AMERICAN SOCIETY OF REGIONAL ANESTHESIA AND PAIN MEDICINE: www.asra.com INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP): www.iasp-pain.org NATIONAL PAIN FOUNDATION: www.painconnection.org PAIN TREATMENT TOPICS: www.pain-topics.org PAIN.COM: www.pain.com

Quote

THE MAYDAY FUND: www.painandhealth.org

“Pain is multidimensional. It has physical, emotional, practical, and spiritual dimensions.”

— Dr. Charles F. Von Gunten, provost and vice president for the Center for Palliative Studies at San Diego Hospice

BRIAN DOUGLAS LAWENDA, MD Radiation Oncology San Diego • (619) 532-7274 KEMING LIN, MD Hematopathology Carlsbad • (760) 268-6200 ANITA PINTO, MD Pediatrics El Cajon • (619) 442-0945 MICHAEL JOSEPH PORTER, MD Cardiovascular Disease • Clinical Cardiac Electrophysiology La Jolla • (858) 658-0088 IAN MACKINNON PURCELL, MD Neurology San Diego • (619) 229-4941 FRANKLIN SEDARAT, MD Anatomic Pathology and Clinical Pathology Carlsbad • (760) 268-6211

SWATI AJAY SHAH, MD Anatomic Pathology and Clinical Pathology and Hematology Carlsbad

ZHAO WU, MD Anatomic Pathology and Clinical Pathology Carlsbad • (760) 268-6211

MARTIN ELLIOT SODOMSKY, MD Psychiatry San Diego • (858) 352-8239

HOLLY BEKE YANG, MD Internal Medicine San Diego • (619) 688-1500

MICHELLE ANDREA SPRING, MD Plastic Surgery San Diego • (858) 974-9876

Rejoining SDCMS-CMA Members!

PAUL J. POCKROS, MD Gastroenterology • Hepatology La Jolla • (858) 554-8879

JEFFREY NEAL STONEBERG, DO Internal Medicine San Diego

ALLAN I. SILVER, MD Obstetrics and Gynecology La Jolla • (858) 453-0753

ANNETTE MELANIE VOLLRATH, MD Internal Medicine • Geriatric Medicine San Diego

ELIZABETH GORHAM SILVERMAN, MD Obstetrics and Gynecology La Jolla • (858) 453-0753

LISA JOAN WASTILA, MD Internal Medicine La Jolla • (858) 657-8000

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y l Noted f e i Br

Quote corpore sed mens est aegro magis aegra, malique in circumspectu stat sine fine sui. (The mind grows sicker than the body in contemplation of its suffering.)

— Ovid (Latin Poet, 43BCE–17CE)

Please Welcome SDCMS’ Board of Directors for 2008–09

The Following Physicians Were Dropped From Membership in SDCMS-CMA Roy David Amir, MD Janna Z. Andrews, MD Mohammed T. Bailony, MD Katherine Helen Balazy, MD Michael Conroy Bannach, MD Rosalyn Baxter-Jones, MD, MD Christopher J. Bengs, MD Prakash Krishin Bhatia, MD Anthony Steven Bianchi, MD Patrick Bart Bownes, MD Kristin Joy Ament Brownell, MD Can Q. Bui, MD Kevin B. Calhoun, MD Noli Agreda Cava, MD Ned H. Chambers, MD Robyn Grossman Cohen, MD Paul Bowman Corbett, MD Richard D. Coutts, MD Rafael Enrique Cuellar, MD Anna Rita Foraci, DO Sheila Fallon Friedlander, MD Joshua D. Golden, MD Dennis A. Goodman, MD Arthur L. Gruen, MD Abhay Gupta, MD, MD David A. Haffie, DO James Robert Hemp, MD Daniel William Hershey, MD Thomas A. Joas, MD Kevin Michael Kelly, MD Thomas Gerald Kelly, MD Christopher S. Kelsey, MD Paul Euin Kim, MD Ilene Judith Klein, MD James G. Knight, MD Marvin M. Kripps, MD Jose R. Leon, MD Wilson Lee Liu, MD Gene Ma, MD, MD

PRESIDENT: Stuart Cohen, MD, MPH PRESIDENT-ELECT: Lisa Miller, MD (AMA Alternate) PAST PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Alternate) SECRETARY: Robert Wailes, MD (CMA Trustee) TREASURER: Susan Kaweski, MD COMMUNICATIONS CHAIR: Joseph Scherger, MD, MPH (Delegation Vice Chair) EAST COUNTY GEOGRAPHIC DIRECTORS: William Tseng, MD, and Woody Zeidman, MD HILLCREST GEOGRAPHIC DIRECTORS: Thomas McAfee, MD, and Roneet Lev, MD KEARNY MESA GEOGRAPHIC DIRECTORS: Adam Dorin, MD, and Sherry Franklin, MD (Board Representative to Executive Committee) LA JOLLA GEOGRAPHIC DIRECTORS: Steven Poceta, MD, and Wayne Sun, MD NORTH COUNTY GEOGRAPHIC DIRECTORS: James Schultz, MD, Douglas Fenton, MD, and Tony Blain, MD SOUTH BAY GEOGRAPHIC DIRECTORS: Vimal Nanavati, MD, and Anna Seydel, MD AT-LARGE DIRECTORS: Jeffrey Leach, MD (Delegation Chair), Robert Peters, MD (Board Representative to Executive Committee), David Priver, MD, Wayne Iverson, MD, Paul Kater, MD, John Allen, MD, Kevin Malone, MD EAST COUNTY GEOGRAPHIC ALTERNATE DIRECTOR: Venu Prabaker, MD HILLCREST GEOGRAPHIC ALTERNATE DIRECTOR: Eric Yu, MD KEARNY MESA GEOGRAPHIC ALTERNATE DIRECTOR: Jason Lujan, MD LA JOLLA GEOGRAPHIC ALTERNATE DIRECTOR: Brendan Gaylis, MD NORTH COUNTY GEOGRAPHIC ALTERNATE DIRECTOR: Steven Green, MD SOUTH BAY GEOGRAPHIC ALTERNATE DIRECTOR: Asha Devereaux, MD AT-LARGE ALTERNATE DIRECTORS: Carol Young, MD (SDCMS Foundation President), Richard Butcher, MD, Ben Medina, MD, James Bush, MD, Edward Singer, MD, Leonard Kornreich, MD, Jerome Robinson, MD YOUNG PHYSICIANS SECTION DIRECTOR: Mihir Parikh, MD RESIDENT PHYSICIAN DIRECTOR: Kimberly Lovett, MD RETIRED PHYSICIAN DIRECTOR: Glenn Kellogg, MD MEDICAL STUDENT DIRECTOR: Geraldine Kang CMA SPEAKER OF THE HOUSE: James Hay, MD (AMA Delegate) CMA PAST PRESIDENTS: Robert Hertzka, MD (AMA Delegate), and Ralph Ocampo, MD CMA TRUSTEES: Catherine Moore, MD, Diana Shiba, MD, Theodore Mazer, MD ALTERNATE RESIDENT PHYSICIAN DIRECTOR: Jeffrey Ramos, MD ALTERNATE RETIRED PHYSICIAN DIRECTOR: (empty) CMA/AMA MEDICAL STUDENT REPRESENTATIVE: Mani Akhtari

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Alan S. Maisel, MD Anthony Markarian, MD, MD Dale E. Martin, MD Robert Lawrence Matorin, MD Robert M. Maywood, MD Laurence A. Miller, MD Nathan A. Miller, MD Peter J. Minkoff, MD William E. Monk, MD Eileen Stack Natuzzi, MD Dat William Nguyen, MD Andrew Kwong Keong Phoon, MD Karel V. Placek, MD Samuel Isreal Poniachik, MD Carlos Martin Quiros, MD Bijan Razi, MD, MD Douglas W. Reavie, MD Spencer Ted Rickwa, DO Jeffrey E. Schultz, MD Mahnaz Shahidi-Asl, MD, MD Wesley Ryan Smidt, MD Nojan Talebzadeh, MD, MD Lokesh S. Tantuwaya, MD Neil T. Tarzy, MD Paul S. Teirstein, MD Lakshmi Kumari Thirunagari, MD Alfredo Barrios Tiu, DO Alex E. Torres, MD Carmelita Luna Uy, MD Rene A. Vega, MD Sunnyline Vendiola, MD Gregory L. Wakeman, DO Peter C. Walther, MD Alan Carl Westeren, MD Harvey R. Wieseltier, MD Julie Marie Wilcox, MD Frank A. Winton, MD John A. Young, MD

Thank you to the 97% of

SDCMS members who renewed their memberships in 2008.

And thank you to the 178 new physicians who have joined SDCMS so far this year!

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RISK TIP

Should You Provide Medical Care for Your Employees?

By THE SCPIE COMPANIES common dilemma for many physicians is deciding whether they should personally provide medical care for their employees. At first glance, treating staff members would seem to be a valuable employee benefit; however, once a physician begins to treat an employee, a patient-physician relationship is established, making the doctor legally liable for the interaction and its consequences.

Treating staff members can be rife with potential problems.

Some prime examples: • You may be tempted to keep less-than-thorough records of the care you deliver to your own staff. This can be especially true with regard to documenting psycho-social factors in appropriate detail because you know that all of your employees have access to the record (regardless of the office rules).

• You may give an employee advice while you’re hurrying down a hallway or getting into your car. Nothing shows up in the chart, no vital signs are taken, and there is no tracking of the drug samples you may have given to the employee.

• Because of the confidentiality issue, your employees may be reluctant to use your services to the extent that they should. For instance, a female staff member may be willing to have you check out her cold but be extremely reluctant to have you perform something as personal as a pelvic exam. As a result, that employee might not receive the care she needs to maintain good health.

Be aware that the American College of Physicians discourages the practice of treating staff members. The organization’s ethics manual asserts that “physicians should be very cautious about assuming the care of closely associated employees.”

The question every doctor needs to answer is, “Do I really want to treat my staff?” Remember, deciding not to provide such care is a perfectly acceptable position. You’ll never get into trouble by politely saying no, while you may get into all sorts of trouble by saying yes. Whatever you decide, make your policy clear in your personnel manual and stick to it.

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Evidence-based Medicine

Tips for Finding the Best Evidence

By PAT SARCHET AND KAREN HESKETT

he nuts and bolts of evidence-based practice literature searching are straightforward and understandable. It only takes four steps to quickly find therapy articles in the medical literature. First, write a succinct clinical question; second, deconstruct the clinical question into a “PICO;” third, find search words for each of the concepts in the PICO; and fourth, search the databases for the evidence you need.

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STEP 1: Write a Succinct Clinical Question Describing Your Case Example: “In a two-year-old Mexican American female with otitis media, will watchful waiting versus antibiotics result in the elimination of otitis media?”

STEP 2: Use the PICO Technique to Deconstruct the Clinical Question PICO is an evidence-based search technique that reveals key

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aspects pertinent to your patient, the presenting problem, the treatment options, and the family’s values and preferences. In this step you deconstruct the clinical question into its various components, which will help you to identify key terms to use when searching the literature.

P

Patient or Population and Presenting Problem

In a two-year-old Mexican American female with otitis media

I

Intervention (the treatment you want to test)

will watchful waiting

C

Comparison (gold standard, control therapy, or placebo)

verses antibiotics (or a specific antibiotic)

O

Outcome(s)

result in the elimination of otitis media

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STEP 3: Find Search Terms in the PICO and Think About Synonyms ‘P’ Terms

‘I’ Terms

‘C’ Terms

‘O’ Terms

Otitis media Earache Ear infection

Watchful waiting Placebo No treatment

Antibiotics Amoxicillin Cephalosporins

None

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The patient’s age and gender, found in the clinical question, can be used, not as search terms but rather in PubMed limits to reduce your article yield, if needed. Also remember that a patient’s ethnic group can be a factor in your search.

STEP 4: Search PubMed Clinical Queries (http://pubmed.gov): Clinical Queries is a quick way to find good evidence-based articles in PubMed. It is located in the left-hand tool bar. Sample search: otitis media AND watchful waiting AND antibiotics.

TRIP Database (www.tripdatabase.com/index.html): The TRIP Database simultaneously searches a variety of high-quality, evidence-based resources including evidence-based synopses, clinical questions, guidelines, e-textbooks, medical images, patient information, systematic reviews, core general medical journals, specialist journals, and more. Sample search: otitis media AND watchful waiting AND antibiotics.

Cochrane Library of Systematic Reviews (from Online Clinical Library at http://gort.ucsd.edu/clinlib/ - UCSD faculty, staff, and students only): The Cochrane Library is a highly respected resource for systematic reviews. Sample search: otitis media AND watchful waiting If you need help in searching for the best evidence, contact Pat Sarchet, clinical outreach librarian at the UCSD Biomedical Library, at (858) 534-1196 or at psarchet@ucsd.edu.

?

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.

ABOUT THE AUTHOR: Ms. Sarchet is a clinical outreach librarian, and Ms. Heskett is an instruction coordinator at the UCSD Biomedical Library.

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Public Health

HUMAN WEST NILE VIRUS CASES BY YEAR OF REPORT SAN DIEGO COUNTY, 2003–2007

2003 TOTAL CASES: 1

Fight the Bite!

What West Nile Virus Illness Means to You

Locally Acquired?

Yes: 0 No: 1 Unknown: 0

2004 TOTAL CASES: 2 Locally Acquired?

Yes: 0 No: 1 Unknown: 1

2005 TOTAL CASES: 1 Locally Acquired?

Yes: 0 No: 1 Unknown: 0

2006 TOTAL CASES: 2 Locally Acquired?

Yes: 1 No: 1 Unknown: 0

2007 TOTAL CASES: 16 Locally Acquired?

Yes: 15 No: 1 Unknown: 0

By MICHAEL DORSEY

he Vector Control Program (VCP) operates within the County of San Diego Department of Environmental Health (DEH). The VCP is responsible for mosquito and vector-borne disease surveillance and control services in all 18 cities, as well as the unincorporated areas of the county. The VPC first detected West Nile Virus (WNV) in San Diego County in 2003. The VPC works collaboratively with the Community Epidemiology Branch (CEB) of public health to investigate human cases. No known human cases of WNV were locally acquired in San Diego until 2006. All previous cases investigated by CEB were acquired outside the county — the first case investigated in San Diego County was in 2003. In 2007, there were 15 locally acquired human infections with the majority of those infected above 50 years of age.

In order to minimize the exposure to citizens of San Diego County from WNV, the

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VCP developed a WNV Strategic Response Plan: an integrated, risk-based approach that has three response levels identified as normal season, emergency planning, and epidemics. The VCP operates under the normal season response level. Between August and September 2007, the VCP elevated their response level to emergency planning due to the increased number of reported human WNV cases.

The VCP utilizes a wide range of vector surveillance techniques to detect the presence of WNV in the environment. Some of the more common methods of surveillance include: • sentinel chickens • dead bird pick-up • mosquito trapping and pooling • “green swimming pool” flyovers • investigating and inspecting the over 900 known mosquito breeding areas within the county

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Resource: County of San Diego, Health & Human Services Agency, Community Epidemiology Branch.

Sentinel chicken serology is performed for the presence of antibodies to WNV. The VCP maintains four flocks of chickens located strategically throughout the county.

Dead birds are one of the earliest warning signs that WNV is present in the area. The Corvid family, including crows, ravens, and jays, are especially susceptible to the virus. Raptors such as falcons and hawks can be susceptible to the virus as well. Mosquitoes are trapped using either a Gravid or CDC trap and then are pooled for laboratory testing. The VCP uses the sheriff’s helicopter for flying over neighborhoods and looking for neglected or “green” swimming pools, which are prime habitats for breeding mosquitoes. VCP staff routinely investigate and inspect the known mosquito breeding areas within the county to determine the mosquito population levels for appropriate treatment.

Control of mosquito sources and popu-

“Privileged to Provide Care and Clinical Research Since 1975”

In order to minimize the exposure to citizens of San Diego County from WNV, the VCP developed a WNV Strategic Response Plan: an integrated, risk-based approach that has three response levels identified as normal season, emergency planning, and epidemics.

lations by VCP has been traditionally through the use of chemicals such as “Golden Bear,” a petroleum-based insecticide and mechanical habitat removal. Over the past few years, the VCP has shifted away from these environmentally sensitive control measures to more environmentally friendly control measures, such as mosquito fish, larvacides, and habitat management.

Mosquito fish — Gambusia affinis — are small, freshwater fish that eat mosquito lar-

Mosquitoes can breed wherever they can find standing water to lay their eggs — all they need is a quarter of a cup of water.

The San Diego Arthritis Medical Clinic is a leading investigational site for the study of:

Rheumatoid Arthritis Osteoarthritis Osteoporosis Fibromyalgia Gout Lupus

wildlife. They kill the larvae before they can develop into biting adults. They are applied by a helicopter to the vegetation in the larger bodies of water that cannot be applied by hand. The VCP is developing a Vector Control Habitat Management Plan that will be used as a model plan for eliminating mosquito breeding sources.

Mosquitoes can breed wherever they can find standing water to lay their eggs — all they need is a quarter of a cup of water.

Backyard breeding sources of mosquitos are common in San Diego County and require homeowners to assist in the fight against WNV. Outreach through presentations, media events, press releases, website postings, and written materials is consistently provided by the VCP to residents, businesses, and agencies throughout the year.

This year, the VCP is focusing their outreach efforts on senior organizations and “baby boomers.” For more information about the VCP, call (858) 694-2888 or visit the DEH website at www.sdcounty.ca.gov/deh/pests/wnv.html.

If your patient's musculoskeletal or rheumatologic condition is not well-controlled, please contact us about our research at:

619.287.1966 San Diego Arthritis Medical Clinic 3633 Camino del Rio South, 3rd Floor (1.7 miles east of Texas Street) San Diego, CA 92108 Michael I. Keller, M.D., Director Puja Chitkara, M.D. Ara H. Dikranian, M.D. Oleg Gavrilyuk, M.D. G. Paul Ignat, M.D. Roger Kornu, M.D. Timothy F. Lazarek, F.N.P. Michael Meng, D.C.

ABOUT THE AUTHOR: Mr. Dorsey is

vae and are ideal for controlling mosquito larvae in backyard ponds, birdbaths, fountains, animal troughs, unused swimming pools, and other standing water sources.

The larvicides used by the VCP are a Bacillus bacteria that acts specifically on mosquito larvae and will not harm other

the chief of the Community Health Division for the San Diego County Department of Environmental Health and is responsible for overseeing the Vector Control Program; the Local Enforcement Agency; the Occupational Health Program, and the Radiological Health Program.

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619.287.9730 www.SanDiegoArthritis.com Offices: Mission Valley, Poway, Chula Vista, El Centro, & Yuma, AZ

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Public Health

Quarterly Report • Issue No. 1 • Data for January – December 2007

Sexually Transmitted Diseases

By ELAINE PIERCE, MD, MPH, STD CONTROL OFFICER AND MEDICAL DIRECTOR OF THE COUNTY STD CLINICS

F

rom 2006 to 2007, reported chlamydia cases increased by 6 percent, and reported gonorrhea cases decreased by 14 percent in the county. Peak ages for these diseases are the teens and twenties, reflecting the need for frequent screening in these age groups.

CDC recommends that all women 25 and younger be screened at least annually for chlamydia; women of any age should be screened periodically based on risk factors, such as new or multiple partner(s), substance abuse problems, or a previous STD. Persons who have had chlamydia or gonorrhea are at high risk of repeat infection; therefore, retesting at approximately three months after original diagnosis should be standard practice.

In 2007, primary and secondary syphilis increased by 47 percent, compared to 2006.

Unlike cases before 1998, the current outbreak is predominantly in men who have sex with men (MSM; 84 percent). Heterosexual cases, while proportionately low, increased

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exposed within the previous 60 days by 67 percent since 2006. A positive associshould be tested and treated (or the last ation between syphilis and HIV has been partner if no contact has occurred within found (syphilis cases who are HIV positive the last 60 days). For primary, secondary, — MSM: 57 percent; heterosexual: 19 perand early latent cent). Persons with syphilis, partners exsyphilis have a higher posed within the previrisk of methamphetaTo report an STD case, call ous 90 days should be mine use (women: 40 (619) 692-8520 or fax prophylactically treated percent; MSM: 27 per(619) 692-8541. cent; heterosexual men: even if the partner’s RPR or VDRL is nega13 percent). These data The STD clinic can underscore the importive. Due to the long be reached at incubation period of tance of obtaining sexual (619) 692-8550 or via fax syphilis, the serologic and behavioral histories at (619) 692-8543. titer may remain negato determine the syphilis tive for up to 90 days screening frequency apdespite infection. If expropriate for each indiposure occurred prior to 90 days, treatvidual. Because of the higher burden of ment decisions may be determined by disease in the MSM community, screening is test result as long as a thorough physical recommended every three to six months for sexually active MSM. exam reveals no inTimely evaluation of partners is essential to prevent the cycle of reinfection. dication of disease.

For chlamydia and gonorrhea, partners

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Chlamydia Cases by Year, San Diego, 1993-2007

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AS SCIENTIFIC PHYSICIANS, WE NEED TO PROMOTE

OR NOT? OK, We Know the Question — So What’s the Answer?

By ROBERT E. WAILES, MD

THE BEST TREATMENTS BASED ON STUDIES AND PROVEN OUTCOMES. AS HEALERS, WE NEED TO LISTEN TO OUR PATIENTS AND SEE WHAT WORKS FOR THEM IN THEIR WORLD.

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he answer to the question, “To suffer or not?” depends on the source of suffering. For a pain medicine specialist there are many sources and many answers. We are still a new specialty — patients and even physicians don’t really know exactly what we do. In fact, we are a growing specialty composed of anesthesiologists and physiatrists (among others) with specialized fellowship training who use a multidisciplinary approach for the diagnosis and treatment of pain-related problems. While most simple pain problems are handled well by primary care physicians and many specialists, we focus our attention on the challenging cases. Our most common problems deal with spine pathology, but we handle everything from headaches to cancer pain to complex regional pain syndrome.

Like most physicians, our first challenge is to get an accurate diagnosis. Some problems, like fibromyalgia, can be very difficult to diagnose and ultimately treat.

Other problems, like an L5-S1 herniated disc, are easy to diagnose and fairly straightforward to treat. After diagnosing the problem, we must make decisions on utilizing the best treatment options. The strength of our specialty is the depth and variety of available treatment options. This issue will highlight two different courses of treatment alternatives within our specialty.

Bill McCarberg, MD, from Kaiser is a very well-respected, internationally known figure in our specialty.

While initially trained in family practice, he went on to develop and specialize in the conservative treatments of many chronic pain problems. His article [see page 26] highlights the incidence and under-treatment of pain.

Furthermore, it highlights the importance of many primary care approaches using a variety of techniques. We are also fortunate to have Mark Wallace, MD, from UCSD, director of the Pain Medicine Fellowship Program and a full professor in the Department of Anesthesiology (and Pain Medicine). He is well known for his research and presentations around the globe. His article [see page 30] highlights interventional techniques, using the most modern technologies available. Some of these are specialized injections and some are more ad-

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vanced, including the use of implantable stimulators and pumps.

While the use of a spinal cord stimulator or intrathecal infusion pump seems a far cry from conservative therapy, it is, in fact, simply another option on a long and complicated treatment algorithm. By necessity, the conservative and interventional techniques complement each other in the overall management of a complex pain patient. Both authors would agree that we must remain open-minded regarding the many therapeutic options required to meet our patients’ needs. These two brief articles can only scratch the surface of many of the treatment options that we use in our specialty.

They also don’t cover the multiple treatment options available to the general public that are not endorsed by most physicians. This includes everything imaginable — from magnets to medical foods to copper bracelets. While we may shun many of these, we must accept that they are heavily used and accepted by the public. Most have never been studied scientifically so may potentially have some efficacy despite our “scientific intuitions.” This is certainly true if one includes the placebo effect. While this may be short-lived, it highlights the power of suggestion, especially if it is from a trusted source.

As scientific physicians, we need to promote the best treatments based on studies and proven outcomes. As healers, we need to listen to our patients and see what works for them in their world. As pain medicine specialists, we need to try to bridge this gap to get the best and most satisfying outcomes for our patients. Most physicians are very good at this, but I hope the two pain articles in this issue stimulate some interest in the variety of new options available to our suffering patients.

ABOUT THE AUTHOR: Dr. Wailes, who is board-cer-

tified by the American Board of Pain Medicine and the American Board of Anesthesiology, with added qualifications in pain medicine, is a pain medicine specialist and the medical director of Pacific Pain Medicine Consultants, located in northern San Diego County.

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PERSISTENT

PAIN

ITS MANAGEMENT REMAINS AN ELUSIVE AND FRUSTRATING GOAL

By BILL MCCARBERG, MD

P

becomes more difficult. In a recent survey, only 34 percent of internists reported that they felt comfortable with their abilPain is the most common reason patients seek medical care, ities to manage patients with chronic pain (6). In a related araccounting for 80 percent of total visits to physicians’ offices ticle, Ballantyne wrote that the most difficult issue now facing (1, 2). In most cases, the patient understands the underlying physicians is “whether and how to prescribe opioid therapy disease process (e.g., pharyngitis, gastroenteritis, migraine for chronic pain that is not associated with terminal disease, headache). Pain associated with these disorders causes the paincluding pain experienced by the increasing number of patient to seek help from his or her physician. Although it tients with cancer in remission” (7). is difficult to determine the prevalence of pain in In part, physicians are hesitant to prescribe opiexact numbers, recent surveys suggest that 75– oids because they lack both the understanding 105 million Americans experience pain of how to accurately assess pain and the daily or intermittently (3, 4, 5). The knowledge of available pain therapies.

In treating chronic management of persistent pain is a comPrimary care physicians struggle with pain, recommendations plex enterprise. Pain management reunexplained variability among pain pashould take into consideration mains an elusive and frustrating goal tients. Physical abnormalities are not life stressors, pacing daily actividespite a growing knowledge about the predictive of pain severity or dysfuncpatho-physiology of pain. tion (8). Large numbers of patients exties, depression, anxiety, and perience pain that may be constant over worsening of underlying CHRONIC PAIN MANAGEMENT: THE STATUS QUO long periods of time, and yet their life pathology as well as functioning is not changed in major ways. medication.

With the onset of pain, most patients attempt Conversely, there are other patients with self-care with over-the-counter products and/or similar structural abnormalities who suffer subself-help techniques (e.g., distracting activities, rest). stantially more and cannot maintain their usual levWhen these methods fail to afford adequate relief, the paels of activity (9). Patients whose lives are significantly tient generally seeks help from a medical professional. In many disrupted by pain engage in behaviors that are maladaptive, ancases — and particularly in healthcare systems with limited access ticipate more distress, amplify sensations associated with pain, to specialty care — the gatekeeping primary care provider is the spend more time resting, and complain of less ability to control first medical contact. The primary care provider recommends pain (10, 11). treatment and refers the patient for appropriate specialty care, such At the same time, surveys evaluating the adequacy of pain as a physical medicine assessment for low back pain. treatment demonstrate that the current system is broken (12).

When pain becomes chronic, and specialty care is ineffecPatients report that they are not asked about pain, that they are tive in improving the underlying condition, care management afraid to report pain to their primary care providers, and that REVALENCE OF PAIN IN THE UNITED STATES

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they are not offered treatment. In one recent survey, 22 percent of pain patients reported being uncomfortable discussing pain with their personal physicians, 13 percent said they were denied pain medication or referrals to pain specialists, and 70 percent reported experiencing continued pain despite treatment (13). Much of this system failure can be attributed to the treatment at the primary care level.

SEARCHING FOR SOLUTIONS

There have been tremendous advances in the knowledge of pain patho-physiology, the understanding of treatments for pain, and recognition of the value in an interdisciplinary approach to pain management. On the scientific front, there has been an explosion in pain research, and new pharmaceutical agents have become available for treating different types of pain.

Complementary and alternative therapies for pain management have gained recognition.

Novel interventional techniques and surgeries have been introduced. Professional pain societies have sprung up, and training is now available to provide physicians and other healthcare professionals with expertise in pain management. Despite this unprecedented progress, pain care remains grossly inadequate and under-treatment of pain is still considered pandemic. The reasons for this continuing failure are varied, but it is clear that new solutions must focus on primary care.

BARRIERS TO TREATING PAIN

Many barriers to the management of pain have been well documented in this text and others (14). The obstacles relate to the medical system, providers, patients, and regulatory and governmental agencies.

BARRIERS TO MANAGEMENT OF PAIN MEDICAL SYSTEM:

• • • •

Access to Medical Care Access to Specialists Denied Coverage of Medication or Procedures Denied Coverage of Complementary and Alternative Medicine (CAM) Therapy • Preauthorization Requirements

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PATIENTS:

NEW FOCUS

• Poor Lifestyle Choices • Fear to Accept Proven Treatment • Expectation of Cure • Stigma of Psychiatric Care • Beliefs About Aging PROVIDERS:

• • • • •

Lack of Knowledge Bias Toward Treatment Failure to Refer Nihilistic Care Beliefs About Aging

REGULATORY AND GOVERNMENTAL AGENCIES:

• Lack of Medicare Reimbursement • Oversight of Opioid Prescribing Many physicians are often uncomfortable treating patients with persistent pain. In addition to a relative lack of knowledge, there are a number of other underlying reasons for this.

MYTHS AND BIASES PATIENTS: Without conscious intention, people attach meaning to all sensory experiences. The smell of a rose may hold a special meaning to someone who received her first bouquet for the high school prom. The sound of the musical tune “Jingle Bells” may signify happiness, family gatherings, and holiday gifts. Pain, especially when it is persistent, often conveys a sense that the person is being punished for some real or perceived infraction. The common idioms associated with pain seem to confirm this understanding: “No pain, no gain.” “You need to feel this.” “Offer it up.”

Too often, patients with chronic pain believe that they suffer because of some mistake they made — “I had a hard life, Doc. Of course I have pain” — or that pain is to be expected as a part of aging. There is so much meaning attached to pain, sometimes of a religious nature, that it is difficult to convince the patient otherwise. These beliefs about “needing pain” or “deserving pain” complicate treatment.

PROVIDERS: Providers are often suspicious of patients who complain of pain. Physicians understand certain types of pain — cancer pain, end-of-life pain, or acute trauma/illness pain — but are less accepting of the persistent pain that is symptomatic of less-defined conditions. We ask, “Why do some patients complain while others, with the same pathology or anatomy, do not?” “What is the secondary gain?” “Is this pain real?”

When pain is not easily explained, bias leads the primary care provider to suspect psychiatric causes. In addition, psychiatric comorbidities are common with persistent pain. Although specialists are more likely to understand the connection between anatomy and psychiatry, the primary care provider may believe that the persistence of the pain relates directly to the depression or anxiety thereby depreciating the pain complaint. Patients perceive this attitude as devaluing their experience.

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Persistent pain patients have similarities to and differences from patients with other chronic illnesses. They are both chronic conditions where cure is unlikely. Self-management is the key to success. Denial about the disease and non-adherence to treatment recommendations are common and expected challenges for the provider.

On the other hand, psychiatric issues are more common with persistent pain and interfere with treatment. Patients resist psychosocial diagnosis and interventions. Opioid management that only occurs in persistent pain problems is challenging for the patient and the provider. Non-adherence to treatment recommendations increases morbidity and mortality in diabetes, hypertension, and congestive heart failure. In chronic pain, non-adherence increases work stress, requiring more office visits, documentation, and medication surveillance. Although regulatory scrutiny does not often occur, the perception of legal difficulties increases practice discomfort.

In managing pain, it is important for the physician to understand that pain scores are highly subjective and that the focus must be on function. Although measuring pain is important and mandated in a variety of settings (15), the provider must not lose sight of the twin goals of treatment: function and adaptation.

A new pain complaint or worsening symptoms do not necessarily mandate more medication. In treating diabetes, a worsening HgbA1C leads the physician to recommend adjustments in diet, exercise, and medication. Similarly, in treating chronic pain, recommendations should take into consideration life stressors, pacing daily activities, depression, anxiety, and worsening of underlying pathology as well as medication. When the primary care provider understands that an increase in pain does not necessarily mean increasing the patient’s opioid drug, treatment issues become easier.

CONCLUSIONS

Persistent pain, a highly prevalent condition in the United States, has a significant impact on our health and productivity as a society as well as on our medical and financial resources. The barriers to managing chronic pain are significant but not insurmountable. Persistent pain is similar to other chronic illness but also has many differences, making management complicated and difficult in the busy provider office. A new skill set is required by the provider to help the deplorable under-treatment of pain. Available tools (e.g., questionnaires, pain diaries, pain scales) and techniques (e.g., reflective listening, goal setting) make it possible for the physician to provide management for patients with chronic pain.

Diabetes, chronic obstruction pulmonary disease, and other chronic, complicated illnesses require other skills yet have been handled brilliantly in the primary care setting.

Some of the most appreciative patients are those who have a sympathetic provider to help them with chronic pain. Yet treating chronic pain patients is rarely met with enthusiasm. Patients with chronic pain are complicated and rarely cured. They

make little progress toward normal life functioning and often have complex psychosocial issues that a physician cannot address. There is never sufficient time to adequately follow up patients with pain. We all have learned how to deal with difficult, complex, and complicated care issues, and we can do the same with our chronic pain patients. We all must accept learning a new skill set; otherwise, there will be no end to the tragedy of under-treated pain.

RESOURCES: 1) Harstall C. How prevalent is chronic pain? Pain: Clinical Updates. 2003;X:1-4.

2) O’Rorke JE, Chen I, Genao I, Panda M, Cykert S. Physicians’ comfort in caring for patients with chronic nonmalignant pain. Am J Med Sci. 2007;333:93-100.

3) Gallup, Inc. Pain in America: Highlights from a Gallup survey. June 9, 1999.

4) Bostrom BM, Ramberg T, Davis BD, Fridlund B. Survey of post-operative patients’ pain management. J Nurs Manag. 1997;5:341-349.

5) Dworkin R, Backonja M, Rowbotham M, et al.

Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol.

2003;60:1524-1534.

6) O’Rorke JE, Chen I, Genao I, Panda M, Cykert S. Physicians’ Comfort in Caring for Patients with Chronic Nonmalignant Pain. Am J Med Sci. 2007;333:93-100.

7) Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 349:1943-1953, 2003.

8) Flor H, Turk DC. Chronic back pain and rheumatoid arthritis: predicting pain and disability from cognitive variables. J Behav Med. 1988;11:251-265.

9) Sanders SH, Brena SF, Spier CJ, Beltrutti D, McConnell H, Quintero O. Chronic back pain patients around the world: cross-cultural similarities and differences. Clin J Pain. 1992;8:317-323.

10) Reesor KA, Craig KD. Medically incongruent chronic back pain physical limitations, suffering, and ineffective coping. Pain. 1988;32:35-45.

11) Pinsky J. Chronic pain syndromes and their treatment. In: Brodwin MG, Tellez F, Brodwin SK, eds. Medical, Psychosocial and Vocational Aspects of Disability. Athens, GA: Elliott & Fitzpatrick, 1993:179-194.

12) Dahlman G-B, Dykes A-K, Elander G. Patients’ evaluation of pain and nurses’ management of analgesics after surgery. The effect of a study day on the subject of pain for nurses working at the thorax surgery department. J Adv Nurs. 1999;30:866-874.

13) Drayer R, Henderson J, Reidenberg M. Barriers to better pain control in hospitalized patient. J Pain Symptom Manage. 1999;17:434-440.

14) Guideline for the management of pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis; 2nd edition, 2002, American Pain Society Glenview, IL. 15) Jacox AK, Carr DB, Capman CR, et al. Acute pain management: Operative or medical procedures and trauma; Clinical Practice Guideline No. 1.

In one recent survey, 22 percent of pain patients reported being uncomfortable discussing pain with their personal physicians, 13 percent said they were denied pain medication or referrals to pain specialists, and 70 percent reported experiencing continued pain despite treatment.

Dr. McCarberg, founder of the Chronic Pain Management Program for Kaiser Permanente in San Diego, is on the board of directors of the American Academy of Pain Medicine, is president of the Western Pain Society and is adjunct assistant clinical professor at the UCSD School of Medicine.

ABOUT THE AUTHOR:

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INTERVENTIONAL

THERAPIES

FOR THE TREATMENT OF

CHRONIC PAIN

By MARK S. WALLACE, MD

P

ain is the most common reason for patients to seek medical attention. Chronic pain has major effects on patients physically, psychologically, and socially and is a major cause of healthcare costs, disability, and lost workdays. There are numerous therapies for the treatment of chronic pain.

Although there are a few medications with FDA indications for the treatment of pain, the majority of treatments are off-label use of drugs that have modest effects on pain. Interventional therapies have been used for decades to treat chronic pain; however, there is limited evidence that they result in long-term reductions in pain. Why are these therapies continuing to be used if there is no solid evidence supporting efficacy?

Most studies done on the interventional therapies base outcome on cure rather than palliation. Ninety percent of the practice of medicine is based on palliation, as there are cures for less than 10 percent of all disease states. The interventional therapies should be viewed as palliative rather than curative, and some patients will require repeated interventional therapies for prolonged periods of time for pain relief and improved quality of life. This article will discuss the various interventional therapies used to treat chronic pain, provide the current evidence on efficacy, and provide recommendations on how these therapies can be used to the maximum benefit of the chronic pain patient.

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of 1,081 subjects using the interlaminar and caudal approach to the epidural space. Twelve of the 18 studies showed signifEvidence-based medicine is important to improve outcomes icant pain relief up to three months. Eight of the studies with all medical therapies. However, strict adherence to evi- showed pain relief beyond three months. Seven of the studies dence-based medicine can also be detrimental to patient care were double blind, placebo controlled, and, of these, five if the treatment does not lend itself to rigorous clinical trials showed significant relief of pain up to three months. So why or if the outcomes of the research are based on a small, highly did the American Academy of Neurology conclude that the selected patient population that may not be representative of routine use of ESIs was not indicated for the treatment of the actual population. This can result in patients being denied radiculopathy? Because they were evaluating the outcomes very effective treatments. Evidence-based medicine is intended based on cure rather than palliation. to measure four outcomes: efficacy, safety/tolerability, ease of A major problem with the studies on the interlaminar and use, and costs. The highest level of efficacy measurement is caudal approach to the epidural space is that fluoroscopy was through multicenter, double-blind, randomized, placebo-con- not used, thus the exact level of steroid placement was untrolled trials. All of the current pharmaceuticals that have FDA known. Since the advent of fluoroscopic guidance for ESIs, approval for the treatment of pain have passed this standard. the use of the transforminal approach has become a more However, most of the off-label pharmaceuticals and all of the common practice, which allows precise placement of the interventional therapies have not been subjected to this level steroid at the level of radicular symptoms. Since 1996, there of efficacy measurement. have been three published double-blind, randomized, conThere are obvious reasons why interventional therapies have trolled trials evaluating this technique in a total of 264 subnot been evaluated with multicenter, blinded, randomized tri- jects. All three trials demonstrated both short- and long-term als. These include ethical limitations and difficulties in blind- reduction in pain. ing invasive therapies, cost prohibition, and difficulties in With the exception of cervical transforaminal approach, the recruiting subjects for such studies. Therefore, in the absence risk associated with ESIs is very low. There have been many reof high-quality, efficacious trials, one relies on clinical experi- ports of serious neurological injury, including spinal cord and ence to determine efficacy. Many of the intervenbrainstem infarcts, with some leading to death after tional therapies for pain fall into this category, cervical transforaminal steroid injections. The with small clinical trials and vast clinical exmechanism of this complication appears to perience demonstrating efficacy. Clinical be related to the injection of particulate experience also demonstrates safety for steroid into the vertebral or spinal radicNinety percent of most, but not all, interventional theraular artery leading to massive central the practice of medicine pies with reasonable ease of use and nervous system infarction. However, is based on palliation, as costs as compared to chronic pharmathere is some evidence that the carrier there are cures for less ceutical use. of depomedrol may be toxic to the than 10 percent of all blood brain barrier. The use of dexamdisease states.

EPIDURAL STEROID INJECTIONS (ESI) ethasone, a non-particulate steroid, appears to be void of this risk.

Epidural steroid injections (ESI) are one of Given the low risk of ESIs, it is reasonable the most commonly used interventions to manto offer patients who want to avoid surgery reage both acute and chronic spinal radicular pain. Of all peated injections no more often than every three the interventional therapies for pain management, ESIs have months if they demonstrate prolonged pain relief. However, been the most studied. A recent report from the therapeutics patients with severe radicular pain unresponsive to ESIs will and technology subcommittee of the American Academy of likely benefit from early surgical intervention. The SPORT Neurology concluded that ESIs for the treatment of lum- study shows that early recovery in such patients is quite good; bosacral radiculopathy did not result in pain relief beyond however, at one year there was no difference in outcome bethree months and did not impact function or the need for sur- tween those that received early surgery and those that were gery. Since 1971, there have been 18 studies involving a total managed conservatively.

EVIDENCE-BASED MEDICINE AND INTERVENTIONAL PAIN THERAPIES

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Some patients will do well with interventional therapies alone; however, many patients will require that this therapy be used with other treatments, such as pharmacologic, psychologic, and rehabilitative approaches.

relief; however, there are no clinical studies evaluating the long-term benefit.

SPINAL CORD STIMULATION (SCS)

Spinal cord stimulation (SCS) involves placing electrodes in the posterior epidural space over the dorsal columns of the spinal cord. Stimulation of the dorsal columns produces pleasant parasthesias over large areas of the body corresponding with the level of the dorsal column stimulated. Spinal cord stimulation is usually reserved for extremity pain, but newer technologies are allowing stimulation of pain located in the trunk such as the low back and thoracic region.

The most common indication of SCS is for patients who have failed back surgery. Re-operation on these patients has been shown to have poor outcomes, and SCS is a reasonable alternative. Studies have demonstrated a 50–70 percent success rate (defined as >50 percent reduction in pain) with a three-toseven year follow-up. Most failures after two years of therapy are usually due to fibrosis around the contact, which inhibits the flow of the electrical current. Newer technology allows for the current to be fractionated resulting in the ability to steer the current through the impendence created by the fibrosis. This will likely result in better long term outcomes.

SPINAL DRUG DELIVERY

TREATMENT OF FACET JOINT AND SACROILIAC JOINT PAIN

Facet pain has been estimated to account for as high as 47 percent of low back pain and 63 percent of cervical pain.

Blockade of the medial branches to the facet joints can be diagnostic for pain arising from these structures. Many patients who respond to medial branch blocks will benefit from radiofrequency lesioning. A randomized sham study of radiofrequency lesioning for cervical facet pain in 24 patients resulted in an average duration of pain relief of 263 days in the treatment group as compared to 80 days in the sham group. A randomized sham study of this technique for low back pain was performed in 31 patients. At 12 months, seven patients in the treatment group continued to report pain relief as compared to two patients in the sham group.

Sacroiliac joint pain is a common cause of chronic low back pain with an estimated incidence of up to 30 percent. The injection of corticosteroid into the joint can result in significant

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The spinal cord dorsal horn is rich in receptors and ion channels that are involved in pain transmission. By delivering drugs directly into the spinal fluid that target these mechanisms, pain can be reduced using a fraction of the dose required for systemic delivery with fewer side effects. For terminally ill patients, this can be achieved with a percutaneous catheter and external pump. For the long-term delivery of intraspinal medications, an implanted pump is required that is refilled percutaneously every 30–90 days.

Most studies evaluating the efficacy of spinal drug delivery report on retrospective chart reviews that show good to excellent pain relief in 60–90 percent of subjects. A recent randomized controlled trial of implanted spinal drug delivery compared to medical management in over 200 cancer pain patients showed that significantly more patients who received the spinal infusion reported successes and fewer drug side effects.

Ziconotide, a non-opioid, is the first FDA approved drug for intrathecal use in almost two decades. It was subjected to rigorous multicenter, randomized, controlled trials in over 1,200 sub-

jects and showed a significant decrease in pain over placebo.

Although there are high up-front costs of implanted spinal drug therapy, cost analysis shows that at 22–25 months there are cost savings associated with this therapy.

CONCLUSION

Pain is often multi-factorial with both physical and psychological components driving the pain. As a single modality, interventional therapies are less effective than when integrated into a multidisciplinary model of pain management. Some patients will do well with interventional therapies alone; however, many patients will require that this therapy be used with other treatments, such as pharmacologic, psychologic, and rehabilitative approaches. There is evidence that the interventional therapies result in prolonged pain relief. However, like almost all other therapies for pain, they should be viewed as palliative, not curative. For some, it is a lifelong treatment. For others it is a short-term treatment that may buy the patient time until they receive treatments directed at long-term pain relief.

ABOUT THE AUTHOR: Dr. Wallace is professor of clinical anesthesiology and program director of the UCSD Center for Pain Medicine.

Most studies done on the interventional therapies base outcome on cure rather than palliation.

SUGGESTED READING: 1

2

3

4

Carette S, Leclaire R, Marcus S, et al. Epidural corticosteroid injection for sciatica due to herniated nucleus pulposus. NEJM 366:1634–40, 1997.

Riew KD, Yin Y, Gilulu L, et al. The effect of nerve root injection on the need for operative treatment of lumbar radicular pain. A prospective randomized, controlled double-blind study. J Bone Joint Surg Am 82A:1589–93, 2000 Karppinen J, Malmivaara A, Kurunlaht M, et al.

Periradicular infiltration for sciatica: A randomized controlled trial. Spine 26:1059–67, 2001.

Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radiofrequency neurotomy for chronic cervical zygapophyseal joint pain. NEJM 335:1721–6, 1996.

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6

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Smith TJ, Staats PS, Deer T, et al. Randomized controlled trial of implant drug delivery system compared with comprehensive medical management for refractory cancer pain: Impact on pain drug related treatment and survival. J Clin Oncol 20:4040–9, 2002.

Coffey RJ, Lozano AM. Neurostimulation for chronic noncancer pain: An evaluation of the clinical evidence and recommendation for future trial design. J Neurosurg 105:175–89, 2006.

North R, Shipley J, Prager J, et al. Practice parameters for use of spinal cord stimulation in the treatment of chronic neuropathic pain. Pain Med 8(suppl 4):5200–75, 2007.

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IT HURTS MANAGING THE PAIN PATIENT

By SUSAN SHEPARD, MSN, MA, RN

T

he patient’s pain started on an otherwise normal day — another day of hard work as a certified nurse assistant who frequently does more physically demanding work than she should. She woke up with excruciating pain in her back. When she called her family physician, she was told that she didn’t need to be seen, that she just needed to rest and use NSAIDS for a day or so.

Fast forward a few years. The patient, still in the same job, injured her back again, overexerting herself at work. This time, the pain didn’t go away. The patient was seen by multiple physicians, none of whom could alleviate the pain to the patient’s satisfaction.

Does this patient seem familiar to you? She represents your

The guidelines suggested in this article are not rules, and they do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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patient in the ED who hears the nurse say quietly, “There’s another ‘seeker’ in bed two.” She is the patient in the exam room who cries in disbelief when you tell her that she is being overly emotional and needs to see a psychiatrist. She is the customer in the pharmacy being lectured about the dangers of addiction to narcotics. Treating the chronic pain patient can be difficult and frustrating, not only to the patient but also to you.

FACTS AND FIGURES

The American Pain Foundation tells us that pain affects more Americans than diabetes, heart disease, and cancer combined.

A National Center for Health Statistics Report found that more than one-quarter of Americans (26 percent) age 20 and over — an estimated 76.5 million Americans — reported problems with pain of some sort that lasted for more than 24 hours. More than half of all hospitalized patients experienced pain in the last days of their lives, and, although therapies are present to alleviate most pain for those dying of cancer, research shows that 50–75 percent of patients die in moderate to severe pain. An NIH survey indicated that low back pain was the most common type of pain, followed by severe headache or migraine pain, neck pain, and facial ache or pain (1).

under-treatment by some physicians. This is compounded by a lack of research on pain across racial and ethic differences, as well as cultural attitudes toward pain management. In the elderly population, 25–50 percent can expect to suffer pain.

Under-treatment in the pediatric population is even worse.

The FDA has only recently required that new medications be evaluated for efficacy and safety in the pediatric population.

Gender is also a bias in pain management. Women seek help more frequently than men but are less likely to receive treatment. They are often viewed as hysterical or oversensitive (2).

THE BARRIERS

Patients with untreated pain often feel that the physicians they consult are unfeeling, paternalistic, judgmental gatekeepers.

The pressures on physicians that may contribute to this perception include poor training in pain management or training against the use of opioids for chronic pain, feedback from pharmacists about over-prescribing, pressure from reimbursement channels to hold down costs, bad experiences with other opioid patients, and the knowledge that honest physicians have been unfairly indicted for their prescribing habits.

In order to meet patient and physician needs, several guidelines need to be in place.

NOT EVERYONE IS TREATED THE SAME

Disparities in healthcare are also evident in pain management. African Americans and Hispanics are affected by racial profiling for diversion and

GUIDELINES

A National Center for Health Statistics Report found that more than one-quarter of Americans (26 percent) age 20 and over — an estimated 76.5 million Americans — reported problems with pain of some sort that lasted for more than 24 hours.

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Physicians who treat chronic pain need to be comfortable and secure in their competency. Many times pain is under-treated because of

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CLINICAL PEARLS lack of training. The California Society of Anesthesiologists provides online CME on pain management and end-of-life • All patients deserve to be thoroughly assessed for pain and care that includes preventive measures to help reduce the practo have their pain managed appropriately to increase the titioner’s risk of suffering a medical-legal action (3). quality of life.

Physicians and surgeons may have to deal with breakthrough • BTP is a common and frequently debilitating experience pain (BTP) in patients with cancer and non-cancer-related pain. for patients with non-cancer-related pain.

Treatment regimens can incorporate non-pharmacologic • Because of the risk for misuse and/or abuse of and pharmacologic treatment that include opioids. opiate agents, patients with chronic pain should Because different treatment approaches are posbe evaluated and supported according to sible, additional education may enhance the their level of risk. provider’s ability to tailor BTP treatment by The American Pain • Pain patients need to be listened to, rematching pharmacology of the drug to: the Foundation tells us that ceive validation of symptoms, have subtype of BTP, the patient’s risk for their fears calmed, be treated with repain affects more Ameriabuse, and the capacity to monitor the paspect and belief, and have a medical tient. Medscape, a free resource for physicans than diabetes, heart partner for dealing with their pain. cians and nurses, provides more disease, and cancer Pain, although not objective, is real. information on BTP management (4). combined.

Don’t fail to treat the pain.

Because narcotic prescriptions are aggres• Understand the barriers to effective pain sively monitored by multiple agencies, physimanagement. cians may worry that prescribing narcotics can • Prescribe only to your patients. cost them their license. The Medical Board of Cali• Educate and provide informed consent. fornia, which provides guidelines for prescribing controlled • Document: Use a flow sheet to help monitor prescription substances for pain, assures California physicians and surgeons refills. that they need not fear disciplinary or other actions for the mere • Don’t hesitate to get help. fact of having prescribed opioids in the course of treatment of a person for intractable pain. The appropriate use of opioids RESOURCES: has been recognized in the California Intractable Pain Treat1) American Pain Foundation. The APF Newsroom Pain Facts page. Availment Act (Section 2241.5 [c] of the California Business and able at: www.painfoundation.org/page.asp?file=Newsroom/PainFacts.htm.

Professions Code). The board expects physicians and surgeons Accessed March 20, 2008. to follow the standard of care in managing pain patients (5).

2) Ibid.

The fear of addiction is another barrier to opioid pain man3) California Society of Anesthesiologists. Online CME Program page.

Available at: www.csahq.org/cme2/course.php?course=3. Accessed March agement — the result can be under- or non-treatment of 20, 2008. moderate-to-severe pain. Douglas L. Gourlay, MD, and 4) Medscape from WebMD. CME page. Available at: Howard A. Heit, MD, have advocated the use of a “universal www.medscape.com/viewprogram/7869. Accessed March 15, 2008. precautions” approach to all pain patients, especially those 5) Medical Board of California. Guidelines for Prescribing Controlled Subwho are considered for a therapeutic trial of opioids to imstances for Pain. Available at: www.medbd.ca.gov/pain_guidelines.html.

Accessed March 15, 2008. prove quality of life. These universal precautions are stan6) Medscape from WebMD. Viewpoint page. dardized assessments and management Available at: approaches to chronic pain that inwww.medscape.com/viewarticle/503596. Acclude a substance use assessment, a cessed March 24, 2008.

GOT CLINICAL PEARLS? stratification of patients into three groups to determine a particular setSDCMS Physicians: ting to manage the pain, and applying Share your clinical pearls with your 10 steps of precautions (6). Following colleagues via San Diego Physician. these precautions may prevent another ABOUT THE AUTHOR: Ms. Shepard Send them to Editor@SDCMS.org, and we will consider publishing bad experience with managing the is director of patient safety education for them in a future issue! pain patient.

The Doctors Company.

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

The

Pulse

MESSAGE FROM THE PRESIDENT

Dear Foundation Friends: Greetings to all of our Foundation supporters! Last month we had the opportunity to thank our donors from this year and years past at an evening in their honor.

Donors and friends of the Foundation were treated to a private reception at the Lyceum and invited to a comedic performance that followed. It was a wonderful opportunity for our board of directors and Foundation staff to personally meet many of our Foundation donors. Special thanks go out to our wonderful sponsors for making this evening possible, especially Software Partners and an anonymous donor for their generous contributions!

Our mission to address unmet healthcare needs for all patients and physicians through education, innovation, and service is being realized through many ongoing initiatives. Project Access San Diego (PASD) is one of our largest programs on

the runway right now. This project is a care coordination initiative to connect uninsured and underinsured patients with pro-bono or deeply discounted healthcare services. It is already generating much recognition in the community for being a model program.

The Foundation continues to support medical students with loan and scholarship programs. I was honored to present the UCSD School of Medicine Senior Award to Melissa Lorang at its award ceremony on May 31, 2008. This student demonstrated exemplary public service and volunteerism while maintaining high standards in academics. Congratulations Melissa! You can read more about our award winner on our website (www.SDCMSF.org). Additionally, I accompanied nine UCSD students on a Legislative Day in April to Sacramento. This experience was funded by our Hertzka Policy and Training endowment, which provides opportunities for medical students to learn the ropes of the political process.

Our Retired Physicians Society continues to flourish, with new members joining monthly. The Foundation supports our retired physicians with quarterly luncheons hosted around San Diego County. Our

UCSD medical students participate in a legislative training with SDCMS leadership in Sacramento. Back Row (from left): James Perry, Michael Rochon-Duck, Jason Kroening, Eric Diaz, Amir Misaghi, George Zhu, Joseph Buckwalter, Benjamin Hu. Front Row: Dr. Robert Hertzka, Sen. Denise Moreno-Ducheny, Paula Tran, and Foundation president, Dr. Carol Young.

BOARD OF DIRECTORS Carol Young, MD, President, Rheumatology, Escondido Ralph Ocampo, MD, Secretary/Treasurer, General Surgery, Retired James Hay, MD, Immediate Past President, Family Medicine, Encinitas Sarah Aghassi, Esq., Director, Office of Strategy and Intergovernmental Affairs, County of San Diego Ellen Beck, MD, Family Medicine, San Diego John Berger, MD, Family Medicine, San Diego Edgar D. Canada, MD, Anesthesiology, San Diego

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last luncheon was held in April at Palomar Pomerado Hospital, where Orlando Portale (chief innovation officer at PPH) presented a virtual hospital experience with a live, online demonstration of the planned new campus in Escondido. It was amazing to see the technological innovations planned for that hospital and the dreams for the future! Our next luncheon is on July 24, 2008. Admiral Christine Hunter will be our keynote speaker at the Admiral Baker Club House. The Retired Physicians Society also has an active historical project documenting the history of physicians in San Diego County. Please check our website or contact the Foundation if you would like more information about attending these fun luncheons or learning more about our historical society!

I cannot thank you enough for all of your contributions to the SDCMS Foundation, be it time or dollars. As board president and as a practicing physician in the community, I am so proud that our Foundation is giving back so much to so many.

Have a great summer!

Sincerely, Carol L. Young, MD, President of the Board

Judy Forrester, Consultant, Forrester Enterprises Tom Gehring, CEO, San Diego County Medical Society Theodore M. Mazer, MD, Otolaryngology and Head and Neck Surgery, San Diego Albert Ray, MD, Family Medicine, San Diego

Officer, City of San Diego Richard S. Ledford, President, Ledford Enterprises Michael I. Neil, BGN, USMC Retired, President, Neil, Dymott, Perkins, Brown and Frank

STAFF ADVISORY COUNCIL James Lewis Bowers, PhD, Consultant for Philanthropy Steven A. Escoboza, President/CEO, Hospital Association of San Diego and Imperial Counties Ronne Froman, RADM, USN Retired, Chief Operating

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Aron R. Fleck, MBA, Executive Director Tana Lorah, Associate Director Stephen H. Carson, MD, Chief Medical Officer Pediatrics, San Diego Claudia Gastelum, PASD Care Coordinator

In the Spotlight: Meet a Physician Volunteer Showcasing a Foundation Inititative MEET DR. JAMES T. HAY

Project Access San Diego: A Flagship Program for San Diego’s Uninsured and Underinsured

You can pick up the paper or hear on the news just about every day that healthcare services for patients who are uninsured or underinsured are dwindling. We know that the federal government is overburdened and that the State of California is in an economic crunch. Inevitably, the budget cuts will affect the medical support programs for patients in San Diego County. Well, the good news is that while other programs are evaluating and assessing for financial cuts, Project Access San Diego is growing!

Project Access San Diego (PASD) is modeled after a successful, nationwide program being implemented in 50 cities around the country. The heart of the program is to help patients who cannot afford medical services and who do not have health insurance receive medical care that has been donated or deeply discounted by healthcare providers, including physicians (primary care and specialty care), ancillary services, and prescriptions.

Many caregivers in San Diego County offer charity care as a matter of course but never receive the support they need to offer ancillary services or

SDCMSF: When was your medical practice founded?

DR. HAY: I started North Coast Family Medical Group (NCFMG) in 1978, and we have been providing family medical care to Encinitas and North County residents ever since.

SDCMSF: How are you involved in the community?

DR. HAY: I have been an activist in the politics of healthcare by participating in the California Medical Association (currently as an officer), in the California and American Academies of Family Physicians, in the San Diego County Medical Society (president 2001), and in Our AMA (a delegate since 2004). I was the first president of the SDCMS Foundation, which is dedicated to fulfilling the unmet healthcare needs for all San Diegans, and I’m the “champion” for physician volunteerism in the Foundation’s Project Access San Diego. I am also a board member of the American Red Cross and of 211 San Diego.

SDCMSF: Speaking of Project Access San Diego, what is your level of involvement with patient care in this program?

DR. HAY: In addition to serving on the Project Access Leadership Committee, I have volunteered to provide a “medical home” for two patients per year in my office. My four partners have also offered the same opportunity, so our medical group will provide medical homes for up to 10 patients each year.

SDCMSF: Why do you think Project Access is such a great initiative?

DR. HAY: The ability to overcome the barriers of access to healthcare for indigent patients in San Diego County through this program is mutually rewarding. I can care for patients knowing that Project Access will help coordinate the ancillary needs of my patients. I also know that those who do not qualify for any other healthcare coverage will get an opportunity to receive quality care from my group and from the consultants who partner with us.

And I get the satisfaction of providing that needed care to someone who needs it.

prescription benefits. Patients referred in to our program will be working with our in-house care coordinators to connect them with pro-bono or discounted healthcare services. PASD provides the support that physicians need to execute quality care to these patients. PASD also tracks and measures the contributions of our physician and healthcare partners to relate to the patients and the community the value contributed in healthcare dollars and appointments!

PASD is funded by numerous grants and has generated enthusiasm in the county to give patients access to quality care and provide physicians the support they need to assist needy patients in San Diego.

PASD is expanding its capacity and needs your help! Can you see one or two patients a year pro-bono or for discounted services? If you would like to find out how to get involved, please contact Aron Fleck at (858) 300-2780 or visit our website to see how PASD is giving back. Call us today!

Access information about other Foundation initiatives at www.SDCMSF.org.

The Coverage Initiative Program The County of San Diego Health and Human Services Agency is offering the Coverage Initiative (CI) Program to uninsured adults with diabetes and/or hypertension. To be eligible for this program, individuals must be between the ages of 21–64, uninsured, county residents who suffer from chronic health conditions of diabetes and/or hypertension, U.S. citizens or legal, permanent residents for the past five years, and have income between

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135 and 200 percent of the federal poverty level. A goal of the program is to provide disease management services that cover immediate and ongoing medical care and thereby reduce individuals’ reliance on hospital emergency rooms by assigning them to a medical home at a neighborhood community health center. Potential patients may contact Monica Tucker at (858) 492-1380 to learn more about the program.

RETIRED PHYSICIANS SOCIETY EVENTS Thursday, July 24, 2008 — Admiral Baker Club House Thursday, October 23, 2008 — Sharp Chula Vista Thursday, January 22, 2009 — San Diego Zoo Hospital

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San Diego County Medical Society Take Advantage of These SDCMS-CMA Benefits!

EMR SOFTWARE: SDCMS has partnered with Allscripts to provide special preferred early adopter pricing and discounts for SDCMS members on their HealthMatics EHR and practice management solutions. Contact Jamie Smolin at (310) 490-9711 or at Jamie.Smolin@Allscripts.com.

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PRACTICE MANAGEMENT CONSULTING: Practice Performance Group has signed an agreement to offer SDCMS members practice management consulting discounts (equal to 10% or $500, whichever is larger), free half-day seminars at SDCMS (watch your faxes and emails), and a free one-year subscription to their newsletter. Call (800) 452-1768 or visit www.PPGConsulting.com.

SDCMS PICTORIAL MEMBERSHIP DIRECTORY: Appear in CMA REIMBURSEMENT HOTLINE: (888) 401-5911 — Free SDCMS’ annual pictorial membership directory. Receive a free directory each year and a 50% discount on any addi- CMA LEGAL INFORMATION HOTLINE: (415) 882-5144 — Free tional directories purchased. Contact SDCMS. CODING HOTLINE: Access a coding hotline free of CMA LEGISLATIVE HOTLINE: (866) 462-2819 — Free charge (provided by CHMB Solutions). Email your coding CMA PHYSICIAN CONFIDENTIAL LINE: A free, 24-hour question(s) to SDCMS at Coding@SDCMS.org. phone service for physicians, dentists, medical students, SAN DIEGO PHYSICIAN MAGAZINE: Receive a free sub- residents, and their families and colleagues who may have scription to the voice of San Diego County’s physicians. an alcohol or other chemical dependence or mental/bePlace free classified ads and discounted display ads. Con- havioral problem. Completely confidential. Using it will not result in any form of disciplinary action or referral to any tact SDCMS. disciplinary body. Call (213) 383-2691.

SAN DIEGO MAGAZINE: Receive a gift subscription (active physician members) or a discounted subscription (res- LOCAL, STATE, AND FEDERAL PHYSICIAN ADVOCACY: ident physician members). To sign up, contact SDCMS. To SDCMS-CMA continue to be vigilant in our protection of update your subscription address, contact San Diego Mag- MICRA, in fighting against nonphysician scope of practice expansions (all scope bills in 2006–07 were killed!), in workazine at (888) 350-0963 or at sdgm@kable.com. ing closely with our political representatives and other SDCMS EMAIL NEWSLETTER, “NEWS YOU CAN USE”: healthcare stakeholders to fix our broken healthcare fiReceive, free of charge, the latest in medical, local, state, nancing system, and in doing everything we need to do to and federal news critical to your practice … free of adver- protect physicians’ interests wherever they are challenged. tising. Contact SDCMS. Contact SDCMS.

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

Contact SDCMS. Call Catherine Sherman at (888) 687-4240, ext. 14.

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

FULL-TIME SDCMS OFFICE MANAGER ADVOCATE: Let CORPORATE LEGAL SERVICES: Receive a free consulta- HIPAA COMPLIANCE: Receive a discount on a complete, your office manager and staff know that they have a fulldo-it-yourself HIPAA privacy and security compliance toolkit tion and discounts on corporate legal services. Call Ladd time office manager advocate on staff at SDCMS ready to (CD ROM). Call David Ginsberg at PrivaPlan at (877) 218-7707.

Young Attorneys at Law at (619) 564-6696. help them with any questions they may have, free of CALIFORNIA EMERGENCY DRIVING EMBLEM: Receive charge. Contact Lauren Woods at (858) 300-2782 or at BILLING SOLUTIONS: Receive a 50% discount on your first California physician emergency driving emblem LWoods@SDCMS.org. startup fees and a $33 per physician per month services free of charge, and any additional emblems at the discredit. Contact Ron Anderson (CHMB Solutions) at (760) 520 SDCMS NEWS ALERTS: Stay informed of the news that counted price of $10 each. Contact SDCMS. 1340 or at randerson@chmbsolutions.com. affects your bottom line and your patients’ health with EPOCRATES CLINICAL REFERENCE GUIDES: Receive a faxed and emailed alerts sent by SDCMS to you, free of PROFESSIONAL LIABILITY INSURANCE: Most SDCMS 30% discount off of a one-year subscription and a 35% charge … and free of advertising! Contact SDCMS. members who use The Doctors Company for their profesdiscount off of a two-year subscription to Epocrates’ clinsional liability insurance receive a 5% discount on their ical reference guides. Students and residents receive a 50% SDCMS AND CMA WEBSITES: Access, free of charge, the professional liability insurance. Contact SDCMS. discount. Contact Epocrates at (800) 230-2150 or visit “Member Physicians” section of SDCMS’ website and the members-only section of CMA’s website to find valuable re SAN DIEGO COUNTY PHYSICIAN MAILING LISTS: Receive www.cmanet.org. one free physician mailing list annually and a discount on CMA ON-CALL DOCUMENTS: You can access, free of sources, such as a list of San Diego County physician NPIs, all additional mailing lists requested in the same year. Con- charge, thousands of pages of medical-legal, regulatory, and updated weekly. Contact SDCMS. tact SDCMS. reimbursement information, through CMA’s online library. ENGAGEMENT IN HEALTHCARE ISSUES: Be a part of the SDCMS MEMBERSHIP CERTIFICATE: Receive a free Contact CMA at (415) 882-5144, at legalinfo@cmanet.org, solution! Become involved in any of a broad spectrum of or visit www.cmanet.org. opportunities both SDCMS and CMA afford their member SDCMS membership certificate. Contact SDCMS. physicians, including joining an SDCMS or CMA committee Delivered diWEEKLY NEWSLETTER, “ALERT”:

CMA’S AUTO INSURANCE: Along with your spouse, receive disor becoming a physician leader. Contact SDCMS. counts of 4.5% to 14% on all lines of coverage from the Au- rectly to you, free of charge, via email or fax. Contact Katherine Gallia at CMA at (916) 551-2074 or at tomobile Club of Southern California. Contact SDCMS. kgallia@cmanet.org.

TAMPER-RESISTANT PRESCRIPTION PADS: Receive dis CONTRACT ANALYSIS: Receive free access to CMA’s counts on tamper-resistant prescription forms. Contact Model Managed Care Contract and objective written analySDCMS. ses of major health plan contracts. As well, receive from INVESTMENTS: Invest with Dunham & Associates and CMA-contracted attorneys a 15% discount on other con(858) 565-8888 • SDCMS@SDCMS.org discount your SDCMS dues by $150. Call Jeff Dunham (Dun- tract analysis services. Call CMA at (415) 882-3361 or visit www.cmanet.org. ham & Associates) at (619) 308-9700.

CONTACT SDCMS TODAY

Classifieds

DONATED ITEMS MEDICAL JOURNALS: Retired neurologist has several neurological medical journals that range from 1960 to present. Some are bound. Please contact Dr. Levine at (619) 588-4929 if interested. [562] FREE CPAP MACHINE: This is an opportunity to obtain a used CPAP machine in excellent condition for a deserving patient or institution. Call Irv Sherman at (858) 487-6370. [548] OFFICE SPACE CARMEL VALLEY OFFICE SPACE: Office space to share or sublease in busy, solo OB/GYN office. Ideal for OB/GYN, internal medicine, osteopath, dermatology, or other sub-specialty. Excellent referral potential.

Scripps medical office building. Call Liz at (858) 259-9900. [593]

"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 FOR RENT: Convenient location, free parking, in Clairemont (Balboa/Genesee). 1,350ft2, three exam rooms, two bathrooms, lab, share with one other doctor. Office located next to lab/draw station, Internet access ready. Reasonable rent. Call (858) 277-9669 or email ykidsd@aol.com. [588]

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]

CLAIREMONT MESA: Small, two-office space for rent in newly constructed medical office. Not a shared space! Approximately 400ft2, built to maximize space, light and airy! Great for therapist, research, small specialty practice, etc. Building is recently renovated, common-area bathrooms, breakrooms, elevator, T1 available, and free parking. Centrally located between highways 52, 805, 163, and 15 for easy hospital and facility access. Contact (858) 268-1111, ext.

311, for more details. [587]

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 I78. Ample patient parking. Contact Kristina at (760) 942-9028 or by email at Kristina@sdsleepclinic.com for more information. [520]

OFFICE SPACE FOR RENT IN ENCINITAS, 92024: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway. Features include two spacious exam rooms, private consultation/doctor’s office, lunch room, private bathroom, and a spacious waiting room shared with one other doctor.

Share lab, ultrasound, and bone density equipment.

Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (858) 7563021 or email ktagdiri@gmail.com for more information. [586] SOLANA BEACH MEDICAL CENTER: 2,374ft2 for lease; $2.75/ft2 plus utilities and janitorial services. Ready to move in but tenant improvement allowable. Easy access to I-5. Serving Del Mar through Encinitas.

Call (760) 431-4238. [584] 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 orthopaedic surgeon situated in highly desirable location in a beautiful new building at 7910 Frost Street. The new hospital under construction for Sharp Memorial Hospital 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]

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) 9311134 or shamshoian@coveycommercial.com. [556] OFFICE SPACE AVAILABLE: Office space at the corner of 8th Avenue and Washington Street in Hillcrest.

Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555] OFFICE TO SHARE: Office available in desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior design renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom (including shower), and kitchen. Contact us at San Diego Vein Institute at (760) 944-9263. [546]

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

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]

SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA IN CARMEL VALLEY: A portion of an upscale, 4,000ft2 medical spa available for sublease. Ideal for an ophthalmologist, plastic surgeon, ENT, and cosmetic dentist. Sublease includes a spacious reception and waiting area, six exam/procedure rooms, surgery suite, two dental chairs, three doctor offices, and consultation room. Easy access to I-5, 805, 56, and I-15. Located inside a medical and dental office building within a retail center. Contact Janice at (858) 481-7701 or janice@laser-clinique.com for more information. [561] MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS): OB/GYN-type consultation room and one to two exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door.

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

Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557]

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]

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.

TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at KLaCruz@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $100 for the first 75 words and $0.50 per word thereafter (limit 100 total words).

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Classifieds SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MIDWAY): Share fully furnished, six-exam-room/twooffice suite with internist. Ample free parking, great location. Contact Elaine Watkins at (858) 945-3813 or at ejwatkins@gmail.com. [527] MEDICAL SPACE FOR LEASE: 2,350-11,761ft2 completed shell building on Highway 86 in Imperial County for $2.05ft2/month. Please contact Dr. Maghsoudy at (760) 730-3536 or at afsaneh_maghsoudy@hotmail.com. [525] 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 Chula Vista Hospital.

Office includes three exam rooms and one treatment room, and is 1,700ft2. Support staff available. Contact Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521] MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscale medical spa in Eastlake available to sublet a portion of the facility to a specialist. Ideal for plastic surgeon or aesthetic physician performing minimally invasive procedures. Also open to acupuncturist or wellness/antiaging physician, which complements the spa and noninvasive aesthetic services currently being offered.

Call (619) 228-4483 for more information. [519] MEDICAL OFFICE AVAILABLE TO SHARE: Primary care office available to share. Store-front building with great visibility and recently updated interior. Current physician has been in practice for 10 years and wants to cut down on hours. Lots of opportunities for a starting physician or specialist. Office staff available to share if needed. Call (619) 575-4442 or fax letter of interest to (619) 575-1297. [518] OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501] MEDICAL OFFICE SPACE: Approximately 1,289ft2; conveniently located about one mile east of Tri-City Hospital in a four-unit building. Three exam rooms (one leaded) and two baths. Nice layout and ample parking. Office is ideal for a solo practitioner. For further details, contact Wendy Shumate, MD, at (760) 6304715 or Aruna Garg, MD, at (760) 724-8562. [478] MEDICAL OFFICE SPACE AVAILABLE: Medical office space located in Hillcrest available. The space is approximately 4,500ft2 with several advantages for a group of one to four surgical specialists. There is ample parking, a full outpatient surgical center on first floor of the building, and a therapy area on the second floor. Ample medical records storage space and phone and computer wiring already installed. For more information, please contact (619) 299-0007. [462] OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one parttime physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 432-6644 or at EIM2006@sbcglobal.net. [459] SPACE FOR LEASE (CORONADO): Brand new building in Coronado. Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435] NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): Inhouse, accredited surgery office available. 3,000ft2 includes exam room, dexa scanner, and physical therapy. Ideal for a pain management or newly starting orthopedic physician. Call John at (619) 549-8870 for more details. [398]

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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] PHYSICIAN POSITIONS AVAILABLE URGENT CARE: Busy practice, established in 1982, seeks a full-time or part-time physician. Fax CV to (619) 442-2245 [595] INTERNAL MEDICINE — SAN MARCOS: North County Health Services, a Joint Commission, federally qualified community health center, has opportunity for fulltime BC/BE internal medicine physician to work Monday through Friday and one Saturday per month.

Attractive compensation package includes bonus for call and incentive. Benefits package includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [590] FAMILY PRACTICE — OCEANSIDE: North County Health Services, a Joint Commission, federally qualified community health center, has opportunity for BC/BE family practice physician to work Monday through Friday and occasional Saturdays (shared with other clinicians). Attractive compensation package includes bonus for call and incentive. Benefits package include PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure.

Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [591] OB/GYN PHYSICIAN — ENCINITAS: North County Health Services, a Joint Commission, federally qualified community health center, has an opportunity for BC/BE OB/GYN. Hours and call shared with other clinicians and NMWs. Attractive compensation includes call and incentive pay. Benefit program includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [592] EXCELLENT OPPORTUNITY FOR OB/GYN: Full service OB/GYN position available in North County. Willing to consider part- and full-time positions. Advanced 3D/4D ultrasound, in-office procedures (Essure, endometrial ablations), minimally invasive gynecology, urogynecology with urodynamics, infertility and obstetrics. Amazing future. Combine the best of technology with compassionate care. Email CV to

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robertbiter@gmail.com or fax to (760) 642-0802.

[589] UROLOGIST NEEDED: We have an immediate opening for a part-time or per diem urologist to join our multispecialty medical office located in La Mesa. We are a busy office with exceptional staff, and we need an exceptional individual to join our team. We offer flexibility, independence, and a great office environment.

Please contact Sedrak at (310) 717-9121 or email your resume to Harmonymedicalgroup@yahoo.com. [585] TEMPORARY PCP COVERAGE SOUGHT: BC/BE internist or family practice doctor sought to cover three-month maternity leave for private practice internist in Kearny Mesa area starting August 2008. Hours are M–F, 7:30 a.m.–1:30 p.m. No hospital work or call.

Please fax CV to (858) 277-0690 or call (858) 2770696. [583] 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 after-hours calls. Fax CV to Hjordis Williams, office manager, at (858) 5654146, email to hjordis.williams2@sharp.com, or call (858) 565-4117. [578] PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR: Temecula independent diagnostic testing facility seeks physician to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month, typically scheduled for nine-hour shifts. Candidates must have California license. Please contact Lynn at (619) 819-6577 for more information, or fax your CV to (619) 241-7790 for immediate consideration. [572] 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] 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] 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] FAMILY PRACTICE (CHULA VISTA): Seeking a family practice physician to cover solo physician practice one week every two months. Contact Ann at (619) 4221324 or at doctorwp@pacbell.net. [451] FAMILY PRACTICE DOCTORS NEEDED: Full time and part time; days, nights, and weekends available. Fax CV to La Costa Urgent Care at (760) 603-7719. [449] NONPHYSICIAN POSITIONS AVAILABLE RN, NP, PA: Registered nurse, nurse practitioner, or physician assistant needed for Encinitas ENT, facial plastic surgery practice. Dermatology, laser, and filler experience preferred. Call Carol at (760) 944-4211.

[594]

Classifieds REGISTERED NURSE: Family medicine office in Torrey Hills 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]

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

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

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] 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: Four-physician internal medicine practice in Chula Vista seeks part-time/full-time nurse practitioner. Work with a quality group; reasonable hours. Previous experience is preferable; salary negotiable depending on experience. Call (619) 421-4470 or (619) 421-4000. [488] PHYSICIAN 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]

HOUSEKEEPER: Seeking weekly/bi-weekly housekeeping position in San Diego County. Bilingual, 20 years experience. Honest! (619) 787-8257 Ask for Carmen.

[581]

DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

MEMBERSHIP DIRECTORY

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent financing available for physicians! Includes purchase of a practice, equipment, partner buyout, working capital, and real estate. Call Monica Coburn at CBN Financial: (702) 310-7111 or mcoburn@communitybanknv.com. [522] BILLING, CONSULTING, OUTSOURCING: We are committed to maximizing your bottom line! Our billing service uses state-of-the-art technology to ensure charge capture, code validation, electronic submission and remittance, payment postings, patient statements, structured follow-up and appeals, electronic document storage and meaningful reporting. Supplemental services include online appointment scheduling, automated call reminders, scan systems, and other technological advances.

Consulting services include accounts payable, auditing, business development, electronic medical record selection and implementation, credentialing, contracting (payor, physician, and staff), executive assistant, financial management, information systems, operational management, practice assessment, practice management, relocation management, and other technological advances.

Contact us today for your free consult! Contact Kena Galvan (619) 326-0700 or kena.galvan@abssol.com. [452] RMC VINYL REPAIR PLUS: Medical equipment upholsterer. Expert in repair and replacement of medical fixture upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service! Call (619) 443-4060. [400]

2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT: Excellent condition; 2K in recent/routine maintenance, new front eisenglass, 3.5 years remaining on full-warranty ($6,000 value), only a paltry100 hours for two pristine 220-hp engines, GPS, generator, TV/DVD/stereo/air/heat and much more.

Exact boat with less features costs $150K; $98,000 (firm) to first buyer. (858) 254-0202.

[454]

MEDICAL EQUIPMENT ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vascular, abdominal, small parts, five transducers: $6,000. Quinton 4000 monitor with Q55 treadmill, recording paper, electrodes, crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619) 460-0083 or (619) 518-9542. [513]

2008-2009

MEDICAL BILLING CONNECTION (MBC): After your patients’ 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) 9804808, ext. 102. [575]

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

SAN DIEGO COUNTY MEDICAL SOCIETY

CME/CERTIFICATION COURSES

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JULY 21, 2008

DARI PEBDANI SAN DIEGO MAGAZINE 619.744.0528 darip@sandiegomagazine.com

2003 BMW M3 CONVERTIBLE (RED, MANUAL): Very good condition, low miles, and new tires: $33,750. (858) 254-0202. [453]

J U LY

DEADLINE TO ADVERTISE

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D I E G O

P H Y S I C I A N . o r g

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OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY

JULY 2008

Winner

“Most Improved Publication/Trade” (Circulation Under 50,000)

PHOTOGRAPH BY VICTORIA MCCLELLAND

The Maggie Awards are produced by the Western Publications Association.

Congratulations SDCMS Member Physicians— Your Magazine is an Award Winner!

MAKING THE RIGHT CHOICE... in Medical Malpractice Liability Insurance.

The Fairway Choice: • Coverage for Wide Variety of Specialties and Procedures including Alternative Medicine • Medical Board Defense Coverage Options

Through our new Partner Plan, physicians will be eligible for additional premium discounts when applying for a Medical Office Package, Workers Compensation or Employee Benefit Plan!

• Binding Arbitration to Control Claim Settlements • Physician Owned Company • Premium Discounts Available to Association Members • A+ Rated (AM Best) Reinsurance • Risk Management Services Available Limits: $1,000,000 Per Claim/$3,000,000 Aggregate $2,000,000 Per Claim/$4,000,000 Aggregate

1

Deductibles Available: $0 to $100,000

Fairway Physicians Insurance Company A Risk Retention Group 30401 Agoura Road, Suite 101 Agoura Hills, CA 91301 Phone 818-889-7399 Facsimile 818-979-8003 www.fairwayphysicians.com info@fairwayphysicians.com

We hate lawsuits. We loathe litigation.

We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head.

We make CME easy, free, and online.

We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company.

Donald J. Palmisano, MD, JD, FACS Board of Governors, The Doctors Company Past President, American Medical Association

The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. To learn more about our professional liability program for SDCMS members, call (858) 452-2986.

Endorsed by

Š 2008. The Doctors Company. All rights reserved.

$5.95 | www.SANDIEGOPHYSICIAN.org

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